fluids & aki
DESCRIPTION
Fluids are GOOD. Fluids & AKI. Volume overload is BAD. UGLY Fluids cause AKI. N Engl J Med 2004. EGDT: fluids are good & prevent AKI. Lin et al, Shock 2006. Phase-contrast MRI 10 septic AKI patients 11 normal volunteers . RRT: 9 Anuria: 3 CrCl>60 mL/min: 2. RF in non AKI. - PowerPoint PPT PresentationTRANSCRIPT
•Fluids & AKI
Fluids are GOOD
Volume overload is BAD
UGLY Fluids cause AKI
N Engl J Med 2004
•EGDT: fluids are good & prevent AKI
Lin et al, Shock 2006
Prowle et al Crit Care Med 2012
RF in non AKIRRT: 9 Anuria: 3CrCl>60 mL/min: 2
Phase-contrast MRI10 septic AKI patients11 normal volunteers
•Renal Plasma Flow and GFR
Prowle et al. Renal Failure 2010
Systematic reviewHuman studies22 articles250 patients
•RBF decreased in sepsis and early AKI?
Langenberg et al. Kidney Int 2006
7 SheepE. Coli infusion
•EGDT and AKI
Prowle et al. Crit Care 2012
•Fluids & AKI
Fluids are GOOD
Volume overload is BAD
UGLY Fluids cause AKI
•Fluid bolus? The FEAST trial
Maitland et al. NEJM 2011
N = 3141 childrenSevere infection
Conservative Liberal P
7 d volume balance (mL)
-136 mL ± 491 +6992 ± 502 <0.001
Death at 60 days 25.5% 28.4% 0.30Ventilator free days 14.6 ± 0.5 12.1 ± 0.5 <0.001ICU free days:
Day 1-7 0.9 ± 0.1 0.6 ± 0.1 <0.001Day 1-28 13.4 ± 0.4 11.2 ± 0.4 <0.001
Wiedemann, N Engl J Med 2006
PRCTN = 1000
•Fluid-Management in ARDS
Wiedemann et al. N Engl J Med 2006
•Venous pressure & ↘ renal bloodflow
Winton, J Physiol 1931
•AKI & CVP, CI, systolic BP, & PCWP
Mullens et al. JACC 2009
CVP CI
PCWPSBP
•AKI & CVP, CI, systolic BP, & PCWP
Mullens et al. JACC 2009
CVP CI
PCWPSBP
•Volume and outcome in AKI-RRT
Bouchard et al. KI 2009, Payen et al. Crit Care 2008, Grams et al. CJASN 2011, Vaara et al. Crit Care 2012
•Negative FB during CRRT is good
Bellomo et al. Crit Care Med 2012
•Negative FB during CRRT is good
Bellomo et al. Crit Care Med 2012
•Fluids & AKI
•Summary Recent PRCT’s HESStudy N Surviv
al AKI Other side effects
Magder, CABG10% HES 250/0,5
262 Less Better HD
FIRST, trauma6% HES 130/0,4
67 P42 B
LessSame
Better lactate ↘More blood
CRYSTMAS severe sepsis6% HES 130/0,4
196 Same
6S severe sepsis6% HES 130/0,42
798 Worse More
More blood
CHEST ICU6% HES 130/0,4
7000
Same More
Liver, pruritus, blood products
Magder et al Crit Care Med 2010, James et al. J Trauma 2011, Guidet et al. Crit Care 2012, Perner et al. NEJM 2012, Myburgh et al. NEJM 2012
•AKI after gelatin
Schabinski et al. Intensive Care Med 2009
ObservationalN = 1383 HESN = 1528 GEL
MVR adjusted Risk for AKI after >33mL/kg GEL: OR 1.99 (1.05-3.79)HES: OR 1.85 (1.01 – 3.41)
•PRCT’s on albumin
n Survival AKI Bleeding/coagulation
SAFE 6997 Same More PC
SAFE TBI 460 Worse More PC
FEAST sepsis 3141 Worse
SAFE severe sepsis 1218 No diff (trend)
No diff No diff
CRYSTMAS severe sepsis
196 No diff No diff
EARSS severe sepsis 792 No diff No diff ALBIOS severe sepsis
1818 No diff No diff No diff
•Saline vs. Plasmalyte ®?
Shaw et al. Ann Surg 2012
Saline = More complications and use of resources:❖ Major infection❖ Dialysis❖ Blood transfusions❖ Electrolyte disturbances
N = 30,994 vs. 926Major abd surgery
•Chloride liberal/restrictive fluid therapy
AKI stage 2-3
Yunos et al. JAMA 2012
•Take home messages
Fluids and AKI: just enough!✓Not too little✓Not too much
Fluids and AKI: beware for the ugly.
•Fluids & AKI
To pee or not to pee: Fluids & AKI
Eric Hoste MD, PhDGhent University
Hospital
•CHEST: HES 130/0.4 vs. Saline
Myburgh et al. NEJM 2012
HES Saline
•CHEST: HES 130/0.4 vs. Saline
Myburgh et al. NEJM 2012
HES Saline
Perner et al. NEJM 2012