Reanimación hídrica NEJM 2013
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Presentación basada en el articulo Fluid Resucitation del NEJM 2013
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Reanimación hídrica NEJM 2013
- 2. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 3. • No existe liquido para reanimación IDEAL. • Tipo y dosis Resultados. • Efectos hemodinámicos Coloides = Cristaloides. • Albumina Coloide referencia limitada por costo. • Reanimación hídrica en pacientes críticos y sepsis temprana. • Aumenta mortalidad en TCE. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 4. • Almidón hidroxietil Aumenta tasa de TRR y eventos adversos UCI • SSN Acidosis metabólica e IRA. • Hipertónicas Seguridad? • Común Edema intersticial. • LEV = Medicamento. • Indicaciones, contraindicaciones, toxicidad Eficacia y Toxicidad. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 5. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 6. • Robert Lewins (1832) Efectos Sln. Salina Alcalina pandemia de cólera. • Cantidad adm. = Perdida • Sidney Ringer (1885) SS fisiológica EDA Pediatría. • Alexis Hartmann modifica SS fisiológica. • Fraccionamiento sanguineo (1941) Albumina humana Quemados en ataque Pearl Harbor. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 7. • Pacientes llevados a Qx. • Quemados. • Trauma severo. • UCI. • Objetivo: Restaurar Volumen Intravascular. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 8. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 9. • Modelo compartimental clásico: • Intravascular. • Extravascular: • Intracelular. • Intersticial. • Ernest Starling (1896) Vénulas Capilares y postcapilares Membrana semipermeable Absorben liquido de espacio intersticial. • Presión oncotica e hidrostática determinan cambios transvasculares. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 10. • Capa Glicocalix Endotelial: • ‘’Red de proteoglicanos y glicoproteínas unidas a membrana en el lado luminal de las células endoteliales.’’ • Espacio subglicocalix Produce presión coloido- oncotica IMPORTANTE en flujo transcapilar. • Absorción no ocurre a traves de capilares venosos • Espacio intersticial Liquido intersticial Poros grandes Retorna como Linfa. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 11. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 12. • Estructura y función de Glicocalix Determinantes de la permeabilidad de la membrana. • Perdida integridad Edema intersticial. • Sepsis. • Trauma. • Cirugía. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 13. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 14. • Incremento del volumen IV predecible y sostenido. • Composición química similar a LEC. • Metabolizado y completamente excretado sin acumulación tisular. • No efectos adversos metabólicos o sistémicos. • Costo- efectivo. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 15. Cristaloides: • Soluciones de iones. • Libremente permeable. • Sodio y Cloro Tonicidad • 3:1 • Edema intersticial. • Baratos FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13. Coloides: • Suspensión de moléculas en solución transporte • Incapaz de cruzar membrana capilar semipermeable saludable Mejor • 1:1 • Caros
- 16. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 17. • Coloide de referencia. • Componente del fraccionamiento de la sangre. • Tratado térmicamente Prevenir transmisión de patógenos. • Cara. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 18. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 19. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 20. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 21. • HES • Gelatina succinilada. • Preparado de gelatina- poligelina unido a urea. • Dextranos • Mínimos beneficios clinicos. • Costosos. • Nefrotoxicidad. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 22. • HES: • Sustitución de hidroxietilo de aminopectina. • Sorgo, maíz o papa. • Alto grado de sustitución de glucosa bloquea hidrólisis por amilasas plasmáticas inespecíficas Mejor expansión IV: • Acumulo en piel, riñón e hígado. • Peso molecular alto (>200kD) Cuagulopatía • Mortalidad, IRA, uso de terapia de reemplazo renal. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 23. • Actualmente HES 6% - PM: 130 kD - Sustitución Molar 0,38- 0,45. • Cristaloides como solución de transporte. • Usados en: • Qx. Mayor. • Militares. • UCI. • Dosis max. Día: 33- 50 mL/kg FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 24. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 25. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 26. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 27. • Solución salina Sodio y cloro Isotónica comparada con LEC. • Sobrecarga de agua y sodio Mejor pequeños volumenes con altas concentraciones. • Cristaloides ‘’fisiológicos’’ o ‘’balanceados’’ similares al LEC Ringer y Hartmann. • Administración excesiva Hipercloremeia, acidosis metabolica, hipotonicidad y cardiotoxicidad FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 28. • Primera line en reanimación hídrica: • Pacientes llevados a cirugía. • Trauma • Cetoacidosis diabética. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 29. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 30. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 31. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 32. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 33. • Varia dependiendo estado de la enfermedad. • Hipotensión sistólica y Oliguria 200- 1000 mL de cristaloide o coloide? FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 34. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 35. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
- 36. FINFER, Simon R. Vincent, Jean L. Resucitation Fluids. Review Article. Critical Care. NEJM. September 26, 2013. 369; 13.
Notas del editor
- Del tipo y la dosis van a depender los resultados en los pacientes. No ventajas, los dos iguales efectos hemodinámicos.
- Terapia de Reemplazo Renal. Injuria Renal Aguda. Hipertonicas no se ha definido seguridad Edema intesrsticial sobre todo en estados inflamatorios que es donde mas se usa.
- Robert invetigo esto hace casi 200 años y aun sigue vigente y tenido en cuenta en la actualidad. Solucion Salina Fisiologica fue desarrollada en 1885 por Sidney Ringer para hidratar niños con EDA
- Casi en todos estos pacientes por no decir todo… se usan liquidos
- Starling fisiologo ingles.
- Recientemente se ha cuestiona este modelo de compartimento Este retorno es una respuesta mediada simpaticmente.
- Leakly: perdida de intengridad de la capa de glicocalix
- Coindiciones inflamatorias como las nombradas donde los liquidos son frecuentemente usados.
- Estes liquido ideal, no esta disponible para uso clinico… no existe.
- Coloides: No pasa debido al peso molecular de sus molecular. Cristaloides tienen sodio y cloro que determinan tonicidad del fluido.
- Albumina humana 4 o 5%.
- In 1998, the Cochrane Injuries Group Albumin Reviewers published a meta-analysis de 30 ensayos ramdomizados incluyendo 1419 paciente aleatorizados comparing the effects of albumin with those of a range of crystalloid solutions in patients with hypovolemia, burns, or hypoalbuminemia and concluded that the administration of albumin was associated with a significant increase in the rate of death (relative risk, 1.68; 95% confidence interval [CI], 1.26 to 2.23; P<0.01).17 Despite its limitations, including the small size of the included studies, this meta-analysis caused substantial alarm, particularly in countries that used large amounts of albumin for resuscitation
- investigators in Australia and New Zealand conducted the Saline versus Albumin Fluid Evaluation (SAFE) study, a blinded, randomized, controlled trial, to examine the safety of albumin in 6997 adults in the ICU.18 The study assessed the effect of resuscitation with 4% albumin, as compared with saline, on the rate of death at 28 days. The study showed no significant difference between albumin and saline with respect to the rate of death (relative risk, 0.99; 95% CI, 0.91 to 1.09; P = 0.87) or the development of new organ failure.
- In 2011, investigators in sub-Saharan Africa reported the results of a randomized, controlled trial — the Fluid Expansion as Supportive Therapy (FEAST) study23 — comparing the use of boluses of albumin or saline with no boluses of resuscitation fluid in 3141 febrile children with impaired perfusion. In this study, bolus resuscitation with albumin or saline resulted in similar rates of death at 48 hours, but there was a significant increase in the rate of death at 48 hours associated with both therapies, as compared with no bolus therapy (relative risk, 1.45; 95% CI, 1.13 to 1.86; P = 0.003). The principal cause of death in these patients was cardiovascular collapse rather than fluid overload or neurologic causes, suggesting a potentially adverse interaction between bolus fluid resuscitation and compensatory neurohormonal responses.24 Although this trial was conducted in a specific pediatric population in an environment in which critical care facilities were limited or absent, the results call into question the role of bolus fluid resuscitation with either albumin or saline in other populations of critically ill patients.
- El uso de dextranos ya ha sido sustituida por las otras. Por esas 3 cosas su uso es dificil de justificar en la UCI
- El sorgo es una hierba de la familia de las gramineas cuyas semillas se usan para hacer harina. Se acumula en tejidos reticulo endoteliales y en piel produce prurito. Coagulopatia tipo alteraciones en viscoelasticidad y fibrinolisis. Peso molecular alto y con stante de sustitucion molar >0,5 y concentracion del 10% aumenta mortalidad….
- In a blinded, randomized, controlled trial involving 800 patients with severe sepsis in the ICU,30 Scandinavian investigators reported that the use of 6% HES (130/0.42), as compared with Ringer’s acetate, was associated with a significant increase in the rate of death at 90 days (relative risk, 1.17; 95% CI, 1.01 to 1.30; P = 0.03) and a significant 35% relative increase in the rate of renal-replacement therapy. These results are consistent with previous trials of 10% HES (200/0.5) in similar patient populations.
- In a blinded, randomized, controlled study, called the Crystalloid versus Hydroxyethyl Starch Trial (CHEST), involving 7000 adults in the ICU, the use of 6% HES (130/0.4), as compared with saline, was not associated with a significant difference in the rate of death at 90 days (relative risk, 1.06; 95% CI, 0.96 to 1.18; P = 0.26). However, the use of HES was associated with a significant 21% relative increase in the rate of renalreplacement therapy.31 Both the Scandinavian trial and CHEST showed no significant difference in short-term hemodynamic resuscitation end points, apart from transient increases in central venous pressure and lower vasopressor requirements with HES in CHEST. The observed ratio of HES to crystalloid in these trials was approximately 1:1.3, which is consistent with the ratio of albumin to saline reported in the SAFE study18 and in other recent blinded, randomized, controlled trials of HES. La ventajas con HES fueron aumento de PVC, disminucion de requerimientos de vasopresor, aumento del GU en pciente con bajo riesgo de IRA. Desventajas: terapia de reemplazo renal, aumenta el uso de transfusiones, eventos adversos como el prurito
- Xq 0,9% El fisiólogo holandés Hartog Hamburger en estudios de lisis de glóbulos rojos en 1882 y 1883 sugirieron que la concentración de sal en la sangre era de 0,9% Entre comillas xq no son propiamente fisiologicas. Hipotonicdad con lactato y cardiotox con acetato.
- A matched-cohort observational study compared the rate of major complications in 213 patients who received only 0.9% saline and 714 patients who received only a calcium-free balanced salt solution (PlasmaLyte) for replacement of fluid losses on the day of surgery.44 The use of balanced salt solution was associated with a significant decrease in the rate of major complications (odds ratio, 0.79; 95% CI, 0.66 to 0.97; P<0.05), including a lower incidence of postoperative infection, renal-replacement therapy, blood transfusion, and acidosis-associated investigations.
- 760 paciente entre 2008 y 2009 In a single-center, sequential, observational ICU study,45 the use of a chloride-restrictive fluid strategy (using lactated and calcium-free balanced solutions) to replace chloride-rich intravenousfluids (0.9% saline, succinylated gelatin, or 4% albumin) was associated with a significant decrease in the incidence of acute kidney injury and the rate of renal-replacement therapy.
- In trials of liberal versus goal-directed or restrictive fluid strategies in patients with the acute respiratory distress syndrome (particularly in perioperative patients),49,50 restrictive fluid strategies were associated with reduced morbidity. However, since there is no consensus on the definition of these strategies, high-quality trials in specific patient populations are required