Transcript Diapositiva 1 - Area-c54

3.5
14 l
25 l
1832 Robert Lewins
1855 Sidney Ringer
8 mg NaCl, 0,3 g KCl, 0,33 g CaCl
1l di H2O
Alexis Hartmann
1941 Albumina
Elettroliti
ECF / ICF
ECF
mEq/l
Fabbisogno
mEq/k/d
Na
ECF
135 - 146
1.5
K
ICF
3.1 – 4.2
1.0 – 1.5
0.85 – 1.25
8 – 20
2 – 2.6
10
2.7 – 4.5
20 – 40
Mg
Ca
ICF
ECF
PO43-
ICF
Cl
ECF
H2O
ECF/ICF
97- 107
20 – 30 ml/d
I cristalloidi sono soluzioni che
contengono soluti di peso molecolare
inferiore ai 30 kDa : generalmente sali o
glucosio.
Essi passano con facilità attraverso la
membrana dei capillari. Possono essere
isotonici,ipotonici o ipertonici.
K+
HCO3
Cl
140
3.6-5.1
30
100
154
0
0
154
1026
513
0
0
513
7.5% Saline
2400
1250
0
0
1250
Ringer Lactate
273
6.5
130
4
28
109
Ringer Acetate
270
6
130
4
30
110
Plasmalyte A
294
7.4
140
5
50
98
5% glucose D5W
253
4
0
0
0
0
Solution
Osmolality
Ph
Plasma
295
7.4
0,9% Saline
308
5.0
3% Saline
Na +
HES solutions
I colloidi sono soluzioni
di molecole ad elevato
peso
molecolare
che passano
difficoltà
are produced
by hydroxyethyl
substitution ofcon
amylopectin
obtained from
l’endotelio.
sorghum, maize, or potatoes.
L’interesse nei loro confronti è legato alla
A high degree of substitution on glucose molecules protects against
maggiore
volume
oltre che
hydrolysis efficacia
by non specificcome
amylaseseffetto
in the blood,
thereby prolonging
expansion,
but this action
increases the ed
potential for HES to
adintravascular
interessanti
propietà
reologiche
accumulate in reticuloendothelial tissues, such as skin
antiinfiammatorie.Comunque,
inkidney.
ampi studi
(resulting in pruritus), liver, and
randomizzati,i colloidi non si sono dimostarti
Succinylated gelatin, urea linked gelatin
superiori in termini di misuredi outcome di
Dextran solutions.
elevato profilo come la mortalità.
Solution
Osmolality
(mOsm)
Na +
(mM)
Mw
(kDa)
Plasma
295
140
Varying
Low
Albumin 4%,5%
300
130-160
69
70 -100
Albumin 20%,25%
1500
125
69
200 -300
Hespan 6 in ns
309
154
600
100 – 160
20 ml/Kg/die
Hestend 6%
307
143
670
100 -160
1.4 hr;20 ml/kg/d
Voluven6% in ns
296
140
130
1 :1
Volulyte 6%
296
140
130
1 :1
Gelofusin 4% in ns
274
154
30
1:1
No upper limits
Rheomacrodex 10%
Dextran 40 in ns
350
154
40
175
1.5 gr/kg/die
Macrodex 6%
Dextran 70 in ns
300
154
70
100
in lactate electrolite solution
in balanced salt solution
Initial volume Plasma half life (Hr) /
expansion (%) dosage limit
16 – 24;no limit
16 – 24;no limit
50 ml/Kg/die
50 ml/Kg/die
1.5 gr/kg/die
HES solutions (10%)
with a molecular weight of more than 200 kD
and a molar substitution ratio of more than 0.5
HES solutions (6%)
with a molecular weight of 130 kD and molar substitution ratios
of 0.38 to 0.45.
HES is 33 to 50 ml per kilogram of body weight per day.
I Generazione
450/0.7
HMW/HMS
Hetastarch
II Generazione
70/0.5
200 - 260/0.5
200/0.62
Pentastarch
III Generazione
130/0.4
130/0.42
Tetrastarch
Voluven
Venofundin
IV Generazione
Balanced
130/0.42
Tetraspan
The observed ratio of HES to crystalloid in
these trials was approximately 1:1.3,
which is consistent with the ratio of
albumin to saline reported in the SAFE
study.
The selection and use of resuscitation fluids is based on physiological principles,
but clinical practice is determined largely by clinician preference, with marked
regional variation.
Despite what may be inferred from physiological principles, colloid solutions do
not offer substantive advantages over crystalloid solutions with respect to
hemodynamic effects.
Although albumin has been determined to be safe for use as a resuscitation fluid
in most critically ill patients and may have a role in early sepsis, its use is
associated with increased mortality among patients with traumatic brain injury.
The use of hydroxyethyl starch (HES) solutions is associated with increased rates
of renal-replacement therapy and adverse events among patients in the intensive
care unit (ICU).
There is no evidence to recommend the use of other semisynthetic
colloid solutions.
Balanced salt solutions are pragmatic initial resuscitation fluids,
although there is little direct evidence regarding their comparative
safety and efficacy.
The use of normal saline has been associated with the
development of metabolic acidosis and acute kidney injury.
The safety of hypertonic solutions has not been established.
All resuscitation fluids can contribute to the formation of interstitial
edema, particularly under inflammatory conditions in which
resuscitation fluids are used excessively.
Critical care physicians should consider the use of resuscitation
fluids as they would the use of any other intravenous drug.
Although the use of resuscitation fluids is one of the most
common interventions in medicine ,no currently available
resuscitation fluid can be considered to be ideal.
Selection, timing, and doses of intravenous fluids should be evaluated
as carefully as they are in the case of any other intravenous drug, with
the aim of maximizing efficacy and minimizing iatrogenic toxicity.
In summary:
Chloride is implicated in impaired renal function with
hyperchloraemia resulting in less natiuresis than might be expected after
- hyperchloraemic acidosis is seen with the use of
saline infusion.
large volumes of saline and is almost certainly due to
Chloride may influence the renal vasculature.
the chloride load;
There is also some evidence that renin secretion is mediated by chloride.
- there appear to be some side-effects associated
Hyperchloraemia
may
alsobut
influence
coagulation.
with saline
use,
to date
these have not
Thromboelastography indicates more effects on coagulation and platelet
translated into clinically important outcomes,
function with saline when compared with a balanced salt solution
though this may be through lack of data.
Is usually the result of sodium bicarbonate infusion for
metabolic acidosis,or aggressive use of hyprtonic saline
to treat intracranial pressure.
When renal sodium excretion is impaired it may be
necessary to increase it with a diuretic.
Because the urinary sodium concentration during
furosemide (~ 80 mEq/l) is less than plasma sodium
concentration, diuresis can aggravate the hypernatremia.
Lactate clearance = LactateED Presentation - LactateHour 6 × 100
LactateED Presentation
Associations between increased cumulative positive fluid
balance and long-term adverse outcomes have been
reported in patients with sepsis.
In trials of liberal versus goal-directed or restrictive fluid
strategies in patients with the acute respiratory distress
syndrome (particularly in perioperative patients),
restrictive fluid strategies were associated with reduced
morbidity.
However, since there is no consensus on the definition of
these strategies, high-quality trials in specific patient
populations are required.
Recently advocated approaches include waiting until the rate of drainage is
less than 100 mL , less than 150 mL less than 2 mL/kg body weight, less
than 200mL, less than 300 mL , or less than 400mL per 24 hours, or
essentially ignoring the rate of drainage .
Since properly functioning, non occluded chest tubes typically produce
some fluid, it is unusual to wait until there is no drainage to remove tubes,
although this approach has also been described
Because of this increased rate of absorption, a 10- fold
Visceral
and
parietal
pleural
layers 30results
to 40 µm
increase
in the
rate
of fluid
production
in only a
15%
to 20%
increase
inboth
steady-state
pleural: 4,000
fluid volume.
Pleural
surface
area of
hemithoraces
cm2
In addition to increased pleural fluid volume/pressure,
Pleural
bodyand
weight
: 0.13 ± 0.06
mL
stimulation
of α2fluid/kg
-adrenergic
β2-adrenergic
receptors
appears to increase lymphatic drainage from the pleural
Pleural
fluid adult
layer normally
5 to 35 µm
space in rabbits.
A 70-kg
should be able to
reabsorb 470 mL of pleural fluid per day from each
Production and
to 0.02
mL /clinically
kg / h
hemithorax.
Two reabsorption
studies of : 0.01
patients
with
apparent pleural effusions
estimated the rate of
Microvascular
filtrate
Protein
reabsorption
as 0.11
and. 0.36
mL/content
kg /h : approx. 1 g/dL
Ann Thorac Surg 2013;96:2262–7
In summary, judging from the variety of approaches
described in the literature and available data bearing
on the safety of these approaches, there appears to
be no consensus as to the rate of drainage that should
be used as a threshold for tube removal and no
evidence to suggest that it is unsafe to remove tubes
that still have a relatively high rate of fluid drainage.
To help resolve this question, a non inferiority
randomized trial is currently examining patientcentered outcomes to assess the safety of removal of
chest tubes independent of the rate of drainage
relative to a 2 mL/kg body weight per day threshold.
Ann Thorac Surg 2013;96:2262–7
2000 – 2007
6083 pts
Sottoposti a resezione polmonare in elezione
199 ( 3,8%) leak persistente
194,dimessi a casa ritornano a controllo a 16 gg