MALBRAIN ET AL’S “ROSE” CONCEPT OF PHASES OF CRITICAL ILLNESS
Resuscitation phase (R)
Salvage or rescue treatment with fluids administered quickly as a bolus (4 mL kg-1 over 10 to 15 minutes) The goal is early adequate goal directed fluid management (EAFM), fluid balance must be positive and the suggested resuscitation targets are: MAP > 65 mm Hg, CI > 2.5 L min-1m-2, PPV < 12%, LVEDAI > 8 cm m-2.
Optimisation phase (O)
occurs within hours ischaemia and reperfusion degree of positive fluid balance may be marker of severity in this phase risk of polycompartment syndrome unstable, compensated shock state requiring titrating of fluids to cardiac output Targets: MAP > 65 mm Hg , CI > 2.5 L min-1m-2, PPV < 14%, LVEDAI 8−12 cm-1m-2, IAP (< 15 mm Hg ) is monitored and APP (> 55 mm Hg ) is calculated. Preload optimised with GEDVI 640—800 mL m-2
Stabilisation phase (S)
evolves over days fluid therapy only for normal maintenance and replacement absence of shock or threat of shock Monitor daily body weight, fluid balance and organ function Targets: neutral or negative fluid balance; EVLWI < 10−12 mL kg-1 PBW, PVPI < 2.5, IAP < 15 mm Hg , APP > 55 mm Hg , COP > 16−18 mm Hg , and CLI < 60
Evacuation phase (E)
patients who do not transition from the ‘ebb’ phase of shock to the ‘flow’ phase after the ‘2nd hit’ develop global increased permeability syndrome (GIPS) fluid overload casues end-organ dysfunction requires late goal directed fluid removal (“de-resuscitation”) to achieve negative fluid balance need to avoid over enthusiastic fluid removal resulting in hypovolaemia
MALBRAIN ET AL’S “ROSE” CONCEPT OF PHASES OF CRITICAL ILLNESS
ResponderEliminarResuscitation phase (R)
Salvage or rescue treatment with fluids administered quickly as a bolus (4 mL kg-1 over 10 to 15 minutes)
The goal is early adequate goal directed fluid management (EAFM), fluid balance must be positive and the suggested resuscitation targets are:
MAP > 65 mm Hg, CI > 2.5 L min-1m-2, PPV < 12%, LVEDAI > 8 cm m-2.
Optimisation phase (O)
occurs within hours
ischaemia and reperfusion
degree of positive fluid balance may be marker of severity in this phase
risk of polycompartment syndrome
unstable, compensated shock state requiring titrating of fluids to cardiac output
Targets: MAP > 65 mm Hg , CI > 2.5 L min-1m-2, PPV < 14%, LVEDAI 8−12 cm-1m-2, IAP (< 15 mm Hg ) is monitored and APP (> 55 mm Hg ) is calculated. Preload optimised with GEDVI 640—800 mL m-2
Stabilisation phase (S)
evolves over days
fluid therapy only for normal maintenance and replacement
absence of shock or threat of shock
Monitor daily body weight, fluid balance and organ function
Targets: neutral or negative fluid balance; EVLWI < 10−12 mL kg-1 PBW, PVPI < 2.5, IAP < 15 mm Hg , APP > 55 mm Hg , COP > 16−18 mm Hg , and CLI < 60
Evacuation phase (E)
patients who do not transition from the ‘ebb’ phase of shock to the ‘flow’ phase after the ‘2nd hit’ develop global increased permeability syndrome (GIPS)
fluid overload casues end-organ dysfunction
requires late goal directed fluid removal (“de-resuscitation”) to achieve negative fluid balance
need to avoid over enthusiastic fluid removal resulting in hypovolaemia
Concepto de las fases del paciente crítico de Malbrain
ResponderEliminarROSE (Resucitation, Optimisation, Stabilisation, Evacuation)
Resucitación: tratamiento de rescate, administrando fluidos rápidamente en forma de bolos
Optimización: administración titulada de fluidos de acuerdo a objetivos de IC, PAM >= 65 mmHg. Rx de síndrome policompartimental
Estabilización: fluidoterapia solo de mantenimiento, vigilar peso corporal, vigilar balance de fluidos. Objetivos: balance neutro o negativo
Evacuación: objetivo: remover fluidos (de-resucitación), balances negativos. GIPS (síndrome de aumento de la permeabilidad global)