Société d’Anesthésie de Charleroi www.sacnet.be. 12 Février 2008 Anesthésie et ORL : « quid de l’otologie et de la rhinologie ? « M. Van Boven JP Lechat.

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Presentation transcript:

Société d’Anesthésie de Charleroi

12 Février 2008 Anesthésie et ORL : « quid de l’otologie et de la rhinologie ? « M. Van Boven JP Lechat

Avril 2008Anti-aggrégants et anti-plaquettaires 14 Juin 2008Atelier Echo

« STRATEGIE PERFUSIONNELE PERI-OPERATOIRE »

WET or DRY ?

WET or DRY ? WEANING Upadya, ICM, 2005 All ICU MV patients Prospective observation Fluid balance

Frutos-Vivar, Chest, 2006, 130 Prospective observation All ICU MV patients Fluid balance WET or DRY ? WEANING

Alsous, Chest, 2000, 117 Retrospective data collection Septic shock Fluids balance Negative fluid balance predicts survival in septic shock WET or DRY ? SURVIVAL

Sakr, Chest, 2005, 128 ALI-ARDS Prospective observation Fluids balance WET or DRY ? SURVIVAL

WET or DRY ? Humphrey, Chest, 1990, 97 Retrospective observation ARDS patients Capillary Wedge Pressure The lowest CWP consistent with a adequate CO improves ARDS survival WET or DRY ? SURVIVAL

Eisenberg, ARRD, 1987, 136 Prospective data collection All critically ill patients Extravascular lung water WET or DRY ? SURVIVAL

Hayes, NEJM, 1994, 330, 1717

Q f = K [(P mv – P pmv ) –  (  mv -  pmv )] Pressions Hydrostatiques Pressions Oncotiques

Q f = K [(P mv – P pmv ) –  (  mv -  pmv )] Pressions Hydrostatiques Pressions Oncotiques

Q f = K [(P mv – P pmv ) –  (  mv -  pmv )]

Q f = K [(P mv – P pmv )

Rivers E et al. N Engl J Med 2001;345:

Martin, CCM, 2005

Fluid management in ALI. NEJM, 2006, 354, 2564 mean = 24 hours after ALI criteria meeting mean = 43 hours after ICU admission no severe comorbidity -Lung -Kidney -Heart no risk of death within 6 months patients screened patients excluded

Fluid management in ALI. NEJM, 2006, 354, 2564 LIBERALCVP mmHg PAOP14-18 mmHg CONSERVATIVECVP <4 mmHg PAOP <8 mmHg

Fluid management in ALI. NEJM, 2006, 354, 2564

Cumulative at day / /- 491

Fluid management in ALI. NEJM, 2006, 354, 2564

Hemodynamics ! lower mean arterial pressure lower cardiac index Lung function better injury score better oxygenation index lower plateau pressure lower PEEP

Fluid management in ALI. NEJM, 2006, 354, 2564 Hemodynamics lower mean arterial pressure lower cardiac index Lung function better injury score better oxygenation index lower plateau pressure lower PEEP Metabolic function higher oncotic pressure, Hgb, albumine levels higher creatinine values metabolic alkalosis (hypoCl - ) electrolyte imbalance (hypoK +, hyperNa + )

Fluid management in ALI. NEJM, 2006, 354, 2564 Conservative strategy Improves lung function Shortens duration of MV Shortens ICU LOS

« In acute critical illness, treat early to achieve optimal goals and prevent MOF » Kern, CCM, 2002, 30 -Initial net positive fluid balance phase -Diuretic phase Alsous, Chest, 2000, 117

« Fluid management is a matter of timing » Otero, Chest, 2006, 130

Je me mouille !