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Infusionskurs XVI
Volumenüberladung fördert MODS Einleitung: Natrium und Wasser
(„Warum ist es meist zuviel“)
Arbeitsgemeinschaft Klinische Ernährung
13. Oktober 2016, 14:00-14:15
Ass.Prof.PD Dr. Manfred Hecking, MUW, Nephrologie
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Multiple Organ Dysfunction Syndrome
• Progressive
dysfunction
in 2 or more
organ
system
• Induced by
variety of
acute insults
INCLUDING
sepsis
• Leading
cause of
mortality
after trauma
El Menyar A, et al., International Journal of Clinical Medicine, 2012, 3, 722-730
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Komplikationen von Überwässerung und Hypernatriämie
Besen BA, et al., World J Crit Care Med 2015 May 4; 4(2): 116-129
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Natrium und Wasser:
Eine ‚individuelle‘ Betrachtung
(auch nephrologisch)
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Na
Na
Na
Na Na
Na
Na
Na
Na
Na Na
Na
Na
Na Na
Na
Na
Na Na
Na
Na Na Na
Na Na
Na
Na
Na
Na
Na
Na
Na Na
Na
Na
Na
Na
Na
Na Na
Na
Na Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na Na
Na
Na Na Na
Na
Na Na Na
Na Na
Na
Na
Na
Na
Na
Na Na
Na
Na Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na Na
Na
Na
Na Na
Na Na
Na
Na
Na Na
Na Na
Na Na
Na Na
Na
Na
Na
Na
Na
Na Na Na
Na
Na Na
Na
Na Na
Na
Na Na Na
Na Na
Na
Na
Na Na
Na
Na Na Na
Na
Na
Na
Na
Na Na
Na
K
K
K
K
Natrium ist enger reguliert als Kalium
140 mmol/L Na
4.25 mmol/L K
Na Grenzwerte:
135-145 mmol/L
10 mmol/L normaler
Schwankungsbereich
K Grenzwerte:
3.5-5.1 mmol/L
1.6 mmol/L normaler
Schwankungsbereich
10 mmol von 140 mmol
=7%
1.6 mmol von 4.25 mmol
=38%
140
4.25
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Setpoint wird “verteidigt”
- Durch renale Na Exkretion (bei Nierengesunden)
- Durch Aufnahme freien Wassers (bei Nierenkranken)
- …
Zur „besonderen Rolle“ des Natriums (Natrium Homöostase):
Das „Setpoint“-Konzept
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Dietary Na intake ↑ Some excretion, Some retention
Plasma osmolality ↑, Thirst ↑, ADH ↑
Water retention
Effective circulating volume ↑
Weight ↑, Steady state reached after 3–4 days
Textbuch Wissen zum Natriumhaushalt
Titze J, et al., Kidney Int. 2014 Apr;85(4):759-67
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Natrium Homöostase:
Extrazelluläre Natrium Speicher in der Haut
Machnik, A et al., Nat Med 2009; 15: 545-52
(Low salt diet) (High salt diet)
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Titze J, et al., Kidney Int. 2014 Apr;85(4):759-67
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Natrium- (Harn)-Ausscheidung
und (All Cause-) Mortalität: Die PURE-Studie
O‘Donnell, M et al., N Engl J Med 2014; 14;371(7): 612-23
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http://www.nejm.org/doi/full/10.1056/NEJMoa1304127
Na in der Allgemeinbevölkerung:
Darstellung im „Quick Take Video“ des NEJM
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Interdialytische Gewichtszunahme bei Dialysepatienten
…in Abhängigkeit von Dialysat Natrium und Serum Natrium
Hecking, M et al., Clin J Am Soc Nephrol 2012; 7: 92-100
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Hecking, M et al., Clin J Am
Soc Nephrol 2012; 7: 92-100
DNa und Mortalitätsrisiko: Unterschiedlich je nach
Individualisierungs-Praxis
*Nicht-individualisierte Zentren: gleicher DNa für ≥90% Patienten, Individualisierte: Der Rest
**Japan ausgeschlossen, adjustiert für % Katheter, % Kt/V <1.2, und % SPhos ≥1.8 mmol/L
Clin J Am Soc
Nephrol 2012; 7:
92-100; Nephrol
Dial Transpl, 2012
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Serum Natrium und Mortalität in der Allgemeinbevölkerung
U-förmige Beziehung
Niedriges und hohes Serum Na = Mortalität
Gheorgiade et al, Eur Heart J, 2007 Apr;28(8):980-8
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„Eure Worte seien immer freundlich, doch mit Salz gewürzt; denn ihr müsst
jedem in der rechten Weise antworten können.“ Paulus, 4. Brief an die Kolosser
„Das Nötigste im Le-
ben Des Menschen
sind: / Wasser,
Feuer, Eisen
Und Salz, / kräftiger
Weizen, Milch und
Honig, / Blut der
Trauben, Öl und
Kleidung“ Altes Testament, Buch
Jesus Sirach, Vers 39 – 26
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Natrium und Wasser:
Eine ‚individuelle‘ Betrachtung
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Messung des Flüssigkeitsstatus:
Chronische Überwässerung und Dehydrierung
Wabel P, et al. Blood Purif 2009; 27: 75-80
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Überwässerung und Mortalität in einer großen
internationalen Hämodialyse-Population
Hecking M, Moissl U, Wabel P et al., ERA-EDTA Poster 2015
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Perioperative Fluid Balance
Ernstbrunner, M. et al., PLoS One. 2014 Oct 31;9(10):e111139
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Natrium und Wasser
WARUM ist es meist zuviel?
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Vielleicht deshalb, weil die alten Infusionslösungen
unphysiologisch waren…
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Vielleicht deshalb, weil die alten Infusionslösungen
unphysiologisch waren…
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Vielleicht deshalb, weil auch neuen Infusionslösungen
unphysiologisch sind…
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No Therapy “Zero”thirsting
N=8
Fluid Therapy *
N=7
No Therapy “Zero”thirsting
N=7
Fluid Therapy *
N=8
15 male Volunteers
Study Day 1 6 hours of fasting before admission at clinical
research ward. Physical examination & blood draw.
BCM-measurement from minutes 0 to 300, ECG,
blood pressure & O2 saturation from minutes 0 to 90
and 300, in 10-minute intervals
Study Day2 Fasting and
diagnostic
procedures exactly
as on study day 1,
except blood draw
Study Planning Telephone or mail
contact with eligible
participants, study
enrolment (explanation
& informed consent)
Randomisation
* Fluid Therapy: 0,50ml/kg/min ELO-MEL-isoton® during 60 minutes
2 (1;7)days
2 (1;2) days
Ernstrunner, M et al., in submission
Intravenous Fluid Challenge: A Bioimpedance Spectroscopy-
Based Crossover Study in Healthy Volunteers
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100 200 300 400
-2
-1
0
1
2
Flu
id O
ve
rlo
ad
in L
ite
rs
FO Fluid
FO Zero
Time in Minutes
** *** ***** * * ** ** ** * * p<0,05** *
U U U U U
** **** **
0 100 200 300 40040
45
50
To
tal B
od
y V
olu
me
in L
ite
rs
TBV FLuid
TBV Zero
* * ***** * *** ***** * p<0,05
Time in Minutes
*
0 100 200 300 40024
26
28
30
Intr
ac
ellu
lar
Vo
lum
e in
Lit
ers
ICV Fluid
ICV Zero
* ****** * * ** * ** * p<0,05
Time in Minutes
*
100 200 300 400
-10
-5
0
5
10
Flu
id O
ve
rlo
ad
in %
EC
V
FO in %ECV Fluid
FO in %ECV Zero
*** * ********* ** ******* *** ****
UUUUU
* p<0,05
Time in Minutes
*
0 100 200 300 40016
18
20
22
Ex
tra
ce
llula
r V
olu
me
in L
ite
rs
ECV Fluid
ECV Zero
* * **** ** ** *
*
** ******* ******* * p<0,05
Time in Minutes
** *
0 1 2 3 4 5 60
500
1000
1500
2000
2500
Urine Fluid
Urine Zero
* p < 0.05** * * *
Time in Hours
To
tal a
mo
un
t o
f U
rin
e in
ml
0 50 10040
60
80
100
120
Saturation Fluid
Saturation Zero
Mean Blood
Pressure Fluid
Mean Blood Pressure Zero
Heart Rate Fluid
Heart Rate Zero
D
* p<0,05
** *
* *
D Discharge
Time in Minutes
Sa
tura
tio
n in
%, B
loo
d P
res
su
re
in m
mH
G, H
ea
rt R
ate
in b
pm
0 1 2 3 4 5 665
70
75
80
85
90
Body Weight
Fluid
Body Weight
Zero
* p < 0.05** * * *
Time in Hours
Bo
dy
We
igh
t in
kg
BA
C D
E F
G H
100 200 300 400
-2
-1
0
1
2
Flu
id O
ve
rlo
ad
in L
ite
rs
FO Fluid
FO Zero
Time in Minutes
** *** ***** * * ** ** ** * * p<0,05** *
U U U U U
** **** **
0 100 200 300 40040
45
50
To
tal B
od
y V
olu
me
in L
ite
rs
TBV FLuid
TBV Zero
* * ***** * *** ***** * p<0,05
Time in Minutes
*
0 100 200 300 40024
26
28
30
Intr
ac
ellu
lar
Vo
lum
e in
Lit
ers
ICV Fluid
ICV Zero
* ****** * * ** * ** * p<0,05
Time in Minutes
*
100 200 300 400
-10
-5
0
5
10
Flu
id O
ve
rlo
ad
in %
EC
V
FO in %ECV Fluid
FO in %ECV Zero
*** * ********* ** ******* *** ****
UUUUU
* p<0,05
Time in Minutes
*
0 100 200 300 40016
18
20
22
Ex
tra
ce
llula
r V
olu
me
in L
ite
rs
ECV Fluid
ECV Zero
* * **** ** ** *
*
** ******* ******* * p<0,05
Time in Minutes
** *
0 1 2 3 4 5 60
500
1000
1500
2000
2500
Urine Fluid
Urine Zero
* p < 0.05** * * *
Time in Hours
To
tal a
mo
un
t o
f U
rin
e in
ml
0 50 10040
60
80
100
120
Saturation Fluid
Saturation Zero
Mean Blood
Pressure Fluid
Mean Blood Pressure Zero
Heart Rate Fluid
Heart Rate Zero
D
* p<0,05
** *
* *
D Discharge
Time in Minutes
Sa
tura
tio
n in
%, B
loo
d P
res
su
re
in m
mH
G, H
ea
rt R
ate
in b
pm
0 1 2 3 4 5 665
70
75
80
85
90
Body Weight
Fluid
Body Weight
Zero
* p < 0.05** * * *
Time in Hours
Bo
dy
We
igh
t in
kg
BA
C D
E F
G H
100 200 300 400
-2
-1
0
1
2
Flu
id O
ve
rlo
ad
in L
ite
rs
FO Fluid
FO Zero
Time in Minutes
** *** ***** * * ** ** ** * * p<0,05** *
U U U U U
** **** **
0 100 200 300 40040
45
50T
ota
l Bo
dy
Vo
lum
e in
Lit
ers
TBV FLuid
TBV Zero
* * ***** * *** ***** * p<0,05
Time in Minutes
*
0 100 200 300 40024
26
28
30
Intr
ac
ellu
lar
Vo
lum
e in
Lit
ers
ICV Fluid
ICV Zero
* ****** * * ** * ** * p<0,05
Time in Minutes
*
100 200 300 400
-10
-5
0
5
10
Flu
id O
ve
rlo
ad
in %
EC
V
FO in %ECV Fluid
FO in %ECV Zero
*** * ********* ** ******* *** ****
UUUUU
* p<0,05
Time in Minutes
*
0 100 200 300 40016
18
20
22
Ex
tra
ce
llula
r V
olu
me
in L
ite
rs
ECV Fluid
ECV Zero
* * **** ** ** *
*
** ******* ******* * p<0,05
Time in Minutes
** *
0 1 2 3 4 5 60
500
1000
1500
2000
2500
Urine Fluid
Urine Zero
* p < 0.05** * * *
Time in Hours
To
tal a
mo
un
t o
f U
rin
e in
ml
0 50 10040
60
80
100
120
Saturation Fluid
Saturation Zero
Mean Blood
Pressure Fluid
Mean Blood Pressure Zero
Heart Rate Fluid
Heart Rate Zero
D
* p<0,05
** *
* *
D Discharge
Time in Minutes
Sa
tura
tio
n in
%, B
loo
d P
res
su
re
in m
mH
G, H
ea
rt R
ate
in b
pm
0 1 2 3 4 5 665
70
75
80
85
90
Body Weight
Fluid
Body Weight
Zero
* p < 0.05** * * *
Time in Hours
Bo
dy
We
igh
t in
kg
BA
C D
E F
G H
100 200 300 400
-2
-1
0
1
2
Flu
id O
ve
rlo
ad
in L
ite
rs
FO Fluid
FO Zero
Time in Minutes
** *** ***** * * ** ** ** * * p<0,05** *
U U U U U
** **** **
0 100 200 300 40040
45
50
To
tal B
od
y V
olu
me
in L
ite
rs
TBV FLuid
TBV Zero
* * ***** * *** ***** * p<0,05
Time in Minutes
*
0 100 200 300 40024
26
28
30
Intr
ac
ellu
lar
Vo
lum
e in
Lit
ers
ICV Fluid
ICV Zero
* ****** * * ** * ** * p<0,05
Time in Minutes
*
100 200 300 400
-10
-5
0
5
10
Flu
id O
ve
rlo
ad
in %
EC
V
FO in %ECV Fluid
FO in %ECV Zero
*** * ********* ** ******* *** ****
UUUUU
* p<0,05
Time in Minutes
*
0 100 200 300 40016
18
20
22
Ex
tra
ce
llula
r V
olu
me
in L
ite
rs
ECV Fluid
ECV Zero
* * **** ** ** *
*
** ******* ******* * p<0,05
Time in Minutes
** *
0 1 2 3 4 5 60
500
1000
1500
2000
2500
Urine Fluid
Urine Zero
* p < 0.05** * * *
Time in Hours
To
tal a
mo
un
t o
f U
rin
e in
ml
0 50 10040
60
80
100
120
Saturation Fluid
Saturation Zero
Mean Blood
Pressure Fluid
Mean Blood Pressure Zero
Heart Rate Fluid
Heart Rate Zero
D
* p<0,05
** *
* *
D Discharge
Time in Minutes
Sa
tura
tio
n in
%, B
loo
d P
res
su
re
in m
mH
G, H
ea
rt R
ate
in b
pm
0 1 2 3 4 5 665
70
75
80
85
90
Body Weight
Fluid
Body Weight
Zero
* p < 0.05** * * *
Time in Hours
Bo
dy
We
igh
t in
kg
BA
C D
E F
G H
Ernstrunner, M et al., MS in preparation
Intravenous Fluid Challenge Decreases Intracellular Volume
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Natrium-Laktat – pur
- Natrium 144 mmol/l
- organ. Anion 32 mmol/l
- Chlorid 112 mmol/l
Was wäre der „logische Ersatz für 0.9% NaCl ?
Dies ist eine Basis-Lösung als Ersatz für 0.9% NaCl, die durch
Zusätze modifiziert werden kann.
„bilanzierte“ Lösungen soweit indiziert sind zahlreiche verfügbar
Doch es gibt Hoffnung…
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Vielen Dank !