Learning Objectives: Describe the consequences of hyper- and hypovolemia for surgical and critically ill patients. Develop a fluid management strategy for individual patients

1. FLUID MANAGEMENT – A BALANCED
APPROACH
SYAFRI K.ARIF
DEPARTMENT OF ANESTHESIOLOGY , INTENSIVE
CARE AND PAIN MANAGEMENT
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY

2. Learning Objectives
• Describe the consequences of hyper- and
hypovolemia for surgical and critically ill patients
• Develop a fluid management strategy for
individual patients

3. Fluid Balance

4. Outcome and Surgery
• 48 million in-patient surgeries in the US in 2009
• High risk (> 5% mortality) surgery in the UK
– 12% (24 M) of procedures
– 80% of mortality
• Moderate risk surgery: 40% (96 M)
• Data in Indonesia ??
• GI accounts for half of hospitalizations for complications (GI sensitive
to hypovolemia, catecholamines)
• Complications
– Increase the cost
– Often not directly related to the surgery
– Commonly involve multiple organ systems
– May involve systemic inflammatory response
Inpatient Surgery. http://www.cdc.gov/nchs/fastats/insurg.htm. Accessed February 2012.
Pearse RM, et al. Crit Care. 2006;10(3):R81.
Bennet-Guerrero E, et al. Anesth Analg. 1999;89(2):514-519.

5. Hemodynamic Monitoring During
High-Risk Surgery
A Survey of ASA Members (Sept–Nov 2010)
Cannesson M, et al. Crit Care. 2011;15(4):R197.

6. Does Central Venous Pressure
Predict Fluid Responsiveness?
Deficit or Excess Blood Volume
CONCLUSION: No
Marik PE, et al. Chest. 2008;134(1):172-178.
*

7. Hemodynamic Monitoring During
High-Risk Surgery
A Survey of ASA Members (Sept–Nov 2010)
Cannesson M, et al. Crit Care. 2011;15(4):R197.

8. Hemodynamic Monitoring During
High-Risk Surgery
A Survey of ASA Members (Sept–Nov 2010)
What parameter(s) is (are) involved in
oxygen delivery to the tissues?
Do you believe that oxygen delivery to
the tissues is of major importance in
patients during high risk surgery?
Yes
Cannesson M, et al. Crit Care. 2011;15(4):R197.

9. CVP: Poor Target for Fluid Rx
150 volume challenges; sepsis
Osman D, et al. Crit Care Med. 2007;35(1):64-68.
Drives
excessive
fluid
Failure to
resuscitate

10. Oxygen Delivery
DO2 = CO x Hb x 1.31 x SaO2
mLO2/min g/L mLO2L/min /gHb %
Non
Invasive
Non
? Invasive

11. Hemodynamic Assessment Tools
Palpate pulse
NBP
ECG
Arterial line
Minimally invasive CO
CVP
PA Cath
Less invasive
More invasive
TEE

12. Dynamic Parameters
• Systolic Pressure Variation (SPV)
• Pulse Pressure Variation (PPV)
• Stroke Volume Variation (SVV)

13. Dynamic Parameters Predict Fluid
Responsiveness More Reliably Than
• PCWP
• CVP
• Cardiac output
• Intrathoracic blood volume
• Urine output
• Serum lactate, pH
• Cardiac end diastolic volume
Why?
• Pressure is not volume
• Only dynamic parameters such as SVV, PPV can tell you
where the heart is on the Starling Curve!!

14. PPV/SVV and Diastolic LV Volume
LV Diastolic Volume
LV Stroke Volume

15. PPV and Fluid Responsiveness
120
mmHg
40
Arterial Pressure
PPmax
PPmin
PPmax - PPmin
(PPmax + PPmin)/2
ΔPP =
2 sec
Michard F, et al. Am J Respir Crit Care Med. 2000;162(1):134-138.

16. Pulse Pressure Variation
PPV = 32%
PPV = 5%

17. PPV Predicts Fluid Responsiveness
More Reliably than Static Parameters
Sepsis with Acute Circulatory Failure
ΔPs
Pra
Ppao
100 – Specificity (%)
Sensitivity (%)
ΔPp
Michard F, et al. Am J Respir Crit Care Med. 2000;162(1):134-138.
*

18. Mechanism of SVV
Positive Pressure
Breath
 Intrathoracic Pressure
RV Afterload
RV Preload
LV Preload
Acute SV
Empty Pulmonary Venous System
DelayedSV

19. Can SVV Predict Fluid Responsiveness?
• 25 consecutive patients prior to CABG surgery
• Anesthetized, mechanically ventilated
• Tidal volume 8-10 ml/kg
• CVP, PAC, SVV
• Procedure
– Record baseline when stable
– All patients receive 500 ml hetastarch load
– Record data when stable
Cannesson M, et al. Anesth Analg. 2009;108(2):513-517.
*

20. SVV and PPV Are
Correlated and Predictive
Bland Altman Analysis ROC Curves
Cannesson M, et al. Anesth Analg. 2009;108(2):513-517.
100 – Specificity (%)
Sensitivity (%)
ΔPP and SVV cutoffs = 10%
*

21. PVI Prediction of Volume Response
Responder
Non-Responder
500 ml hetastarch 6%, 10 min
Cannesson M, et al. Br J Anaesth. 2008;101(2):200-206.

22. SVV and PVI Predict Responsiveness
MV Patients Undergoing Major Surgery
Sensitivity
1-Specificity
Conclusion: Both SVV and PVI indicate fluid responsiveness in
mechanically-ventilated patients undergoing major surgery
Zimmermann M, et al. Eur J Anaesthesiol. 2010;27(6):555-561.
CVP
PVI
SVV

23. Limitations of Dynamic Predictors
• Most clinical studies done in well-defined
populations
– Controlled MV with no spontaneous breathing
– Tidal volumes (TVs) > 7 ml/kg
– No cardiac arrhythmias
*

24. The Present and Future
Is the heart pumping enough oxygenated
blood for the body?
Is cardiac output sufficient?
Are the individual tissues getting the oxygen
Volume response to treatment?
Appropriate tissue oxygenation?
they need?
Volume status-would it
help to give fluid?
No
Not much
No
Global
Venous O2
pH, Lactate
CO
Measurement
Tissue O2
Microcirculation
Dynamic
Parameters

25. Fluid Options

26. 60%
Fluids
40%
Solids
67%
Intracellular
33%
Extracellular
67% Interstitial
33% Blood
(70 cc/kg)

27. PLASMA + NaCl 0.9%
Plasma NaCl 0.9%
Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID = 38 mEq/L
Na+ = 154 mEq/L
Cl- = 154 mEq/L
1 liter SID = 0 mEq/L 1 liter
SID : 38 

28. ASIDOSIS HIPERKLOREMIK AKIBAT
PEMBERIAN LARUTAN Na Cl 0.9%
2 liter
=
Plasma
Na+ = (140+154)/2 mEq/L= 147 mEq/L
Cl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
SID : 19  lebih asidosis

29. PLASMA + Larutan RINGER LACTATE
Plasma Ringer laktat
Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
Cation+ = 137 mEq/L
Cl- = 109 mEq/L
Laktat- = 28 mEq/L
SID = 0 mEq/L 1 liter 1 liter
SID : 38
Laktat cepat
dimetabolisme

30. Normal pH setelah pemberian
2 liter
=
RINGER LACTATE
Plasma
Na+ = (140+137)/2 mEq/L= 139 mEq/L
Cl- = (102+ 109)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L
SID = 34 mEq/L
SID : 34  lebih alkalosis dibanding jika
diberikan NaCl 0.9%

31. Balance solution - Plasmalike electrolytes
[mmol/l] NS Ringer RL RA RFundin Plasma
Na+ 154 147 130 130 140 142
K+ 4.0 4 4 4.0 4.5
Ca2+ 2.25 2.7 2.7 2.5 2.5
Mg2+ 1.0 1.0 0.85
Cl- 154 156 108.7 108.7 127 103
HCO3 24
Lactate- -- -- 28.0 -- -- 1.5
Acetate- -- -- -- 28.0 24.0
Malate2- -- -- -- -- 5.0
BEpot -24 -24 3.0 2.5 0 0 ±2
Tonicity
[mOsm/l]
[mOsm/lkg)
304
286
309 273
256
273.4
256
304
286
308
288
Electrolyte balance like in human plasma
=> physiological composition closely
resembling humanplasma needed
Conventional infusion solutions can produce
a number of corrective effects –
both unwanted and unknown.

32. RL and RA are more
R. Zander, Fluid Management, hypotonic compare to
NaCL 0.9% & RF

33. Balance solution - Low Oxygen consumption
To metabolize anions, the body needs O2
Normal O2-consumption: 18 l per hour
Total consumption of oxygen is reduced for about
30% in the acute phase!
Balance Kristaloid :
- Low Oxygen consumption
Compare to Ringer Lactate (RL) & Ringe
Acetate (RA)
- Gentle on the liver
Acetate and Malate – unlike Lactate – are
metabolized in all organs and muscles
Lactate Acetate

34. Hypotonic IV Fluids and Intracranial Pressure
(ICP)
 All body fluids have the same osmotic pressure
as plasma (osmolality)
 The rigidly shaped skull contains 3
incompressible fluid compartments (Brain,
Blood, CNS)
 Intracranial compartment responses to a change
in plasma osmolality:
A decrease in plasma osmolality by
approximately 3% (288 to 280 mosmol/kg
H2O), invariably results in an increase in brain
volume by 3%, causing a decrease in blood
and/or CSF volume by as much as 30%.
288 to 280 mosmol/kg H2O

35. Ringerfundin, Crystalloid Balanced
 Gentle metablism anion (acetate – malate)
due to :
- Low oxygen consumption
- unlike Lactate : acetate – malate are
metabolized in all organs and muscles
 Isotonic, like plasma
Minimal risk in critical ill, pediatric/neonatus
& brain trauma
• BEpot= 0
No change of patient’s acid-base status
 Electrolyte balance like in human plasma
 does not affect electrolyte equilibrium

36. 36

37. Faktor yang mempengaruhi eliminasi preparat
HES :
 Molecular weight (Mw) / Berat Molekul (BM) :
Semakin kecil BM semakin mudah degradasi
Co. HES BM 200 kdl dan HES BM 130 kdl
 Molar substitution (MS) / Derajat Subsitusi (DS) :
6 Hydroxyethyl per 10 glucose units  MS = 6/10 = 0.6 : Semakin kecil MS semakin cepat.
Co. HES 200/ 0.5, HES 130/ 0.42
 C2/C6 ratio:
ratio dari nomor substituents pada carbon atom nomor 2 kemudian 6
Semakin kecil rasio C2/C6 semakin cepat degradasi,
Co. 9:1 dan 6:1
MS >> C2/C6 >
Mw

38. Effective and Safe
HES 130/0.42/6:1 vs HES 200/0.5

39. Colloid HES in different solutions
Note
especially the
differences in
sodium and
chloride
content!
HES 130 in 0.9% saline:
Venofundin Bbraun & Voluven

40. Albumin in Sepsis
Meta-analysis of Mortality
• Meta-analysis of RCTs comparing
albumin with other fluid resuscitation
regimens
• Overall OR for mortality = 0.76
(P = 0.015) with albumin compared
with other resuscitation fluids
• 6 studies from Boldt removed
Albumin Compared to Individual Fluid Regimens
Fluid
Number of
Studies
Total
Participants
OR of Mortality
with Albumin
Delaney AP et al. Crit Care Med. 2011;39(2):386-391.
Supplement. http://links.lww.com/CCM/A220. Accessed February 2012.
P-value
Crystalloid 7 144 0.78 0.04
Starch 12 463 1.04 0.84

41. Comparing Colloids
• Meta-analysis of 70 trials (4375 patients)
– Pooled mortality RR
 Alb/PPF vs HES: 1.14 (95% CI 0.91-1.43)
• Boldt et al excluded: 0.97 (95% CI 0.70-1.35)
 Alb/PPF vs gelatin: 0.97 (95% CI 0.68-1.39)
 Alb/PPF vs dextran: 3.75 (95% CI 0.42-33.09)
 Gelatin vs HES: 1.00 (95% CI 0.80-1.25)
• Conclusions
– No definitive evidence that one colloid better
than any other
– But very wide 95% CIs  larger trials needed
Bunn F, et al. Cochrane Database Syst Rev. 2011;3:CD001319.

42. Meta-Analysis: Colloid vs Crystalloid
• Meta analysis of 8 RCTs1
– Trauma patients: crystalloids favored
– Non-trauma patients: colloids comparable
– Non-septic/elective Sx (BM intact): colloids also efficacious
• A systematic review of 37 RCTs2 does not support the
continued use of colloids for volume replacement in
critically ill patients
• A systematic review of 17 studies3: no overall difference in
mortality, pulmonary edema, or length of stay between
crystalloids and colloids in fluid resuscitation
1. Velanovich V. Surgery .1989;105(1):65-71.
2. Schierhout G, et al. BMJ. 1998;316(7136):961-964.
3. Choi PT, et al. Crit Care Med. 1999;27(1):200-210.

43. Meta-Analysis: Colloid vs Crystalloid
Cochrane review of IV fluids for abdominal aortic surgery
• 38 trials involving 1589 patients included
• No single fluid affected any outcome measure significantly
more than another fluid across a range of outcomes
• No studies examining the effects of combination fluid
therapy; limited data on mortality
• The review concluded that although the beneficial effects
of colloids were confirmed, further studies still required
Toomtong P, et al. Cochrane Database Syst Rev. 2010;1:2-CD000991.

44. Colloids vs Crystalloids in the ICU
• Meta-analysis of 65 trials
• Pooled mortality RR vs. crystalloids:
– All colloids combined: 1.01 (95% CI 0.92-1.10)
– HES: 1.18 (95% CI 0.96-1.44)
– Modified gelatin: 0.91 (95% CI 0.49-1.72)
– Dextran: 1.24 (95% CI 0.94-1.65)
– Dextran in hypertonic crystalloid: 0.88 (95% CI 0.74-1.05)
• Results unchanged after exclusion of Boldt et al
• Conclusion
– No evidence that colloids are more effective than
crystalloids in reducing mortality in people who are
critically ill or injured
Perel P, et al. Cochrane Database Syst Rev. 2011;3:CD000567.

45. •THANK YOU