3.5

3. 14 l 25 l 3.5

6. Glicocalice: Glicoproteine e proteoglicani

8. 1832 Robert Lewins 1855 Sidney Ringer 8 mg NaCl, 0,3 g KCl, 0,33 g CaCl 1l di H2O Alexis Hartmann 1941 Albumina

11. ReIDRATAZIONE Adeguamento volemico

12. I cristalloidi sono soluzioni che contengono soluti di peso molecolare inferiore ai 30 kDa : generalmente sali o glucosio. Essi passano con facilità attraverso la membrana dei capillari. Possono essere isotonici,ipotonici o ipertonici. CRISTALLOIDI

14. HES solutions are produced by hydroxyethyl substitution of amylopectin obtained from sorghum, maize, or potatoes. A high degree of substitution on glucose molecules protects against hydrolysis by non specific amylases in the blood, thereby prolonging intravascular expansion, but this action increases the potential for HES to accumulate in reticuloendothelial tissues, such as skin (resulting in pruritus), liver, and kidney. Succinylatedgelatin, urea linkedgelatin Dextransolutions. I colloidi sono soluzioni di molecole ad elevato peso molecolare che passano con difficoltà l’endotelio. L’interesse nei loro confronti è legato alla maggiore efficacia come effetto volume oltre che ad interessanti propietàreologiche ed antiinfiammatorie.Comunque, in ampi studi randomizzati,i colloidi non si sono dimostarti superiori in termini di misuredioutcome di elevato profilo come la mortalità. Colloidi

16. HES solutions (10%) with a molecular weight of more than 200 kD and a molar substitution ratio of more than 0.5 HES solutions(6%) with a molecular weight of 130 kD and molar substitution ratios of 0.38 to 0.45. HES is 33 to 50 ml per kilogram of body weight per day.

17. I Generazione II Generazione III Generazione IV Generazione 450/0.7 HMW/HMS 70/0.5 200 - 260/0.5 200/0.62 130/0.4 130/0.42 Balanced 130/0.42 Hetastarch Pentastarch Tetrastarch Voluven Venofundin Tetraspan

18. The observed ratio of HES to crystalloid in these trials was approximately 1:1.3, which is consistent with the ratio of albumin to saline reported in the SAFE study.

19. The selection and use of resuscitation fluids is based on physiological principles, but clinical practice is determined largely by clinician preference, with marked regional variation. Despite what may be inferred from physiological principles, colloid solutions do not offer substantive advantages over crystalloid solutions with respect to hemodynamic effects. Although albumin has been determined to be safe for use as a resuscitation fluid in most critically ill patients and may have a role in early sepsis, its use is associated with increased mortality among patients with traumatic brain injury. The use of hydroxyethyl starch (HES) solutions is associated with increased rates of renal-replacement therapy and adverse events among patients in the intensive care unit (ICU). There is no evidence to recommend the use of other semisynthetic colloid solutions.

20. Balanced salt solutions are pragmatic initial resuscitation fluids, although there is little direct evidence regarding their comparative safety and efficacy. The use of normal saline has been associated with the development of metabolic acidosis and acute kidney injury. The safety of hypertonic solutions has not been established. All resuscitation fluids can contribute to the formation of interstitial edema, particularly under inflammatory conditions in which resuscitation fluids are used excessively. Critical care physicians should consider the use of resuscitation fluids as they would the use of any other intravenous drug.

21. Although the use of resuscitation fluids is one of the most common interventions in medicine ,no currently available resuscitation fluid can be considered to be ideal. Selection, timing, and doses of intravenous fluids should be evaluated as carefully as they are in the case of any other intravenous drug, with the aim of maximizing efficacy and minimizing iatrogenic toxicity.

22. HypercloremicAcidosis In summary: - hyperchloraemic acidosis is seen with the use of large volumes of saline and is almost certainly due to the chlorideload; - there appear to be some side-effects associated with saline use, but to date these have not translated into clinically important outcomes, though this may be throughlackof data. Chloride is implicated in impaired renal function with hyperchloraemia resulting in less natiuresis than might be expected after saline infusion. Chloride may influence the renal vasculature. There is also some evidence that renin secretion is mediated by chloride. Hyperchloraemia may also influence coagulation. Thromboelastography indicates more effects on coagulation and platelet function with saline when compared with a balanced salt solution

23. HypervolemicHypernatremia Isusually the resultofsodiumbicarbonateinfusionformetabolicacidosis,or aggressive useofhyprtonic saline totreatintracranialpressure. Whenrenalsodiumexcretionisimpaireditmaybenecessarytoincreaseitwith a diuretic. Because the urinarysodiumconcentrationduringfurosemide (~ 80 mEq/l) islessthan plasma sodiumconcentration, diuresis can aggravate the hypernatremia.

24. Lactate clearance = LactateED Presentation - LactateHour 6 × 100 LactateED Presentation

26. Associations between increased cumulative positive fluid balance and long-term adverse outcomes have been reported in patients with sepsis. In trials of liberal versus goal-directed or restrictive fluid strategies in patients with the acute respiratory distress syndrome (particularly in perioperative patients), restrictive fluid strategies were associated with reduced morbidity. However, since there is no consensus on the definition of these strategies, high-quality trials in specific patient populations are required.

27. Recently advocated approaches include waiting until the rate of drainage is less than 100 mL , less than 150 mL less than 2 mL/kg body weight, less than 200mL, less than 300 mL , or less than 400mL per 24 hours, or essentially ignoring the rate of drainage . Since properly functioning, non occluded chest tubes typically produce some fluid, it is unusual to wait until there is no drainage to remove tubes, although this approach has also been described

28. Because of this increased rate of absorption, a 10- fold increase in the rate of fluid production results in only a 15% to 20% increase in steady-state pleural fluid volume. In addition to increased pleural fluid volume/pressure, stimulation of α2-adrenergic and β2-adrenergic receptors appears to increase lymphatic drainage from the pleural space in rabbits. A 70-kg adult normally should be able to reabsorb 470 mL of pleural fluid per day from each hemithorax. Two studies of patients with clinically apparent pleural effusions estimated the rate of reabsorption as 0.11 and 0.36 mL/ kg /h Visceral and parietal pleural layers 30 to 40 µm Pleural surface area of both hemithoraces : 4,000 cm2 Pleural fluid/kg body weight : 0.13 ± 0.06 mL Pleural fluid layer 5 to 35 µm Production and reabsorption : 0.01 to 0.02 mL / kg / h Microvascular filtrate . Protein content : approx. 1 g/dL Ann Thorac Surg 2013;96:2262–7

29. In summary, judging from the variety of approaches described in the literature and available data bearing on the safety of these approaches, there appears to be no consensus as to the rate of drainage that should be used as a threshold for tube removal and no evidence to suggest that it is unsafe to remove tubes that still have a relatively high rate of fluid drainage. To help resolve this question, a non inferiority randomized trial is currently examining patient-centered outcomes to assess the safety of removal of chest tubes independent of the rate of drainage relative to a 2 mL/kg body weight per day threshold. Ann Thorac Surg 2013;96:2262–7

30. 2000 – 2007 6083 pts Sottoposti a resezione polmonare in elezione 199 ( 3,8%) leak persistente 194,dimessi a casa ritornano a controllo a 16 gg