Fluid Management in Acute Lung Injury: Strategies for Success

1. Société d’Anesthésie de Charleroi www.sacnet.be

2. 12 Février 2008 Anesthésie et ORL : « quid de l’otologie et de la rhinologie ? «  M. Van Boven JP Lechat

3. Avril 2008 Anti-aggrégants et anti-plaquettaires 14 Juin 2008 Atelier Echo

4. « STRATEGIE PERFUSIONNELE PERI-OPERATOIRE »

5. WET or DRY ?

6. WET or DRY ?

8. WET or DRY ? WEANING Upadya, ICM, 2005 All ICU MV patients Prospective observation Fluid balance

9. WET or DRY ? WEANING Frutos-Vivar, Chest, 2006, 130 Prospective observation All ICU MV patients Fluid balance

10. WET or DRY ? SURVIVAL Alsous, Chest, 2000, 117 Retrospective data collection Septic shock Fluids balance Negative fluid balance predicts survival in septic shock

11. WET or DRY ? SURVIVAL Sakr, Chest, 2005, 128 ALI-ARDS Prospective observation Fluids balance

12. WET or DRY ? SURVIVAL WET or DRY ? Humphrey, Chest, 1990, 97 Retrospective observation ARDS patients Capillary Wedge Pressure The lowest CWP consistent with a adequate CO improves ARDS survival

13. WET or DRY ? SURVIVAL Eisenberg, ARRD, 1987, 136 Prospective data collection All critically ill patients Extravascular lung water

15. Hayes, NEJM, 1994, 330, 1717

16. Qf = K [(Pmv – Ppmv) – s (pmv- ppmv)] Pressions Oncotiques Pressions Hydrostatiques

17. Qf = K [(Pmv – Ppmv) – s (pmv- ppmv)] Pressions Oncotiques Pressions Hydrostatiques

18. Qf = K [(Pmv – Ppmv) – s (pmv- ppmv)]

19. Qf = K [(Pmv – Ppmv)

21. Rivers E et al. N Engl J Med 2001;345:1368-1377

22. Rivers E et al. N Engl J Med 2001;345:1368-1377

23. Rivers E et al. N Engl J Med 2001;345:1368-1377

24. Rivers E et al. N Engl J Med 2001;345:1368-1377

25. Rivers E et al. N Engl J Med 2001;345:1368-1377

27. Martin, CCM, 2005

28. Martin, CCM, 2005 Martin, CCM, 2005

29. Fluid management in ALI. NEJM, 2006, 354, 2564 mean = 24 hours after ALI criteria meeting mean = 43 hours after ICU admission no severe comorbidity -Lung -Kidney -Heart no risk of death within 6 months 11.512 patients screened 10.511 patients excluded

30. Fluid management in ALI. NEJM, 2006, 354, 2564 LIBERAL CVP 10-14 mmHg PAOP 14-18 mmHg CONSERVATIVE CVP <4 mmHg PAOP <8 mmHg

31. Fluid management in ALI. NEJM, 2006, 354, 2564

32. Fluid management in ALI. NEJM, 2006, 354, 2564 Cumulative at day 7 +6992+/-50 -136 +/- 491

33. Fluid management in ALI. NEJM, 2006, 354, 2564

34. Fluid management in ALI. NEJM, 2006, 354, 2564 Hemodynamics ! lower mean arterial pressure lower cardiac index Lung function better injury score better oxygenation index lower plateau pressure lower PEEP

35. Fluid management in ALI. NEJM, 2006, 354, 2564 Hemodynamics lower mean arterial pressure lower cardiac index Lung function better injury score better oxygenation index lower plateau pressure lower PEEP Metabolic function higher oncotic pressure, Hgb, albumine levels higher creatinine values metabolic alkalosis (hypoCl-) electrolyte imbalance (hypoK+, hyperNa+)

36. Fluid management in ALI. NEJM, 2006, 354, 2564 • Conservative strategy • Improves lung function • Shortens duration of MV • Shortens ICU LOS

37. -Initial net positive fluid balance phase -Diuretic phase Alsous, Chest, 2000, 117 « In acute critical illness, treat early to achieve optimal goals and prevent MOF » Kern, CCM, 2002, 30

38. « Fluid management is a matter of timing » Otero, Chest, 2006, 130

39. Je me mouille !