1 / 54

Advancements in Volume Resuscitation and Colloids

Advancements in Volume Resuscitation and Colloids. Matthew S. Giuca, MD Assistant Professor of Anesthesiology Stony Brook University Medical School Nassau Anesthesia Associates Department of Anesthesia Winthrop University Hospital. Disclosures & Cavets.

kat
Download Presentation

Advancements in Volume Resuscitation and Colloids

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Advancements in Volume Resuscitation and Colloids Matthew S. Giuca, MD Assistant Professor of Anesthesiology Stony Brook University Medical School Nassau Anesthesia Associates Department of Anesthesia Winthrop University Hospital

  2. Disclosures& Cavets • No Disclosures or conflicts of interest • Caveats….. • Email: mgiuca@winthrop.org • Grateful and honored

  3. Objectives • Discuss Advancements in Volume Resuscitation management • Explain the definition of a Colloid and discuss risks vs benefits of utilization • Present evidence based expert opinions and journal articles that reflect international standards of care • Discuss methodology and approach to different patient populations • Get to the point quickly so you don’t miss any text messages

  4. Goals of Therapy Select a treatment that ameliorates end organ damage and has a favorable benefit to risk profile Evidence based Cost effective Upholds national and community standards Long track record in complex patient populations

  5. History Of Volume Resuscitation • Prior to 1795 – • 1795 – First human to human blood transfusion? - Philip Syng Physick, an American physician from Philadelphia, not published. • 1827 - Cholera epidemic strikes - Cholera started in India, spread to Russia by 1829 then England in 1831 and the United States by 1832 claiming thousands of lives. • 1829 - First documented blood transfusion - Williams Blundell (1790–1878), an English physician and obstetrician • 1830 - First successful blood transfusion - Blundell successfully transfuses a woman dying of severe postpartum hemorrhage • 1830 - First intravenous use of water - Herman and Jaehnichen, Russians physicians desperate in the face of cholera • 1832 - First saline infusion - Thomas Latta injects 6 pints of a solution of 1⁄2 concentration of soda and subcarbonate soda (58 mEq Na, 49 mEq Cl, 9 mEq HCO3). • 1833 - First successful saline infusion - Latta’s 2nd patient, 330 cm3 of fluid over 12 h and survives. • 1834 - First use of intravenous albumin - John Mackintosh, Scottish physician and student of Latta comments that “it would be advisable to make the fluid resemble as much as possible the serum of blood, by adding albumin obtained from egg”.

  6. History Of Volume Resuscitation • 1849 - Blood transfusions deemed acceptable - Walton, a famous English physician reviewed all transfusions to date and concluded the procedure a success with a mortality rate of 30%. He judged that the quantity of blood transfused should be no less than 6 oz and no more than 16 oz (roughly 1 unit blood). • 1876 - Ringer’s solution introduced - containing 8 g NaCl, 0.3 g KCl and 0.33 g CaCl • 1894 - Citrate introduced as an anticoagulant - Sir Almroth Wright, an English pathologist introduces the use of citrate as an anticoagulant • 1901 - Blood groups identified - Karl Landsteiner of Austria discovered three of the four major blood groups and is awarded the Nobel Prize for his work in 1930. • 1907 - Blood groups identified - Jansky from Chekoslovakia discovers the fourth blood group • 1908 - Blood typing become commercially available • 1932 - First blood bank established – Leningrad, 2 years later the first American blood bank by Bernard Fantus. • 1930 – Rochester plastic needle - In 1950 David Masa, at the Mayo Clinic, introduced the plastic needle, similar to today’s needles.

  7. ColloidComparison

  8. PRISMA, GRADE & PRIORI Criteria

  9. Dr. Joachim Boldt

  10. FDA Safety Communication:Boxed Warning on increased mortality and severe renal injury, and additional warning on risk of bleeding, for use of hydroxyethyl starch solutions in some settings • Date: June 24 2013 • Recommendations for Health Professionals • Do not use HES solutions in critically ill adult patients including those with sepsis, and those admitted to the ICU. Avoid use in patients with pre-existing renal dysfunction. Discontinue use of HES at the first sign of renal injury. Need for renal replacement therapy has been reported up to 90 days after HES administration. Continue to monitor renal function for at least 90 days in all patients. Avoid use in patients undergoing open heart surgery in association with cardiopulmonary bypass due to excess bleeding. Discontinue use of HES at the first sign of coagulopathy.

  11. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 R. Phillip Dellinger, MD; Mitchell M. Levy, MD; Andrew Rhodes, MB BS3 et al.. • Hemodynamic Support and Adjunctive Therapy (Table 6) • G. Fluid Therapy of Severe Sepsis • We recommend crystalloids be used as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B). • We recommend against the use of hydroxyethyl starches (HES) for fluid resuscitation of severe sepsis and septic shock (grade 1B). (This recommendation is based on the results of the VISEP [128], CRYSTMAS [122], 6S [123], and CHEST [124] trials. The results of the recently completed CRYSTAL trial were not considered.)

  12. TABLE 8. Recommendations: Other Supportive Therapy of Severe Sepsis K. blood Product Administration • Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults (grade 1B). • Not using erythropoietin as a specific treatment of anemia associated with severe sepsis (grade 1B). • Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D). • Not using antithrombin for the treatment of severe sepsis and septic shock (grade 1B). • In patients with severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. We suggest prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D).

  13. Is Albumin Acceptable for…..

  14. Transfusion Trigger

  15. Crystalloid Comparison

  16. Which has more Sodium?

  17. Whether you reach for colloids or crystalloids you still need to have the right measures to guide your volume therapy….

  18. The Challenge Hypoperfusion Organ dysfunction Adverse outcome Edema Organ dysfunction Adverse outcome Complications OPTIMAL Hypovolemic Overloaded VolumeLoad Bellamy MC. Br J Anaesth. 2006;97:755-757.

  19. Fluid Balance and Outcomes Hospital Mortality Cumulative Fluid Balance (day 4) Group Rosenberg AL, et al. J Intensive Care Med. 2009;24(1):35-46.

  20. ResuscitationProtocols Based on Hemodynamic Monitoring Improve Survival and Reduce Morbidity: Goal Directed Therapy (GDT) • Early goal-directed therapy for severe sepsi - Rivers et al. New Engl J Med 345:1368-77, 2001 • Intra-operative goal-directed therapy - Gan et al . Anesthesiology 97:820-6, 2002 • Post-operative resuscitation in high risk patients - McKendry et al. Br Med J 329:258-65, 2004 - Pearse et al. Crit Care 9: R687-93, 2005

  21. Adequate Oxygen delivery? • SvO2: mixed venous oxygen saturation consumption & delivery • C(a-v)O2: arterial-venous oxygen content difference consumption & cardiac output • Lactate: the demand and need of the use of oxygen consumption & cardiac output

  22. SvO2 Diagnostic Algorithm

  23. SvO2vs ScVO2

  24. SvO2vs ScVO2

  25. SvO2vs ScVO2

  26. A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients Hamilton M et al. Anesth Analg 2011;112:1392–402 • 

  27. A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients Other: FloTrac, LidCOplus,
CVP/arterial line, DX2020. Hamilton M et al. Anesth Analg 2011;112:1392–402

  28. Does Pressure = Volume?

  29. Does CVP Predict Fluid Responsiveness? between CVP and circulating blood volume across a wide spectrum of clinical conditions Pooled ROC curve was 0.56 Marik, PE. Chest 2008;134:172-178

  30. Does CVP Predict Circulating Volume? Marik, PE. Chest 2008;134:172-178

  31. Neither CVP or Ppao reflect Ventricular Volumes or tract preload-responsiveness Kumar et al. Crit Care Med 32:691-9, 2004

  32. Physiological limitations • PAOP • LV diastolic compliance • Pericardial restraint • Intrathoracic pressure • Heart rate • Mitral valvulopathy • CVP • RV dysfunction • Pulmonary hypertension • LV dysfunction • Tamponade & hyperinflation • Intravascular volume expansion

  33. Goal Directed Therapy • Stroke Volume (SV) • Stroke Volume Variation (SVV) • Pulse Pressure Variation (PPV) • Cardiac Index (CI) • Velocity Time Index (VTI) • Oxygen Delivery (DO2) • Oxygen Consumption (VO2) • Venous Saturation (SVO2) • Flow time (FTc) • Gastric Mucosal pH (pHi)

  34. Minimally Invasive Cardiac Output • Stroke volume variation and pulse pressure variation – Lithium indicator dilution (LiDCO)
 – Arterial pulse waveform (APCO/FloTrac) • Indicator/Thermodilution
 – Pulse contour (PiCCO)
 – Lithium indicator dilution (LiDCO) – NICO (CO2) • Doppler
 – (EDM, UMSCOM, Hemosonic) – Transesophageal echo • Thoracicelectricalbioimpedence/bioreactance • Pulse oximetry plethysmography (respiratory variation) • Endorganperfusion
– Gastric tonometer, Cytoscan

  35. 2 Parameters for Fluid Responsiveness SVV ∆SV

  36. 1 SVV

  37. Stroke Volume Variation SVmax SVmean SVmin Svmax - SVmin SVV % = SVmean

  38. Plot on the FS Curve >13 Stroke Volume Preload Independent Preload Dependent 0 0 Preload On the Absorption of Fluids from the Connective Tissue Spaces.Starling EHJ Physiol. 1896 May 5; 19(4):312-26.

  39. SVV is Based upon Rhythmic Interaction between heart and lungs SVV doesn’t predict Preload Responsiveness when there isn’t a rhythmic interaction So… common examples Spontaneous breathing Other Rythms - A-Fib Small Tidal Volumes (8cc/kg IBW) *Open Chest & IABP Great… now what?!?!

  40. Change in Stroke Volume 2 ∆SV

  41. ∆ SV * Normal ∆ SV ≤ 10% ∆ SV ≥ 10% HF 0 0 Preload

  42. ∆ SV 250 – 500cc / < 10 2 1 45˚ for 2min

  43. 2 Parameters for Fluid Responsiveness >10% >13% SVV ∆SV

  44. What is “Fast-Track Recovery”? “An interdisciplinary multimodal concept to accelerate postoperative convalescence and reduce general morbidity (including POI) by simultaneously applying several interventions” What are the appropriate choices in constructing fast-track, multimodal protocols? Mattei P. World J Surg. 2006;30:1382-1391.
Person B, Wexner S. Curr Probl Surg. 2006;43:6-65

More Related