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ARDS and Fluid
Shige Inoue M.D. , Ph.D.
Institute of Innovative Science and Technology Department of Emergency and Critical Care Medicine
Tokai University, School of Medicine, Japan
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Self-IntroductionTokai University, School of Medicine
2000 M.D.2008 Ph.D.2008-2010 Post Doc. Washington University in St. Louis (USA) 2010 Assistant Professor
Dr. Helicopter
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Why “Fluid”?
ARDS and Fluid
Sepsis and Fluid
Agenda
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Early Goal Directed Therapy ( EGDT)
Lactate
Lactate < 4 mmol/L
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EGDT improves survival after sepsis
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-1377
In-hospital mortality
(all patients)
0
10
20
30
40
50
60 Standard therapyEGDT
28-day mortality
60-day mortality
Mo
rta
lity
(%
)
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Goal for the first 6hrs after septic shock ( 1 C)
Early goal directed therapy
Directed Goal
CVP 8-12mmHgMAP 65mmHg≧Urine 0.5ml/kg/h≧SCVO2 70%≧
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How to improve hypoxia in the peripheral tissue?
O2 delivery↑ O2 consumption↓
Fluid therapy Hypothermia ?Treatment
Purpose
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River in the body
O2 O2 O2 O2
Hb Hb
CVPSVRICI
Port A Port B
DO2=CaO2( ship ) ×CO ( river )
Ship factorCaO2(ml/L ) =1.34×Hb×SaO2 +0.0031×PaO2
River factor CO = HR×SV
Preload ( water volume, depth )Afterload ( bund, wall )Cardiac function ( stream )
CVP CI
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Goals during the first 6 hrs of resuscitation:• a) Central venous pressure 8–12 mm Hg• b) Mean arterial pressure (MAP) ≥ 65 mm Hg• c) Urine output ≥ 0.5 mL/kg/hr• d) Central venous (superior vena cava) or ScvO270% or 65%, respectively (grade 1C).
• 2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).
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∗ Is the patient “SHOCK”? ( lactate acidosis hypothermia )∗Early Goal Directed Therapy∗ Goal∗ Monitor CVP MAP urine vo
lume ScvO2 ( Lactate clearance)
Summary so far
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• 1. We recommend crystalloids be used as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).
• 3. We suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).
Crystalloid or Colloid?
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Is HES harmful?
• 2. We recommend against the use of hydroxyethyl starches (HES) for fluid resuscitation of severe sepsis and septic shock (grade 1B).
• (This recommendation is based on the results of the VISEP [128], CRYSTMAS [122], 6S [123], and CHEST [124] trials. The results of the recently completed CRYSTAL trial were not considered.)
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JAMA. October 09, 2013. doi:10.1001/jama.2013.280502
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Crystalloids group isotonic or hypertonic saline Ringer lactate solution
Colloids group• gelatins, dextrans, • hydroxyethyl starches,• 4%or 20% of albumin
Patients• Sepsis 54%• Trauma 6%• Hypovolemic shock (without sepsis and trauma) 40%
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Among ICU patients with hypovolemia, the use of colloids vs crystalloids did not result in a significant difference in 28-day mortality.
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Although 90-day mortality was lower among patients receiving colloids, this finding should be considered exploratory and requires further study before reaching conclusions about efficacy.
HES vs. Saline
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ARDS
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Fluid or Lung?
Lung
Fluid
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30% of the cohort was shock
New Eng J Med 2006
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Fluid therapy for ARDSShock?
Fluid challenge and EGDT
+
Shock?
-
Fluid restriction
Keep MAP>70 by vasopressor etcKeep Urine output>0.5ml/kg by furosemide etc
Reduce the volume to normal body weight
-
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AgingSepsisAdult Elderly
Infection
CD8+T cells
CD4+T cells
CD8+T↓
% CD28+↓
CD4+T↓ % PD-1↑
Treg ↑
Reduction of immunocompetent T cells in elderly sepsis
Immunosupression
Inoue et al. Crit Care Med. 2013
Normal function
impaired function
Summary on the paper
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10/27 Opening ceremony of new metro in Istanbul Bogazi.
Fatih Sultan Mehmet Köprüsü
Voyage of frigate Ertugrul to Japan
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Tokai University School of Medicine Japan
Acknowledgements
Dept. of Immunology Takehito Sato
Dept. of innovative science and technology (Inoue’s Labo) Kyoko Suzuki-Utsunomiya Sayuri Chiba Yukako Komori
Teaching and Research Support Center Yoshinori Okada Yumi Iida Yoshiko Shinozaki Kayoko Iwao