Volumentherapie bei Sepsis & MODS: Was bleibt noch übrig?

Transkript

1 Volumentherapie bei Sepsis & MODS: Was bleibt noch übrig? A.Valentin Allgemeine u. Internist. Intensivstation II. Med. Abt., Rudolfstiftung, Wien

2 Was bisher geschah Kristalloid vs. Kolloid unklar Albumin Revival? HES in Mißkredit Pulmonaliskatheter obsolet? Statische hämodynamische Parameter wertlos? Dry is better than wet? Early goal directed therapy in Diskussion Sepsis Guidelines Update 2008

3

4 Was? Wann? Wieviel? Wie lange? Wie schnell? Welches Ziel?

5 Nguyen HB, Ann Emerg Med 2006

6 Su F, Shock 2007 CI SV MAP SVR

7 Parker MM, Ann Intern Med 1984

8 Dellinger RP, Crit Care Med 2003

9 Akuter Patient: Hypovolämisch Suspekte Sepsis ICU-Patient (bereits infundiert): Profitiert von weiterer Volumsgabe Risiko durch weitere Volumsgabe Good ventricular function Bad ventricular function

10 Not one size fits all

11 Was? Wann? Wieviel? Wie lange? Wie schnell? Welches Ziel?

12 A comparison of albumin and saline for fluid resuscitation in the intensive care unit Finfer S, NEJM 2004

13 VISEP Brunckhorst et al., NEJM 2008 Graph from Wiedermann CJ, BMC Emergency Medicine 2008

14 Elektrolytgehalt von Kristalloiden 0,9 % NaCl Ringerlösung Fresenius Ringerlaktat Fresenius Na (mmol/l) ,2 131 K (mmol/l) 4,0 5,4 Cl (mmol/l) ,7 111,8 Ca (mmol/l) ,85 Laktat 28,3 ph ,5-6,3 Osmolarität (mosmol/l) Ringer Ringer (Hersteller abhängig) Ringerlaktat!!!!!!!

15

16

17

18 Was? Wann? Wieviel? Wie lange? Wie schnell? Welches Ziel?

19 Septic shock is a (short) pause in the act of dying

20 EGDT vs standard Abolute Risk Reduction (mean) 20 ± 13 % EGDT vs standard Relative Risk Reduction (mean) 46 ± 26 % Rivers E, Curr Opin Anaesthesiol 2008

21 Early goal-directed therapy in the treatment of severe sepsis and septic shock Rivers E et al, NEJM 2001 Treatment 0-6h Total fluids (ml) Standard therapy EGDT P value Red-cell transfusion (%) Standard therapy EGDT P value Any vasopressor (%) Standard therapy EGDT P value Dobutamine (%) Standard therapy EGDT P value 3499± ±2984 < < <0.001

22 Impact of components of the EDGT bundle 330 pts., prospective observational study on quality indicators Nguyen HB, Crit Care Med 2007

23 van den Beest PA, Crit Care 2008 The Rivers study does not reflect European reality?

24 O2 Zufuhr oder non-invasive Beatmung oder Intubation und lungenprotektive Beatmung Sedierung und Analgesie Arterielle Kanüle und ZVK Optimierung des ZVD < 8mmHg Volumenersatz kristallin/kolloidal 8-12 mmhg Optimierung des MAP <65 mmhg Vasopressoren Noradrenalin 65/ 90 mmhg Nein Optimieren der Zentralvenösen Sättigung >70% <70% Zielgrössen erreicht? Hk <30% Hk >30% Erythrozyten Konzentrate Inotropika Dobutamin

25 O2 Zufuhr oder non-invasive Beatmung oder Intubation und lungenprotektive Beatmung Sedierung und Analgesie Arterielle Kanüle und ZVK? Optimierung des ZVD < 8mmHg Volumenersatz kristallin/kolloidal 8-12 mmhg Optimierung des MAP <65 mmhg Vasopressoren Noradrenalin 65/ 90 mmhg? Optimieren der Zentralvenösen Sättigung >70% Hk <30% Erythrozyten Konzentrate <70% Hk >30% Inotropika Dobutamin Nein Zielgrössen erreicht?

26 96 septic patients Osman D, Crit Care Med 2007 Volume challenge: 500 ml HES 6% 43% responder = CI increased 15% CVP < 8 mmhg PPV 51% NPV 65% CPV < 12 mmhg PPV 47% NPV 67% PAOP < 11 mmhg PPV 54% NPV 74%

27 Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. After 3l saline Kumar A, Crit Care Med 2004 After 3l saline

28 Zentral-venöse Sauerstoffsättigung S v(c) O 2 (%) Zentralvenös Gemischt venös Zielbereich S v(c) O 2 reflektiert klinisch online die globale Gewebssauerstoffbalance

29 O 2 EXTRAKTION? OXYGEN EXTRACTION Cell O 2 Arterial Inflow (CO) capillary O 2 O 2 O 2 O2 O 2 O 2 O2 Venous Outflow (CO) VO 2 = CO x (CaO 2 -CvO 2 ) (Adapted from the ICU Book by P. Marino)

30 Relationship between pulmonary hydrostatic pressure and lung edema formation Calfee CS, Chest 2007; Staub NC, Chest 1978

31 CVP FACCT Wiederman NEJM 2006 PAOP

32 ARDS Network Fluid and Catheter Treatment Trial (FACTT)

33 FACCT Wiederman NEJM 2006

34 FACCT Translation into clinical practice Patients in shock MAP < 60 mmhg Vasopressors (except dopamine < 5µg/kg/min) Free fluid management 71% had pneumonia or sepsis as source of ALI Late phase Mean time from admission to protocoll: 43 hours Fluid balance Liberal: plus 1liter/day Conservative zero over the first 7 days Pats with need for dialysis exluded

35 ARDS network FACCT Patients in shock: Same results with restriced and liberal fluid management

36 VISEP Brunckhorst et al., NEJM 2008

37 Liberal vs. conservative vasopressor use to maintain mean arterial blood pressure during resuscitation of septic shock: an observational study. Subramanian S, Int Care Med l in 6 h 5.5 l in 6 h

38 EGDT and Abdominal compartment syndrom?

39 Michard F, Crit Care Med 2000 Respiratory changes in arterial pressure in a mechanically ventilated patient Lamia B, Crit Care 2005 PP (%) = PPmax-PPmin (PPmax+PPmin/2)x100 PP 13% predictive of response to fluid PP < 13% predictive of non-response to fluid

40 Arterial PPV predicting fluid responsivness Range of threshold values: 9-17% Monnet X, Curr Opin Crit Care 2007

41 Surviving Sepsis Campaign Guidelines 2008, Int Care Med 2008 Hypotension oder Laktat > 4mmol/l Sofortige Schocktherapie 1C we recommend 1C Ziele ZVD 8-12 mmhg (12-15 unter Beatmung) MAP 65 mmhg Harnproduktion 5ml/kg/h S VO2 65% oder S cvo2 70% Volumenersatz kristallin/kolloidal Vasopressoren Noradrenalin

42 Surviving Sepsis Campaign Guidelines 2008, Int Care Med 2008 Hypotension oder Laktat > 4mmol/l Sofortige Schocktherapie 1C we recommend 1C Ziele ZVD 8-12 mmhg (12-15 unter Beatmung) MAP 65 mmhg Harnproduktion 5ml/kg/h S VO2 65% oder S cvo2 70% Volumenersatz kristallin/kolloidal Vasopressoren Noradrenalin Optimieren von 2C Volumen we suggest VO2 cvo2 Hk <30% Erythrozyten Konzentrate <65% oder 70 % Hk >30% Inotropika Dobutamin

43

44 Intracellular acidosis due to bicarbonate administration Boyd JH, Curr Opin Crit Care 2008

45 Int Care Med 2008 Surviving Sepsis Campaign Guidelines 2008 Hemodynamic support: fluid therapy Cristalloids or colloids 1B Target a CVP of 8mmHg ( 12 if MV) Fluid challenges over 30 minutes 1000ml cristalloids or ml colloids Reduce fluid administration if cardiac filling pressures increase without hemodynamic improvement 1D 1C 1D Strong Recommendation

46 Calfee CS, Chest 2007 ARDS Network Simplified conservative fluid management in pts with ALI CVP PAOP (mmhg) (mmhg) >8 >12 MAP 60 mmhg no vasopressors for 12h Average urin output < 0.5ml/kg/h Furosemide not if Crea > 2 or ARF and Average urin output 0.5ml/kg/h Furosemide not if Crea > 2 or ARF <4 <8 Fluid bolus* as fast as possible Fluid bolus* as fast as possible Furosemide not if Crea > 2 or ARF No intervention *Fluid bolus: 15ml/kg over 1h Reassess in 1 h Reassess in 4 h

47 Rivers E, NEJM 2001

48 , although infusing fluids is a cornerstone of supportive care during sepsis, the optimal modalities and volume are difficult to determine and choices should be driven by objectives in the individual patient.

49 Volumstherapie bei Sepsis und MODS: Rechtzeitig Ausreichend Ziel gesteuert Situationsgerecht V T EGDT Conservative fluid management