VolumentherapieVolumentherapiebei Sepsis & MODS:bei Sepsis & MODS:

Was bleibt noch Was bleibt noch üübrig ?brig ?

A.ValentinA.ValentinAllgemeine u. Internist. IntensivstationAllgemeine u. Internist. IntensivstationII. Med. Abt., Rudolfstiftung, WienII. Med. Abt., Rudolfstiftung, Wien

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

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

Nguyen HB, Ann Emerg Med 2006

Su F, Shock 2007

CI

SV

MAP

SVR

Parker MM, Ann Intern Med 1984

Dellinger RP, Crit Care Med 2003

Akuter Patient:•Hypovolämisch•Suspekte Sepsis

ICU-Patient (bereits infundiert):•Profitiert von weiterer Volumsgabe•Risiko durch weitere Volumsgabe

Good ventricular function

Bad ventricular function

Not one size fits all

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

A comparison of albumin and saline for fluid resuscitation in the intensive care unit

Finfer S, NEJM 2004

VISEPBrunckhorst et al., NEJM 2008

Graph from Wiedermann CJ, BMC Emergency Medicine 2008

Elektrolytgehalt von Kristalloiden 0,9 % NaCl

Ringerlösung „Fresenius“

Ringerlaktat „Fresenius“

Na (mmol/l) 154 147,2 131

K (mmol/l) 4,0 5,4

Cl (mmol/l) 154 155,7 111,8

Ca (mmol/l) 2.25 1,85

Laktat 28,3

pH 5-7 5-7 5,5-6,3

Osmolarität (mosmol/l) 308 309 278

Ringer ≠ Ringer (Hersteller abhängig) ≠ Ringerlaktat !!!!!!!

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

Septic shock is a (short) pausein the act of dying

EGDT vs standard

AboluteRisk Reduction (mean)

20 ± 13 %

EGDT vs standard

RelativeRisk Reduction (mean)

46 ± 26 %

Rivers E, Curr Opin Anaesthesiol 2008

Treatment 0-6h

Total fluids (ml)Standard therapyEGDTP value

3499±24384981±2984

<0.001Red-cell transfusion (%)

Standard therapyEGDTP value

18.564.1

<0.001Any vasopressor (%)

Standard therapyEGDTP value

30.327.40.62

Dobutamine (%)Standard therapyEGDTP value

0.813.7

<0.001

Early goal-directed therapy in the treatment of severe sepsis and septic shock

Rivers E et al, NEJM 2001

Impact of components of the EDGT bundle

330 pts., prospective observational study on quality indicatorsNguyen HB, Crit Care Med 2007

van den Beest PA, Crit Care 2008

The Rivers study does not reflect European reality ?

O2 Zufuhr oder non-invasive Beatmung oder Intubation und lungenprotektive Beatmung

Arterielle Kanüle und ZVK

Sedierung und Analgesie

Optimierung des ZVD < 8mmHg Volumenersatzkristallin/kolloidal

8-12 mmHg

Optimierung des MAP <65 mmHg VasopressorenNoradrenalin

≥65/≤90 mmHg

Optimieren derZentralvenösen Sättigung

Hk <30% ErythrozytenKonzentrate>70%

<70%InotropikaDobutamin

Hk >30%

Zielgrössen erreicht ?Nein

O2 Zufuhr oder non-invasive Beatmung oder Intubation und lungenprotektive Beatmung

Arterielle Kanüle und ZVK

Sedierung und Analgesie

Optimierung des ZVD < 8mmHg Volumenersatzkristallin/kolloidal

8-12 mmHg

Optimierung des MAP <65 mmHg VasopressorenNoradrenalin

≥65/≤90 mmHg

Optimieren derZentralvenösen Sättigung

Hk <30% ErythrozytenKonzentrate>70%

<70%InotropikaDobutamin

Hk >30%

Zielgrössen erreicht ?

?

?

Nein

Osman D, Crit Care Med 2007• 96 septic patients

• Volume challenge:500 ml HES 6%

• 43% responder=CI increased ≥ 15%

• CVP < 8 mmHgPPV 51%NPV 65%

• CPV < 12 mmHgPPV 47%NPV 67%

• PAOP < 11 mmHgPPV 54%NPV 74%

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.

After3l saline

Kum

ar A

, Crit

Car

e M

ed 2

004

After3l saline

Zentral-venöse Sauerstoffsättigung

Sv(c)O2 (%)

ZielbereichZentralvenös ≥70 Gemischt venös ≥65

Sv(c)O2 reflektiert klinisch “online“

die globale Gewebssauerstoffbalance

OXYGEN EXTRACTION

VO2 = CO x (CaO2 - CvO2)

ArterialInflow(CO) capillary

O2

O2

O2

O2 O2

O2

O2

VenousOutflow(CO)

Cell

O2

(Adapted from the ICU Book by P. Marino)

O2 EXTRAKTION ?

Relationship betweenpulmonary hydrostatic pressure and lung edema formation

Calfee CS, Chest 2007; Staub NC, Chest 1978

FACCTWiedermanNEJM 2006CVP

PAOP

ARDS NetworkFluid and Catheter Treatment Trial (FACTT)

FACCTWiedermanNEJM 2006

FACCTTranslation into clinical practice

• Patients in shock– MAP < 60 mmHg– Vasopressors (except dopamine < 5µg/kg/min)

• 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

Free fluid management

ARDS network FACCT

Patients in shock:Same results with restriced and liberal fluid management

VISEPBrunckhorst et al., NEJM 2008

Liberal vs. conservative vasopressor use to maintain mean arterial blood pressure during resuscitation of septic shock: an observational study. Subramanian S, Int Care Med 2008

3.3 l in 6 h 5.5 l in 6 h

EGDT and Abdominal compartment syndrom ?

Respiratory changes in arterial pressurein a mechanically ventilated patient

Lam

ia B

, Crit

Car

e 20

05

PPmax-PPminPP (%) =

(PPmax+PPmin/2)x100

PP ≥ 13% predictive of response to fluidPP < 13% predictive of non-response to fluid

Michard F, Crit Care Med 2000

Arterial PPVpredicting

fluid responsivness

Range ofthreshold values:

9-17%

Monnet X,Curr Opin Crit Care 2007

Hypotension oder Laktat > 4mmol/l

Sofortige Schocktherapie

ZVD 8-12 mmHg(12-15 unter Beatmung)

Volumenersatzkristallin/kolloidalMAP ≥ 65 mmHg

Harnproduktion ≥ 5ml/kg/h

SVO2 ≥ 65% oder ScVO2 ≥ 70%

„werecommend“

Ziel

e

1C

1C

VasopressorenNoradrenalin

Surviving Sepsis Campaign Guidelines 2008, Int Care Med 2008

Hypotension oder Laktat > 4mmol/l

Sofortige Schocktherapie

ZVD 8-12 mmHg(12-15 unter Beatmung)

Volumenersatzkristallin/kolloidalMAP ≥ 65 mmHg

VasopressorenNoradrenalin

Optimieren vonSVO2 oder ScVO2

Hk <30% ErythrozytenKonzentrate

<65% oder 70 %InotropikaDobutamin

Hk >30%

Harnproduktion ≥ 5ml/kg/h

SVO2 ≥ 65% oder ScVO2 ≥ 70%

„werecommend“

Ziel

e

1C

1C

2CVolumen

„wesuggest“

Surviving Sepsis Campaign Guidelines 2008, Int Care Med 2008

Intracellular acidosis due to bicarbonate administration

Boyd JH, Curr Opin Crit Care 2008

Int Care Med 2008Surviving Sepsis Campaign Guidelines 2008

Stro

ng R

ecom

men

datio

n

Hem

odyn

amic

sup

port:

flui

d th

erap

y

Cristalloids or colloids1B

1CTarget a CVP of ≥ 8mmHg (≥ 12 if MV)

Fluid challenges over 30 minutes1000ml cristalloids or 300-500ml colloids

1D

1DReduce fluid administration if

cardiac filling pressures increasewithout hemodynamic improvement

Calfee CS, Chest 2007

ARDS NetworkSimplified conservative fluid management in pts with ALI

• MAP ≥ 60 mmHg• no vasopressors for ≥ 12h

CVP(mmHg)

PAOP(mmHg)

Average urin output Average urin output < 0.5ml/kg/h< 0.5ml/kg/h

Average urin outputAverage urin output≥≥ 0.5ml/kg/h0.5ml/kg/h

>8 >12 FurosemideFurosemidenot if Crea > 2 or ARF

FurosemideFurosemidenot if Crea > 2 or ARF

4-8 8-12 Fluid bolus*Fluid bolus*as fast as possible

FurosemideFurosemidenot if Crea > 2 or ARF

<4 <8 Fluid bolus*Fluid bolus*as fast as possible No interventionNo intervention

and

Reassessin 1 h

Reassessin 4 h

*Fluid bolus:15ml/kg over ≤ 1h

Rivers E, NEJM 2001

…, 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.

Volumstherapie beiVolumstherapie beiSepsis und MODS:Sepsis und MODS:

•• RechtzeitigRechtzeitig•• AusreichendAusreichend•• Ziel gesteuertZiel gesteuert•• Situationsgerecht Situationsgerecht

•• EGDTEGDT•• Conservative fluid Conservative fluid

management

V

managementT