Koloidy v kardioanestezii CON. T. Kotulák Klinika anestezie a resuscitace, IKEM, Praha a 1. LF UK a VFN, Praha

Transkript

1 Koloidy v kardioanestezii CON T. Kotulák Klinika anestezie a resuscitace, IKEM, Praha a 1. LF UK a VFN, Praha

2 strategie tekutinové terapie cíle tekutinové terapie: udržení adekvátního perfuzního tlaku udržení adekvátního srdečního výdeje oba tyto parametry jsou určující pro RBF RBF je spolu s glomerulárním arteriolárním tonem a koloidním osmotickým tlakem proteinů v plasmě - transglomerulární gradient

3 možnosti tekutinové terapie: objemová terapie: krystaloidy koloidy - syntetické, krevní deriváty balancované, nebalancované normotonické, hypertonické

4 Tekutinová terapie - HES HES: vysoce polymerizované molekuly cukrů, charakterizované: Molekulární vahou kda Poměrem molární substituce (poměr glukózových skupin molekuly škrobu substituovaných hydroxyetyl skupinou 0,35 0,5) Koncentrací 6%, 10% Poměrem C2/C6 Původ brambory nebo kukuřice

5 HES - AKI Hypotézy: Mechanismus není zcela objasněn Hyperonkotické selhání ledvin: redukce GFR sekundárně při redukci FF (Moran 1987) Akumulace filtrovaných koloidních molekul s následnou tubulární obstrukcí a medulární hypoxií Vysoká koncentrace HES molekul v ledvině při sekci (Lukasewitz 1998) Osmotic nephrosis like lesions a opožděná funkce graftu u Tx od donorů léčených HES (Cittanova 1996)

6 HES - AKI - depozita v ledvině Joannidis M. ISICEM 2015

7 HES - AKI

8 HES - AKI Identifikovali 34 studií + 4 probíhající 33 studií u dospělých pacientů, n= 2577 Intervence: HES 6% 130/0,4, 200/0.5 a 200/0.6, pouze 4 studie 10% 200/0.5 Porovnávaný roztok: Albumin, želatina, RF, FR

9 HES - AKI HES versus ostatní tekutiny HES léčení pacienti bez sepse měli nesignifikantní pokles potřeby RRT ve srovnání s jinými roztoky HES léčení pacienti se sepsí měli 1,59 krát vyšší riziko potřeby RRT ve srovnání s jinými roztoky (95% CI 1,2 2,1)

10 A Multi-centre Randomized Controlled Trial of Fluid Resuscitation With Starch (6%Hydroxyethyl Starch 130/0.4) Compared to Saline (0.9% Sodium Chloride) in Intensive Care Patients on Mortality Primary Outcome Measures: All cause 90 days mortality Secondary Outcome Measures: Renal failure requiring renal replacement therapy will be assessed using hospital records. [ Other organ failures will be assessed using the Sequential Organ Failure Assessment (SOFA) score which is based on biochemical and bio-physiological parameters recorded in the hospital record. ICU, hospital and 28 day mortality Quality of life will be assessed using the EQ-5D questionnaire. Functional status will be assessed using the Glasgow Outcome score. Estimated Enrollment: 7000

11

12 Crystalloid Versus Hydroxyethyl Starch Trials (CHEST) A Multi-centre Randomized Controlled Trial of Fluid Resuscitation With Starch (6%Hydroxyethyl Starch 130/0.4) Compared to Saline (0.9% Sodium Chloride) in Intensive Care Patients on Mortality Primary Outcome Measures: All cause 90 days mortality Secondary Outcome Measures: Renal failure requiring renal replacement therapy will be assessed using hospital records. [ Other organ failures will be assessed using the Sequential Organ Failure Assessment (SOFA) score which is based on biochemical and bio-physiological parameters recorded in the hospital record. ICU, hospital and 28 day mortality Quality of life will be assessed using the EQ-5D questionnaire. Functional status will be assessed using the Glasgow Outcome score. Estimated Enrollment: 7000

13 Crystalloid Versus Hydroxyethyl Starch Trials (CHEST) A Multi-centre Randomized Controlled Trial of Fluid Resuscitation With Starch (6%Hydroxyethyl Starch 130/0.4) Compared to Saline (0.9% Sodium Chloride) in Intensive Care Patients on Mortality Primary Outcome Measures: All cause 90 days mortality Secondary Outcome Measures: Renal failure requiring renal replacement therapy will be assessed using hospital records. [ Other organ failures will be assessed using the Sequential Organ Failure Assessment (SOFA) score which is based on biochemical and bio-physiological parameters recorded in the hospital record. ICU, hospital and 28 day mortality Quality of life will be assessed using the EQ-5D questionnaire. Functional status will be assessed using the Glasgow Outcome score. Estimated Enrollment: 7000

14 6S Trial Group Scandinavian Critical Care Trials Group.

15 6S Trial Group Scandinavian Critical Care Trials Group.

16 Crystmas study

17 Crystmas study

18

19

20 From: Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation: A Systematic Review and Meta-analysis JAMA. 2013;309(7): doi: /jama Figure Legend: The varying sizes of the boxes represent the weight in the analysis. HES indicates hydroxyethyl starch. Risk ratios (RRs) are derived by a random-effects model using Mantel-Haenszel tests.

21 T

22 A Multi-centre Randomized Controlled Trial of Fluid Resuscitation With Starch (6%Hydroxyethyl Starch 130/0.4) Compared to Saline (0.9% Sodium Chloride) in Intensive Care Patients on Mortality Primary Outcome Measures: All cause 90 days mortality Secondary Outcome Measures: Renal failure requiring renal replacement therapy will be assessed using hospital records. [ Other organ failures will be assessed using the Sequential Organ Failure Assessment (SOFA) score which is based on biochemical and bio-physiological parameters recorded in the hospital record. ICU, hospital and 28 day mortality Quality of life will be assessed using the EQ-5D questionnaire. Functional status will be assessed using the Glasgow Outcome score. Estimated Enrollment: 7000

23 A Multi-centre Randomized Controlled Trial of Fluid Resuscitation With Starch (6%Hydroxyethyl Starch 130/0.4) Compared to Saline (0.9% Sodium Chloride) in Intensive Care Patients on Mortality Primary Outcome Measures: All cause 90 days mortality Secondary Outcome Measures: Renal failure requiring renal replacement therapy will be assessed using hospital records. [ Other organ failures will be assessed using the Sequential Organ Failure Assessment (SOFA) score which is based on biochemical and bio-physiological parameters recorded in the hospital record. ICU, hospital and 28 day mortality Quality of life will be assessed using the EQ-5D questionnaire. Functional status will be assessed using the Glasgow Outcome score. Estimated Enrollment: 7000

24

25

26

27

28

29

30

31

32

33

34

35

36 T

37 T

38 T

39 T

40 T

41 T

42

43

44 koloidy v kardiochirurgii - závěr použití koloidů je omezené absolutní hypovolémie - život ohrožující krvácení albumin? cena T

45

46

47

48