Rola nowoczesnych koloidów w anestezjologii i intensywnej terapii Dr n. med. Mirosław Czuczwar II Klinika Anestezjologii i Intensywnej Terapii Uniwersytet Medyczny w Lublinie

Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. .

FEAST TRIAL Miejsce Populacja Randomizacja Afryka subsaharyjska 3141 dzieci w wieku od 60 dni do 12 lat Ciężka gorączka Zaburzenia świadomości Niewydolność oddechowa Niewydolność krążenia Kryteria wykluczenia Ciężkie niedożywienie Wstrząs o etiologii nieinfekcyjnej Gastroenteritis Randomizacja Kontrola : 2,5 – 4 ml/kg/h płynoterapia podtrzymująca (8 h – 10ml/kg) Bolus krystaloidów: 20 ml/kg 0,9% NaCl (8 h – 40 ml/kg) Bolus koloidów: 20 ml/kg 5% albumin (8 h – 40 ml/kg) Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. .

Cele leczenia płynami zapewnienie stabilizacji hemodynamicznej optymalizacja dowozu tlenu do tkanek zachowanie właściwych stosunków pomiędzy objętością wewnątrz- i pozanaczyniową korekta zaburzeń równowagi kwasowo-zasadowej prewencja uszkodzenia reperfuzyjnego Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Healey MA et al. J. Trauma 1998

Mokro, sucho czy jeszcze jakoś inaczej… Okołooperacyjne ryzyko powikłań Optymalna płynoterapia Obciążenie płynowe A B C Nie ma i nie będzie UNIWERSALNYCH wytycznych dotyczących OPTYMALNEJ płynoterapii Wytyczne powinny dotyczyć konkretnych sytuacji klinicznych Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Bellamy, editorial: Wet, dry or something else? BJA 2006

Goal-directed therapy Korzyść Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Dawka Mike Grocott, FORTE 2010

Roztwór fizjologiczny soli 0,9% roztwór soli kuchennej nie jest ani normalny ani fizjologiczny stężenie chlorków i sodu jest wyższe niż w osoczu wzrost oporu naczyniowego w nerkach obniżenie aktywności układu RAA brak większości elektrolitowych składników osocza brak dwuwęglanów lub ich prekursorów kwasica metaboliczna z rozcieńczenia kwaśne pH Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Stoneham MD and Hill EL. Br J Clin Pract 1997 Reid F et al. Clin Sci 2003; 104: 17-24 Wakim KG. JAMA 1970 Skellett S et al. Arch. Dis. Child. 2000;83;514-516 Durek G. Okołooperacyjna terapia płynowa. Medipress 2005;42.

Płyn wewnątrzkomórkowy Dystrybucja podanych dożylnie roztworów w przestrzeniach płynowych organizmu Osocze Płyn śródmiąższowy Płyn wewnątrzkomórkowy Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Koloidy 0.9% NaCl 5% Glukoza 20 40 60 80 100 % wagi ciała Lobo. Proc Nutr Soc 2004;63:453–6

Spadek dowozu O2 do tkanek Zalety i wady krystaloidów ZALETY WADY Zrównoważony skład elektrolitów Krótkotrwałe utrzymywanie się w naczyniach Właściwości buforujące Konieczność stosowania dużych objętości Łatwość podania Ryzyko wywołania hipotermii Brak ryzyka reakcji niepożądanych Obniżenie COP osocza Brak wpływu na hemostazę Ryzyko wystąpienia obrzęków Zwiększenia diurezy Ryzyko przewodnienia Niska cena Spadek dowozu O2 do tkanek Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Durek G. Okołooperacyjna terapia płynowa. Medipress 2005;42.

Krystaloid czy koloid? Korzyści ze stosowania koloidów szybkie uzupełnienie przestrzeni wewnątrznaczyniowej szybki, silniejszy i dłużej trwający efekt objętościowy obserwowany po przetoczeniu pozytywny wpływ na hemodynamikę, perfuzję narządową i dowóz tlenu Utrata krwi do 15% masy ciała - roztwór krystaloidowy Utrata krwi przekraczająca 15% masy ciała – roztwór koloidowy Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Boldt. British Journal of Anaesthesia. 2007 Lang K et al. Anesth Analg 2001

Dystrybucja podanych dożylnie roztworów w przestrzeniach płynowych organizmu PRZEDZIAŁ 5% glukoza 0.9% NaCl koloidy Wewnątrznaczyniowy ↑ ↑↑↑ Śródmiąższowy ↑↑ – Wewnątrzkomórkowy Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Lobo. Proc Nutr Soc 2004;63:453–6

Ciśnienie koloidoosmotyczne osocza podczas operacji kardiochirurgicznych u niemowląt * Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . * p < 0.05 Haneda et al. Tohoku J Exp Med 1985;147:65–71

Koloidy vs krystaloidy - wpływ na stężenie tlenu w tkankach u pacjentów poddawanych rozległym zabiegom w obrębie jamy brzusznej Volume input / output (cumulative) End of surgery First postoperative day HES group RL group Ringer’s lactate (ml) 2070 ± 870 5940 ± 1910* 3050 ± 440 11740 ± 2630* Colloids (ml) 1850 ± 380 2920 ± 360 – - Urine (ml) 640 ± 230 1980 ± 250* 2620 ± 370 5960 ± 420 *p < 0.05 vs HES group This slide shows results from a study investigating tissue oxygenation in 42 patients given either a colloid (6% HES130/0.4) plus a crystalloid (Ringer’s lactate), or only a crystalloid (Ringer’s lactate) following elective major abdominal surgery. Fluids were administered perioperatively and continued for 24 h on the intensive care unit to keep central venous pressure between 8 and 12 mmHg. As shown in the table, patients who were treated only with a crystalloid received more fluid that those treated with a colloid + crystalloid. Urine output was significantly larger in the crystalloid group than in the HES-treated patients. As shown in the figure, tissue oxygen tensions increased significantly in HES-treated patients (a maximum of 59% at T4), but decreased significantly in the RL-treated group (a maximum of -23% at T4). The highest differences between the two groups were seen on the morning of the first post-operative day (T4). In conclusion, not only are colloids effective in maintaining volume, but significantly less fluid is required (compared with crystalloid therapy alone), meaning less haemodilution and better maintained tissue oxygenation. Lang et al. Anesth Analg 2001;93:405–9

Ewolucja koloidów Żelatyny (1915) Dekstrany (1947) HES (1974) Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . HES (1999) 6% HES 130/ 0.4

Roztwory koloidowe Naturalne Syntetyczne Albuminy pochodzenia ludzkiego dostępność postulowane korzyści nie potwierdzone w badaniach klinicznych Syntetyczne Żelatyny mała cząsteczka 35 kDa (próg nerkowy – 69 kDa) – szybkie wydalanie z moczem krótkotrwały efekt objętościowy minimalny wpływ na hemostazę Dekstrany ryzyko anfilaksji i zaburzeń krzepnięcia (podobne do ch. von Willebrandta) mogą zaburzyć odczyt próby krzyżowej Hydroksyetylowana skrobia (HES) hydroliza skrobi - amylopektyna (kukurydza lub ziemniak) – cząsteczka podobna do glikogenu substytucja resztami hydroksyetylowymi (zabezpieczenie przed osoczową amylazą) Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Finfer S et al. N Engl J Med. 2004;350:2247-56.

Wpływ podawanych płynów (bolus 1 l) na objętość wewnątrznaczyniową po 90 minutach 1000 900 800 700 600 Objętość płynu w IVC (ml) 500 400 300 Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . 200 100 6% HES 5% Albumina Żelatyna 0,9% NaCl Lamke & Liljedahl. Resuscitation 1976;5:93–102

Nazewnictwo roztworów HES Stopień Podstawienia Stężenie roztworu (g/l) Masa cząsteczkowa Wzór podstawienia C2/C6 6% HES 130 / 0.4 /9:1 Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Finfer S et al. N Engl J Med. 2004;350:2247-56.

Farmakokinetyka roztworów HES 130/0,42 i HES 200/0,5 po kolejnych podaniach u zdrowych ochotników Dawka dzienna – 50 g Hydroxyethyl starches can accumulate in the circulation when administered repeatedly. Such accumulation is thought to be partly responsible for undesirable effects such as tissue storage and blood coagulation impairment. In this study in healthy volunteers, the pharmacokinetics of HES 130/0.42/6:1 were investigated using a crossover design with HES 200/0.5 serving as control. HES (50 g of each type) was administered in 4 h day 21 for a period of five consecutive days. HES serum concentrations were used for computation of pharmacokinetic coefficients. The circulation was freed from the load with HES 130/0.42 within 20 h after end of the previous infusion, while the amount of HES 200/0.5 increased continuously from one administration to the other. Elimination half-life (shown on the slide) was significantly lower with HES 130/0.42. Repeated administration of a low molecular weight starch (HES 130/0.42 vs HES 200/0.5) showed no accumulation and fewer tendencies to time-dependent changes in pharmacokinetic parameters. 130 kDa is the ideal size of starch for optimal microcirculation function. Lehmann et al. Br J Anaesth 2007;98:635–44

Farmakokinetyka 10% roztworu HES 130/0,42 podawanego zdrowym ochotniom w dawce 500 ml/d Hydroxyethyl starches can accumulate in the circulation when administered repeatedly. Such accumulation is thought to be partly responsible for undesirable effects such as tissue storage and blood coagulation impairment. In this study in healthy volunteers, the pharmacokinetics of HES 130/0.42/6:1 were investigated using a crossover design with HES 200/0.5 serving as control. HES (50 g of each type) was administered in 4 h day 21 for a period of five consecutive days. HES serum concentrations were used for computation of pharmacokinetic coefficients. The circulation was freed from the load with HES 130/0.42 within 20 h after end of the previous infusion, while the amount of HES 200/0.5 increased continuously from one administration to the other. Elimination half-life (shown on the slide) was significantly lower with HES 130/0.42. Repeated administration of a low molecular weight starch (HES 130/0.42 vs HES 200/0.5) showed no accumulation and fewer tendencies to time-dependent changes in pharmacokinetic parameters. 130 kDa is the ideal size of starch for optimal microcirculation function. Waitzinger et al, Clin Drug Invest, 2003

Wpływ roztworów HES na hemostazę Szybko degradowane roztwory HES mają minimalny lub żaden wpływ na krzepnięcie krwi HES 450/0.7 HES 200/0.62 HES 200/0.5 HES 70/0.5 HES 130/0.4–0.42 krwawienie Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . Kozek-Langenecker. Anesthesiology 2005;103:654–60

Bezpieczeństwo roztworu HES 130/0,4 u pacjentów z ciężką niewydolnością nerek Jungheinrich C. Anesth Analg, 2002

Minimalny klirens kreatyniny w okresie pooperacyjnym (mL/min) Bezpieczeństwo roztworu HES 130/0,4 u pacjentów z przedoperacyjną niewydolnością nerek operowanych z powodu TAB Minimalny klirens kreatyniny w okresie pooperacyjnym (mL/min) Szczytowy wzrost stężenia kreatyniny w osoczu (µmol/L) do 6 doby po operacji Godet et al. Eur J Anaesthesiol 2008;25:986–94

Co to jest SID? Czyli co nieco o teorii Stewarta Krew zawiera silne jony, które całkowicie dysoscjują Na+, K+, Ca++, Mg++ i Cl- Krew zawiera również substancje nie całkowicie zdysocjowane siarczan, octan, mleczan, β-hydroksymaślan SID = [silne kationy] - [silne aniony] Wartość fizjologiczna w osoczu 42 mEq/L Roztwór 0,9% NaCl jest całkowicie zdysocjowany [Na+] – [Cl-] = 0 Przetoczenie dużej ilości 0,9% NaCl obniża SID osocza Możliwość rozwoju kwasicy metabolicznej The slide gives an explanation of strong ion difference (SID). Morgan. Crit Care 2005;9:204–11

Wpływ podawania roztworów zbilansowanych i niezbilansowanych na równowagę kwasowo-zasadową * + Grupa zbilansowana - HES 130/0.4 + krystaloidy Grupa niezbilansowana HES 130/0.4 + krystaloidy Wartość wyjściowa Po zabiegu 5 h OIT 1sza doba 2ga - 6 - 4 - 2 2 4 BE (mmol/L) Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . +P <0.05 różnica od wartości wyjściowej *P <0.05 różnica pomiędzy grupami Boldt et al. Intensive Care Med 2009;35:462–470

Wpływ podawania roztworów zbilansowanych i niezbilansowanych na równowagę kwasowo-zasadową HES 130/0.4 zawieszony w roztworze zbilansowanym HES 130/0.4 zawieszony w roztworze 0,9% NaCl 1 ** -1 ** ** ** ** -2 Nadmiar zasad (mmol/l) -3 -4 **p < 0.01 Zmienna metryczna: [95% przedział ufności] -5 Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. . T0 T1 T2 T3 T4 T5 T0 = po indukcji znieczulenia T1 = po indukcji znieczulenia T2 = po zakończeniu krążenia pozaustrojowego T3 = po zakończeniu zabiegu chirurgicznego T4 = 1h po przybyciu do OIT T5 = pierwszy dzień po operacji Base E. Standl T. J Cardiothorac Vasc Anesth; [Epub ahead of print] 2011

Pooperacyjna kwasica hiperchloremiczna u pacjentów chirurgicznych w podeszłym wieku 70 60 50 p = 0.0001 40 Kwasica hiperchloremiczna (%) 30 The IV administration of sodium chloride solutions may produce a metabolic acidosis and gastrointestinal dysfunction. These data are taken from a prospective, randomised, blinded study in 47 elderly patients undergoing major, non-cardiac surgery who received either balanced or unbalanced crystalloid plus colloid therapy. Patients in this study received an intraoperative fluid regimen of either • Hartmann’s solution and 6% hetastarch in balanced electrolyte and glucose injection or • 0.9% sodium chloride solution and 6% hetastarch in 0.9% sodium chloride solution. Starch is not responsible for the hyperchloraemic acidosis seen in this study, it is the solution in which it is dissolved. Starches dissolved in 0.9% NaCl cause significantly more metabolic acidosis than starches dissolved in a physiologically balanced solution. 20 10 HES w 0,9% NaCl HES w roztworze zbilansowanym Wilkes et al. AnesthAnalg2001;93:811–6

Możliwy lub prawdopodobny Pooperacyjna kwasica hiperchloremiczna u pacjentów chirurgicznych w podeszłym wieku 400 PONV Ból brzucha Ból głowy Pragnienie Hiperwentylacja 350 300 250 Liczba zgłoszonych zdarzeń niepożądanych HES w 0,9% NaCl 200 HES w roztworze zbilansowanym 150 The IV administration of sodium chloride solutions may produce a metabolic acidosis and gastrointestinal dysfunction. These data are taken from a prospective, randomised, blinded study in 47 elderly patients undergoing major, non-cardiac surgery who received either balanced or unbalanced crystalloid plus colloid therapy. Patients in this study received an intraoperative fluid regimen of either • Hartmann’s solution and 6% hetastarch in balanced electrolyte and glucose injection or • 0.9% sodium chloride solution and 6% hetastarch in 0.9% sodium chloride solution. Starch is not responsible for the hyperchloraemic acidosis seen in this study, it is the solution in which it is dissolved. Starches dissolved in 0.9% NaCl cause significantly more metabolic acidosis than starches dissolved in a physiologically balanced solution. 100 50 Możliwy lub prawdopodobny związek z terapią Całkowita liczba zdarzeń Wilkes et al. AnesthAnalg2001;93:811–6

Idealny roztwór koloidów powinien nie kumulować się w osoczu i tkankach nie wpływać na hemostazę i czynność nerek łatwo poddawać się eliminacji z organizmu Idealny roztwór koloidów powinien HES 130/0,4 A także: być zawieszony w zrównoważonym do składu osocza roztworze krystaloidowym 0,9% roztwór soli kuchennej nie jest ani normalny ani fizjologiczny stężenie chlorków i sodu jest wyższe niż w osoczu brak dwuwęglanów lub ich prekursorów kwaśne pH Piazza et al. IJGM 2011: 287–95

Dostępne na rynku roztwory HES Składniki mmol/l Osocze HAES Steril Voluven Tetraspan Volulyte Plasma Volume Na 142 154 140 137 130 K 4 5,36 Cl 101 118 110 112 Ca 2,5 0,912 Mg 1,5 1 0,984 Octany/ Jabłczan/ Mleczan NA 24/5/0 34/0/0 27/0/0 Koloid HES Stężenie koloidu 6% 6%, 10% Mcz 200 MS 0,4-0,55 0,38-0,45 0,42 C2/C6 5:1 9:1 6:1 osmol 288 309 308 296/297 286,5 277 Different types of colloids and crystalloids, as described in this slide, are currently available for fluid therapy. There is currently a wide variation in the types and amount of fluids used throughout the world. Common perceptions are that the Americans appear to use albumin more than Europeans, Scandinavians use Ringer’s acetate more than other Europeans, the Germans use a lot of hydroxyethyl starch dissolved in saline and the English prefer to use gelatin. Nobody understands the reasons for these differences, and they just make the situation very confusing. One of the aims of the FORTE programme is to put the science back into fluids and to try and understand the real differences between the different types of fluids, and determine the best solution for different situations, to come to an optimised solution. .

„PRIMUM NON NOCERE” PODSUMOWANIE „… ograniczona opublikowana wiedza dot. efektu zbilansowanych roztworów na wynik leczenia nie pozwala obecnie zalecić zamiany terapii płynowej na preparaty zbilansowanych koloidów.” Wlew zrównoważonego roztworu koloidowego na bazie HES: jest pozbawiony możliwości wywoływania jatrogennych zaburzeń elektrolitowych. nie wpływa na równowagę kwasowo-zasadową chorego powoduje szybki, silniejszy i dłużej trwający efekt objętościowy w porównaniu do roztworów krystaloidów nie powoduje zaburzeń krzepnięcia „PRIMUM NON NOCERE” Guidet, Critical Care, 2010, 14:325