Blackwater treatment and reuse in practice in Södertälje, Sweden
Robert G. Hahn, MD, PhD Research Director, Södertälje Hospital; Professor of Anesthesiology,...
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Transcript of Robert G. Hahn, MD, PhD Research Director, Södertälje Hospital; Professor of Anesthesiology,...
![Page 1: Robert G. Hahn, MD, PhD Research Director, Södertälje Hospital; Professor of Anesthesiology, Linköping University; Associate professor, Karolinska institute,](https://reader031.fdocuments.in/reader031/viewer/2022032706/56649dff5503460f94ae799e/html5/thumbnails/1.jpg)
Robert G. Hahn, MD, PhD
Research Director, Södertälje Hospital; Professor of Anesthesiology, Linköping University; Associate professor, Karolinska institute, Sweden.
BAXTER Satellite Symposium
Why do balanced crystalloids change the paradigm?
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Fluid therapy might be more difficult than you think!
Fluid Management
Crystalloid Colloid
BalancedUnbalanced Natural
Isotonic SalineRinger´s Solution
Plasma-LyteRinger’s LactateRinger’s Acetate
Hartmann’s
Human AlbuminBlood
Different fluids with different modes of action, and different side effects
HESDextranGelatin
Synthetic
MD-IV-235 09-2013
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…metabolic acidosis which increases breathing and serum potassium.
….impairs renal blood flow and GFR by 10-15%.
…symptoms on 2-L infusion (slight mental confusion, abdominal pain)
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Niels Van RegenmortelBalanced Crystalloids – from Evidence to Clinical Reality
Robert Hahn Conclusion - alternatives to HES and saline
Dileep Lobo Key Considerations to Make the Right Choice
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*
Isotonic saline
Osmolar substances
Isotonic saline(mOsm/L H2O) Extracellular (mOsm/L H2O)
Plasma* Interstitial*
Sodium (Na+) 154 142 139
Potassium (K+) 0 4.2 4
Calcium (Ca2+) 0 1.3 1.2
Magnesium (Mg2+) 0 0.8 0.7
Chloride (Cl-) 154 100 100
Bicarbonate (HCO3-) 0 24 28.3
Protein 0 1.2 0.2
Others 0 20.3 19.4
Total mOsm/l 308 295 295
Reference values taken from Guyton´s Textbook of Physiology. They are affected by many variables, including the patient population and the laboratory methods used
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Ringer´s lactate
Osmolar substances
Ringer´´s lactate (mOsm/L) Extracellular (mOsm/L)
Plasma* Interstitial*
Sodium (Na+) 131 142 139
Potassium (K+) 5 4.2 4
Calcium (Ca2+) 2 1.3 1.2
Magnesium (Mg2+) 1 0.8 0.7
Chloride (Cl-) 111 100 100
Bicarbonate (HCO3-) 30 (lactate) 24 28.3
Protein 0 1.2 0.2
Others 0 20.3 19.4
Total mOsm/l 279 295 295Reference values are affected by many variables, including the patient population and the laboratory methods used
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Sterofundin
Osmolar substances
Sterofundin (mOsm/L H2O) Extracellular (mOsm/L H2O)
Plasma* Interstitial*
Sodium (Na+) 145 142 139
Potassium (K+) 4 4.2 4
Calcium (Ca2+) 2.5 1.3 1.2
Magnesium (Mg2+) 0 0.8 0.7
Chloride (Cl-) 127 100 100
Bicarbonate (HCO3-) 24 (acetate), 5 (malate) 24 28.3
Protein 0 1.2 0.2
Others 0 20.3 19.4
Total mOsm/l 309 295 295
Reference values are affected by many variables, including the patient population and the laboratory methods used
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Plasma-Lyte
Osmolar substances Plasma-Lyte (mOsm/L) Extracellular (mOsm/L)
Plasma* Interstitial*
Sodium (Na+) 140 142 139
Potassium (K+) 5 4.2 4
Calcium (Ca2+) 0 1.3 1.2
Magnesium (Mg2+) 1.5 0.8 0.7
Chloride (Cl-) 98 100 100
Bicarbonate (HCO3-) 27 (acetate),
24 (gluconate) 24 28
Protein 0 1.2 0.2
Others 0 20.3 19.4
Total mOsm/l 295 295 295Reference values are affected by many variables, including the patient population and the laboratory methods used
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Acetate – a buffer similar to lactate, but can be metabolized in all body cells and not only in the liver (and kidney). * Metabolized to HCO3 faster than lactate. * Requires only half as much O2 as lactate to produce HCO3.* Does not confuse serum lactate measurements in shock states.
Gluconate – a food additive used to improve taste.* Occurs naturally in fruit juice and honey. * Daily production in intermediary metabolism 30 g per day
(approximately 4 L of PlasmaLyte per day).* TOXNET: Non-toxic. Low priority for further work.
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J Crit Care 2012; 27: 138-145.
After 4-6 hours of Plasma-Lyte versus isotonic saline:
Bicarbonate correction 8.4 versus 1.7 mmol/l
After 6-12 hours of Plasma-Lyte versus isotonic saline:
Bicarbonate correction 12.8 versus 6.2 mmol/l
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Comparison between Ringer och NaCl i.v.Williams et al. Anesthesia & Analgesia 1999; 88: 999-103.
• 20 volunteers Ringer or NaCl 50 ml/kg i.v./1 h.
• Tiredness and ”problems to think” in 13/20 after NaCl, none after Ringer.
• Abdominal pain after NaCl in 10/20 volunteers, only 1/20 after Ringer.
• First void after 106 min for NaCl, 80 min for Ringer.
• pH fell 0.04 after NaCl.
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NaCl during surgery Wilkes et al. Anesthesia & Analgesia 2001; 93: 811-816
• Randomized to NaCl or Ringer, c:a 4 liters.• 47 pat. > 60 years, major surgery.• NaCl was followed by:
– Metabolic acidosis (standard bicarbonate -5.5 mmol/L).– Poorer blood perfusion of the gut.– Half as high urinary flow.– Adverse events 379 versus 272.– Nausea and vomiting 23 versus 12 events.– Postoperative vomiting in 8 versus 3 patients.
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60 patients from 4 tertiary hospitals.Compared to Hartmann, PlasmaLyte was followed by:
* Smaller base deficit (0.4 mmol/L)* Serum chloride levels lower.* Lactate levels lower (0.8 mmol/L)* Fewer complications
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Summary isotonic saline vs. balanced fluids
• Isotonic saline gives rise to metabolic acidosis and inhibits kidney function – kidney injury?
• Various symptoms on infusion.• More complications after surgery.• Higher mortality?
Plasma-Lyte is a slight/moderate improvement
over buffered Ringer solutions – ”balance” is optimal.
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Indications for isotonic saline
• Vomiting• Head injury (or use PlasmaLyte)
• Pediatric surgery (or use PlasmaLyte)
• Hyponatraemia & hypochloraemia• Together with erythrocytes (or use PlasmaLyte)
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Robert G. Hahn, MD, PhD
Research Director, Södertälje Hospital; Professor of Anesthesiology, Linköping University; Associate professor, Karolinska institute, Sweden.
ABSTRACT SESSION
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Serum urea/creatinine ratio predicts successful loop diuretic therapy incongestive heart failureVerbrugge F, Duchenne J, Dupont M, Mullens W
Evaluation of CardioPAT autotransfusion system in elective cardiac surgeryDe Decker K, Bogaert T, Gooris T, Stockman B
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Congestive heart failureExpanded heart chambers (BNP rise)Fluid retention due to impaired kidney perfusion (renin etc. high)
Treated with fluid restriction, diuretics and vasodilators
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J Am Coll Cardiol2011; 58: 383-385
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Evaluation of CardioPAT autotransfusion system in elective cardiac surgeryDe Decker K, Bogaert T, Gooris T, Stockman B
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