10 - P.van Der Linden - The Role of Artificial Colloids in Paediatric Fluid Resuscitation

8/2/2019 10 - P.van Der Linden - The Role of Artificial Colloids in Paediatric Fluid Resuscitation

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TheThe RoleRole ofof ArtificialArtificial ColloidsColloids inin PediatricPediatric

uu esusc a onesusc a on

,

CHU Brugmann-HUDERF, Free University of Brussels


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Intraoperative: the 4-2-1 rule with isotonic crystalloids; glucose onlyfor high-risk populations (i.e. neonates)

Immediate postop period: 2/3 of the calculated volume with isotonic

crystalloid. Subsequent fluids: Glu 5% NaCl 0.45%

From Bailey AG et al. Anesth Analg 110:375-90, 2010.


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,

monitored goal-directed combination of both crystalloid andcolloid therapy, similar to that occurring in adult surgical patients

Rather than extrapolating adult and animal data to asuscep e popu a on, researc s ou e rec e owar

safety and outcomes of synthetic colloid use in children

From Bailey AG et al. Anesth Analg 110:375-90, 2010.


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Parameters Predicting Fluid Responsiveness in

Postoperative Cardiac Surgery Children

children after VSD repair

Res irator variations of transthoracic echo-derived

parameters:Aortic blood flow velocity (Vpeak)

10 ml/kg HES 130/0.4 over 20min

Responders:stroke volume increase >15%

0,83 (0,61-1,00): p=0.01

0,85 (0,69-1,00): p=0.01

0,48 (0,22-0,73) p=NS

From Choi DY et al. Pediatr Cardiol 31:1166-70, 2010.


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Colloids In Pediatric Sur ical Patients

Studies are few in number and small in size

Albumin has been considered the gold standard for

maintenance of colloid osmotic pressure in infants and

plasma expander in this population

From Schwartz U. Anaesthesist 48:41-50, 1999.From Soderlind M et al. Paediatr Anaesth 11:685-9, 2001.


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HES 130/0.42/6:1 For Perioperative

Plasma Volume Replacement in Children

From Smpelmann R et al. Pediatr Anaesth 18:929-33, 2008.


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HES 130/0.42/6:1 For Perioperative

Plasma Volume Replacement in Children

No serious adverse drug reactions were observed

From Smpelmann R et al. Pediatr Anaesth 18:929-33, 2008.


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Perioperative Volume Replacement in Children

Balanced Vs Unbalanced HES 130/0.42/6:1

Unbalanced: 10 5 ml/kg (N=249)

Balanced: 9 7 ml/kg (N=147)

No serious adverse drug

reactions were observed

Smpelmann R et al. Pediatr Anaesth 20:100-4, 2010.


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Effects of HES 130/0.4/9:1 on Clot

Formation in Children

Prospective randomized study - non cardiac surgery (N=42)

Children (3-15 kg) assigned to receive 15 ml/kg of 5%a um n, mo e u ge a n or . :

Changes after gelatin nearly equal to albumin Changes in coagulation time, clot formation time, angle, clot

pronounced after HES

From Haas T et al. Anaesthesia 62:1000-7, 2007.


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Effects of HES 130/0.42/6:1 on Clot

Formation in Children

Prospective randomized study all surgeries (N=50)

Children (3-50 kg) assigned to receive 10 ml/kg of 4%mo e u ge a n or . :

Clot formation time Maximum clot elasticity

No significant difference between gelatin and HES

From Osthaus WA et al. Acta Anaesthesiol Scand 53:305-10, 2009.


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Effects of HES 130/0.4 on Clot Formation in

Children

Different populations (age surgical procedures) ?

Different pharmacokinetic properties (C2/C6 ratio) ?

Haas T et al. Anaesthesia 2007 vs Osthaus WA et al. Acta Anaesthesiol Scand 2009.


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HES130/0.4/9:1 Vs. Albumin in Young

Children Undergoing Non-cardiac SurgeryPros ective randomized o en multicenter stud

Children < 2 years undergoing non cardiac surgery (N=82)

6% HES 130/0.4/9:1: 16.0 ml/kg.

From Standl T et al. Eur J Anaesth 25:437-45, 2008.


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HES130/0.4/9:1 Vs. Albumin in Young

Children Undergoing Non-cardiac Surgery

6% HES 130/0.4/9:1: 16.0 ml/kg

5% Human albumin: 16.9 ml/kgComparable hemodynamic profile and COP

From Standl T et al. Eur J Anaesth 25:437-45, 2008.


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HES130/0.4 in Children Undergoing Surgery

Relatively low volume of starch infused

Low bleedin risk sur er


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Albumin vs Crystalloids for Pump Priming

in Cardiac Surgery

Meta-analysis of controlled trials (adult and pediatric patients):21 studies, 1346 patients

Albumin prime reduces:

The on-bypass drop in platelet count

pooled WMD: -23,8 10 /L [-42,8 to -4,7 10 /L]The colloid oncotic pressure decline

- - -

9 9

, , ,

The on-bypass positive fluid balance

pooled WMD: -584 ml [-819 to -348 ml]e pos opera ve we g ga n

pooled WMD: -1,0 kg [-0,6 to -1,3 kg]

From Russel JA et al. J Cardiothorac Vasc Anesth 18:429-437, 2004.


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um n: a s e v ence o n ca ene

=

No quantitative meta-analysis

In cardiac surgery, albumin vs crystalloid administration:Higher colloid osmotic pressure

Reduced ulmonar oedema

Greater hemodilution

n y pe a r c s u es: pa en s...

From Haynes GR et al. Eur J Anaesthesiol 20:771-793, 2003.


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Hetastarch vs Albumin

for Postoperative Volume Expansion

Randomized double-blind

study (N=47)

19

Final PT (s)

Children: 1 - 15.5 years

Volume expansion "as 17

18

clinically indicated"- 5% albumin: 20.5 9.5 ml/kg- 6% hetastarch: 17.9 9.0 ml/kg

16

Clinical bleeding : NS14

0 10 20 30 40

13

From Brutocao D et al. J Cardiothorac Vasc Anesth 10:348-351, 1996.


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Fluid Management in Pediatric Cardiac Surgery:

os - ypass

Prospective randomized study

Post-bypass fluids (10 ml/kg)

20

ml/kg (0-24 h)

-

- HES 130/0.4 (N=21) 15

an ar ze antransfusion policy 10

HES infusion prolonged INR

(but not aPTT)

5

in comparison to FFP Blood loss RBCs FFP

FFP HES

From Chong Sung K et al. Acta Anaesthesiol Scand 50:108-111, 2006.


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.Pros ective randomized observer-blinded stud N=119

Fluid management: pre, per and postop: max 50ml/kg.d- um n group =- HES 130/0.4 6% group (N=60)

First objective: calculated blood loss

The stud was desi ned to demonstrate the e uivalence between 6% HES 130/0.4

and 4% albumin regarding the calculated blood loss. Equivalence was defined as

35 ml of pure RBCs. Assuming a SD of 62 ml, a total number of 55 patients in each

rou had to be included to obtain a ower of 0.8 and a = 0.05

From Hanart C et al. Crit Care Med 37: 696-701, 2009.


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.Pros ective randomized observer-blinded stud N=119

Fluid management: pre, per and postop: max 50ml/kg.d- um n group =- HES 130/0.4 6% group (N=60)

First objective: calculated blood lossSecondary objectives:Allogeneic blood exposure

Intra-operative fluid balance

From Hanart C et al. Crit Care Med 37: 696-701, 2009.

Non cyanotic disease


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Non-cyanotic disease(CPB circuit: Dideco Inc, Mirandola, Italy)

.

Children stratified accordin to wei ht and the resenceor the absence of a cyanotic disease

yano c seaseWeight Oxygenator Prime volume

(ml)Albumin group HES group

.4.7 12.0 kg Lilliput 2 550 10 1412.0 20.0 kg EOS I 750 5 520.0 35.0 kg EOS II 850 1 2

Non-cyanotic disease

Weight Oxygenator Prime volume

(ml)

Albumin group HES group

< 4.7 kg Lilliput 1 350 6 34.7 12.0 kg Lilliput 2 550 21 2112.0 20.0 kg EOS I 750 7 6

20.0 35.0 kg EOS II 850 4 5

(CPB circuit: Dideco Inc, Mirandola, Italy)


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.


Transfusion tri er

On-bypass: 20% hematocritPost-bypass: 24% hematocrit

Additional fluids

- 'ICU: 4% albumin


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Transfusion tri er

On-bypass: 20% hematocritPost-bypass: 24% hematocrit

Additional fluids

- 'ICU: 4% albumin


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.

4% albumin 6% HES 130/0.4

Age (mo)[range]

27,5 35,0[ 1,5 - 160 ]

33,7 37,9[ 1 - 162 ]

Preop weight (kg)[range]

9,9 7,2[ 3,7 - 35,0 ]

10,8 7,2[ 3,3 - 33,6 ]

Preop RBC mass (ml) 292 231 322 225

CPB time(min) 105 40 112 35

Aortic clamp (min) 51 26 59 34


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120

60

80 40

60

20

40 20

0 0

.


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Posto cristalloids ml/k Posto colloid ml/k

80 40

60 30

40 20

20 10

0 0



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.

60

120

-

40 80

60

20

20

40

0 0

.


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.

80

80

60 60

40 40

20 20

0 0

.


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.

120

80

20

60

20

40

00

.


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.

120

60

80 40

p


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Perop fluid in (ml/kg) Perop fluid out (ml/kg) Perop fluid balance (ml/kg)

200 200

60

p


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Albumin vs HES 130/0.4

in Pediatric Cardiac Surgery

Calculation of glomerular filtration rate (GFR) according to Schwartz GJ et al.

Pediatrics 1976; 58:259-263

From Hanart C et al. Eur J Anaesth abstract, 2009.


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ICU LOS (d)[range]

5,7 5,4[ 2 - 34 ]

6,8 6,1[ 2 - 28 ]

Hospital LOS (d)[range]

15,6 11,4[ 2 - 68 ]

16,3 9,4[ 6 - 52 ]

Postop weight (kg)[range]

9,9 7,0 10,8 7,0

Wei ht difference k - 0 03 0 91 -0 06 1 08


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Albumin vs HES 130/0.4

n e atr c ar ac urgery

Limitations of the study Effects on long term outcome ?

-

Not a pure double-blind comparison


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Colloids in Pediatric Cardiac Surgery:

e uture

HES 130/0.4 versus 5 % albumin Prospective randomized double-blind study (N=60)

Safety analysis up to 30-day postop

Saline versus balanced HES 130/0.4 Prospective randomized double-blind study

First objective: calculated blood loss

Secondary objectives: renal function, inflammatory response


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HES 130/0.4 in Pediatric Surgery Patients:

onc us ons

HES 130/0.4 may represent an interesting alternative

to albumin in children undergoing surgery, in particular

profile of this 3rd generation of HES

Next step: to evaluate the potential benefit of a

balanced fluid replacement strategy


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Thank You For Your Attention


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Colloids: Natural Vs. Synthetics

4-5% 3-4%

6%

Volemic ex ansionimmediate (%)

duration (h)

100

4

70 - 90

2 - 3

100-120

4

allergyhemostasis

+

++

rena unc on

Max daily dose (ml/kg) no no 50

Price (Euros) 40 4 9-12

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10 - P.van Der Linden - The Role of Artificial Colloids in Paediatric Fluid Resuscitation