Colloids versus Crystalloids: Do we have an answer yet??
|
|
- Cornelius Gardner
- 7 years ago
- Views:
Transcription
1 Colloids versus Crystalloids: Do we have an answer yet?? Lauralyn McIntyre MD, FRCP(C), MHSc Scientist, Ottawa Hospital Research Institute Assistant Professor, University of Ottawa Department of Epidemiology and Community Medicine Center for Transfusion and Critical Care Research
2 Conflicts of Interest Unrestricted funds CSL Behring
3 The Colloid Crystalloid Question Is one of the oldest Basic yet fundamental question The first intervention given To every patient Often several litres Since fluids critical for achievement of hemodynamic stability, there is a potential for impact on clinically important outcomes
4 Main categories of usual care resuscitation fluids Crystalloid Fluid Normal Saline Ringers Lactate Colloid Fluid Albumin Hydroxyethyl starch
5 Main categories of usual care resuscitation fluids Crystalloid Fluid Normal Saline Ringers Lactate Colloid Fluid Albumin Hydroxyethyl starch Other Colloids: Gelatins Dextrans
6 Components of Normal Saline and Ringers Lactate Na+ mmol/l Osmolarity Clmmol/L K+ mmol/l Ca++ mmol/l Lactate mmol/l Normal Saline Ringers Lactate
7 Albumin Most common human plasma protein (60%) Synthesized in the liver Molecular weight of 66 Kd Responsible for 80% osmotic pressure Available: Iso oncotic (4 5%) Hyper oncotic (20 25%) Quinlan et al, Hepatology, 2005
8 What are hydroxyethyl starch (HES) fluids? Amylopectin starch (branched chain glucose molecules) Hydroxyethylation at C2 and C6 carbon units (substitution) Vary in size ( kd) Vary in the amount of substitution and ratio of substitution
9 Rationale for Resuscitating with Colloids compared to Crystalloids Plasma 3 L ISS 10 L IC 30 L Blood Cells 2 L
10 Rationale for Resuscitating with Colloids compared to Crystalloids Plasma 3 L ISS 10 L IC 30 L Blood Cells 2 L Iso-oncotic colloid
11 Iso-oncotic colloid Hyper-oncotic colloid Rationale for Resuscitating with Colloids compared to Crystalloids Plasma 3 L ISS 10 L IC 30 L Blood Cells 2 L
12 Iso-oncotic colloid Hyper-oncotic colloid Rationale for Resuscitating with Colloids compared to Crystalloids Plasma 3 L ISS 10 L IC 30 L Blood Cells 2 L
13 Iso-oncotic colloid Hyper-oncotic colloid Rationale for Resuscitating with Colloids compared to Crystalloids Plasma 3 L Optimization of the microcirculation?impact on microcirculatory dysfunction ISS 10 L IC 30 L?Modulation of inflammatory response Blood Cells 2 L
14 The Colloid Crystalloid Question Research on this question for several decades And yes, there have been many studies and many systematic reviews
15 Cochrane Systematic Reviews Author/Year Fluids compared # Studies Perel, 2011 Colloids vs Crystalloids 56 Bunn, 2011 Colloid vs Colloid 72 Alderson 2009 Albumin vs no albumin 37 Dart 2010 HES vs other fluid 34
16 Cochrane Systematic Reviews Author/Year Fluids compared # Studies Perel, 2011 Colloids vs Crystalloids 56 Bunn, 2011 Colloid vs Colloid 72 Alderson 2009 Albumin vs no albumin 37 Dart 2010 HES vs other fluid 34 So why are we still studying this question?
17 Small sample size Cochrane Systematic Reviews Single centre Dated resuscitation protocols Insufficient dose Author/Year Fluids compared # Studies Perel, 2011 Colloids vs Crystalloids 56 Surrogate outcomes Bunn, 2011 Colloid vs Colloid 72 Few studies in the critically ill Alderson 2009 Albumin vs no albumin 37 Low methodological rigor (risk of bias high) Dart 2010 HES vs other fluid 34 So why are we still studying this question?
18 SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries Finfer et al, Critical Care, 2010; 14:R185
19 SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries Finfer et al, Critical Care, 2010; 14:R185
20 SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries Finfer et al, Critical Care, 2010; 14:R185
21 SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries Finfer et al, Critical Care, 2010; 14:R185
22 SAFE TRIPS II: International cross sectional study 391 ICUs and 25 countries Finfer et al, Critical Care, 2010; 14:R185
23 Are colloid fluids better maintained in the intravascular space as compared to
24 RCT/Yr Population Fluid Comparators Ratio Crystalloid/Colloid SAFE/04 VISEP/08 McIntyre/08 Critically ill N = 6997 Severe Sepsis/ Septic Shock N = 537 Septic Shock N = 40 4% albumin vs normal saline 10% HES vs ringers lactate 10% HES vs normal saline Hartog et al, Anesth and Anal 2011, 112:
25 RCT/Yr Population Fluid Comparators Ratio Crystalloid/Colloid SAFE/04 VISEP/08 McIntyre/08 Critically ill N = 6997 Severe Sepsis/ Septic Shock N = 537 Septic Shock N = 40 4% albumin vs normal saline 10% HES vs ringers lactate 10% HES vs normal saline Hartog et al, Anesth and Anal 2011, 112:
26 RCT/Yr Population Fluid Comparators Ratio Crystalloid/Colloid SAFE/04 VISEP/08 McIntyre/08 Critically ill N = 6997 Severe Sepsis/ Septic Shock N = 537 Septic Shock N = 40 4% albumin vs normal saline 10% HES vs ringers lactate 10% HES vs normal saline Hartog et al, Anesth and Anal 2011, 112:
27 RCT/Yr Population Fluid Comparators Ratio Crystalloid/Colloid SAFE/04 VISEP/08 McIntyre/08 Critically ill N = 6997 Severe Sepsis/ Septic Shock N = 537 Septic Shock N = 40 4% albumin vs normal saline 10% HES vs ringers lactate 10% HES vs normal saline? Endothelial Cell Leak Hartog et al, Anesth and Anal 2011, 112:
28 Are there potential harms associated with the use of colloid fluid in the
29 Hydroxyethyl starches Albumin Coagulopathy yes yes Transmission viral infection no yes Anaphylaxis yes (<0.006%) yes (<0.1%) Pruritis yes no Renal Failure yes? Grocott, M, Anesthesia and Analgesia, 2005
30 Hydroxyethyl starches Albumin Coagulopathy yes yes Transmission viral infection no yes Anaphylaxis yes (<0.006%) yes (<0.1%) Pruritis yes no Renal Failure yes? Grocott, M, Anesthesia and Analgesia, 2005
31 Brunkhorst et al, NEJM, 2008
32 Baseline Characteristics Mean (SD) Ringers Lactate N=275 HES N=262 Age 64.9 ± ± 13.3 Sex (male) (%) APACHE II Score 20.3 ± ± 6.7 P value Results (%) *RRT 18.8% 31% Acute renal failure day Mortality 24.1% 26.7% day Mortality 33.9% 41% *RRT = renal replacement therapy Brunkhorst et al, NEJM, 2008
33 VISEP trial: HES dose and RRT Brunkhorst et al, NEJM, 2008
34 VISEP trial: HES dose and RRT Limitations of the VISEP Trial Fluid protocol violations No criteria for dialysis Un-blinded study Brunkhorst et al, NEJM, 2008
35 What evidence related to HES is forthcoming? Trial Population Fluids compared Primary Outcome 6S Severe Sepsis N = 800 Voluven vs Ringers lactate 90 Day Mortality or Dialysis CHEST Critically ill N = 7000 Voluven vs Normal Saline 90 Day Mortality
36 Finfer et al, NEJM 2004; 350:
37
38
39
40
41 Survival in SAFE TBI sub-group (n = 460) Survival 28 Days Survival 24 Months 20.4% 33.2%
42 Survival in SAFE TBI sub-group (n = 460) Survival 28 Days Survival 24 Months 20.4% Severe TBI (N = 290) RR and 95% CI: 1.88 (1.31 to 1.70) 33.2%
43 SAFE TBI comments Post - hoc sub group analysis Co-interventions for TBI not described Biological mechanisms not clear Intracranial hypertension 30% vs 34% albumin vs normal saline
44 Predefined sub-group with severe sepsis n = 1218 Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
45 SAFE Severe Sepsis: Baseline Characteristics Albumin Saline Age 60.5 ± ±17.1 Gender (male) 59.6% 57.1% APACHE II 21.6± ±7.7 Septic Shock 34.8% 37.3% ARDS 6.5% 6.8% Ventilation 56.8% 59.4%
46 SAFE Severe Sepsis: 28 day mortality Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
47 SAFE Severe Sepsis: 28 day mortality Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
48 SAFE Severe Sepsis: 28 day mortality No differences in renal injury between fluid groups Finfer et al, Intensive Care Medicine, published on line, October 6, 2010
49 Maitland et al, NEJM, 2011 FEAST Trial 3141 African children with febrile illness and impaired perfusion Randomized to boluses of 5% albumin, normal saline, or no bolus
50 FEAST Trial 3141 African children with febrile illness and impaired perfusion Randomized to boluses of 5% albumin, normal saline, or no bolus Bolus 5% albumin Bolus normal saline Control 48 hour death 10.6% 10.5% 7.3% 4 week death 12.2% 12.0% 8.7% Neurologic sequlae Increased ICP or pulmonary edema 2.2% 1.9% 2.0% 2.6% 2.2% 1.7% Maitland et al, NEJM, 2011
51 More evidence for albumin in sepsis is coming EARRS Trial ALBIOS Trial PRECISE Trial Populatio n Septic shock within first 6 hours ICU admission Severe Sepsis/Septic Shock within 24 hours in ICU Early Septic shock from the ED Sample Size Interventi on Primary Outcome Open label 100 mls 20% albumin Q8H versus normal saline for first 3 days in ICU 28 Day Mortality Open label Up to 300 mls infused 20% albumin vs crystalloid fluid according to albumin levels in ICU Double blind Head to Head 500 ml boluses 5% albumin versus normal saline starting in ED 28 Day Mortality 90 Day Mortality
52 Colloids versus Crystalloids for Fluid Resuscitation: Do we have the ANSWERS yet? Populations Albumin Hydroxyethyl starch Heterogeneous critically ill Yes Evidence coming Septic shock Evidence coming Evidence coming Trauma SG evidence SG evidence ARDS SG evidence SG evidence Traumatic Brain Injury SG evidence SG evidence Sub Arachnoid Hemorrhage?? SG = evidence from sub group
Optimal fluid therapy in 2013. Eric Hoste Department of Intensive Care Medicine Ghent University Hospital Ghent University
Optimal fluid therapy in 2013 Eric Hoste Department of Intensive Care Medicine Ghent University Hospital Ghent University EGDT: fluids are good & prevent AKI Lin et al, Shock 2006 EGDT and AKI Prowle et
More informationThe Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy
The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy Cindy Goodrich RN, MS, CCRN Content Description Sepsis is caused by widespread tissue injury and systemic inflammation resulting
More informationThe Initial and 24 h (After the Patient Rehabilitation) Deficit of Arterial Blood Gases as Predictors of Patients Outcome
Biomedical & Pharmacology Journal Vol. 6(2), 259-264 (2013) The Initial and 24 h (After the Patient Rehabilitation) Deficit of Arterial Blood Gases as Predictors of Patients Outcome Vadod Norouzi 1, Ali
More informationSepsis: Identification and Treatment
Sepsis: Identification and Treatment Daniel Z. Uslan, MD Associate Clinical Professor Division of Infectious Diseases Medical Director, UCLA Sepsis Task Force Severe Sepsis: A Significant Healthcare Challenge
More informationMedical Direction and Practices Board WHITE PAPER
Medical Direction and Practices Board WHITE PAPER Use of Pressors in Pre-Hospital Medicine: Proper Indication and State of the Science Regarding Proper Choice of Pressor BACKGROUND Shock is caused by a
More informationSubject: Severe Sepsis/Septic Shock Published Date: August 9, 2013 Scope: Hospital Wide Original Creation Date: August 9, 2013
Stony Brook Medicine Severe Sepsis/Septic Shock Recognition and Treatment Protocols Subject: Severe Sepsis/Septic Shock Published Date: August 9, 2013 Scope: Hospital Wide Original Creation Date: August
More informationSepsis Reassess patient Monitor and maintain respiratory/ hemodynamic status
Patient exhibits two or more of the following SIRS criteria: Temperature greater than 38 o C (100.4 o F) or less SIRS than criteria 36 o C (96.8 o F) Heart Rate greater than 90 beats/minute Respiratory
More informationTranexamic Acid. Tranexamic Acid. Overview. Blood Conservation Strategies. Blood Conservation Strategies. Blood Conservation Strategies
Overview Where We Use It And Why Andreas Antoniou, M.D., M.Sc. Department of Anesthesia and Perioperative Medicine University of Western Ontario November 14 th, 2009 Hemostasis Fibrinolysis Aprotinin and
More informationSeptic Shock: Pharmacologic Agents for Hemodynamic Support. Nathan E Cope, PharmD PGY2 Critical Care Pharmacy Resident
Septic Shock: Pharmacologic Agents for Hemodynamic Support Nathan E Cope, PharmD PGY2 Critical Care Pharmacy Resident Objectives Define septic shock and briefly review pathophysiology Outline receptor
More informationVASOPRESSOR AGENTS IN SEPTIC SHOCK
VASOPRESSOR AGENTS IN SEPTIC SHOCK Daniel De Backer Head Dept Intensive Care, CHIREC hospitals, Belgium Professor of Intensive Care, Université Libre de Bruxelles President European Society of Intensive
More informationA Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit
The new england journal of medicine original article A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit The SAFE Study Investigators* abstract background It remains uncertain
More informationDecreasing Sepsis Mortality at the University of Colorado Hospital
Decreasing Sepsis Mortality at the University of Colorado Hospital Maureen Dzialo, RN, BSN - Nurse Manager, Cardiac Intensive Care Unit Olivia Kerveillant, RN Clinical Nurse III, Medical Intensive Care
More informationAktuelle Literatur aus der Notfallmedizin
05.02.2014 Aktuelle Literatur aus der Notfallmedizin prä- und innerklinisch Aktuelle Publikationen aus 2012 / 2013 PubMed hits zu emergency medicine 12,599 Abstract OBJECTIVES: Current American Heart
More informationVasopressors. Judith Hellman, M.D. Associate Professor Anesthesia and Perioperative Care University of California, San Francisco
Vasopressors Judith Hellman, M.D. Associate Professor Anesthesia and Perioperative Care University of California, San Francisco Overview Define shock states Review drugs commonly used to treat hypotension
More informationOmega-3 fatty acids improve the diagnosis-related clinical outcome. Critical Care Medicine April 2006;34(4):972-9
Omega-3 fatty acids improve the diagnosis-related clinical outcome 1 Critical Care Medicine April 2006;34(4):972-9 Volume 34(4), April 2006, pp 972-979 Heller, Axel R. MD, PhD; Rössler, Susann; Litz, Rainer
More informationPlumbing 101:! TXA and EMS! Jay H. Reich, MD FACEP! EMS Medical Director! City of Kansas City, Missouri/Kansas City Fire Department!
Plumbing 101:! TXA and EMS! Jay H. Reich, MD FACEP! EMS Medical Director! City of Kansas City, Missouri/Kansas City Fire Department! EMS Section Chief! Department of Emergency Medicine! University of Missouri-Kansas
More information2011 EBM-hyperglycemia
嗎 2011 EBM-hyperglycemia 陳 莉 瑋 醫 師 一 定 要 打 打 bolus insulin? 用 FinePrint 列 印 - 可 在 www.ahasoft.com.tw/fineprint 訂 購 Question 1 Is bolus insulin necessary in DKA? P:DKA adult patient I:initial bolus insulin+insulin
More informationTelemedicine Resuscitation & Arrest Trials (TreAT)
Telemedicine Resuscitation & Arrest Trials (TreAT) Telemedicine within the ED for treating Severe Sepsis: A Hub and Spoke Telemedicine pilot SUMR Intern: Karole Collier Mentor: Dr. Brendan Carr & Dr. Anish
More informationESCMID Online Lecture Library. by author
Do statins improve outcomes of patients with sepsis and pneumonia? Jordi Carratalà Department of Infectious Diseases Statins for sepsis & community-acquired pneumonia Sepsis and CAP are major healthcare
More informationEmergency Fluid Therapy in Companion Animals
Emergency Fluid Therapy in Companion Animals Paul Pitney BVSc paul.pitney@tafensw.edu.au The administration of appropriate types and quantities of intravenous fluids is the cornerstone of emergency therapy
More informationBOARD OF PHARMACY SPECIALITIES 2215 Constitution Avenue, NW Washington, DC 20037-2985 202-429-7591 FAX 202-429-6304 info@bpsweb.org www.bpsweb.
BOARD OF PHARMACY SPECIALITIES 2215 Constitution Avenue, NW Washington, DC 20037-2985 202-429-7591 FAX 202-429-6304 info@bpsweb.org www.bpsweb.org Content Outline for the CRITICAL PHARMACY SPECIALTY CERTIFICATION
More information2002 burns responsible for 322,000 deaths world wide. aboriginal community in NA Most burns occur in the urban environment
Burn Injuries: The Problem 2002 burns responsible for 322,000 deaths world wide 4 th as cause of unintentional child injury death in the USA 3 rd leading cause of unintentional death in aboriginal community
More informationThe OPALSO Prehospital Research Group OPALS
The O Prehospital Research Group The Resuscitation Outcomes Consortium Studies: Trauma Study Hypertonic Resuscitation following Traumatic Injury Purpose of the Study To determine if Hypertonic Saline with
More informationIntravenous Fluid Selection
BENNMC03_0131186116.qxd 3/9/05 18:24 Page 20 seema Seema-3:Desktop Folder:PQ731: CHAPTER 3 Intravenous Fluid Selection LEARNING OBJECTIVES By the end of this chapter, you should be able to: Describe and
More informationSE5h, Sepsis Education.pdf. Surviving Sepsis
Surviving Sepsis 1 Scope and Impact of the Problem: Severe sepsis is a major healthcare problem that affects millions of people around the world each year with an extremely high mortality rate of 30 to
More informationHypertonic saline in critical care: a review of the literature and guidelines for use in hypotensive states and raised intracranial pressure*
doi:10.1111/j.1365-2044.2009.05986.x REVIEW ARTICLE Hypertonic saline in critical care: a review of the literature and guidelines for use in hypotensive states and raised intracranial pressure* G. F. Strandvik
More informationPurpose: To evaluate the effect of HES solutions on renal outcomes and mortality among critically ill patients requiring acute volume resuscitation.
Renal outcomes and mortality following hydroxyethyl starch resuscitation of critically ill patients: systematic review and meta-analysis of randomized trials Ryan Zarychanski, Alexis F Turgeon, Dean A
More informationHead Injury. Dr Sally McCarthy Medical Director ECI
Head Injury Dr Sally McCarthy Medical Director ECI Head injury in the emergency department A common presentation 80% Mild Head Injury = GCS 14 15 10% Moderate Head Injury = GCS 9 13 10% Severe Head Injury
More informationFLUID & ELECTROLYTE THERAPY Lyon Lee DVM PhD DACVA
FLUID & ELECTROLYTE THERAPY Lyon Lee DVM PhD DACVA Purposes of fluid administration during the perianesthetic period Replace insensible fluid losses (evaporation, diffusion) during the anesthetic period
More informationSUMMARY OF PRODUCT CHARACTERISTICS. Albuman 200 g/l is a solution containing 200 g/l (20%) of total protein of which at least 95% is human albumin.
Albuman 200 g/l SPC 01 December 2015 SUMMARY OF PRODUCT CHARACTERISTICS 1. NAME OF THE MEDICINAL PRODUCT Albuman 200 g/l solution for infusion 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Albuman 200 g/l
More informationRecommendations: Other Supportive Therapy of Severe Sepsis*
Recommendations: Other Supportive Therapy of Severe Sepsis* K. Blood Product Administration 1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial
More informationExtracorporeal Life Support Organization (ELSO) Guidelines for Neonatal Respiratory Failure
Extracorporeal Life Support Organization (ELSO) Guidelines for Neonatal Respiratory Failure Introduction This neonatal respiratory failure guideline is a supplement to ELSO s General Guidelines for all
More informationBUNDLES IN 2013: SURVIVING SEPSIS CAMPAIGN
BUNDLES IN 2013: SURVIVING SEPSIS CAMPAIGN R. Phillip Dellinger MD, MSc, MCCM Professor of Medicine Cooper Medical School of Rowan University Professor of Medicine University Medicine and Dentistry of
More informationInternational Guidelines for Management of Severe Sepsis and Septic Shock
International Guidelines for Management of Severe Sepsis and Septic Shock Sponsoring organizations: American Association of Critical-Care Nurses American College of Chest Physicians American College of
More informationSystolic Blood Pressure Intervention Trial (SPRINT) Principal Results
Systolic Blood Pressure Intervention Trial (SPRINT) Principal Results Paul K. Whelton, MB, MD, MSc Chair, SPRINT Steering Committee Tulane University School of Public Health and Tropical Medicine, and
More informationCore Measures SEPSIS UPDATES
Patricia Walker, RN-BC, BSN Evidence Based Practice Manager Quality Management Services UCLA Health System, Ronald Reagan Medical Center Core Measures SEPSIS UPDATES Sepsis Core Measures Bundle Requirements
More informationCENTER FOR DRUG EVALUATION AND RESEARCH
CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 205029Orig1s000 SUMMARY REVIEW Cross Discipline Team Leader Review 4. Nonclinical Pharmacology/Toxicology In their review of the original application,
More informationCopyright 2004 Massachusetts Medical Society. All rights reserved. Volume 350(22), 27 May 2004, pp 2247-2256
1 of 13 11/06/2006 9:59 PM Copyright 2004 Massachusetts Medical Society. All rights reserved. Volume 350(22), 27 May 2004, pp 2247-2256 A Comparison of Albumin and Saline for Fluid Resuscitation in the
More informationPatient Schematic. Perkins GD et al The Lancet, 385, 2015, 947-955
Lancet March 2015 Patient Schematic Perkins GD et al The Lancet, 385, 2015, 947-955 Background Adequate CPR is critical for survival for CA patients Maintenance of high-quality compressions during OHCA
More informationFLUID AND BLOOD THERAPY
FLUID AND BLOOD THERAPY PURPOSE To familiarize and acquaint the transfer Paramedic with the skills and knowledge necessary to adequately maintain fluid and blood therapy in the interfacility transfer environment
More informationRGN JOY LAUDE WATFORD GENERAL HOSPITAL, ENGLAND
RGN JOY LAUDE WATFORD GENERAL HOSPITAL, ENGLAND Monitor patient on the ward to detect trends in vital signs and to manage accordingly To recognise deteriorating trends and request relevant medical/out
More informationAdvantages and disadvantages of CRRT in ARF patients. Norbert Lameire Renal Division University Hospital Ghent, Belgium
Advantages and disadvantages of CRRT in ARF patients Norbert Lameire Renal Division University Hospital Ghent, Belgium Alexandria, 17/2/2005 Indications for RRT in critically ill ARF patients Renal Replacement
More informationInpatient Code Sepsis March Update. Sarah Prebil
Inpatient Code Sepsis March Update Sarah Prebil 3 hour bundle Time is life Kumar et al. Crit Care Med 2006; 34:1589-1596 But Sarah, why are you harassing us about sepsis? Pilot Results 10 Code Sepsis pabents
More informationTITLE 836 INDIANA EMERGENCY MEDICAL SERVICES COMMISSION. ARTICLE 1.5 Trauma Field Triage and Transport Destination Requirements
TITLE 836 INDIANA EMERGENCY MEDICAL SERVICES COMMISSION ARTICLE 1.5 Trauma Field Triage and Transport Destination Requirements 836 IAC 1.5-1 Purpose Affected: [IC 10-14-3-12; IC 16-18; IC 16-21-2; IC 16-31-2-9;
More informationPaddy McMaster Consultant in Paediatric Intensive Care University Hospital of North Staffordshire Stoke on Trent UK
Paddy McMaster Consultant in Paediatric Intensive Care University Hospital of North Staffordshire Stoke on Trent UK Haemofiltration Plasmafiltration In sepsis / SIRS Excluded: not sepsis, subgroup analysis
More informationWhat is the Future of Epinephrine in Cardiac Arrest? Pros and Cons
What is the Future of Epinephrine in Cardiac Arrest? Pros and Cons Melissa L. Thompson Bastin, PharmD., BCPS Komal A. Pandya, PharmD., BCPS 0 Presenter Disclosure Information Melissa L. Thompson Bastin,
More informationUnderstanding Lactate in an Intensive Care Setting. Hilary G. Mulholland
Understanding Lactate in an Intensive Care Setting by Hilary G. Mulholland S.B., Massachusetts Institute of Technology (2014) Submitted to the Department of Electrical Engineering and Computer Science
More informationLynda Richardson, RN, BSN Sepsis/Septic Shock Abstractor. No disclosures
Lynda Richardson, RN, BSN Sepsis/Septic Shock Abstractor No disclosures 1 2 3 Discuss data requirements -3 hour bundle -6 hour bundle Challenges and compliance issues Success 4 Based on the Surviving Sepsis
More informationAcute on Chronic Liver Failure: Current Concepts. Disclosures
Acute on Chronic Liver Failure: Current Concepts Vandana Khungar, MD MSc Assistant Professor of Medicine University of Pennsylvania, Perelman School of Medicine September 20, 2015 None to declare Disclosures
More informationChildren ARE just small adults V I C K I L. S A K A T A, M D
Children ARE just small adults V I C K I L. S A K A T A, M D Objectives At the end of this presentation participants should be able to: Identify historical context for the phrase Children are not just
More informationChapter 16. Learning Objectives. Learning Objectives 9/11/2012. Shock. Explain difference between compensated and uncompensated shock
Chapter 16 Shock Learning Objectives Explain difference between compensated and uncompensated shock Differentiate among 5 causes and types of shock: Hypovolemic Cardiogenic Neurogenic Septic Anaphylactic
More informationStatistics for the intensivist (3) ICU Fellowship Training Radboudumc
Statistics for the intensivist (3) ICU Fellowship Training Radboudumc Comparison of means Single observed mean with hypothesized value Two means arising from paired data Two means from unpaired data Confidence
More informationIt is recommended that the reader review each medical directive presented in this presentation along with the actual PCP Core medical directive.
It is recommended that the reader review each medical directive presented in this presentation along with the actual PCP Core medical directive. This presentation will highlight the changes and any new
More informationClinical practice guideline: Red blood cell transfusion in adult trauma and critical care*
Special Article Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care* Lena M. Napolitano, MD; Stanley Kurek, DO; Fred A. Luchette, MD; Howard L. Corwin, MD; Philip
More informationPaediatric fluids 13/06/05
Dr Catharine Wilson Consultant Paediatric Anaesthetist Sheffield Children s Hospital. UK Paediatric fluids 13/06/05 Self assessment: Complete these questions before reading the tutorial. Discuss the answers
More informationIntravenous Fluids: Composition & Uses. Srinidhi Jayaram, PGY1
Intravenous Fluids: Composition & Uses Srinidhi Jayaram, PGY1 Body Fluid Compartments Total Body Water (TBW): 50-70% of total body wt. Avg. is greater for males. Decreases with age. Highest in newborn,
More informationof the Dossier Volume: Page:
. -. Baxter Healthcare Corporation ~ 2. SYNOPSIS Name of Company individual Study Table (ForNd&mzfAufhoriiy = 3axter Healthcare Corporation Referring to Part Use Of@) %me of Finished Product: 3iaspirin
More informationPressure Ulcers in the ICU Incidence, Risk Factors & Prevention
Congress of the Critical Care Society of South Africa Sun City, 10-12 July 2015 Pressure Ulcers in the ICU Incidence, Risk Factors & Prevention Stijn BLOT Dept. of Internal Medicine Faculty of Medicine
More informationInpatient Heart Failure Management: Risks & Benefits
Inpatient Heart Failure Management: Risks & Benefits Dr. Kenneth L. Baughman Professor of Medicine Harvard Medical School Director, Advanced Heart Disease Section Brigham & Women's Hospital Harvard Medical
More informationQuiz 5 Heart Failure scores (n=163)
Quiz 5 Heart Failure summary statistics The correct answers to questions are indicated by *. Students were awarded 2 points for question #3 for either selecting spironolactone or eplerenone. However, the
More informationNew Anticoagulants and GI bleeding
New Anticoagulants and GI bleeding DR DANNY MYERS MD FRCP(C) CLINICAL ASSISTANT PROFESSOR OF MEDICINE, UBC Conflicts of Interest None I am unbiased in the use of NOAC s vs Warfarin based on risk benefit
More informationThe Clinical Evaluation of the Comatose Patient in the Emergency Department
The Clinical Evaluation of the Comatose Patient in the Emergency Department patients with altered mental status (AMS) and coma. treat patients who present to the Emergency Department with altered mental
More informationU.S. Food and Drug Administration
U.S. Food and Drug Administration Notice: Archived Document The content in this document is provided on the FDA s website for reference purposes only. It was current when produced, but is no longer maintained
More informationRuchika D. Husa, MD, MS Assistant t Professor of Medicine in the Division of Cardiology The Ohio State University Wexner Medical Center
Modified Early Warning Score (MEWS) Ruchika D. Husa, MD, MS Assistant t Professor of Medicine i in the Division of Cardiology The Ohio State University Wexner Medical Center MEWS Simple physiological scoring
More informationTitle/Description: Admission Criteria, Discharge Criteria, and Standards of Operation of the Pediatric Intensive Care Unit.
University of Kentucky / UK HealthCare Policy and Procedure Policy # CH02-02 Title/Description: Admission Criteria, Discharge Criteria, and Standards of Operation of the Pediatric Intensive Care Unit.
More informationChronic Critical Illness: Can it be prevented? Carmen C Polito, MD Pulmonary & Critical Care Medicine Emory University Atlanta, GA cpolito@emory.
Chronic Critical Illness: Can it be prevented? Carmen C Polito, MD Pulmonary & Critical Care Medicine Emory University Atlanta, GA cpolito@emory.edu Data free zone Disclosures A (Very) Old Case 65 year-old
More informationperfusion pressure: Definitions. Implication on management protocols. What happens when CPP is too low, and when it is too high? Non-invasive CPP?
7. Cerebral perfusion pressure: Definitions. Implication on management protocols. What happens when CPP is too low, and when it is too high? Non-invasive CPP? Definitions of CPP Thanks to Dr. E. Schmidt
More informationDengue haemorrhagic fever CHAPTER 3. Treatment
Dengue haemorrhagic fever CHAPTER 3 Treatment Loss of plasma volume The major pathophysiological abnormality seen in DHF/DSS is an acute increase in vascular permeability leading to loss of plasma from
More informationAdvanced Clinical Decision Support & Acute Kidney Injury
Advanced Clinical Decision Support & Acute Kidney Injury Dr Jamie Coleman Senior Lecturer in Clinical Pharmacology and Honorary Consultant Physician eprescribing & CDS in Birmingham, UK Jamie Coleman 1
More informationTransfusion Medicine
Transfusion Medicine Chapter 5 Transfusion Medicine Routine Transfusion Therapy Blood products should not be transfused on a unit basis in children Base the volume of transfusion products on weight to
More informationOverall Goals/Objectives - Surgical Critical Care Residency Program The goal of the Pediatric Surgical Critical Care Residency program is to provide
Overall Goals/Objectives - Surgical Critical Care Residency Program The goal of the Pediatric Surgical Critical Care Residency program is to provide advanced proficiency in the care and management of critically
More informationPain Management in the Critically ill Patient
Pain Management in the Critically ill Patient Jim Ducharme MD CM, FRCP President-Elect, IFEM Clinical Professor of Medicine, McMaster University Adjunct Professor of Family Medicine, Queens University
More informationJohn E. O Toole, Marjorie C. Wang, and Michael G. Kaiser
Hypothermia and Human Spinal Cord Injury: Updated Position Statement and Evidence Based Recommendations from the AANS/CNS Joint Sections on Disorders of the Spine & Peripheral Nerves and Neurotrauma &
More informationSEPSIS IN INFANTS AND CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline
SEPSIS IN INFANTS AND CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. This guideline is for the management of sepsis in Infants and children. For full guidance please see the Surviving
More informationAmerican Thoracic Society Documents
American Thoracic Society Documents An Official ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient An International Consensus Conference in Intensive
More informationNew and Emerging Immunotherapies for Multiple Sclerosis: Oral Agents
New and Emerging Immunotherapies for Multiple Sclerosis: Oral Agents William Tyor, M.D. Chief, Neurology Atlanta VA Medical Center Professor, Department of Neurology Emory University School of Medicine
More informationAntioxidantien - ein Irrweg? REDOXS & OMEGA Studie
www.lknoe.a AKE Herbsttagung 2013 St. Wolfgang Antioxidantien - ein Irrweg? REDOXS & OMEGA Studie Friedrich Längle Chirurgische Abteilung REDOX A Randomized Trial of Glutamine and Antioxidants in Critically
More informationKING FAISAL SPECIALIST HOSPITAL AND RESEARCH CENTRE (GEN. ORG.) NURSING AFFAIRS. Scope of Service PEDIATRIC INTENSIVE CARE UNIT (PICU)
PICU-Jan.2012 Page 1 of 7 Number of Beds: 18 Nurse Patient Ratio: 1:1-2 : The Pediatric Intensive Care Unit (PICU) provides 24 hour intensive nursing care for patients aged neonate through adolescence.
More informationA simple to implement algorithm for natural direct and indirect effects in survival studies with a repeatedly measured mediator
A simple to implement algorithm for natural direct and indirect effects in survival studies with a repeatedly measured mediator Susanne Strohmaier 1, Nicolai Rosenkranz 2, Jørn Wetterslev 2 and Theis Lange
More informationLothian Diabetes Handbook MANAGEMENT OF DIABETIC KETOACIDOSIS
MANAGEMENT OF DIABETIC KETOACIDOSIS 90 MANAGEMENT OF DIABETIC KETOACIDOSIS Diagnosis elevated plasma and/or urinary ketones metabolic acidosis (raised H + /low serum bicarbonate) Remember that hyperglycaemia,
More informationANTIBIOTICS IN SEPSIS
ANTIBIOTICS IN SEPSIS Jennifer Curello, PharmD, BCPS Clinical Pharmacist, Infectious Diseases Antimicrobial Stewardship Program Ronald Reagan UCLA Medical Center October 27, 2014 The power of antibiotics
More informationAspects of resuscitation in trauma
British Journal of Anaesthesia 1997; 79: 226 240 Aspects of resuscitation in trauma J. P. NOLAN AND M. J. A. PARR In 1988, the Royal College of Surgeons Working Party Report on the management of patients
More informationLeanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting Nashville, TN
Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, NP Education Specialist LRM Consulting Nashville, TN Learning Outcomes Identify triggers to the IIR. Describe the pathophysiologic changes that
More informationTHERAPY INTENSITY LEVEL
THERAPY INTENSITY LEVEL TILBasic = TIL Basic. CDE Variable TILBasic = TIL Basic; Global summary measure of Therapy Intensity Level for control of Intracranial Pressure (ICP).. CDE Definition This summary
More informationZika Virus. Fred A. Lopez, MD, MACP Richard Vial Professor Department of Medicine Section of Infectious Diseases
Zika Virus Fred A. Lopez, MD, MACP Richard Vial Professor Department of Medicine Section of Infectious Diseases What is the incubation period for Zika virus infection? Unknown but likely to be several
More information4.1b(i) Composition of Enteral Nutrition: Fish Oils, Borage Oils and Antioxidants* April 2013
4.1b(i) Composition of Enteral Nutrition: Fish Oils, Borage Oils and Antioxidants* April 2013 2013 Recommendation: Based on 2 level 1 studies and 5 level 2 studies, the use of an enteral formula with fish
More informationUltrafiltration in PD: Physiologic Principles
Ultrafiltration in PD: Physiologic Principles Ali K. Abu-Alfa, MD, FASN Professor of Medicine Head, Division of Nephrology and Hypertension American University of Beirut Beirut, Lebanon Adjunct Faculty
More informationAdult CCRN/CCRN E/CCRN K Certification Review Course: Endocrine 12/2015. Endocrine 1. Disclosures. Nothing to disclose
Adult CCRN/CCRN E/CCRN K Certification Review Course: Carol Rauen RN BC, MS, PCCN, CCRN, CEN Disclosures Nothing to disclose 1 Body Harmony disorders and emergencies Body Harmony (cont) Introduction Disorders
More informationApplying the 2016 ASPEN/ SCCM Critical Care Guidelines to Your Practice. Susan Brantley, MS, RD, LDN
Applying the 2016 ASPEN/ SCCM Critical Care Guidelines to Your Practice Susan Brantley, MS, RD, LDN Objectives: Upon completion of this presentation, participants should be able to: 1. Distinguish the
More informationF.E.E.A. FONDATION EUROPEENNE D'ENSEIGNEMENT EN ANESTHESIOLOGIE FOUNDATION FOR EUROPEAN EDUCATION IN ANAESTHESIOLOGY
créée sous le Patronage de l'union Européenne Detailed plan of the program of six courses 1. RESPIRATORY 1. ESPIRATORY AND THORAX 1.1 Physics and principles of measurement 1.1.1 Physical laws 1.1.2 Vaporizers
More informationImproving the reporting of Medication Incidents. From Incident Reporting to Controls Assurance
Improving the reporting of Medication Incidents From Incident Reporting to Controls Assurance Quote Strive for perfection in everything you do. Take the best that exists and make it better. When it does
More informationACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) S. Agarwal, MD, S. Kache MD
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) S. Agarwal, MD, S. Kache MD Definition ARDS is a clinical syndrome of lung injury with hypoxic respiratory failure caused by intense pulmonary inflammation that
More informationAKI in Acute Dialysis Units outside ICU across Finland
AKI in Acute Dialysis Units outside ICU across Finland Mikko Haapio, MD Consulting Nephrologist Helsinki University Central Hospital Department of Nephrology mikko.haapio@hus.fi FINNAKI-Nephro In conjunction
More informationMEDICAL INTENSIVE CARE UNIT - HEALTH SCIENCES CENTRE Reviewed August 2011
MEDICAL INTENSIVE CARE UNIT - HEALTH SCIENCES CENTRE Reviewed August 2011 Goal The rotation in the Medical Intensive Care Unit at HSC is designed to allow the resident to encounter patients with tertiary
More informationOxygen - update April 2009 OXG
PRESENTATION Oxygen (O 2 ) is a gas provided in compressed form in a cylinder. It is also available in liquid form, in a system adapted for ambulance use. It is fed via a regulator and flow meter to the
More informationINTRAVENOUS FLUIDS. Acknowledgement. Background. Starship Children s Health Clinical Guideline
Acknowledgements Background Well child with normal hydration Unwell children (+/- abnormal hydration Maintenance Deficit Ongoing losses (e.g. from drains) Which fluid? Monitoring Special Fluids Post-operative
More informationAtrial Fibrillation in the ICU: Attempting to defend 4 controversial statements
Atrial Fibrillation in the ICU: Attempting to defend 4 controversial statements Salmaan Kanji, Pharm.D. The Ottawa Hospital The Ottawa Hospital Research Institute Conflict of Interest No financial, proprietary
More informationOxygen Therapy. Oxygen therapy quick guide V3 July 2012.
PRESENTATION Oxygen (O 2 ) is a gas provided in a compressed form in a cylinder. It is also available in a liquid form. It is fed via a regulator and flow meter to the patient by means of plastic tubing
More informationAPPENDIX B SAMPLE PEDIATRIC CRITICAL CARE NURSE PRACTITIONER GOALS AND OBJECTIVES
APPENDIX B SAMPLE PEDIATRIC CRITICAL CARE NURSE PRACTITIONER GOALS AND OBJECTIVES The critical care nurse practitioner orientation is an individualized process based on one s previous experiences and should
More informationCLINICAL GUIDELINE FOR MANAGEMENT OF NEUTROPENIC SEPSIS IN CANCER PATIENTS 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE FOR MANAGEMENT OF NEUTROPENIC SEPSIS IN CANCER PATIENTS 1. Aim/Purpose of this Guideline 1.1. Systemic cancer treatments and immunological therapies can suppress the ability of the bone
More information