salon a 13 kasim 11.30 12.45 emre karakoç-i̇ng
TRANSCRIPT
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Do We Still Need Colloids for Fluid Rescucitation?
Dr. Emre KarakoçÇukurova Üniversitesiİç Hastalıkları Yoğun Bakım Bilim Dalı
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Resusitasyon Sıvıları Crystaloids vs Colloids
Albumin; preferred colloid Cost Might increase mortality in raumatic brain injury
HES More RRT High mortality ?
Balanced Crystaloid solutions 9% NaCl; metabolic asidosis and AKI Hypertonic salt solutions
Safety? N Engl J Med 2013;369:1243-51.
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Grading System
1- Strong recommendation Highly recomended
2- weak recommendationWe recommend
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Fluid Resuscitation Albumin in the resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystaloids (grade2C)
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Fluid Resuscitation
Against the use of hydroxyethyl starches for the fluid resuscitation of severe sepsis and septic shock(Grade 1B)
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SAFE Study
6045 patients 4% albumin vs %9NaCl
BMJ 2006;333:1044.
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1218 patients 603 albumin 4% and 615 SF
SAFE Study - SEPSİS
Intensive Care Med (2011) 37:86–96
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SAFE Study – SEPSIS – ORGAN faılure
Corrected Mortality Ratio: ALBUMIN vs. SF:
P= 0.03 odds ratio: 0.71; 95% CI: (0.52–0.97)
Intensive Care Med (2011) 37:86–96
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Colloids Hydroxyethyl starch solutions (HES)
6%, molecular weight 130 kDMax. Daily dose 30 – 50 ml/kg/day
Gelatin Dextran solutions
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VISEP Study 537 severe sepsis patients (275 Ringer
Lactate - 262 HES) HES…. 10% > 200kD
N Engl J Med 2008;358:125-39.
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28 mortality mortalite: no differenceRL: 66/274 (24.1 %). HES: 70/262 (26.7 %)
90 day mortality: no differenceRL: 93/274 (33.9 %). HES: 107/261 (41.0
%) SOFA Scores
More AKI with HES (p < 0.001)More coagulation problems with HES
(p=0.02) Renal replasman teraphy
RL: 51/272 (18.8 %). HES: 81/261 (31.0 %)
VISEP Study
N Engl J Med 2008;358:125-39.
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VISEP Study
Renal replasman teraphy and 90 day mortality are associated with cumulative HES doses (P<0.001 and P = 0.001sırası ile) fakat Ringer Laktat ile ilişkili değildir (P = 0.11 and P = 0.31, respectively).
N Engl J Med 2008;358:125-39.
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Low Molecular Weight HES.CHEST Study
7000 ICU patients 3315 HES, 3336 SF
N Engl J Med 2012;367:1901-11.
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More RRT with HESMore transfusionMore side effects
Low Molecular Weight HES.CHEST Study
N Engl J Med 2012;367:1901-11.
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HES (130/0.42) vvs Ringer Acetate Severe Sepsis (6S Study) 800 patients HES maks. 33
ml/kg 400 HES - 400
RA No difference
28 mortality Number of
organ failure
Volume 0
10
20
30
40
50
60
90 günlük mortalite RRT gereksinimi
Per
cen
t (%
)HES
RA
Significant DifferencesP=0.03
P=0.04
N Engl J Med 2012;367:124-34.
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Protocol violation28 patients in HES group and 41 patients in
RA group (More fluid then maximum daily doses)
No Criteria to start RRT Fluis volume; Acording to clinical evaluation..
HES (130/0.42) vvs Ringer Acetate Severe Sepsis (6S Study)
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HES (130/0.4) vs. SFCRYSTMAS Study 186 sepsis patients 100 HES and 96 SF Hemodynamic targets
MAP ≥ 65 mmHg and at least 2 of the 3 criteria for 4 hours
1-CVP 8 – 12 mmHg 2-Urine output > 2 ml/kg 3-ScvO2 ≥ 70 %
Guidet et al. Critical Care 2012, 16:R94
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Max. fluid: 50 ml/kg 1st day and 25 ml/kg until 4th day.
NS
HES (130/0.4) vs. SFCRYSTMAS Study
Guidet et al. Critical Care 2012, 16:R94
P=0.018
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No difference in AKI No difference in 28 days mortality
HES %31 ve SF %25.3 (p>0.05)
HES (130/0.4) vs. SFCRYSTMAS Study
Guidet et al. Critical Care 2012, 16:R94
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So …Which Fluid ?
As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.
The Cochrane Library 2013,
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Last words are not spelled yet…
Keep calm and follow the guidelines…
Conclusion