Practical Issues in Anesthesia and Intensive Care 2013

262 Pages·2014·2.97 MB·English

by  Biagio Allaria (auth.)

Practical Issues in
Anesthesia and
Intensive Care 
Biagio Allaria
Editor
Practical Issues in Anesthesia and
Intensive Care 2013
Biagio Allaria
Editor
Practical Issues in
Anesthesia and
Intensive Care 2013
123
Editor
Biagio Allaria
Former Directorof theCriticalPatient
Department of theNationalInstitute
fortheStudy and Treatmentof Tumors
Currently ConsultantinClinical Risk Management
National InstitutefortheStudy andTreatment of Tumors
Milan
Italy
ISBN 978-88-470-5528-5 ISBN 978-88-470-5529-2 (eBook)
DOI 10.1007/978-88-470-5529-2
SpringerMilanHeidelbergNewYorkDordrechtLondon
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Contents
1 Perioperative Fluid Therapy and Fluid Therapy in Patients
with Sepsis in Search of Clarification . . . . . . . . . . . . . . . . . . . . . 1
Biagio Allaria
2 Enough has been Written About the Treatment of ALI,
but has Enough been Said About how to Prevent It?. . . . . . . . . . 17
Biagio Allaria
3 Prevention of Perioperative Myocardial Ischemia . . . . . . . . . . . . 29
Biagio Allaria
4 Postoperative Respiratory Failure after Major Abdominal
Surgery: Definition, Diagnosis and Prevention. . . . . . . . . . . . . . . 43
Davide Chiumello and Cristina Mietto
5 Lights and Shadows on Aerosol Therapy in Mechanically
Ventilated Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Davide Chiumello and Silvia Coppola
6 Update on Lung Imaging to Select Ventilatory Management
in ARDS Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Davide Chiumello, Sara Froio and Silvia Coppola
7 Chest X-Ray in ICU: An Examination in Which There
is Too Much Confidence. Possible Alternatives . . . . . . . . . . . . . . 103
Marco Vittorio Resta and Dario Niro
8 Continuous Renal Replacement Therapy (CRRT)
in Intensive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Filippo Mariano
v
vi Contents
9 Loss of Self-Regulation in Interstitial Fluid Dynamics
of Septic Patients, and Oedema Development Patterns. . . . . . . . . 145
Emanuela Biagioni and Massimo Girardis
10 How to Prevent and Effectively Treat
Postoperative Shivering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Marco Dei Poli
11 Epidemiology, Etiopathogenesis, Diagnosis, and Treatment
of Postoperative Paralytic Ileus in Intensive Care . . . . . . . . . . . . 175
Marco Dei Poli
12 Which Adult Patients Undergoing Noncardiac Surgery
Should be Monitored Postoperatively in ICU?. . . . . . . . . . . . . . . 199
Franco M. Bobbio Pallavicini
13 Invasive Candidiasis in the Intensive Care Setting. . . . . . . . . . . . 235
Andrea De Gasperi, Paola Cozzi and Stefania Colombo
Perioperative Fluid Therapy and Fluid 1
Therapy in Patients with Sepsis
in Search of Clarification
Biagio Allaria
1.1 Introduction
Avitalpartofaddressingthisquestionisthatfluidtherapy,whetherperioperative
orincriticalconditions,shouldfollowasingleimportantfactor:tomaintaingood
perfusion and oxygenation of the tissue. However, the behavior of individual
organs and regions varies greatly in response to different diseases and even from
one patient to the next with the same disease.
It is therefore very difficult to obtain precise information about perfusion and
peripheraloxygenationsinceitisnotanoverallphenomenonbutthesumofmany
regional perfusions that behave differently. Thus SV-O (or, more simply,
2
ScVO ), which is a satisfactory mirror of perfusion and peripheral oxygenation,
2
saysnothingabouttherealsituationindifferentregions:wedonotknowifadrop
in SV-O is linked to an intestinal, muscular, or cutaneous perfusion defect, etc.
2
There are methods to assess the microcirculation but even these, if used stati-
cally,maynotbehelpful.YettheOxygenChallengeTest,basedontheresponseto
transcutaneous PO (tPO )uponinhalationofO at100 %(FiO 100 %),maybe
2 2 2 2
of help.
TheincreaseinFiO to100 %leadstoanimprovementintPO onlywhenthe
2 2
transportation ofhyperoxygenated blood tocells is possible.Therefore,a positive
OxygenChallengeTestleadstoafavorableprognosis.Infact,whilebaselinetPO
2
measured in one region is not indicative of tPO in all regions, it seems that a
2
B.Allaria(&)
FormerDirectoroftheCriticalPatientDepartmentoftheNationalInstitute
fortheStudyandTreatmentofTumors,currentlyConsultantinClinicalRiskManagement,
NationalInstitutefortheStudyandTreatmentofTumors,
ViaVenezian1,20133,Milan,Italy
e-mail:[email protected]
B.Allaria(ed.),PracticalIssuesinAnesthesiaandIntensiveCare2013, 1
DOI:10.1007/978-88-470-5529-2_1,(cid:2)Springer-VerlagItalia2014
2 B.Allaria
positiveOxygenChallengeTestfortPO inoneregionisvalidforallotherregions
2
in both hemorrhagic and septic patients [1].
Reduced baseline tPO may be linked to a macrocirculation defect in the
2
transportation of O (such as hemorrhage or cardiac insufficiency) while in septic
2
patients who have already undergone fluid resuscitation and with a high cardiac
output, this is more likely to be due to microcirculation damage.
In all three cases hyperoxygenation increases tPO when tissue perfusion is
2
guaranteed and does not increase it when it is not [2], and while baseline tPO
2
variesfromregiontoregion,thepositiveresponsetohyperoxygenationassessedin
one region seems to apply to all other regions (muscles, bladder, kidneys, skin,
liver, etc.).
However, tPO is still barely in use as a monitoring technique and therefore it
2
cannot clearly be considered a standard technique for assessing the need for fluid
support in the body.
We mention this in this introduction only as an example of one of the trends
underway.
Furthermore, we cannot treat indifferently the monitoring of highly varied
clinical situations since this must be personalized based on a range of
requirements.
We have therefore decided to address the theme of fluid therapy in order to
deepen knowledge of the strategies for control and optimization of the volemic
status in two different clinical situations: perioperative conditions and sepsis.
1.2 Strategies for the Control and Optimization
of the Perioperative Volemic Status
It should first be said that we are not only addressing the issues of absolute or
relativeperioperativehypovolemiabutalsocasesofhypervolemiathatareatleast
as dangerous as hypovolemia and are often overlooked.
Itisveryeasytoadministerexcessivedosesoffluidinperioperativesituations,
asaresultoferroneous assumptions.Thefirstisthatfastingfor12ormorehours
leads to dehydration of the patient. In reality it has been known for more than
30 years that fasting, even during open-abdomen surgery, leads to fluid loss of
1 ml/kg/handisthereforeoflittleimportance[3].Variousassumptionshavebeen
comparedwiththispreciseassessment,namelythatduringopen-abdomensurgery
the loss of fluid is equal to 10 times as much (10 ml/kg/h). Based on these
assumptions, the trend in recent decades has been for the perioperative hyperin-
fusion offluids.
It is now, however, the case to drastically reduce infusions but more recent
studies by Rehm, who has focused on perioperative volemic patterns, seems to
show a negative perioperative balance of 3–6 liters using the restrictive criteria
described [4, 5].
1 PerioperativeFluidTherapyandFluidTherapyinPatientswithSepsis 3
Yet Heckel asks in an interesting work from 2011 [6], considering that the
patient has lost very little fluid and volemic findings show considerable periop-
erative losses that are not justified by the clinical reality, where does the missing
fluid loss end, considering that this volemic loss lasts until 72 h after surgery?
Theusualopinionisthatitendswiththeappearanceofa‘‘thirdspace’’andthat
itisgenerallydividedintotwoparts:theanatomicalthirdspacethatcoincideswith
the interstice and the non-anatomical third space that comprises spaces that are
normally free of fluid such as the peritoneal, pleural or pericardial cavities, the
intestine, and injured or traumatized tissue.
In the perioperative phase the shift offluids is predominantly toward the third
anatomic space or interstice.
In an interesting study from 2008, Chappel [7] identified two types of fluid
release toward the interstices. The first occurs in small quantities, even in normal
patients, andcan reach abnormallevelsinspecificsituations inwhich itincreases
hydrostatic pressure and/or reduces oncotic pressure, as is often the case with
perioperative fluid overloading.
The second is abnormal fluid release caused by changes to the endothelial
barrier which, promoted by BNP, is released in the event of overloading but also
by organ manipulation (primarily the intestines) due to surgery. The fluids that
enter the interstice in this situationare rich inprotein while thoseof the first type
are devoid of it.
Fromtheseobservationsitisclearthatperioperativefluidoverloadingisatleast
asimportantasunderfilling,towhichwehavealwayspaidgreatattention.Wecan
thinkofonlytwoconditionsinfluencedheavilybyedema:intestinalperistalsisand
alveolar-capillary distribution of O . When is postoperative paralytic ileus and
2
whenisO desaturationsecondarytounderestimatedinterstitialedema?Interstitial
2
edema is, in fact, caused by tissue perfusion disorders no more or less than
hypovolemia. However, the phenomenon is anything butrareif Lowell’s findings
of 1990 [8] are true, namely that 40 % of patients undergoing major general
surgery showed a 10 % increase in weight, which was correlated with mortality.
It is therefore clear that perioperative infusions are performed very cautiously,
taking care to replace only the visible losses (urine, blood, possible loss due to
diarrhea, etc.) and by controlling weight, daily if possible. Postoperative weight
gainmaybecausedonlybywaterretention,whichistheresultoffluidenteringthe
interstice.
However, hypotension and oliguria may be confirmed in the perioperative
phase, which are expressions of possible hypovolemia for which sufficient infor-
mation is required.
Letusnowmoveontothesecondimportantaspectoftheperioperativevolemic
status of patients, namely hypovolemia.
It is important not to confuse the concept of hypovolemia with that of extra-
vascular dehydration. Diuresis and perspiratio counterbalanced by infusions first
leadstoareductionintheamountoffluidthatisfreeofproteinsandelectrolytesin
the interstices and only later reduces the circulating volume. Therefore, extra-
vascular dehydration is prevented by introducing crystalloids in proportion to the
4 B.Allaria
losses.Itisclearthatthecrystalloidsareinfusedintheintravascularspacebutthe
rapidequilibriumbetweentheintravascularspaceandinterstitialspacemeansthat
the administered fluids are distributed where they are required, namely the
interstices.
Thesituationofhypovolemiafollowingsuddenlossofmassduetohemorrhage
orpersistentextravasculardehydrationwhichresultsintheremovaloffluidsfrom
circulation is a completely different situation.
In such cases, in theory the crystalloids may have a short, volemic, expansive
effect but rapidly enter the interstices therefore losing their expansive volemic
aspect. Only one-fifth of infused crystalloids remain in circulation and to obtain
the same volemic expansion produced by colloids, a quantity of crystalloids four
times higher is required [9]. It is clear that these are only general concepts since
they cannot predetermine the percentage of crystalloids that leave the circulation
in each patient, considering that the endothelial barrier is not equal in every
patient,and,evenwithoutseriousdamagetothebarriercausedbysepsis,different
patternsarepossibleindifferentpatientsandthereforedifferentamountsofinfused
fluid loss from the circulation to the interstices. It remains true that theoretically
the restoration of interstitial fluids occurs with crystalloids and that colloids are
more effective for volemic restoration. However, some considerations must be
made for colloids.
There is only one natural colloid that is available inclinical practice: albumin.
Muchhasbeenwrittenontherealuseofalbuminasavolemicexpansiveagent.
Omitting the numerous clinical trials that are often in disagreement with each
other, we will refer to only two articles.
The first is a review by Cochrane of 30 randomized studies in a total of 1,419
criticallyhypovolemicpatientsinwhomcrystalloidsandalbuminweremeasured.
Albumin did not enable a reduction in mortality, but tended to increase it [10].
The SAFE study in 6,997 patients compared fluid resuscitation with albumin
and saline solutions [11] but did not show any advantage in patients treated with
albumin in terms of either mortality or duration of stay in intensive care or
duration of mechanical ventilation.
Today it therefore does not seem acceptable to use human albumin for plasma
expansion.
We have only just ceased saying that crystalloids are not suitable for volemic
expansion, if not for very short periods, and therefore there remains nothing that
pointstowardartificialcolloids.Leavingasidedextrans,whicharealwaysusedto
a lesser extent, we can see how and if gelatins and hydroxyethyl starch can be
used. Gelatins, which are polypeptides produced from bovine collagen, have a
molecular weight that varies from 30,000 to 35,000 Da, and are usually well
tolerated. They do not influence coagulation or cause organ damage other than to
the kidneys, where gelatins may create problems, at least according to some
authors [12].
Insomepatients,suchasthoseagedover80whoundergoheartsurgery,Boldr
etal.compared6 %hydroxyethylstarch(HES)130/0.4and4 %gelatin,revealing
greater renal dysfunction in patients treated with gelatin [13].