Volumenterapi ved sepsis

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1 Volumenterapi ved sepsis
Jonas Nielsen, PhD Reservelæge Anæstesiologisk afdeling 532 Hvidovre Hospital

2 Sepsis Generel inflamation Vasodilatation – nedsat modstand
Hjertepåvirkning –sys/dia dysfunktion Endothelpåvirkning - plasmalækage Intensiv medicin; red.: A Larsson, S Rubertsson FYA Symposium 16/

3 Sepsis diagnose FYA Symposium 16/11 2009
Dellinger RP, et. al: Crit Care Med 2008; 36:  

4 Svær sepsis FYA Symposium 16/11 2009
Dellinger RP, et. al: Crit Care Med 2008; 36: FYA Symposium 16/

5 Shock - differentialdiagnoser
Hypovolemic - loss of intravascular volume Cardiogenic - impaired pump function Obstructive - of the heart, arteries or of the large veins Distributive – i.e. sepsis FYA Symposium 16/ Weil MH, Shubin H: Adv Exp MedBiol 1971, 23:13-23.

6 FYA Symposium 16/

7 FYA Symposium 16/

8 FYA Symposium 16/

9 FYA Symposium 16/ Rivers E. N Engl J Med, Vol. 345(19)

10 FYA Symposium 16/ Rivers E. N Engl J Med, Vol. 345(19)

11 FYA Symposium 16/ Rivers E. N Engl J Med, Vol. 345(19)

12 Preload og fluid responsiveness

13 Starling kurve FYA Symposium 16/

14 Flow l/min Kontraktilitet Afterload Preload FYA Symposium 16/

15 Preload – statiske mål Tryk Volumen
CVP - højre ventrikel fyldningstryk PWP – venstre ventrikel fyldningstryk Volumen Venstre ventrikel fyldning – ekko Højre ventrikel volumen - termodilution GEDV - PiCCO ITBV – PiCCO, impedans, LiDCO FYA Symposium 16/

16 Preload - tryk Subjects: Normal healthy volunteers (n 12 )
Interventions: Pulmonary catheterization during 3 L of normal saline infusion over 3 hrs. FYA Symposium 16/ Kumar et al. Crit Care Med (3)

17 Dynamiske parametre FYA Symposium 16/

18 Pulstrykvariation FYA Symposium 16/

19 Diametervariation i vena cava
Patients: 39 mechanically ventilated septic shock patients. Intervention: 8 ml/kg HAES 6% in 20 min. Responders: 15% increase in CO (measured echocardiographically Vena cava measured sub xiphoidal LAX N=35; septisk shock; IPPV 8 ml/kg HAES over 20 min R: >15% CI stigning FYA Symposium 16/ Feissel et al. Intensive Care Med (2004) 30

20 Pulse pressure variation
Septisk shock IPPV Volumenload FYA Symposium 16/ Michard F et al. Am J Respir Crit Care Med 2000, 162

21 Pressure support N=30 Septisk shock PS ventilation 500 ml colloid
Thirty consecutive patients with septic shock were included. All were on pressure support ventilation, monitored using the PiCCO system and receiving 500 ml of colloid on clinical indications. Arterial pulse contour SVV and the transpulmonary thermodilution cardiac index were measured before and after fluid challenge. Perner A et al. Acta Anaesthesiol Scand 2006; 50: 1068–1073 FYA Symposium 16/

22 Passivt benløft N=15; Shock IPPV PLR > 4min. RFL > 20 min. Patients: Thirty-nine patients with acute circulatory failure who were receiving mechanical ventilation and had a pulmonary artery catheter in place. Interventions: PLR for > 4 min and a subsequent 300-mL RFL for > 20 min. FYA Symposium 16/ Boulain T et al. CHEST 121(4), 2002

23 Fluid responsiveness Væskebolus bruges til at vurdere volumenrespons – enten 250 ml iv eller strakt benløft – ved positivt repons CVP stiger >2 mmHg og bedring af hjertefunktion og vævsgennemblødning observeres. FYA Symposium 16/

24 Regional gennemblødning og iltforbrug

25 Mikrocirkulation ”Arterial oxygen content, arterial pressures, velocity of the bloodstream, mode of the cardiac work, mode of the respiration are all incidental and subordinate; they all combine to serve the cell” Pflueger 1886 FYA Symposium 16/

26 Mikrocirkulation FYA Symposium 16/

27 SvO2=SaO2-(VO2/(hgb*1,39*CO))
…summen af alle oxidative processer i kroppen….. SvO2=SaO2-(VO2/(hgb*1,39*CO)) SvO2= SaO2-(VO2/CO) FYA Symposium 16/

28 SvO2 ændringer FYA Symposium 16/11 2009
Bloos et al Intensive Care Med (2005) 31:911–913 FYA Symposium 16/

29 SvO2 eller ScvO2 Patients: 32 critically ill patients with triple-lumen central vein catheters, including 29 patients requiring pulmonary artery catheterization. FYA Symposium 16/ Reinhardt K et al. Intensive Care Med (2004) 30

30 ScvO2 vs. CO FYA Symposium 16/11 2009
Krantz T et al Acta Anaesthesiol Scand 2005; 49: 1149—1156 FYA Symposium 16/

31 S-Laktat Hyperlaktatæmi Hypoperfusion – aneorob forbrænding
Øget glycolyse Leversvigt/nyresvigt Adrenalin Reperfusion FYA Symposium 16/

32 S-Laktat FYA Symposium 16/11 2009
Design: Prospective observational study. Setting: An urban emergency department and intensive care unit over a 1-yr period. Patients: A convenience cohort of patients with severe sepsis or septic shock. Interventions: Therapy was initiated in the emergency department and continued in the intensive care unit, including central venous and arterial catheterization, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, and inotropes when appropriate. Low 31 High 80 FYA Symposium 16/ Nguyen HB, Crit Care Med 2004 Vol. 32, No. 8

33 Hvordan gør man?

34 sepsispakken Operation life FYA Symposium 16/

35 FYA Symposium 16/ Operation life

36 24 timer Operation life FYA Symposium 16/

37 Volumenvalg

38 NaCl vs. albumin FYA Symposium 16/11 2009
Finfer S et al. NEJM(2004) 350;22 FYA Symposium 16/

39 NaCl vs. albumin FYA Symposium 16/11 2009
Finfer S et al. NEJM(2004) 350;22 FYA Symposium 16/

40 NaCl vs. albumin FYA Symposium 16/11 2009
Finfer S et al. NEJM(2004) 350;22 FYA Symposium 16/

41 HAES vs Ringer FYA Symposium 16/11 2009
Brunkhorst FM et al. NEJM(2008) 358;2 FYA Symposium 16/

42 Blod TRICC studiet: 838 Intensiv patienter
Randomiseret til Liberal vs. restriktiv transfusion Transfusionstrigger 10 g/dl (~ 6 mmol/L) vs. 7 g/dl (~ 4,5 mmol/L) Primær outcome: 30 dages mortalitet Herbert PC NEJM (1999) 340;6 FYA Symposium 16/

43 TRICC studiet FYA Symposium 16/ Herbert PC NEJM (1999) 340;6

44 TRICC studiet FYA Symposium 16/ Herbert PC NEJM (1999) 340;6

45 TRICC studiet Herbert PC NEJM (1999) 340;6 FYA Symposium 16/

46 Konklusion Tidlig målrettet intervention og behandling bedre prognose.
Laktat er den væsentligste enkelt markør for diagnose, prognose og behandlingseffekt. FYA Symposium 16/

47 Hvad bør monitoreres MAP - >65 mmHg
CVP – 8-12 mmHg (stigning på 2 mmHg ved væskebolus) ScvO2 – >70% S-Laktat – <2 mmol/l kliniske tegn på hypoperfusion. ALTID – finde og behandle udløsende årsag !!!!!! FYA Symposium 16/

48 TAK ! FYA Symposium 16/