Principles of intravenous fluid therapy

Principles of intravenous fluid therapy

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Principles of intravenous fluid therapy

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1. Principles of intravenous fluid therapy Jonathan Paddle Consultant in Intensive Care Medicine Royal Cornwall Hospitals NHS Trust 3rd September 2007

7. The present day?

8. Current controversies in fluid therapy How much fluid to give Which fluid to use

9. Assessment of volume status Look at the patient: Pulse Blood pressure Capillary refill Mucous membranes Peripheral circulation Thirst

10. Assessment of volume status Try a more invasive approach: Urine output Arterial line Central venous line PA catheter Oesophageal doppler

11. Assessment of volume status How about blood tests? U&Es Haematocrit Plasma/urine osmolality Arterial blood gases Lactate

12. Assessment of volume status

13. Trauma 598 adults with penetrating torso injuries Randomised to standard care or no fluids until time of operation

14. Trauma Cochrane Database of Systematic reviews Six randomised controlled studies No evidence in support or against early aggressive fluid resuscitation 52 animal trials hypotensive resuscitation reduced risk of death

15. Peri-operative 138 patients undergoing major elective abdominal surgery Randomised to one of three groups (one control and two goal directed therapy groups

16. Peri-operative Goal-directed therapy was aimed at optimising oxygen delivery to tissues with: Fluids Inotropes Guided by invasive PA catheter monitoring

17. Peri-operative

18. However? RCT 172 patients undergoing elective colorectal resection Restrictive fluid regime (to maintain neutral body weight) vs. standard post-op fluids

19. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock Emanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early Goal-Directed Therapy Collaborative Group Volume 345: 1368-1377 November 8, 2001

20. Rivers E et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. NEJM 2001; 345: 1368-77

21. Protocol group

23. Treatment given

24. The take-home message! Resuscitate with fluids early and aggressively They won?t get overloaded They won?t get pulmonary oedema They will be less likely to need ICU Be guided by markers of tissue perfusion Urine output Lactate Consider central venous oxygen saturations

25. FACTT Study Comparison of two fluid management strategies in acute lung injury Randomised controlled trial 1001 patients with ARDS or ALI Conservative v liberal fluid therapy Also compared PAC or CVC Mortality at 60 days, vent free days, organ failure free days

26. FACTT Fluid restriction 43 hrs post admission 24 hours post ALI/ARDS Renal failure pts excluded Volume replete patients

27. FACTT No significant difference in mortality Restrictive fluid group had: Better oxygenation indexes More ventilator free days Less renal failure in conservative group Recommendations: Conservative fluid approach without PAC But????..

28. FACTT Increase in cardiovascular failure days in patients in conservative group Caution in fluid depleted patients. Relative young age of patients ? Realistic study population

30. What is the choice?

31. Fluid distribution

32. Practical differences

33. Albumin vs. crystalloid

34. HES vs. crystalloid

35. Gelatin vs. crystalloid

36. Dextran vs. crystalloid

39. Study design 16 centres in Australia and New Zealand Randomised, double-blind, trial of 4% albumin compared to 0.9% Saline for fluid resuscitation in the ICU Study fluid given until death, discharge or 28 days

40. Study design 6997 Patients enrolled 90% power to detect 3% difference in mortality from baseline of 15% mortality A priori sub-groups identified: Trauma Severe Sepsis ARDS

41. Fluids administered and effect

42. Outcome

43. Outcome

44. Subgroup Outcome: 28 day mortality

45. What about starches? Starches are polymers of glucose a1,6 linkages produce branched chains called amylopectins Hydroxyethyl radicals can be substituted on glucose units, hence

46. Why might they be useful? Large molecules, so retained in the plasma Stable molecules, so have a sustained effect Some evidence of specific anti-inflammatory properties that may be therapeutic

47. Endothelial properties Prospective RCT, single centre 66 patients >65 years old Major abdominal surgery Ringer?s lactate (n=22) Normal saline (n=22) HES 130/0.4 (n=22) From induction of anaesthesia until 1st post-op day to keep CVP 8-12mmHg

48. Endothelial properties

49. Why might they be bad? Potential risk of anaphylaxis Some starch solutions cause coagulation disorders Risk of renal impairment Known incidence of pruritis

50. Incidence of anaphylaxis French multicentre study 49 hospitals 19593 patients Overall 1 in 456 had an anaphylactoid reaction

51. Coagulation disorders

52. Renal Impairment 129 patients in three centres Severe sepsis / septic shock 6%HES 200/0.6 vs. 3% Gelatin Prospective RCT

53. Renal Impairment

54. Renal Impairment 40 patients, single centre HES 130/0.4 vs. Gelatin Prospective RCT

55. Renal Impairment

56. Pruritis 85 consecutive cardiac patients Structured interview 58 received EloHAES 27 received no HES

57. Pruritis Pruritis experienced in: 13 (22%) of EloHAES patients 0 (0%) of non-HES patients (P=0.007) Median onset (range) 4 (1-12) weeks Greatest duration >9 months

58. Time to put it all together!

59. How much fluid Trauma Restrictive fluid strategy until bleeding controlled Peri-operative Fluids early (?pre-op), then cut back Sepsis Early aggressive fluids to restore perfusion Restrict fluids late to avoid oedema

60. Which fluid It probably doesn?t matter! Avoid dextrose (water) as large volumes will be required, worsening tissue oedema If using crystalloid, the patient will require 1.4 times the volume compared to colloid Crystalloid may be better in trauma Colloid (or possibly starches) may be better in critically ill / sepsis

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