Goal Directed Therapy »prévient-elle de l`insuffisance rénale post

Lille – 25 mars 2010
La “Goal-Directed Therapy” prévient-elle
de l’insuffisance rénale postopératoire ?
Benoit Vallet
Pôle d’Anesthésie Réanimation
Hôpital Huriez
CHRU de Lille - France
[email protected]
Conflit d’Intérêt
• Consultant pour Edwards Lifesciences
Définir l’insuffisance rénale ?
RIFLE criteria for Acute Kidney Injury (AKI)
Bellomo et al Crit Care 2004;8:R204–12
Injury
Urine output criteria
 GFR >25% or
creatinine × 1.5
or creatinine > 15 mg/L
UO < 0.5 mL/kg/h
×6 h
 GFR >50% or
 creatinine × 2
or creatinine > 20 mg/L
Failure
Loss
ESRD
 GFR >75% or
 creatinine × 3 or
creatinine > 40 mg/L
or acute  > 5 mg/L
High
sensitivity
UO < 0.5 mL/kg/h
×12 h
UO < 0.3mL/kg/h
×24 h or
anuria ×12 h
Oligu
ria
Risk
Creatinine criteria
High
specificity
Persistent ARF = complete loss of
renal function > 4 weeks
End-stage renal disease
Second International Consensus Conference of the Acute
Dialysis Quality Initiative (ADQI) Group
Normal creatinine
Man: 7-13.5 mg/L
Woman: 5-12 mg/L
Vs RIFLE criteria, the AKIN criteria do not materially improve the sensitivity, robustness
or predictive ability of the definition and classification of AKI in the first 24 h after ICU admission
Development and Validation of an AKI Risk Index
for Patients Undergoing General Surgery
Results from a national data set
Kheterpal S et al. Anesthesiology 2009;110:505-15
•
•
Outcome data from general surgery procedures performed in 121 US
medical centers (2005-2006)
152,244 operations reviewed;75,952 met the inclusion criteria; and 762
(1.0%) were complicated by AKI (increase in serum creatinine >20 mg/L
or ARF necessitating dialysis)
•
•
The primary outcome was AKI within 30 days
30-day mortality among patients with and without AKI was compared
•
11 independent preoperative predictors:
–
–
–
–
–
•
•
>56 yr
- male
emergency surgery
- intraperitoneal surgery,
diabetes
- active congestive heart failure
ascites
- hypertension
mild or moderate preoperative renal insufficiency
Patients with six or more risk factors had a 9% incidence of AKI
Patients experiencing AKI had an 8x increase in 30-day mortality
Glomerular filtration rate (GFR) is affected by
hydrostatic and osmotic pressure
Soluté de remplissage et risque rénal ?
Type de Soluté de Remplissage et Risque Rénal
Schortgen F, Girou E, Deye N, Brochard L; CRYCO Study Group
Intensive Care Med 2008;34:2157-68
Inflammation
Endothelium Injury
Kidney Function
Qu’est-ce que la “Goal-Directed Therapy” (GDT) ?
En simplifiant à l’extréme : la GDT applique le principe de Frank et Starling
En simplifiant à l’extrême : la GDT applique le principe de Frank et Starling
Pas de réserve de précharge
= “non répondeur”
Volume
d’éjection
systolique
(VES)
Réserve de précharge
= “répondeur”
Remplissage
Remplissage
Précharge ventriculaire
Goal-Directed Therapy : Detecting patients who will be able to turn fluid
loading into a significant increase in SV (“Fluid responsive”)
Oesophageal Doppler Guided Fluid Management
Non fluid responsive
SV
Reserve of
preload = fluid
responsive
Preload
DURING “HIGH-RISK SURGERY”…
De nombreuses études ont démontré que la « maximalisation »
du VES améliorait le pronostic des patients…
Mythen et al. Arch Surg 1995
Sinclair et al. BMJ 1997
Venn et al. Br J Anaesth 2002
Gan et al. Anesthesiology 2002
Conway et al. Anaesthesia 2002
Wakeling HG et al. Br J Anaesth 2005
Noblett SE et al. Br J Surg 2006
DURING “HIGH-RISK SURGERY”…
De nombreuses études ont démontré que la « maximalisation »
du VES améliorait le pronostic des patients…
Mythen et al. Arch Surg 1995
Sinclair et al. BMJ 1997
Venn et al. Br J Anaesth 2002
Gan et al. Anesthesiology 2002
Conway et al. Anaesthesia 2002
Wakeling HG et al. Br J Anaesth 2005
Noblett SE et al. Br J Surg 2006
Goal-directed Intraoperative Fluid Administration Reduces
Length of Hospital Stay after Major Surgery
Gan TJ et al. Anesthesiology 2002;97:820-6
• 100 pts
• ASA 1-3
• Major elective surgery + anticipated blood loss >500mL
• Volume expansion Doppler-guided vs control
• Continuous crystalloid infusion 5mL/kg/h
Goal-directed Intraoperative Fluid Administration Reduces
Length of Hospital Stay after Major Surgery
Gan TJ et al. Anesthesiology 2002;97:820-6
• 100 pts
• ASA 1-3
• Major elective surgery + anticipated blood loss >500mL
• Volume expansion Doppler-guided vs control
• Continuous crystalloid infusion 5mL/kg/h
Acute renal dysfunction
4% vs 8%
 Hospital stay:
5 + 3 vs 7 + 3 days
Goal-directed Intraoperative Fluid Administration Reduces
Length of Hospital Stay after Major Surgery
Gan TJ et al. Anesthesiology 2002;97:820-6
• 100 pts
• ASA 1-3
• Major elective surgery + anticipated blood loss >500mL
• Volume expansion Doppler-guided vs control
• Continuous crystalloid infusion 5mL/kg/h
Acute renal dysfunction
4% vs 8%
 Hospital stay:
5 + 3 vs 7 + 3 days
Intraoperative Oesophageal Doppler Guided Fluid Management
Shortens Postoperative Hospital Stay after
Major Bowel Surgery
Wakeling et al. Brit J Anaest 2005;95:634-42
GDT-Doppler patients:
- Larger volume of iv colloids
64 ctrls vs 64 GDT
than controls (median 2000
vs 1500 mL, P<0.01)
- Higher CO
- Higher SV
- Higher DO2
-  GI morbidity
- 45.3 vs 14.1%
(p<0.001)
- Renal
- 3.1 vs 4.7% (p=0.661)
-  Total number of
patients with
Complications
- 59.3 vs 37.5%
(p=0.013)
En simplifiant à l’extrême : la GDT applique le principe de Frank et Starling
En simplifiant à l’extrême : la GDT applique le principe de Frank et Starling
Est-ce suffisant ?
Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical Patients
Donati et al. Chest 2007;132:1817–24
Intervention
Fluid±RBC±
dobutamine
to maintain
O2ER < 27%
( ScvO2 > 73%
since ScvO2  1 - EO2)
during surgery and
the post-operative
period (24h)
135 patients
Elective major abdominal
surgery or abdominal
aortic surgery
(ASAIII; n = 94)
ScvO2
Low
<73 %
Normal
>73 %
Do
nothing
SaO2
Low
(hypoxemia)
Oxygen therapy,
Increase PEEP
Normal (>95%)
(increased O2ER)
CVP
Myocardial
CVP>10 mmHg dysfunction
Dobutamine
Hypovolemia
CVP<10 mmHg
Fluid
challenge,
RBC…
Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical Patients
Donati et al. Chest 2007;132:1817–24
44.1%
2.6+4.0g/kg/min
4.5%
0.4+2.2g/kg/min
Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical Patients
Donati et al. Chest 2007;132:1817–24
En simplifiant à l’extrême : la GDT applique le principe de Frank et Starling
En simplifiant à l’extrême : la GDT applique le principe de Frank et Starling
La GDT pourrait être avantageusement complémentée
par un paramètre « global » d’utilisation de l’O2
chez les patients les plus à risque…
En simplifiant à l’extrême : la GDT applique le principe de Frank et Starling
La GDT pourrait être avantageusement complémentée
par un paramètre « global » d’utilisation de l’O2
chez les patients les plus à risque…
Quelles sont les preuves ?
•
“Perioperative hemodynamic optimization” or “goal-directed therapy”
refers to the perioperative monitoring and manipulation of
physiologic hemodynamic parameters by means of fluids, red blood
cells, and inotropic drugs
•
With the aim to reach values of cardiac output and oxygen delivery
to face the increase in oxygen demand and to prevent organ failure
20 studies
4,220 patients
13 as “high quality studies”
9 enrolled “high-risk” patients
Sensitivity analysis combining:
- Grade “R” of RIFLE classification
- Stage “1” of AKIN classification
- SCr>20 mg/L, increase>50%
or by 5 mg/L or need of RRT,
disregarding urine output
5.4%
8.3%
6.1%
9.2%
7.3%
11.2%
Un effet de la GDT sur d’autres organes ?
Goal-Directed Haemodynamic Therapy and Gastrointestinal Complications in Major
Surgery: A Meta-Analysis of Randomized Controlled Trials
Giglio MT, Marucci M, Testini M, Brienza N
Br J Anaesth. 2009 Nov;103(5):637-46
•
16 randomized controlled trials (3410 participants)
•
GI complications were ranked as major (required radiological or
surgical intervention or life-threatening condition) or minor (no or
only pharmacological treatment required)
•
Major GI complications were significantly reduced by GDT when
compared with a control group (OR, 0.42; 95% CI, 0.27-0.65)
•
Minor GI complications were also significantly decreased in the GDT
group (OR, 0.29; 95% CI, 0.17-0.50)
•
Treatment did not reduce hepatic injury rate (OR, 0.54; 95% CI,
0.19-1.55)
Quels outils au quotidien ?
Monitorage Automatisé et Invasif
(KT artériel) de la Réponse au Remplissage
PiCCO plus,
Pulsion
Flotrac/Vigileo, Edwards
Intellivue, Philips
S/5, GE
PPmax - PPmin
PPV =
(PPmax + PPmin) /2
4.5%
VES
»
« Plateau
Faible PPV
Large PPV
20.5%
Po
rti
on
ac
se
nd
a
nt
e
∆P
∆P = modifications cycliques de précharge
induites par la ventilation mécanique
REMPLISSAGE
Précharge (P)
Control
Intervention
Critical
CriticalCare
Care2006
2006
Critical
CriticalCare
Care2006
2006
Monitorage Automatisé et Non Invasif
de la Réponse au Remplissage ?
Finometer,
Finapres
CNAP, CNS
PVI/SpO2, Masimo
54 fluid challenges
major hepatic surgery
PPVart 12.5
PPVfina 14
A PVI >14% before volume expansion discriminated
between responders and non-responders
with 81% sensitivity and 100% specificity
Adapted from Cannesson M. et al. Br J Anesth 2008;101:200-6
Non-invasive Prediction of Fluid Responsiveness
Respiratory variation and invasive estimation of arterial pressure
Monnet X, Dres M, Ferré A, Bleibtreu A, Richard C, Teboul JL
ESICM 2009 poster # 0293
PAi
PAni
Pairway
Pulse pressure variation and stroke volume variation: from flying blind to flying right?
Cannesson M, Vallet B, Michard F. Br J Anaesth 2009;103:896-7
La “Goal-Directed Therapy” (GDT) prévient-elle
de l’insuffisance rénale postopératoire ?
•
Oui (vraisemblablement) quand la GDT:
– Est débutée en pré ou per-opératoire
– Est réalisée chez les patients à risque:
• Sujet âgé et/ou avec comorbidités (diabète, HTA, cardiopathie)
• Chirurgie d’urgence ou intrapéritonéale
• Présentant une instabilité hémodynamique préopératoire
– Est réalisée par le remplissage et l’utilisation d’inotropes
•
•
•
Le choix du type de soluté de remplissage doit faire l’objet
d’études complémentaires
Dans la métaanalyse de Brienza et al. (CCM 2009), la mortalité
est réduite par la GDT (OR 0.50; CI 0.31–0.80; p = 0.004),
quoique l’hétérogénéité statistique soit importante
Il apparaît raisonable d’identifier en per-opératoire les patients
(selon la chirurgie envisagée) qui doivent bénéficier de la GDT
pour choisir le monitorage le plus adapté à la conduite du
traitement