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

Sepsis Generel inflamation Vasodilatation – nedsat modstand Hjertepåvirkning –sys/dia dysfunktion Endothelpåvirkning - plasmalækage Intensiv medicin; red.: A Larsson, S Rubertsson FYA Symposium 16/11 2009

Sepsis diagnose FYA Symposium 16/11 2009 Dellinger RP, et. al: Crit Care Med 2008; 36:296-327. 

Svær sepsis FYA Symposium 16/11 2009 Dellinger RP, et. al: Crit Care Med 2008; 36:296-327 FYA Symposium 16/11 2009

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 16/11 2009 Weil MH, Shubin H: Adv Exp MedBiol 1971, 23:13-23.

www.survivingsepsis.org FYA Symposium 16/11 2009

www.survivingsepsis.org FYA Symposium 16/11 2009

www.survivingsepsis.org FYA Symposium 16/11 2009

FYA Symposium 16/11 2009 Rivers E. N Engl J Med, Vol. 345(19)

FYA Symposium 16/11 2009 Rivers E. N Engl J Med, Vol. 345(19)

FYA Symposium 16/11 2009 Rivers E. N Engl J Med, Vol. 345(19)

Preload og fluid responsiveness

Starling kurve FYA Symposium 16/11 2009

Flow l/min Kontraktilitet Afterload Preload FYA Symposium 16/11 2009

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 16/11 2009

Preload - tryk Subjects: Normal healthy volunteers (n 12 ) Interventions: Pulmonary catheterization during 3 L of normal saline infusion over 3 hrs. FYA Symposium 16/11 2009 Kumar et al. Crit Care Med 2004 32(3)

Dynamiske parametre FYA Symposium 16/11 2009

Pulstrykvariation FYA Symposium 16/11 2009

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 16/11 2009 Feissel et al. Intensive Care Med (2004) 30

Pulse pressure variation Septisk shock IPPV Volumenload FYA Symposium 16/11 2009 Michard F et al. Am J Respir Crit Care Med 2000, 162

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 16/11 2009

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 16/11 2009 Boulain T et al. CHEST 121(4), 2002

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 16/11 2009

Regional gennemblødning og iltforbrug

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 16/11 2009

Mikrocirkulation FYA Symposium 16/11 2009

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 16/11 2009

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

SvO2 eller ScvO2 Patients: 32 critically ill patients with triple-lumen central vein catheters, including 29 patients requiring pulmonary artery catheterization. FYA Symposium 16/11 2009 Reinhardt K et al. Intensive Care Med (2004) 30

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

S-Laktat Hyperlaktatæmi Hypoperfusion – aneorob forbrænding Øget glycolyse Leversvigt/nyresvigt Adrenalin Reperfusion FYA Symposium 16/11 2009

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 16/11 2009 Nguyen HB, Crit Care Med 2004 Vol. 32, No. 8

Hvordan gør man?

sepsispakken Operation life FYA Symposium 16/11 2009

FYA Symposium 16/11 2009 Operation life

24 timer Operation life FYA Symposium 16/11 2009

Volumenvalg

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

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

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

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

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 16/11 2009

TRICC studiet FYA Symposium 16/11 2009 Herbert PC NEJM (1999) 340;6

TRICC studiet FYA Symposium 16/11 2009 Herbert PC NEJM (1999) 340;6

TRICC studiet Herbert PC NEJM (1999) 340;6 FYA Symposium 16/11 2009

Konklusion Tidlig målrettet intervention og behandling bedre prognose. Laktat er den væsentligste enkelt markør for diagnose, prognose og behandlingseffekt. FYA Symposium 16/11 2009

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 16/11 2009

TAK ! FYA Symposium 16/11 2009