Hồi sức dịch - Joshua Solomon, md

• Capillary refill is LIKELY better to follow for resuscitation than lactate.[r]

Fluids in Critical Care

JOSHUA SOLOMON, MD ASSOCIATE PROFESSOR OF MEDICINE

NATIONAL JEWISH HEALTH

DENVER, CO

◦ Crystalloid, colloid and balanced solutions

• When to give more?

◦ Goals of resuscitation

Dellinger RP Cardiovascular management of septic shock Crit Care Med 2003;31:946-955.

Timing of fluid

Study Setting EGDT Usual Care

Study Setting EGDT Usual Care EGDT Usual Care

Sepsis Resuscitation Volume

• There are no randomized trials looking at :

◦ Cardiac output before and after 30 cc/kg

◦ Rate or amount of fluid administration in initial

Lee et al Chest 2014

Early Fluid in sepsis….

Vincent et al Crit Care Med 2006

Late Fluid in sepsis….

Bouchard et al Kid Int 2009

7 Day Fluid Balance Conservative Liberal

FACTT Investigators, NEJM 2006

Late Fluid in Sepsis

• Enrolled late in resuscitation (>6hr)

• Net 7L balance at baseline

• Measured response to

500cc NS challenge

• Limited CI response in all patients

Nunes et al Ann Int Care 2014

Type of Fluid

NEJM 2004;350: 2247-56

• 6997 patients in 167 hospitals

• Patients who met criteria to

receive fluid got either 4%

albumin or normal saline

NEJM 2014;370: 1412-21

• 1818 patients in 100 ICUs

• Patients who met criteria to

receive fluid got either 4%

albumin or normal saline

• Received 20% albumin+

crystalloid or crystalloid alone

• No difference in survival at 28

or 90 days

2018 update

• Early fluid critical

• 30 ml/kg fluid within first hour

• Use crystalloid

◦ No benefit to colloid/albumin

◦ Albumin more expensive

• The data are limited for the resuscitation amount

• Be careful of positive fluid balance

Saline vs Balanced Solution

Animal Studies

• Chloride infusion causes renal vasoconstriction,

decreased renal perfusion and GFR

• Effect doubles with volume depletion

Humans

• 20 healthy males, isotonic solution caused

decreased renal cortical tissue perfusion on MRI

• Balanced solution did not

Wilcox et al J Clin Invest 1983 Chowdhury et al Ann Surg 2012 Slide provided by Sarah Sanghavi MD

Raghunthan et al, Crit Care 2014 Yunos et al, JAMA 2012

Zhang et al, BMC Neph 2013

• Cluster-randomized, multiple crossover trial

• 5 ICUs at Vanderbilt in Nashville, TN USA

Outcome Balanced

Crystalloids

Saline Odds Ratio P value

Primary Outcome

Major adverse kidney event 1139 (14.3%) 1211 (15.4%) 0.90 (0.82 to 0.99) 0.04

In hospital death before 30d 818 (10.3%) 875 (11.1%) 0.90 (0.80 to 1.01) 0.06 New renal replacement therapy 189 (2.5%) 220 (2.9%) 0.84 (0.68 to 1.02) 0.08 Final cr > 200% 487 (6.4%) 494 (6.6%) 0.96 (0.84 to 1.11) 0.60

Secondary Outcome

In hospital death before 60d 928 (11.7) 975 (12.4) 0.92 (0.83 to 1.02) 0.13

Mean renal replacement free days 25+/- 8.6 24.8 +/- 8.9 1.11 (1.02 to 1.20) 0.01

NNT = 91

• No difference in hospital-free days

• Lower incidence of major adverse kidney events at 30 days

4.7% vs 5.6%, OR 0.82, 95%CI 0.70 to 0.95, P=0.01

NEJM 2018;378:819-28

When to give more

When to give more fluids?

◦ Pulse Pressure Variation

◦ Stroke Volume Variation

• Other

◦ Central Venous Oxygen Saturation

◦ Passive Leg Raise

◦ lactate

CVP for assessing volume status

Marik P Chest 2008;134(1):172-178.

Shippy CR Crit Care Med 1984 12:107-112.

Pooled area under ROC curve 0.56

CVP for predicting volume responsiveness

CVP for assessing volume status

Static Indices

Dynamic Indices

• 28 ICUs, 424 patients with septic shock

• Resuscitation at normalizing capillary refill or normalizing or decreasing lactate by 20% within

8 hours

• Outcome - all cause mortality 28 days

Hernandez et al, JAMA 2019

Death within 28 days - 34.9% CR vs 43.4% lactate - p=0.06

• Early volume is good, late volume (and

cumulative volume balance) is bad

• For sepsis resuscitation, balanced fluids are

better

• Dynamic indicators are better to assess volume status

• CVP is worthless

• Capillary refill is LIKELY better to follow for

resuscitation than lactate

Thank you!