Remplissage vasculaire et SDRA

Remplissage vasculaire et SDRA Risque pulmonaire spécifique lié au remplissage Risque circulatoire spécifique lié à la ventilation mécanique Autres effets du remplissage Rôle des index prédictifs de la réponse au remplissage Effet sur la durée de ventilation

P pmv pmv Qf P mv mv Qf = Kf [(P mv -P pmv ) - ( mv - pmv )]

Fluid loading & oncotic pressure Qf = Kf [(P mv -P pmv ) - ( mv - pmv )]

N Engl J Med 2004; 350: 22

CRYCO Prospective cohort study Consecutive adult patients admitted in 115 ICUs (30 countries) during a 4 week-period and needing fluid resuscitation for shock in the intensive care unit

736 patients with shock 611 receiving colloids 125 receiving crystalloids % of patients 100 80 Type(s) of colloids administered 60 40 20 0 Starches Gelatins Plasma Albumin Dextrans

Adjusted OR, p Volume of expander > 1.3 L/d 9.03 (4.30-18.90), <0.0001 X ray score > 2 4.36 (2.42-7.84), <0.0001 Sepsis as indication of fluids SAPS II > 50 points Use of colloids Age > 63 years 1.49 (0.84-2.65), 0.17 1.25 (0.70-2.25), 0.45 1.19 (0.51-2.78), 0.68 0.51 (0.28-0.93), 0.03 OR 0 1 2 4 6 8 10 12 Favour ARDS

Schortgen ICM 2010

Mechanical Ventilation in the Chest Left Heart Right Heart Abnormal Lungs Capillaries Healthy lungs Chest wall

Central blood volume Pulmonary arteries: 80 ml Pulmonary capillaries: 120 ml Pulmonary veins: 300ml (500 ml) RV ejection = renewal of central blood volume RV Changes induced by mechanical ventilation LV

INSP. EXP. A Pressure changes induced by Mechanical Ventilation Marked increase in alveolar pressure (A) Modest increase in esophageal (E) (pleural) pressure ZONE III : P PV > P ALV

Chest wall elastance Stiff Soft Soft Stiff E L E w E L E w 25 5 cmh 2 O 15 E tot 15 E tot

SVC SVC is a vessel susceptible to collapse Ppl RA IVC RV Pdist > Pcrit Pdist = RA - Ppl

INSP. EXP. Distending pressure= RA - Ppl SVC Collapse ZONE II : P ALV > P PV ZONE III : P PV > P ALV

HYPOVOLEMIA Basal Expansion

Intra-alveolar pulmonary capillaries are susceptible to collapse Pdist > Pcrit Pdist = P VP - P ALV

INSP. EXP. Collapse of capillaries Distending pressure (Pcwp - PAlv), Becomes negative and < Pcrit ZONE II : P ALV > P PV ZONE III : P PV > P ALV

Nielsen et al ICM 2005;31:1189-94

PAP diastolique Résistances artérielles pulmonaires (60%) Résistances veineuses pulmonaires (40%) PAPO Pcap La Pcap est toujours supérieure à la PAPO

Estimation de la pression capillaire pulmonaire

CCM 2010

Proportion of patients without ARF 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Gelatin, n=64 Hydroxyethylstarch (200/0.6), n=65 Log Rank Test, p=0.018 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 Days

Crystalloids only N=127 Hypooncotic colloids Gelatins 4% albumin N=189 Artificial hyperoncotic colloids Starches Dextrans N=401 Hyperoncotic Albumin N=105

% 45 40 P=0.003 P=0.001 P=0.09 RL (n=262) HES (n=275) 35 30 25 20 15 10 5 0 ARF RRT 90-D mortality

HES: More RRT More hemostasis abnormalities More transfusions More ventilation days

Phase I 6% HES 130/0.4 Phase II 4% Gelatin Phase III Crystalloid Year 2005 2006 2008/09 No of sepsis treated 118 87 141 No of AKI (%) 83 (70) 59 (68) 66 (47) Adjusted OR 95%CI 4.52 (2.27 8.99) 3.65 (1.81 7.35) Ref

6S trial Anders Perner ( Copenhagen, Denmark) 800 pts with septic shock HES acetate vs Ringer acetate Need for RRT 22% vs. 16%, P<0.05 Mortality 51% vs. 43%, P< 0.05

SEDATED PATIENTS, VENTILATED BY POSITIVE PRESSURE AND WITH REGULAR CARDIAC RYTHM Dynamic Indices SVV PPV SPV PAS Paw

PPV C > 30 ml/cmh20 C < 30 ml/cmh20 CCM 2012

Liberal Restrictive Mitchell et al. ARRD 1992

ALI/ARDS PAC CVP Fluid Conservative Fluid Liberal Fluid Conservative Fluid Liberal PAPO<8 PAPO 14-18 CVP<4 CVP 10-14

BALANCE HYDRIQUE OEDEME LESIONNEL FACCT, NEJM 2006