Basic Principles of Critical Care

1. FLUID REPLACEMENT
Gradian Health Systems
Basic Principles of Critical Care
CARDIOVASCULAR SYSTEM

2. Disclaimer
Basic Principles of Critical Care Training I Fluid Replacement
Disclaimer: Gradian Health Systems cannot provide formal recommendations or indications
regarding medical care and clinical service delivery. The tables, checklists, and other clinical
documents referenced in this training have not been validated in all settings. These documents are
intended to serve as examples only. We recognize that all clinical training content and activities
must be customized to meet the needs of each facility and its clinical staff, factoring in available
resources, practitioner skill level, and other environmental considerations.
For any questions regarding the contents or applications of this training,
please contact Gradian Health Systems:
40 W 25th St, 6th Floor
New York, NY 10010 USA
+1 212-537-0340
training@gradianhealth.org

3. Module 3
Gradian Health Systems
Basics Principles of Critical Care
Cardiovascular System

4. Module 3: Cardiovascular System
MODULE OVERVIEW
Lesson 1 I Cardiovascular System Anatomy and Physiology
Lesson 2 I Hemodynamic Monitoring
Lesson 3 I Shock
Lesson 4 I Fluid Replacement
Lesson 5 I Vasoactive Medications
Lesson 6 I Basic ECG Interpretation
Basic Principles of Critical Care Training I Fluid Replacement

5. Components of the Gradian CCV SystemLesson 4: Fluid Replacement
Lesson Objectives
• Describe the types of fluids used in critical care
• Describe indications for fluid therapy
Basic Principles of Critical Care Training I Fluid Replacement

6. Components of the Gradian CCV SystemLesson 4: Fluid Replacement
Key Concepts
• Types of fluid therapy
• Indications of fluid therapy
Basic Principles of Critical Care Training I Fluid Replacement

7. Components of the Gradian CCV SystemFluid Replacement
Fluid Replacement
Intravenous fluid administration should be considered the same way we do
administration of drugs:
• Type
• Indication
• Dose
• Side effects
Basic Principles of Critical Care Training I Fluid Replacement

8. Components of the Gradian CCV SystemFluid Replacement
Fluid Replacement Indications
• Resuscitation
• Replacement
• Maintenance
• Drug administration as diluent
Fluid Types
Balance solutions
• Colloids – gelatins, starches, haemaccel, dextrans, albumin
• Crystalloids – Ringer’s lactate solution, Hartmann’s solution, normal saline
• Crystalloids are further divided into hypertonic, isotonic and hypotonic
Basic Principles of Critical Care Training I Fluid Replacement

9. Components of the Gradian CCV SystemFluid Replacement
Basic Principles of Critical Care Training I Fluid Replacement
Crystalloid
solution
Comments Indication Side effects
3% or 5% saline
(NaCl)
Higher sodium concentration
than plasma; will cause fluid
to move from the intracellular
and interstitial compartments
into the intravascular
compartment. Blood volume
increases.
• Severe
hyponatremia
• Hyperchloremic
metabolic acidosis
• Hypernatremia
• Fluid overload
Mannitol
Composed of simple sugar in
water
• Reducing intracranial
pressure
• Diuresis
• Fluid overload
• Increased diuresis
Hypertonic Crystalloids

10. Components of the Gradian CCV SystemFluid Replacement
Basic Principles of Critical Care Training I Fluid Replacement
Crystalloid
solution
Comments Indication Side effects
Half-saline (0.45%)
Lower sodium concentration
(Na+ 77meq/L) than plasma
• Hypernatremia
• Fluid overload
• Hemolysis of red
blood cells
Hypotonic Crystalloids

11. Components of the Gradian CCV SystemFluid Replacement
Basic Principles of Critical Care Training I Fluid Replacement
Crystalloid
solution
Comments Indication Side effects
0.9% Saline
(normal saline)
Same sodium concentration
as plasma
• Fluid resuscitation
• Maintenance
• Fluid overload
Hyperchloremia
Lactated Ringer’s
273 mOsm/L Na+ 130mEq/L
K + 4 mEq/L Ca++ 3 mEq/L
Cl- 109 mEq/L
• Fluid resuscitation
• Maintenance
• Fluid overload
• Lactic acidosis
5% dextrose in
water
5 g dextrose/100mL
Both iso- and hypotonic
Provide free water and
dextrose
• Hypernatremia
• Fluid overload
• Dilutes plasma
solutes
Isotonic Crystalloids

12. Components of the Gradian CCV SystemFluid Replacement
Colloids
Colloids have large molecules that do not diffuse across membranes and remain
in the intravascular compartment. Also known as plasma expanders. Common
side effects of colloids include fluid overload and allergic reactions.
Basic Principles of Critical Care Training I Fluid Replacement

13. Components of the Gradian CCV SystemFluid Replacement
Basic Principles of Critical Care Training I Fluid Replacement
Colloids Comments Indications Side effects
Albumin (5%) Human albumin
• Hypoalbuminemia
• Fluid resuscitation (volume
expansion for 1-24 hours)
• Allergic reaction
Dextran
Polysaccharide molecules 6%-
Dextran 40
10%- Dextran 70
• Fluid resuscitation (volume
expansion for 1-24 hours)
• Coagulation
disorders
• Allergic reaction
Hydroxyethyl
starch (HES)
1st generation - hespan
2nd generation - hetastarch,
pentastarch
3rd generation - tetrastarch
• Fluid resuscitation (volume
expansion 8-12 hours)
• Anaphylaxis
• Impaired kidney
function
Gelatine
Succinylated gelatin-
Gelofusine, plasmagel
Urea-linked gelatins Haemaccel
• Fluid resuscitation (volume
expansion <6 hours)
• Preloading
• Allergic reaction

14. Components of the Gradian CCV SystemFluid Replacement
Fluid Therapy
• Resuscitation
• Boluses of 250mls to 500mls of crystalloids
• Review response to fluid bolus
• Seek expert review if no improvement with >2L given
• Replacement
• Assess for losses and replace, as needed
• Examples of losses include:
• Diarrhea
• Vomiting
• Polyuria
• Edema
Basic Principles of Critical Care Training I Fluid Replacement

15. Components of the Gradian CCV SystemFluid Replacement
Fluid Therapy
• Maintenance
• Administered via IV if oral/enterally is insufficient
• Approximately 2.5-3L/day for adults
• Maintenance therapy should include sodium and potassium daily
requirements and electrolyte levels
• Precautions need to be taken in sepsis, heart failure and renal failure
Basic Principles of Critical Care Training I Fluid Replacement

16. Components of the Gradian CCV SystemLesson 4: Summary
The primary goals of fluid therapy treatment are resuscitation and correction of
shock in order to achieve adequate perfusion. Fluids should be administered
according to individual needs and assessed on a regular basis.
Basic Principles of Critical Care Training I Fluid Replacement