DrYGeorge - Fluid Balance and Organ Dysfunction 2013 Residen

8/10/2019 DrYGeorge - Fluid Balance and Organ Dysfunction 2013 Residen

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FLUID BALANCE AND ORGANDYSFUNCTION IN

PERIOPERATIVE AND

CRITICAL ILLNESS

Yohanes George


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Outline: Fluid accumulation is associated with adverse

outcomes

Pathophysiology of Fluid shifts in critical illness

Relationship of fluid accumulation to multi organ

dysfunction


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FLUID ACCUMULATION IS ASSOCIATED

WITH ADVERSE OUTCOMES

INTRODUCTION


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SUMMARY OF CLINICAL STUDIES SHOWING AN

ASSOCCIATION BETWEEN FLUID BALANCE AND

CLINICAL OUTCOME


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NEGATIVE FLUID BALANCE PREDICTS

SURVIVAL IN PATIENTS WITH SEPTIC SHOCK

Alsous et al: CHEST 2000; 117:1749-1754

Conclusion: These results

suggest that at least 1 day of

negative fluid balance (


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PEDIATRIC PATIENTS: HIGHER PERCENTAGES OF FLUID

OVERLOAD (FO) AT DIALYSIS INITIATION LINKED WITH

INCREASED MORTALITY

Goldstein,

Pediatrics2001

Foland, CritCare Med 2004

Gillespie,Pediatr

Nephrol 2004

Goldstein, KI2005

Foland J et al: Crit care Med 2004 Aug: 32 (8): 1771-5

%FO was defined as total input minus output (up to 7 daysbefore CVVH) for both hospital stay and ICU stay

10%


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IN SEPTIC PATIENTS WITH AKI, FLUID OVERLOAD WAS

ASSOCIATED WITH DECREASED AT 60 DAYS

Payen et al. Crtical Care 2008. 12:R74


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ACUTE RENAL FAILURE, STRATIFIED BY TIME OF

INITIATION OF RENAL REPLACEMENT THERAPY (RRT)



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IN SEPTIC PATIENTS WITH AKI, FLUID OVERLOAD WAS

ASSOCIATED WITH DECREASED SURVIVAL AT 60 DAYS


ARF (SOFA Score) = Cr > 3.5 mg/dl or UO < 500 mL/day

Early ARF = Occuring within 2 days of ICU admission

Late ARF = Occuring more than 2 days after ICU admission


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EFFECT OF FLUID OVERLOAD IN CRITICALLY ILL

PATIENTS WITH AKI

618 critically ill patients with AKI 396 patients required dialysis

PICARD study Prospective cohort

5 teaching U.S. hospital Between 1999 and 2001

Hypothesis:

Fluid overload in

adult AKI

patients treated

with dialysis

would

independently

contribute to

adverse

outcomes

PICARD Data J Bouchard et al Kidney Int, 2009


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METHODS

Percentage of FO/body weight ( FO)

FO = (daily (total input (L)

total output (L) x 100

body weight (kg)

Data analysis for fluid overload from 3 days beforeconsultation until hospital discharge



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RESULTS

Survival Non-survival P

Mean %FO at

dialysis initiation

8.8% 14.2% 0.01

Adjusted OR for death with %FO >10% at dialysis initiation:

2.07 (95% CI 1.27-3.37)



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INFLUENCE OF FLUID ACCUMULATION ON

MORTALITY



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DIALYZED PATIENTS: KAPLAN-MEIER SURVIVAL

ESTIMATES BY FLUID OVERLOAD STATUS AT DIALYSIS

INITIATION



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DURATION OF FLUID OVERLOAD



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EFFECT OF CORRECTION OF FLUID OVERLOAD


FO < 10 FO > 10 P

Survival rate 65% 44% 0.004

Survival Non-survival P

Mean %FO at

dialysis cessation

13.0% 22.1% 0.004

Adjusted OR for death with %FO > 10% at dialysis cessation: 2.52

(95% CI 1.55-4.08

Effect of fluid overload on survival when FO > 10

at dialysis initiation:


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INFLUENCE OF MODALITY ON FLUID

OVERLOAD



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SUMMARY OF RESULTS

%FO > 10% at dialysis initiation:

2 fold increase in mortality

Duration and correction of fluid overload

influences mortality rates

%FO > 10% at dialysis cessation:

2.5 fold increase in mortality

Modality choice influences fluid management



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PATHOPHYSIOLOGY OF FLUID

SHIFT IN CRITICAL ILLNESS


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The Third Space The Old Paradigm

trapped

The third space in its

traditional interpretation is a

functionally separated part ofthe extra-cellular

compartment which cannot

be localised, but primarily

consumes fluid in the

perioperative context.

It is currently no more than a

myth to explain the otherwise

apparently unexplainable

perioperative fluid shifting


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Classic

perioperative fluid management

Deficits: Estimate Preop NPO (hourly maintenance x duration) Preop bowel preparation (1-1.5L) Preop blood loss (trauma) or fluid loss (burns) Typically replaced over first 2-4 hours

Maintenance: (4-2-1 rule): 4 ml/kg/hr for first 10 kg of body weight 2 ml/kg/hr for 2nd 10 kg of body weight 1 ml/kg/hr for each kg of body weight above 20 kg

3rdSpace: Third space2-10 ml/kg/hr

Blood loss: 3 to 1 ratio of crystalloid to EBL 1 to 1 for colloid or blood

(or hypertonic saline)


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TRADITIONAL CONCEPT OF PERIOPERATIVE

FLUID LOADING

Chappell D et al. Anesthesiology 2008;109:723

Median blood volume status of 13 patients

with ovarian cancer before and after major

abdominal surgery, receiving a standard

infusion regimen (crystalloids: approximately

12 ml/kg/h; blood loss replaced 1:1 with

colloid)


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5100

3800

2000

1700

750

4621

5800

2450

1. Preoperatively fasted

2. Insensible lost

3. 3rdspace

4. Vasodilatation of anesthesia

Direct blood volume

measurements (double-label

technique)

Fluid shift

Where did they

go?..interstitial


TRADITIONAL CONCEPT OF PERIOPERATIVE

FLUID LOADING


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Perioperative weight gain

increases with the

perioperative amount of

infused crystalloids

IMPACT OF TRADITIONAL CONCEPT OF FLUID

LOADING


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THIRD SPACE: FACT OR FICTION?

M. Jacob et al. Best Practice & Research Clinical Anaesthesiology 23 (2009) 145157

1. The third-space fluid losses have never been measured directly, and the

actual location of the lost fluid remains unclear

2. Most of the data do not support the existence of a third space.


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FLUID DYNAMICS ACROSS THE CAPILLARY BEDS

The classicalStarling principles of vascular barrier functioning and capillaries on inward-directed colloid

osmotic pressure gradient is opposed to an outward-directed hydrostatic pressure of fluid and colloids. The

thick arrows symbolize the two schematically opposing forces across the vascular wall, the small one the

small net filtration outwards assumed according to this model.

Jv, net filtration; Kf, filtration coefficient; Pc, capillary hydrostatic pressure; Pi, oncotic pressure in the

interstitial space; Pi, hydrostatic pressure in the interstitial space; Pc, oncotic pressure in the vascular lumen;

Pc, hydrostatic pressure in the vascular lumen; s, reflection coefficient


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SCHEMATIC REPRESENTATION OF CAUSES OF

HYPOALBUMINAEMIA IN CRITICALLY ILL PATIENTS

J.-L. Vincent, Best Practice & Research Clinical Anaesthesiology 23 (2009) 183191


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RESPONSE TO FLUID ADMINISTRATION


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Svensn et al., Anesthesiology (1997), 87

Ki V V

KbKr

(V- V)

V

V= expandable space of volume

V= target volume

Ki = constant fluid infusion rate

K

b

= basal rate of fluid elimination

(perspiration, basal diuresis)

Controlled rate of fluid elimination

proportional by a constantKr

to

the relative deviation ofvfromV

One-compartment Volume of Fluid Space Model


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Svensn et al., Anesthesiology (1997), 87

Two-compartment Volume of Fluid Space Model

KiV

1

V

1

Kb Kr(V1- V1)

V1

KtV

2

V

2

Secondary fluid space

The net rate of fluid exchange between the 2 compartments is

proportional to the difference in relative deviations from the target

volumes by a constant Kt

capillary cell


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colloids

crystalloid:75-80% leaves vasculature after 20 minutes

5% dextrose

capillary

membranecell

membrane

o Clearance of crystalloid during anesthesia and

surgery is 10-20 of that in awake volunteers

oCrystalloid leaves the plasma space, equilibrates

with interstitial space after 20-30 min

Hahn RG. Anesth Analg 2007; 105-304

Plasma

Volume 4.3%

Interstitial

fluid 15.7

VOLUME KINETICS FOR INFUSION CYSTALLOID IN

HEALTHY VOLUNTEER AND ANESTHESIA


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VOLUME KINETICS FOR INFUSION FLUIDS

Hahn GR, Anesthesiology 2010


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VOLUME KINETICS FOR INFUSION FLUIDS IN

DISEASES


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VOLUME KINETICS FOR INFUSION OF

CRYSTALLOID DURING SURGERY AND PRE-

ECLAMPSIA


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VOLUME EFFECT OF CRYSTALLOID


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WHAT ABOUT COLLOID?


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According classical starlings principle, infused iso-oncotic colloids do not change the intravascular

colloid osmotic pressure and cannot cross the

barrier.

Therefore, they should remain theoretically by 100%

within the circulatory space

INTRAVASCULAR VOLUME EFFECT OF COLLOID


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Normovolemia/

hemodilution

Volume loading

Hypervolemia

Not only crystalloids are shifted out of the

vasculature, but also colloids

INTRAVASCULAR VOLUME EFFECT OF COLLOIDS

IN HEALTH AND DISEASES


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Fluid Dynamics Across Capilarry Beds

Revised StarlingPrinciple

M. Jacob et al. Best Practice & Research Clinical Anaesthesiology 23 (2009) 145157


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THE ENDOTHELIAL GLYCOCALIX

Healthy vascular endothelium coated by endothelial glycocalyx a

layer of membrane-bound proteoglycans and glycoproteins.


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THE ENDOTHELIAL GLYCOCALIX

Glycocalyx affect endothelial permeability.

Prevent leukocyte and platelet adhesion.

Decreases inflammation. Bounds plasma proteins and fluids.

700 ~ 1000 mL of non-circulatoryplasma

fixed within.

Maintains oncotic gradientdespiteintravascular and extravascular equilibration.

Jacob M. et al: The endothelial glycocalix affords compatibility of starlings

principle and high cardiac interstitial albumin level. Cardiovasc Res 2007; 73:575-

86


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Levick J. R. J Physiol;2004;557:704-704

STARLING PRINCIPLE NEEDS UPDATE


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POSSIBLE PERIOPERATIVE FLUID MANAGEMENT

TRIGGERS FOR SHEDDING OF THE ENDOTHELIAL

GLYCOCALYX


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hyperglycemia

reperfusion injury

oxidized-LDL

Mechanical stress,

Endotoxin exposure,

Mediator SIRS, and ANP

(Atrial Natriuretic Peptide)Intact glicocalix Loss glicocalix


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Response to Volume Expansion

Volume expansion

Intake of salty food and fluids

excessive IV fluids / hypervolemia

Right atrial distension

increase venous capacitance

secretion of Atrial Natriuretic Peptide (ANP)

increased renal NaCl and H2O excretion

vasodilation

inhibit renin secretion

inhibit aldosterone secretion

Pouta AM: Effect of intravenous fluid preload on vasoactive peptide


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secretion during Caesarean section under spinal anaesthesia.

Anaesthesia 1996: 51.128-132

Responses in the concentrations of ANP in central () and peripheral () veins before and

during spinal anaesthesia for Caesarean delivery after a volume load of 21000 ml of

crystalloid solution (a) and 500 ml of colloid + 1000 ml of crystalloid solution (b). **p 20

All patients

General surgery

Cardiac surgery

* of patients studied that gained weight

*

*

*


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High dose Ringer

s Lacate

Voluven

Low dose Ringer

s Lactate

Voluven


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Post-operative complications


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TAKE HOME MESSAGES


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Type 2 shift - pathologic shift,result of 2 iatrogenic

problems.

Surgical:

Endothelial damage due to mechanical stress, endotoxin exposure,

ischemia-reperfusion injury and SIRS.

Anesthesiolgic:

Acute hypervolemia...!!!! Atrial Natriuretic Peptide

Perioperative fluid shifting


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Preserve endothelial glycocalyx to inhibit type 2

Pathologic shift.

Inflammatory mediators, stress, ischemia-reperfusion injury

can hardly be avoided, minimally invasive surgery

Maintaining vascular normovolemia.

Key to protection of endothelial glycocalyx

Prevent interstitial edema.

Perioperative fluid shifting


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The intravascular deficit after fasting is usually low.

Basal fluid loss via insensible perspiration

approximately 0.5 mL/kg/hr,

Extending to only 1 mL/kg/hr during

major abdominal surgery.

APPROACH TO FLUID MANAGEMENT


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Minimize type 1 shifting

Use crystalloids only when replacing urine production andinsensible perspiration.

Use colloids or blood products for substitution of acute

blood loss

Minimize type 2 shifting

Goal-directed method with available parameters

Conservatively to avoid acute hypervolemia

Use colloids instead of crystalloids.

APPROACH TO FLUID MANAGEMENT


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TERIMA KASIH

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DrYGeorge - Fluid Balance and Organ Dysfunction 2013 Residen