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Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
Emergency lectures - Fluid resuscitation in shock
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Emergency lectures - Fluid resuscitation in shock

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  • See Critique of fluid bolus, Hilton paper in queSee Fluid resusc in septic shock, Boyd paper in queSee Fluid resusc in severe sepsis Vincent paper in que
  • See McSwain paper in queue
  • Other strong predictors of mortality included cirrhosis, BSI, pseudomonas infection, medical admission, female gender, initial sofa score, age, and SAPS II score
  • Microcirculatory blood flow is improved because hypertonic fluid produces hemodilution and decreased blood viscosity
  • Acetate metabolized by most tissue, lactate requires good hepatic/renal functionLess risk of dilutional hyperchloremic acidosis
  • Singer
  • SAFE trialVISEP trialEfficacy and Safety of Colloid resuscitation in Critically Ill - Hartog
  • Albumin is provided free of cost in Australia
  • Albumin is provided free of cost in Australia
  • Dart AB, Mutter TC, Ruth CA, Taback SP. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev 2010;1:CD007594 Ogilvie MP, Pereira BMT, McKenney MG, et al. First report on the safety and efficacy of hetastarch solution for initial resuscitation at a level 1 trauma center. J Am Coll Surg. 2010;210:870–880; discussion 880–882. See also, Hetastarch Ogilvie paper in queSee also, Albumin Rhee paper in que
  • Dart AB, Mutter TC, Ruth CA, Taback SP. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev 2010;1:CD007594 Ogilvie MP, Pereira BMT, McKenney MG, et al. First report on the safety and efficacy of hetastarch solution for initial resuscitation at a level 1 trauma center. J Am Coll Surg. 2010;210:870–880; discussion 880–882. See also, Hetastarch Ogilvie paper in queSee also, Albumin Rhee paper in que
  • See hemodynamic and perfusion Ramos paper in que
  • Transcript

    • 1. Fluid Resuscitation inShockEvie Marcolini, MDAssistant ProfessorEmergency Medicine and Critical CareYale University School of MedicineNew Haven, Connecticut USA
    • 2. Case #1• 68 year old female, brought by family• Not feeling well x 4 days – Heart rate: 140 – Blood pressure: 80/60 – Respiratory rate: 30 – Temperature: 40C/104F• Productive cough x 3 days, decreased oral intake• History of smoking, emphysema, hypertension and diabetes
    • 3. Case #2• 26 year old male, unhelmeted driver of a motorcycle that struck a tree• Found unresponsive – Heart rate: 140 – Blood pressure: 80/60 – Respiratory rate: 30 – Temperature: 35.5C/96F• Patient is pale, cool, sweaty, no evidence of external bleeding, chest trauma or limb trauma• Abdomen distended, rigid
    • 4. • How should we treat these two patients with respect to fluid resuscitation?• What is the latest evidence supporting guidelines for fluid resuscitation?• How do these two patients differ with respect to their fluid requirements?
    • 5. Objectives• Review the types of Shock• Review the evidence for fluid resuscitation: how much to give?• Describe the fluid options for resuscitation• Outline the goals of fluid therapy• Special considerations
    • 6. Types of Shock• Hypovolemic – Hemorrhage – Body fluid loss (gastrointestinal)• Distributive – Sepsis – Anaphylaxis• Cardiogenic – Myocardial infarction – Cardiac valve dysfunction• Obstructive – Tension pneumothorax – Cardiac tamponade
    • 7. Types of Shock• Hypovolemic –Hemorrhage• Distributive –Sepsis
    • 8. Overall Shock Treatment• Depends on type of shock• Fluid is a common denominator – Attenuate inflammatory response – Decrease organ injury – Improve survival• Fluid bolus resuscitation is controversial – Penetrating trauma – Sepsis
    • 9. Fluid ResuscitationWhat are the questions?• How much fluid is enough?• Which type of fluid is best?
    • 10. High volume fluid controversy • US military recommendations: – Hypotensive resuscitation should be used until hemorrhage control is obtained – 1:1:1 resuscitation should be used until hemorrhage is controlled – No data exists to show that colloids are superior to other fluids for resuscitation McSwain NE et al; J Trauma 2011 Aug;71(2):520
    • 11. • 600 hypotensive patients with penetrating torso injuries• Delayed resuscitation resulted in improved survival, fewer complications and shorter hospital length of stay Bickell WH et al. NEJM 1994; 331:1105-9
    • 12. Early aggressive fluids • May prevent hemostatic clot formation • May dilute clotting factors • May contribute to acidosis, hypothermia and coagulopathy • Damage control (DCR) resuscitation avoids these risksDuchesne JC et al. Am Surg 2011 Feb;77(2):201-6
    • 13. • What about non-traumatic septic shock patients?
    • 14. Gold Standard…• “Resuscitation goals included targeted CVP 8-12”• 5000 ml vs 3500 ml fluid given in the first 6 hours of therapy• “Mortality decreased from 46% to 30%” Rivers E et al, NEJM 2001;345:1368-77
    • 15. • “Resuscitation goals for severe sepsis and septic shock include the following: – Central venous pressure: 8–12 mm Hg – Mean arterial pressure >65 mm Hg – Urine output >0.5 mL/kg/hr – Central venous (superior vena cava) or mixed venous oxygen saturation >70%• There is no evidence-based support for one type of fluid over another Dellinger RP et al, Crit Care Med 2004;32:858-873
    • 16. New Standard…• 800 patients with septic shock receiving 5 micrograms of norepinephrine per minute• “A more positive fluid balance at 12 hours and over 4 days is associated with increased mortality”• CVP was correlated with fluid balance at 12 hours, but there was no significant correlation on days 1-4 Boyd JH et al, Crit Care Med 2011;39:259-265
    • 17. New Standard…• 1200 septic patients admitted to European ICUs in a 2 week period• “A positive fluid balance was among the strongest prognostic factors for death” Vincent JL et al. Crit Care Med 2006; 34:344-353
    • 18. What can we conclude about how much fluid to give? • Trauma – Judicious use of fluids until surgical hemostasis seems to be beneficial • Non-trauma – Early goal directed therapy with endpoint of CVP 8-12 has been the gold standard – Evidence is mounting for benefit of less aggressive fluid therapy
    • 19. What about types of fluid?• Fluid options – Human blood products – Crystalloids – Colloids
    • 20. • Prospective liberal vs conservative transfusion study• No improved outcome for transfusion to Hb levels of 10g/dl as opposed to 7 g/dl Hebert PC et al. NEJM 1999;34:409-17
    • 21. • 4900 patients, prospective multi-center observational cohort study• The number of RBC units transfused is an independent predictor of worse clinical outcome Corwin HL et al. Crit Care Med 2004; 32:39-52
    • 22. Recommendations for traumaresuscitation • Prehospital – 1:1 resuscitation should be used a much as possible (blood:plasma) • In-hospital – 1:1:1 resuscitation should be the goal until hemorrhage is controlled (blood:plasma:platelets) – Management of initial coagulopathy of severe blood loss is best achieved by early plasma infusion McSwain NE et al; J Trauma 2011 Aug;71(2):520
    • 23. Crystalloids• Normal saline• Lactated Ringer’s• Hypertonic saline• Plasmalyte
    • 24. Crystalloid compositionSolution Na Cl K Ca Mg Lactate Acetate Gluconate0.9% NaCl 154 154 0 0 0 0 0 0Lactated Ringer’s 130 109 4 3 0 28 0 03% NaCl 513 513 0 0 0 0 0 0Plasmalyte 140 98 5 0 3 0 27 23 Amounts in meq/liter
    • 25. 0.9% SalineAdvantages Disadvantages – Most commonly • Expansion of interstitial used, familiar volume • Dilutional hyperchloremic – Higher osmolarity than acidosis, leading to systemic Ringer’s Lactate; better for vasodilation, pulmonary brain injury patients edema and coagulopathy – May be advantageous in • Larger volume patients with metabolic needed, causing abdominal acidosis compartment syndrome, pulmonary edema – Inexpensive
    • 26. Lactated Ringer’sAdvantages Disadvantages – Sydney Ringer added • Pro-inflammatory, activates potassium and calcium to neutrophils NS to enhance contractility of frog hearts • Cannot be infused with RBC’s due to calcium which binds – Alexis Hartman added citrated blood anticoagulant sodium lactate to correct but not overcorrect • Contains potassium, risk of metabolic acidosis hyperkalemia in renal failure patients
    • 27. Hypertonic SalineAdvantages Disadvantages – 3%, 5%, 7.5%, 23% • Hypernatremia – Raises blood pressure by • Lacking evidence of volume expansion improved outcome for – Improves microcirculation patients with trauma or – Immunomodulation potential sepsis – Improves myocardial contractility – Reduces interstitial and endothelial edema
    • 28. PlasmalyteAdvantages Disadvantages• Physiologic, balanced • Magnesium may counteract• Osmolality/pH similar to vasoconstriction plasma • Possible• Acetate metabolizes to bradycardia, hypotension, wors bicarbonate, produces less ening microcirculation CO2 than lactate • No evidence for superiority• Volume and electrolyte deficit over other crystalloids correction • More expensive (debatable)• Contains metabolizable bases that replace bicarbonate• No calcium - can be combined with blood and medications
    • 29. Crystalloids• There is no proven benefit of one crystalloid over another• Each patient scenario may benefit from different characteristics of each solution• Knowledge of the advantages and disadvantages of each solution translates to patient benefit
    • 30. Colloids • Electrolyte solution with large molecular weight molecules • Theory: increased oncotic pressure keeps fluid within vascular space • Regional differences • UK, China, Australia heaviest users
    • 31. Why consider Colloids?Advantages Disadvantages• More effective volume • Not proven to reduce expansion mortality• Less weight (military use) • More expensive• Recommended for – Low protein states – Malnourishment – Intolerance of large volumes – Ortho/reconstructive (prevention of thrombus)
    • 32. • Prospective, 7000 patients randomized to albumin versus saline for fluid resuscitation• Showed that albumin or normal saline results in similar mortality The SAFE study investigators. NEJM 2004;350:2247-56
    • 33. Colloid myth-busting• More effective plasma expansion – Theory, not borne out in literature – Over time, both are equally effective – Adequate resuscitation achieved with 1-2 fold of total crystalloid compared to colloid – Colloids do not stay intravascular longer, and may leak into the interstitium• Synthetics equally safe, less expensive than albumin – Not enough evidence; may contribute to renal failure, coagulopathy and tissue storage – Albumin may be safer in cirrhosis/SBP, harmful in TBI
    • 34. Colloids• Naturally-occurring – Albumin – Dextran – Blood• Synthetic – Hydroxyethyl starch (HES) – Gelatins
    • 35. Colloid composition Albumin Dextran Hetastarch Gelufosine 5% / 25% 40 / 70Molecular weight 70 / 70 40 / 70 450,000 30,000Sodium level 130-160 154 154 154Osmolality 300-1500 308 310 n/aVolume expansion 500-1700 500-1000 500-700 500Duration <24 h <6-24 h <36 h <4 hAllergic reaction (%) 0.011 0.007-.069 0.085 0.066
    • 36. Albumin• Predominant plasma protein• First derived from plasma in World War II• From pooled human serum albumin• Available in 5% or 25% concentration• Recommended for severe hypoalbuminemia and cirrhosis
    • 37. AlbuminAdvantages Disadvantages – Does not cause – Transfusion reactions inflammation – Reduced ionized calcium – Small volume levels – depressed – Primary antioxidant effects myocardial function – Effects of 25% long-lasting – Decreased GFR in burn (up to 12 hours) patients – Given with loop diuretic to – Expensive (up to 30x more mobilize fluid in volume than crystalloid) overload – More expensive, less available
    • 38. DextranAdvantages Disadvantages – Glucose polymer • Can be associated with – Lowers blood viscosity kidney injury with pre- via disaggregation existing renal dysfunction – Prevents deep venous or hypovolemia thrombosis – Reduced Factor VIII • Can cause anaphylactic activity/fibrin clot reaction (rare) formation – 40,000D or 70,000D molecular weight
    • 39. Hydroxyethyl Starch“Hespan” – Derived from amylopectin – 6% isotonic solution – Low, medium and high molecular weight – Hydrolyzed by amylase, cleared by kidney
    • 40. Hydroxyethyl Starch “Hespan”Advantages Disadvantages – Low volume, easy to – Can cause renal transport failure in septic shock – Rare anaphylaxis patients – Preserves splanchnic – May cause perfusion coagulopathy and – Used in US military in hyperchloremic limited volume to acidosis reduce risk of – Theoretical maximum coagulopathy daily dose = 1.5 liters – May accumulate in plasma and tissues
    • 41. HextendAdvantages Disadvantages• Hextend = 6% Hetastarch • Limited to 1.5 liters in lactated electrolyte • Needs more data to show buffer outcome improvement• Approved by US Food and Drug Administration for hypovolemia in elective surgery• No good data on safety in volume resuscitation
    • 42. GelatinAdvantages Disadvantages – Derived from bovine • Relatively short bone material intravascular half-life – Smaller molecular • Risk of anaphylaxis weight than other colloids – Rapidly excreted by kidneys
    • 43. Colloid conclusions?• HES has best risk/benefit profile – Not enough data – Synthetics cause more anaphylaxis than albumin• Newer HES is safer – Inconclusive literature – Used extensively in Scandanavian and Swiss ICU’s – Canadian survey shows that marketing may influence practice
    • 44. Goals of Fluid Therapy• Replace losses• Protect the kidneys• Maintain osmolarity• Maintain acid-base and electrolyte balance
    • 45. Special Cases• Traumatic brain injury – Not candidate for permission hypotension – Hypotension and hypoxia are two strong markers of poor outcome• Burns – Large fluid requirements up front to restore intravascular volume and maintain end-organ perfusion
    • 46. What can we conclude about how much fluid to give? • Trauma – Judicious use of fluids until surgical hemostasis seems to be beneficial • Non-trauma – Early goal directed therapy with endpoint of CVP 8-12 has been the gold standard – Evidence is mounting for benefit of less aggressive fluid therapy
    • 47. What type of fluid is best?• It really depends on the patient and your situation – Is your patient a trauma or a medical patient? – Is there a high risk of bleeding? – Is cost an issue? – Does your patient have allergies?
    • 48. Case #1• 68 year old female, brought by family• Not feeling well x 4 days – Heart rate: 140 – Blood pressure: 80/60 – Respiratory rate: 30 – Temperature: 40C/104F• Productive cough x 3 days, decreased oral intake• History of smoking, emphysema, hypertension and diabetes
    • 49. Case #1 • This patient needs fluid for : – Loss replacement, renal protection, osmolarity and acid-base performance • There is no great evidence to support the cost of colloid therapy versus crystalloid • Blood transfusion risk outweighs benefit unless hematocrit is below 7 • A more positive fluid balance at 12 hours and over 4 days is associated with increased mortality, and CVP is unreliable after 12 hours • If colloid is used, coagulopathy should be monitored
    • 50. Case #2• 26 year old male, unhelmeted driver of a motorcycle that struck a tree• Found unresponsive – Heart rate: 140 – Blood pressure: 80/60 – Respiratory rate: 30 – Temperature: 35.5C/96F• Patient is pale, cool, sweaty, no evidence of external bleeding, chest trauma or limb trauma• Abdomen distended, rigid
    • 51. Case #2• This patient needs fluid for – Loss replacement, renal protection, osmolarity and acid-base performance• Hypotensive resuscitation should likely be limited to Systolic blood pressure <100• Colloids may stay in the system longer, but outcome benefit is not yet proven
    • 52. Conclusions• Trauma – Judicious use of fluids until surgical hemostasis seems to be beneficial – Early aggressive fluid therapy may be harmful• Non-trauma – Early goal directed therapy with endpoint of CVP 8-12 has been the gold standard – Evidence is mounting for benefit of less aggressive fluid therapy
    • 53. Conclusions– Blood products should be given judiciously, and in a 1:1:1 fashion as appropriate until hemorrhage is controlled– Overaggressive fluid therapy may exacerbate the lethal triad of coagulopathy, hypothermia and acidosis– There is no proven benefit of one crystalloid over another– Colloids do not show an outcome improvement over crystalloids– Each patient scenario should be considered individually
    • 54. Thank you! Evie Marcolini Assistant ProfessorEmergency Medicine and Critical Care

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