Powerpoint slides for Association of Anaesthetists Winter Scientific Meeting, London, Jan 2011.
"Which fluids and when?"
Speaker Dr Craig Morris, Derby, UK
14. Sizes RBC 7 μ Capillary width 5 μ Endothelial cell thickness 0.2 μ Large pore 40 nm Small pore 5 nm The “size” of colloid is not what keeps it put!!! K+ 0.15nm Na+ 0.10 nm Starch fragments 4.5nm Albumin 3.5nm
15. Relative sizes… RBC 7μ Large pore 40nm Small pore 5nm Colloid 5nm (1/10 pore) 1mm muscle 32 endothelial cells 10 000 small pores 2 large pores Pore area <0.05% surface area
30. The life of HES Starting macromolecule In vitro MW EgHemohes200 kDa Voluven 130 kDa In vivo MW EgElohes 145 kDa Voluven 65 kDa Amylase smaller molecules Aim to have in vivo MW above renal threshold Lysis increases osmotic effect!!! 50kDa renal threshold Renally eliminated
31. In vivo lysis HES 6%, 450/0.65 3:1 Br J ClinPharm `1979;7:505- 9
43. Hyperoncotic colloids AKI assoc hyperoncotic starch, albumin,dextran… mannitol But not saline! Shortgen. Intensive Care Med 2008;34:2157- 68 Ragaller et al, J.Am.Soc.Nephrol. 2001
44. VISEP- should I worry? YES! X2 rates CRRT No benefit Alternatives exist Consistent previous work Would you use it as a “drug”? NO! Complex design Lactated solution vs chloride Hyperoncotic colloid Not representative “current” HES Perhaps AKI is only with higher doses 10% 200/0.5... It doesn’t improve heamodynamics, costs more and assoc death
45. I don’t do ICU... Sick laparotomy Pressors AKI Elderly, gent, CT... Avoid 10% 200/ 0.5 Await further studies?...
46. HES 130/ 0.4 N= 363 Retrospective 2 organ failures HES 130/ 0.4 France, non-protocolised 763 ml HES 48 hrs, 1.4l 21 days Both identical >6l crystalloid PRC 2.8 vs 3.9 Boussekey et al., Critical Care, 2010
52. The irony! Gelofusine® is a 4% solution of modified fluid gelatine. It contains 154 mmol/l sodium but only 120 mmol/l chloride because of the substantial negative charge of the gelatine molecules… http://www.iv-partner.com/index.cfm?2A450D1AB7B24C098978DB9F6D6602DB
53. Safer than Cl- ? Acetate-> hypotension Lactate assoc hypotension Osmotic effects Direct toxicity Glucose and protein metabolism Chloride effects? Morris CG et al. Anaesthesia 2009;64:703- 5 Handy JM. BJA 2008;101:141- 50
60. What about Shortgen, VISEP, Cochrane, sepsis, renal impairment, and lack of improved outcomes?...
61. Compared with Gelofusine, the perioperative pulmonary function of patients treated with HES (Elohaes) after AAA was better. Ortho HES 200 0.5 vs 3% gelatine Comparable COP, clinical expansion the haemodynamics in the two colloid groups appeared to be similar, but superior to the Ringer’s acetate group (alb 4% vs 6% 130/0.4) 3.5% urea-linked gelatin is as effective as 6% HES 200/0.5 for volume management in cardiac surgery patients… HES could result in a higher need for allogeneic blood transfusion. Rittoo. BJA 2004 Beyer BJA 1997 Shramko. Perfusion 2010 Linden CJA 2004
66. Lap chole 1l Gelo vs Voluven (4 hrs!)http://clinicaltrials.gov/ct2/show/NCT00868062?term=gelatin+and+hydroxyethyl+starch&rank=1
67.
68. Mortality end point? Major non-cardiac (n= 90) LR vs 6% HES vs 6% balanced Thio + sux OR 7mlkg-1 loading and 5mlkg-1 hr-1 RL intraop Morretti. A+A 2003;96:611- 7
77. Gelatine vs HES sepsis (2001) HES 200/ 0.6 (Elohes) vs 3% gelatin (Plasmagel) ARF, creatinine and oliguria all higher HES HES independent risk factor ARF X 2.57 http://wwdaa.com/adqi/web_users/akin4/references%20AKIN%20wg%204/ Shortgen. Lancet 2001
78. ARDS: Replacement albumin with HES Red= RR ARF/ ARDS Black albumin Green HES (200 to 2002 -> 130 N= 44 http://www.springerlink.com/content/h765t1llj424518m/ http://www.pptaglobal.org/
79. Burns Crystalloid Vs colloid Which type colloid Unresolved… N= 30 HemoHaes 10% 200/0/5 vscrystallloid (LR) 11.2 vs 7.1 (1.6:1) RR death 7.12 CRRT 25% vs 7% ARDS identical Ventilators 7 vs 12 (HES) Bechir M. Crit Care 2010;14:R123
80. Management of Major Trauma Crystalloids initially (1B) Consider hypertonic solutions (2B) Suggest addition of colloids in unstable (2C) “modern HES or gelatin” Avoid dextran or albumin Retrospective aggressive resuscitation-> compartment syd Pre-hospital assoc coagulopathy (>40% 2l, >70% 4l) Rossaint et al: Trauma and bleeding a European Guideline. Crit Care 2010;14:R52 Maegele et al. Injury 2007;38:298- 304
81. EAST: Pre-hospital Level 2 ...vascular access at the scene of injury...delays patient transport to definitive care and... benefit is lacking Iv fluids... Withheld... pre-hospital... patients with penetrating torso injuries Level 3: (a) Iv fluid resuscitation... withheld until active bleeding/hemorrhage addressed (b) Iv fluid... titrated for palpable radial pulse using (250ml) boluses of fluid rather than fixed volumes or continuous administration http://www.east.org/tpg/FluidResus.pdf
82. NICE 2004: Hypovolaemic shock Ie absent radial or central pulse Boluses crystalloid to return pulse Shouldn’t delay transport (ieen route) “...only healthcare professionals who have been appropriately trained in advanced life-support techniques and pre-hospital care should administer intravenous fluid therapy in the pre-hospital setting” https://www.nice.org.uk/niceMedia/pdf/2004_006_prehospfluidtherapy.pdf
83. If fluid is given which type? Level 1: (a) There is insufficient data to recommend one solution or type of fluid... (b) Boluses (250 mL) of 3% and 7.5% hypertonic saline (HTS) are equivalent (...vascular expansion and hemodynamic changes) to large volume boluses (one liter) of standard solutions such as lactated Ringer’s (LR) or 0.9% normal saline (NS)
84. EAST resuscitation trauma Level 1 There is insufficient data to formulate a level 1 recommendation. Level 2 1. During resuscitation, attempts should be made to increase O2 delivery to normalize base deficit, lactate, or pHi during the first 24 hours. The optimal algorithms for fluid resuscitation, blood product replacement, and the use of inotropes and/or vasopressors have not been determined. http://www.east.org/tpg/endpoints.pdf
92. ...34 studies (2607 patients)... RR of kidney failure 1.50 (95% CI 1.20 to 1.87; n = 1199) and 1.38 for requiring RRT (95% CI 0.89 to 2.16; n = 1236) in HES treated individuals compared with other fluid therapies. Subgroup analyses suggested increased risk in septic patients compared to non-septic (surgical/trauma) patientshttp://www.ncbi.nlm.nih.gov/pubmed/20091640?ordinalpos=1&itool= PPMCLayout.PPMCAppController.PPMCArticlePage.PPMCPubmedRA&linkpos=3 http://www2.cochrane.org/reviews/en/ab007594.html
93. Recommendations for practice… No level 1 Fit volunteers tolerate anything All fluids leak and come with baggage Colloids expensive SAFE colloid (4% albumin) vs crystalloid (0.9% saline)= Ratio 1: 1.4 No evidence superiority colloid Albumin ↓morbidity and mortality sepsis Albumin ↑mortality trauma/ TBI
94. Recommendations for practice “Routine” perioperativefluid-> Hartmann’s Gelatine vs HES... Still going! SV/ optimisation both-> gelatine cheaper, no AKI AKI HES MW, substitution, osmolality/ lack crystalloid (+ Sepsis, renal impairment) VISEP 50% ↑CRRT, ↑mortality CHEST ongoing (HES 130/0.4 vs saline) Sepsis or kidney impairment avoid HES
95. Recommendations for practice ARDS pathogenesis + fluid-> controversial ARDS established-> -ve balance Little evidence colloid preventing ARDS Impact hyperCl- unclear Benefit “balanced” alternatives unclear Demand better “balanced”
96. Summary HES fascinating-> evolving drugs Lots volunteer, non-inferiority studies! HES: origin, MW, substitution, C2:C6 Few level 1 recommendations SAFE only robust crystalloid vs colloid (saline/alb) CHEST recruiting (HES/ saline)
97. Thank you So, where does this leave us in the big fluid debate? The present results are interesting and add another little piece to the big puzzle, but much more work is needed before we will be able to see the full picture and to better determine where each fluid fits. Although we use these fluids every day, we still know surprisingly little about them. http://www.anesthesia-analgesia.org/content/104/3/484.full.pdf+html
