Fluid balance and therapy in critically ill

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IV fluids in critically ill patients,composition,osmolarity,uses evidence based

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  • No evidence-based support for one type of crystalloid over another No studies that are specific to sepsis population Note: since development of these guidelines the preliminary results of the SAFE (Fluid resuscitation with Albumin vs. Saline) study results have been reported at the Society of Critical Care Medicine National Scientific Meeting held in Feb. 2004. This randomized controlled trial of over 7,000 patients demonstrated that in the subset of severe sepsis patients there was a mortality benefit with albumin over saline (RR .087; CI 0.74-1.02). This data set was locked in late 2003; therefore, final manuscript publication is pending.
  • Fluid Challenge describes the initial volume expansion period in which the patient’s response is closely monitored. Fluid Challenge must be clearly separated from an increase in maintenance fluid administration Response may be measured by increase in blood pressure and urine output Tolerance may be measured by evidence of intravascular volume overload Input/output ratio is of no utility to judge fluid resuscitation during this time period
  • Fluid balance and therapy in critically ill

    1. 1. Dr Anand.M.TiwariF.N.B critical care medicineIntensivist
    2. 2. Revision of the known facts
    3. 3.  What is the water content of human body? Male female
    4. 4.  50 to 60% of body weight Higher in neonates and children Lower in elderly Lower in women
    5. 5.  40% is intracellular. 20% extracellular 15% is interstitial 5% is intravascular28 L14L3.5 L
    6. 6.  Diffusion Facilitated diffusion Active transport Osmosis Osmolality Calculation 2na+glu/18+ bun/2.8 Freezing pointdepression method
    7. 7.  Hypotonic (cellswells) 200mosm/litre Hypertonic cell shrink–360 mosm/l Isotonic nochange280mosm/l
    8. 8. IntracellularInterstitialIntravascular2/3 1/33/4 1/4
    9. 9. IntracellularInterstitialIntravascular2/3 1/33/4 1/4ECF osmolality = ICF osmolalityK, ATPCreatinine PO4phospholipidsNa, ClHCO3
    10. 10. IntravascularInterstitial3/4 1/4Capillary membranePlasma proteins
    11. 11. IntracellularInterstitialIntravascular2/3 1/33/4 1/4NaKPlasmaNa 153IC K 150
    12. 12. Intracellular InterstitialIntravascular2/3 1/33/4 1/4
    13. 13. IntracellularInterstitial Intravascular2/3 1/33/4 1/4
    14. 14. IntracellularInterstitialIntravascular2/3 1/3666ml 250ml 84ml
    15. 15. IntracellularInterstitialIntravascular2/3 1/3750ml 250ml
    16. 16. IntracellularInterstitialIntravascular2/3 1/31000ml
    17. 17. IntracellularInterstitialIntravascular2/3 1/31000ml
    18. 18.  Intake and output must be balanced.Intake---N fluid ingested—2100 +frommetabolism(200)=2300mloutput—urine-1400+feces(100)-sweat-100- insensible loses—skin-350+lungs350ml Subject to variation environmental condition anddisease states
    19. 19. Weight Water requirement0-10 kg 4mL/kg/hr10-20 kg 40mL/hr +2ml/kg/hr for each kg>10kg>20kg 60ml/hr +1ml/kg/hr for eachkg>20kgfor 60kg man this = 100ml/hr or 2400 ml/24 hrsfor normal people!!
    20. 20. Solutions Volumes Na+K+Ca2+Mg2+Cl- HCO3-Dextrose mOsm/LECF 142 4 5 103 27 280-310LactatedRinger’s130 4 3 109 28 2730.9% NaCl 154 154 3080.45% NaCl 77 77 154D5W 50 250D5/0.45%NaCl77 77 50 4063% NaCl 513 513 10266%Hetastarch500 154 154 3105% Albumin 250,500130-160<2.5 130-160 33025% Albumin 20,50,100130-1 <2.5 130-160 330
    21. 21.  Crystalloidsrelatively large volumefor resus Ideal for repleshingthird space loss Less fear of allergicreaction Used as diluent forionotropicadminstration Colloids Lesser volume betterexpander moreduration Allergic reaction seenas well interfearancewith bloodcrossmatch
    22. 22.  R.L hartmen “solution,balanced salt solution Isotonic -isobaric- iso-osmolar- crystalloidsolution. Concentrations of ions—Na-131mEq/lcalcium-2mEq/lbicarbonate-29mEQ/L ASLACTATEK+ 5MeQ/L, CL- 110mEq/lPh-6.5,osmolarity-279mosm/L Normal saline Isotonicisobaric 0.9% w/vsolution Na+/cl- =154mEq/l Ph-5.00smolarity -308mosm/L --common maintainencefluid till other are madeavailable ---in treatment of diabeticketoacidosis—2 litres --upper intestinalobstruction andhypochloremia
    23. 23.  RL-Solutions provideselectrolytes with lactate. Lactate is rapidly metabolizedin liver to bicarbonate helps incorrection of acidosis Mild to moderate hypovolemiadue to any cause As a maintainence fluid Preloading before spinalanaesthesia Risk—Lactic acidosis hyperkalemia NS-Only fluid compatible withblood. Flushing of dialysis set withsaline Surgeons use for –washing crush injuriesperitoneal lavageunder water seal bottle Can be used as diluent formedicationNS-RISK-Hyperchloraemicmetabolic acidosis more likelywith renal insufficiency
    24. 24.  FULFILLS INDICATIONS OF BOTH 5% DEXAND .9% SALINE Useful particularly in pediatric patient Safely be used as maintainence fluid. Avoid for surgical procedures as dex best mediafor bacterial growth Can be used along with blood
    25. 25.  It provides calories –each gm of glucose 4 kcal. --used to correct water deficit --used to correct hypoglycemia --used as carrier for giving drugsdopamine,aminophylline,noradrenaline,insulin,SNP
    26. 26.  Higher concentration is irritant to vien. Avoid extravasation Water intoxication,odema states Should not be given along with blood transfusion Avoid in known hyperglycemic as maintainencefluid
    27. 27.  Hemaccel 3.5% poly gelatinNa 145/cl 145 k-5.1, ca++-6.25mEq/l Mol wt 30,000 pH 7.3 Half life 4-6hr Use in mod to severe shock. Priming solution
    28. 28.  Citrated blood should not be mixed. Produces histamine release/anaphylactic Dose should not increase 1000ml in 24 hrs. Careful in digitalized patient Avoid in hepatic renal and CCF However unlike other colloids does not causeagglutination and Rolex formation
    29. 29.  6% SOLUTION mol wt-2,00,000da Dose 20ml/kg in 24 h These are hyperoncotic and cause intravascularvolume expansion Duration 12-24 hrs The incidence of anphylactoid reaction is low
    30. 30.  IT interferes PL Aggregation and coagulation. Thermo osmalarity-308mosm/l Ability to with draw fluid from interstital space in tointravascular compartment It should be cautiously used in presence of renalfailure
    31. 31.  Dextran 40/ rheomacrodex --IT decreases viscosity of blood. --it improves micro circulation. --plasma half life 6-12hrs --dose 20 cc/kg/24hrs --it does not interfere with blood gp andcrossmatch
    32. 32.  Accumulation and tissue storage Effects on renal function Coagulopathy and bleeding risk Increase in amylase levels Anaphylactic potentials Cost factors
    33. 33.  New generation colloids-0.4 Molarsubstitution==degradation factor hydroxyl ethyl group No risk of accumulation even with dosages increasedfrom 20ml/kg---50ml/kg No effects on renal and coagulopathy Quest for the new colloid-- Balanced colloid solution like volulyte will end the debate
    34. 34. HES therapywas associatedwith higherHES therapy wasassociated with higherrates of acute renalfailure and renal-replacement therapythan wasRinger’s lactate.N Engl J Med 2008;358:125-39.Copyright © 2008 Massachusetts Medical Society
    35. 35.  What is the first sign of shock? a. Tachycardia b. hypotension c. narrow pulse pressure d. low urine output
    36. 36. parameterclass1 clqss2 class3 class4%bloodvol/cns<15%anxious15-30%agitated30-40%confuse>40%lethargicPulserate<100 >100 >120 >140Supineb.pn n decrease decreasUrineoutput>30ml/hr .20-30ml 5-15ml <5ml
    37. 37. Fluid resuscitation in uncontrolledbleeding is deleteriousDelayed resuscitation is valid in traumasystems with short response times(<20 minutes to hospital from injury)Attempts to control bleed should be givengreater importance
    38. 38. Fluids (pre-op) 2.4 L 0.4 L (p<0.001)Survival 62% 70% (p=0.04)ARDS/ renal failure 30% 23% (p=0.08)Sepsis/ infectionHospital days 14+24 11+19 (p=0.006)N Engl J Med 1994;331:1105-1109.598 patients; penetrating torso injuryField systolic BP <90 mm Hg (58+35)309 289Immediate fluids Delayed until induction
    39. 39. TraumaHaemorrhageCoagulation HypotensionFluidResuscitationHaemorrhageHaemorrhageFluidResuscitationRaisesBPDilutesfactors
    40. 40.  Restores volume +o2 carrying capacity Indicated in severe hemorrhagic shock eg pelvictrauma ,variceal bleed Pre-operative measure Blood products for replenishingcoagulation/factors eg FFP, PL Conc,
    41. 41.  Pyrexial reaction,allergy Transmission of disease-syphilis ,viralhepatitis,HIV,malaria Hemolytic reactions Citrate intoxication Hyperkalemia ,hypothermia Volume overload TRIM,TRALI
    42. 42.  PERIPHERIAL INTRACATH 16G Same gauze central line Hagen poiseuille equation rate @{radius} 4thpowerinversely proportional to length :;; infusion through central catheter will be asmuch as 75% less than infusion rate throughperipheral cathter of equal diameter
    43. 43.  Fluid resuscitation may consist of natural orartificial colloids or crystalloidsNo evidenced-based support for one typeof fluid over another•Crystalloids have a much larger volume ofdistribution compared to colloids•Crystalloid resuscitation requires more fluid toachieve the same endpoints as colloid•Crystalloids result in more edemaChoi PTL. Crit Care Med 1999;27:200-210.Cook D. Ann Intern Med 2001;135:205-208.Schierhout G. BMJ 1998;316:961-964.Fluid Therapy: Choice of FluidFluid Therapy: Choice of FluidGrade CDellinger, et. al. Crit Care Med 2004, 32: 858-873.
    44. 44.  Fluid challenge in patients with suspectedhypovolemia may be given500 - 1000 mL of crystalloids over 30 mins300 - 500 mL of colloids over 30 minsRepeat based on response and toleranceInput is typically greater than output due tovenodilation and capillary leakMost patients require continuing aggressivefluid resuscitation during the first 24 hours ofmanagementFluid Therapy: Fluid ChallengeFluid Therapy: Fluid ChallengeGrade EDellinger, et. al. Crit Care Med 2004, 32: 858-873.
    45. 45.  Central venous pressure (CVP) 8–12 mmHg – Mean arterial pressure (MAP) 65 mmHg – Urine output 0.5 ml/kg h1 – Central venous (superior vena cava) or mixedvenous oxygen saturation 70%. Rationale. Early goal-directed therapy(EGDT)
    46. 46. IntracellularInterstitialIntravascular2/3 1/33/4 1/4Na
    47. 47.  Blood Pressure—not a sensitive marker untilblood loss >30% NIBP-spuriously low measurement in patient withhypovolemia (vasoconstrictor response) Direct IAP better ? Cardiac filling pressures CVP—limitation—Indirect measure
    48. 48. Change in CVP measured beforeand 5 mins after bolus of fluid◦0-3 mmHg: underfilled◦3-5 mmHg: adequately filled◦5-7 mmHg: overfilled
    49. 49.  1 a wave is due to atrialcontraction 2.c wave due to buldgingof tricuspid valve in rtatrium 3 x descent depicts atrialrelaxation 4 v due to rise in atrialpressure before thetricuspid valve opens 5 y decent is due to atrialemptying as blood entersventricles
    50. 50. Watch out forSystolic pressurevariation

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