Fluid management in icu dr vijay

Dr M Vijay kumar MDDr M Vijay kumar MD
Fluid Management inFluid Management in
ED & ICUED & ICU

Fluid Therapy in ER & ICUFluid Therapy in ER & ICU
ObjectivesObjectives
Understand of The Normal Regulation of Fluid BalanceUnderstand of The Normal Regulation of Fluid Balance
Fluid Imbalance In Shock State
Indices of successful resuscitationIndices of successful resuscitation
Early Hemodynamic Optimization
Fluid Therapy (Types) & IndicationFluid Therapy (Types) & Indication
Permissive hypotensionPermissive hypotension
Fluid Resuscitation InFluid Resuscitation In Special situation
( burn, MPE, brain injury, electrolyte dist. AAA, etc.( burn, MPE, brain injury, electrolyte dist. AAA, etc.

•Both under resuscitation and volume overload
increase morbidity and mortality in critically ill
patients.
•Uncorrected hypovolemia, leading to inappropriate
infusions of vasopressor agents, may increase
organ hypo perfusion and ischemia.
•Overzealous fluid resuscitation has been
associated with increased complications, increased
length of ICU and hospital stay, and increased
mortality.
Fluid Therapy in ER & ICUFluid Therapy in ER & ICU

Body Fluid CompartmentsBody Fluid Compartments
 Total Body Water = 60% body weightTotal Body Water = 60% body weight
– 70Kg TBW = 42 L70Kg TBW = 42 L
 2/3 of TBW is intracellular (ICF)2/3 of TBW is intracellular (ICF)
– 40% of body weight, 70Kg = 28 L40% of body weight, 70Kg = 28 L
 1/3 of TBW is extracellular (ECF)1/3 of TBW is extracellular (ECF)
– 20% of body weight, 70Kg = 14 L20% of body weight, 70Kg = 14 L
– Plasma volume is approx 4% of total bodyPlasma volume is approx 4% of total body
weight, but varies by age, gender, bodyweight, but varies by age, gender, body
habitushabitus

Regulation of Fluid Balance
TOTAL BODY FLUID
(40) liters;60%TBW
Red cell volume
(2 liters)
Plasma volume
(3 liters,5 %)
Extracellular
(15 liters,20%)
Blood volume (5 liters)
Intracellular
(25 liters,40%)
The intracellular andThe intracellular and
extracellular compartmentsextracellular compartments
are separated byare separated by
water-permeablewater-permeable
cell membranes.cell membranes.

Blood VolumeBlood Volume
Blood Volume (mL/kg)Blood Volume (mL/kg)
Premature InfantPremature Infant 9090
Term InfantTerm Infant 8080
Slim MaleSlim Male 7575
Obese MaleObese Male 7070
Slim FemaleSlim Female 6565
Obese FemaleObese Female 6060

• Does this patient have adequate organ
perfusion?
– Mean arterial pressure (cerebral and
abdominal perfusion
pressures)
– Urine output
– Mentation
– Capillary refill
– Skin perfusion/mottling
– Cold extremities
– Cold knee’s (Marik’s sign; temperature
gradient between thigh
and knee)

– Blood lactate
– Arterial pH, BE, and HCO3
– Mixed venous oxygen saturation
(SmvO2) or central venous
oxygen saturation (ScvO2)
– Mixed venous pCO2
– Tissue pCO2 (sublingual capnometry or
equivalent)
– Gastric impedance spectroscopy
– Skeletal muscle tissue oxygenation
StO2

• Does this patient have tissue edema?
– Generalized edema
– Pulmonary edema on chest radiograph
– Increased extravascular lung water (PiCCO
technology)
– Increased intra-abdominal pressure

• Is this patient volume responsive?
– Pulse pressure variation (PPV) and/or stroke
volume variation
(SVV)
• Does this patient have preserved LV function?
– ECHO

• If the patient has inadequate organ
perfusion and is volume responsive,
what volume expander do I use?
– Lactated Ringer’s solution (Hartmann’s
solution)
– 5% albumin
– Normal saline
– 1/2 normal saline
– Blood

Fluid & Electrolyte BalanceFluid & Electrolyte Balance
pathophysiology

Hemorrhagic Shock
Rapid reduction in blood volume
Baroreceptor activation
Vasoconstriction
Increased strength
of cardiac
contraction
Increased
heart rate +
increase in the diastolic BP narrow
pulse pressure
Ventricular filling Cardiac output
Hemorrhagic
Shock

Cellular
Dysfunction
Cellular ischemia
Disruption of
cellular
metabolism
Inflammatory
mediators, and
toxic effects of
free radicals
Shock
State
DEATHDEATH
SHOCK
PATHOPHYSIOLOGY
SHOCK
PATHOPHYSIOLOGY
Altered Membrane Potential
Altered Ion Distribution (↑ Intracellular
Ca2+ /Na2+ )
Cellular Swelling
Cytoskeletal Disorganization
Increased Hypoxanthine
Decreased Adenosine 5′-
Triphosphate (ATP)
Decreased Phosphocreatine
Decreased Glutathione
Cellular Acidosis

The American College of Critical Care
Medicine (ACCM) Sep.2004 update
Compensatory
mechanisms
Restore pressure and
flow to vital organs.
In early shock
•Damage to cellular membranes
•Loss of ion gradients
•Leakage of lysosomal enzymes
•Proteolysis due to activation of
cellular proteases
•Reductions in cellular energy stores
Irreversible shock
and death
Fail

Decrease VR
Decrease Tissue Perfusion
Decrease Blood
pressure
Decrease cardiac output
Intracellular
fluid Loss
Cellular
hypoxia
Metabolic Acidosis
Decreased
Myocardial
Contraction
Microcirculatory
Damage
Cellular aggregation
Microcirculatory
obstruction
Decreased
myocardial
function
Decreased
Coronary
Perfusion

IC. WATER ECF
2/3 intrest. 1/3 blood
25
150
15
0.01
2
6
50
Na
K
Mg
Ca
Cl
Hco3
Phos
140
4.5
1.2
2.4
100
25
1.2
Fluid & Electrolyte Balance

Regulation of Fluid BalanceRegulation of Fluid Balance
 Plasma and interstitial fluid are richPlasma and interstitial fluid are rich
in proteins, which determinein proteins, which determine
plasma colloid osmotic pressure.plasma colloid osmotic pressure.

ECC OsmolarityECC Osmolarity
ECF VolumeECF Volume
Prevent swelling orPrevent swelling or
shrinking of the cellsshrinking of the cells
Maintain BPMaintain BP

The net fluid filtered through a capillary bed isThe net fluid filtered through a capillary bed is
determined by both the translumenal hydrostaticdetermined by both the translumenal hydrostatic
pressures and oncotic pressures.pressures and oncotic pressures.
THE STARLING EQUATION

HydrostaticHydrostatic
pressurepressure
OncoticOncotic
pressurepressure
tending to movetending to move
fluid out of thefluid out of the
capillariescapillaries
tending totending to
keep fluidkeep fluid
within thewithin the
capillariescapillaries
THE STARLING
EQUATION
Excess fluid filtered is
collected through the
lymphatic circulation
and returned to the
Systemic circulation
Regulation of
Fluid Balance

Q=K[(Pc-Pi)-@(Oc-Oi)]Q=K[(Pc-Pi)-@(Oc-Oi)]
Indices of Successful Resuscitation in ER
17
Mm
Hg
Oncotic P=25
37
mm
Hg
VenuleArteriole
Pnet =(37-1)+(0-25)=11
Interstitial
Hydrostatic P=1 Pnet =(17-1)+(0-25)=-9

Cellular Pump Failure In Shock
K Na.KATPASE
Pump failure
lead to cellular death
CL
Na
K
Intracellular
Extracellular
Water

Changes in Sk. Muscle Fluid & Elect. In Shock StateChanges in Sk. Muscle Fluid & Elect. In Shock State
INTRACELL. EXTRACELL.COMPONENT
WATER
Na
K

Control of body water and its composition involvesControl of body water and its composition involves::
(1) Atrial natriuretic
peptide
(2) Vasopressin
(3) aldosterone (renin,
angiotensin)
(4) parathyroid hormone
(5) calcitonin
(6) Prostaglandins
(7) dopaminergic receptors
(8) alpha-adrenergic
receptors
(9) the thirst mechanism
(10) intrinsic renal
properties.

The diagnosis and management of shock are among the most
common challenges we must deal with.
Shock may be broadly grouped into five pathophysiologic
categories:
(1) Hypovolemic
(2) Distributive
(3) Cardiac
(4) Obstructive
(6) cytotoxic
Failure of end-organ cellular metabolism is a feature of all five.
ShockShock

Shock StatesShock States
BPBP CVPCVP PCWPPCWP COCO SVRSVR
HypovolemiaHypovolemia
CardiogenicCardiogenic
- LV- LV
- RVOT- RVOT
ObstructionObstruction
DistributiveDistributive
ObstructiveObstructive

DO2
CaO2
CO
Sat %
PaO2
Hgb
HR
SV
Preload
Contractility
Afterload

Assessment of Stages of ShockAssessment of Stages of Shock
% Blood% Blood
Volume lossVolume loss
< 15%< 15% 15 – 30%15 – 30% 30 – 40%30 – 40% >40%>40%
HRHR <100<100 >100>100 >120>120 >140>140
SBPSBP NN N, DBP,N, DBP,
postural droppostural drop
PulsePulse
PressurePressure
N orN or
Cap RefillCap Refill < 3 sec< 3 sec > 3 sec> 3 sec >3 sec or>3 sec or
absentabsent
absentabsent
RespResp 14 - 2014 - 20 20 - 3020 - 30 30 - 4030 - 40 >35>35
CNSCNS anxiousanxious v. anxiousv. anxious confusedconfused lethargiclethargic
TreatmentTreatment 1 – 2 L1 – 2 L
crystalloid, +crystalloid, +
maintenancemaintenance
2 L crystalloid,2 L crystalloid,
re-evaluatere-evaluate
2 L crystalloid, re-evaluate,2 L crystalloid, re-evaluate,
replace blood loss 1:3replace blood loss 1:3
crystalloid, 1:1 colloid or bloodcrystalloid, 1:1 colloid or blood
products. Urine output >0.5products. Urine output >0.5
mL/kg/hrmL/kg/hr

ShockShock
 In approximately 50% of septic patients who
initially present with hypotension, fluids alone
will reverse hypotension and restore
hemodynamic stability

ShockShock
Until restoration of the functional extracellular fluidUntil restoration of the functional extracellular fluid
volume is completed, normal oxygen and nutrientvolume is completed, normal oxygen and nutrient
delivery to the cells and removal of waste products fromdelivery to the cells and removal of waste products from
them cannot occur.them cannot occur.
In approximately 50% of septic patients who initiallyIn approximately 50% of septic patients who initially
present with hypotension, fluids alone will reversepresent with hypotension, fluids alone will reverse
hypotension and restore hemodynamic stabilityhypotension and restore hemodynamic stability

In severe (ED) or long-standing (ICU) shock :In severe (ED) or long-standing (ICU) shock :
The restoration of intravascular volume alone isThe restoration of intravascular volume alone is
insufficient for successful resuscitation.insufficient for successful resuscitation.

Cellular effects of ischemia.Cellular effects of ischemia.
• Altered Membrane Potential
• Altered Ion Distribution (↑ Intracellular Ca2+
/Na2+
)
• Cellular Swelling
• Cytoskeletal Disorganization
• Increased Hypoxanthine
• Decreased Adenosine 5′-Triphosphate (ATP)
• Decreased Phosphocreatine
• Decreased Glutathione
• Cellular Acidosis

 A progressive increase in intracellularA progressive increase in intracellular NaNa andand
water and extracellularwater and extracellular KK occurs with anoccurs with an
associated decrease in extracellular water.associated decrease in extracellular water.
 ThThisis accounting for the loss of functionalaccounting for the loss of functional
extracellular fluid volume.extracellular fluid volume.

Volume Depletion with Depleted Extravascular
Compartment
• Acute blood loss
– Trauma
– GI bleed
• Gastrointestinal tract losses (diarrhea, vomiting,
fistula)
• Decreased fluid intake due to acute medical
conditions
• Diabetic ketoacidosis
• Heat exhaustion
• “Dehydration”

Volume Depletion with Expanded Extravascular
Compartment
• Sepsis
• Pancreatitis
• Trauma
• Surgery
• Burns
• Liver failure
• Cardiac failure

Sepsis (and SIRS)
As a consequence of “leaky capillaries”
and “third space loss” these patients have
a decreased effective intravascular
compartment and tissue edema (enlarged
interstitial compartment).
 As less than 20% of infused crystalloid
remains intravascular in these patients, the
volume of crystalloids should be limited.
The combination of albumin and LR is
recommended.

Indices of successful resuscitation inIndices of successful resuscitation in
ERER

Indices of successful resuscitationIndices of successful resuscitation
Improved blood pressure
Diminished tachy. Falling lactate Normalizing pH
Increasing central venous 02
saturation
Urine output > 0.5 mL/kg/h or improving (in children,
> 1 mL/kg/h; in infants, > 2 mL/kg/h)
LOC
Peripheral perfusion improving, Cardiac output
increasing (normal ≥ 3.5 L/min in adults)

“STATIC” MEASURES OF
INTRAVASCULAR VOLUME
•The Central Venous Pressure (CVP) and
•Pulmonary Capillary Wedge Pressure (PCWP)
•Right ventricular end-diastolic volume(RVEDV)
•Left ventricular end-diastolic area (LVEDA)
•Inferior vena-caval diameter
•Intrathoracic blood volume index (ITBVI),
•Global end-diastolic volume index
(GEDVI)

“DYNAMIC” MEASURES OF
INTRAVASCULAR VOLUME
STATUS
•Pulse pressure variation (PPV)
derived from analysis of the arterial
waveform
• Stroke volume variation
(SVV) derived from pulse contour
analysis

MEASURES OF
VOLUME OVERLOAD
 Extravascular Lung Water
 Intra-Abdominal Pressure
Monitoring

Blood Pressure
A normal blood pressure can be sustained
despite loss of up to 30% of blood volume.
A decrease in MAP should be regarded as a late
finding in hemorrhagic shock

Heart rateHeart rate
• Tachycardia is not a reliable sign of hypotension after
trauma.
• Although tachycardia was independently associated with
hypotension, its sensitivity and specificity limit its
usefulness in the initial evaluation of trauma victims.
• Absence of tachycardia should not reassure the clinician
about the absence of significant blood loss after trauma.
• Patients who are both hypotensive and tachycardic have
an associated increased mortality and warrant careful
evaluation.

Central Venous Oxygen SaturationCentral Venous Oxygen Saturation
ScvO2 also helps to confirm ROSC rapidly.
ScvO2 monitoring is also useful in the postresuscitation
period to help titrate therapy and recognize any sudden
deteriorations in the patient’s clinical condition.

Lactate
As a product of anaerobic glycolysis, lactate is an
indirect measure of oxygen debt. As tissue oxygen
delivery falls below the threshold required for
efficient oxidative phosphorylation, cells metabolize
glucose into pyruvate and then lactate rather than
entering the Krebs cycle.

Lactate
The trend of lactate concentrations is a
better indicator than a single value and it is
a better prognostic indicator than oxygen-
derived variables. It is more sensitive than
blood pressure or CO in predicting mortality
in a dog model of hemorrhage

 Studies have shown that a lactate concentration >4Studies have shown that a lactate concentration >4
mmol/L in the presence of the systemic inflammatorymmol/L in the presence of the systemic inflammatory
response syndrome (SIRS) criteria significantly increasesresponse syndrome (SIRS) criteria significantly increases
intensive care unit (ICU) admission rates and mortalityintensive care unit (ICU) admission rates and mortality
rate in normotensive patientsrate in normotensive patients
•Grzybowski M : Systemic inflammatory response syndrome criteria and
lactic acidosis in the detection of critical illness among patients presenting
to the emergency department . Chest 1996 ; 110 : 145S.
•Moore RB The value of SIRS criteria in ED patients with presumed
infection in predicting mortality . Acad Emerg Med 2001 ; 8 : 477
•Aduen J The use and clinical importance of a substrate-specific electrode
for rapid determination of blood lactate concentrations . JAMA 1994 ; 272 :
1678–1685

Early lactate clearance is associated with improved
outcome in severe sepsis and septic shock
H. Bryant Nguyen, MD, MS;
Prospective observational study
Critical Care Medicine
Volume 32 • Number 8 • August 2004

A positive value denotes a decrease or clearance ofA positive value denotes a decrease or clearance of
lactate, whereas a negative value denotes anlactate, whereas a negative value denotes an
increase in lactate after 6 hrs of ED intervention.increase in lactate after 6 hrs of ED intervention.
Lactate Clearance Definition.Lactate Clearance Definition.

Conclusions:
Lactate clearance early in the hospital course may indicate a
resolution of global tissue hypoxia and is associated with
decreased mortality rate. Patients with higher lactate clearance
after 6 hrs of emergency department intervention have improved
outcome compared with those with lower lactate clearance.
Critical Care Medicine
Volume 32 • Number 8 • August 2004
Early lactate clearance is associated with improved
outcome in severe sepsis and septic shock
H. Bryant Nguyen, MD, MS;

Control of body water and Mechanical ventilationControl of body water and Mechanical ventilation ::
 Mechanical ventilation can decrease the release ofMechanical ventilation can decrease the release of
atrial natriuretic hormone and increase the release ofatrial natriuretic hormone and increase the release of
antidiuretic hormone resulting in retention of sodiumantidiuretic hormone resulting in retention of sodium
and fluids.and fluids.

Minimally invasive hemodynamic monitoringMinimally invasive hemodynamic monitoring
Dynamic Measurements of Fluid ResuscitationDynamic Measurements of Fluid Resuscitation inin
MVMV
SPV and PP, which are dynamic measurements, have been
shown to identify hypotension related to decrease in
preload, to distinguish between responders and
nonresponders to fluid challenge , and to permit
titration of Fluid ressuscitation in various patient
populations.

Systolic pressure variation (SPV) after one mechanical breath
followed by an end-expiratory pause. Reference line permits
the measurement of up and down. Bold Maximal and
minimal pulse pressure. AP Airway pressure; SAP systolic
arterial pressure
Dynamic Measurements of Fluid Resuscitation inin
MVMV

Stroke volumeStroke volume
Stroke volume is the amount of blood ejectedStroke volume is the amount of blood ejected
by the right ventricle in one contraction. It isby the right ventricle in one contraction. It is
calculated using the following formulacalculated using the following formula
Stroke volume (SV) = (Cardiac output x 1000) / Heart rateStroke volume (SV) = (Cardiac output x 1000) / Heart rate
For example, patient with a hear rate of 75beats/minute and cardiac out put of 5litres / minuteFor example, patient with a hear rate of 75beats/minute and cardiac out put of 5litres / minute
stroke volume is calculated as belowstroke volume is calculated as below
SV = (5 X 1000) / 75 = 66.67ml/beatSV = (5 X 1000) / 75 = 66.67ml/beat

Stoke volume variation - SVVStoke volume variation - SVV
Changes in stroke volume over theChanges in stroke volume over the
respiratory cyclerespiratory cycle
SVV should be less than 10%. High SVVSVV should be less than 10%. High SVV
triggers fluid resuscitation.triggers fluid resuscitation.
SVV are only applicable in patients onSVV are only applicable in patients on
fully controlled mechanical ventilation and in regularfully controlled mechanical ventilation and in regular
rhythm with tidal volume at least 8ml/kg.rhythm with tidal volume at least 8ml/kg.

 Cardiac IndexCardiac Index
 Volume of blood pumped by the heart inVolume of blood pumped by the heart in
one minute indexed to body surface area.one minute indexed to body surface area.
 CI = 3 – 5 l/min/mCI = 3 – 5 l/min/m22

Stoke volume indexStoke volume index
Volume pumped by the heart during oneVolume pumped by the heart during one
heart beat indexed to BSAheart beat indexed to BSA
SVI = 40 – 60 ml/mSVI = 40 – 60 ml/m22

GEDVI – global end diastolic volumeGEDVI – global end diastolic volume
indexindex
Volume of blood contained in the fourVolume of blood contained in the four
chambers of the heart indexed to BSA.chambers of the heart indexed to BSA.
GEDVI – 680 – 800 ml/mGEDVI – 680 – 800 ml/m22

Intra-thoracic blood volume indexIntra-thoracic blood volume index
Volume of blood contained in the fourVolume of blood contained in the four
chambers of the heart plus blood volume inchambers of the heart plus blood volume in
the pulmonary blood vessels indexed tothe pulmonary blood vessels indexed to
BSA.BSA.
ITBVI – 850 – 1000 ml/mITBVI – 850 – 1000 ml/m22

Extra vascular lung water indexExtra vascular lung water index
The amount of water content in the lungs;The amount of water content in the lungs;
allows quantification of the degree ofallows quantification of the degree of
pulmonary oedemapulmonary oedema
EVLWI – 3 – 7ml/kg.EVLWI – 3 – 7ml/kg.

Chest x ray changes inChest x ray changes in
pulmonary edemapulmonary edema
1.1. Cephalization of pulmonary vessels,Cephalization of pulmonary vessels,
2.2. Kerley's B lines peribronchial cuffing,Kerley's B lines peribronchial cuffing,
3.3. Bat wing pattern,Bat wing pattern,
4.4. Patchy shawdowing with airPatchy shawdowing with air
bronchograms, andbronchograms, and
5.5. Increased cardiac sizeIncreased cardiac size

Early Hemodynamic
Optimization

Fluid Therapy (Types)Fluid Therapy (Types)
SolutionSolution NaNa CLCL KK MgMg CaCa lactatlactat
ee
otherother PHPH osmosm
D5WD5W DexDex
5g/dl5g/dl
55 253253
0.9NS0.9NS 154154 154154 4.24.2 308308
Ring.Ring. 130130 109109 44 33 2.82.8 6.56.5 273273
Alb5%Alb5% 145145 145145 AlbAlb
5g/dl5g/dl
308308
3%n/s3%n/s 513513 513513 55 1,021,02
77

CrystalloidsCrystalloids
 Crystalloids are fluids that contain water andCrystalloids are fluids that contain water and
electrolytes.electrolytes.
 Crystalloid solutions are used to both provideCrystalloid solutions are used to both provide
maintenance water and electrolytes andmaintenance water and electrolytes and
expand intravascular fluid.expand intravascular fluid.
 distributed in a ratio 1:4 like extracellular fluiddistributed in a ratio 1:4 like extracellular fluid
(i.e., about 20% should remain in the(i.e., about 20% should remain in the
intravascular space).intravascular space).

RingerRinger LactateLactate
 lactated Ringer solution have an electrolyte compositionlactated Ringer solution have an electrolyte composition
similar to extracellular fluid (ECF).similar to extracellular fluid (ECF).
 With respect to sodium, theyWith respect to sodium, they are hypotonicare hypotonic..

RingerRinger LactateLactate
 A buffer is included in place of bicarbonate, whichA buffer is included in place of bicarbonate, which
hydrates to carbonic acid, with production of carbonhydrates to carbonic acid, with production of carbon
dioxide, which diffuses from the solution.dioxide, which diffuses from the solution.
•The lactate content of Ringer’s solution is rapidly
metabolized during resuscitation and does not
significantly affect the use of arterial lactate
concentration as a marker of tissue hypoperfusion

Normal SalineNormal Saline
 Normal saline, 0.9 percent NaCl, is isotonic andNormal saline, 0.9 percent NaCl, is isotonic and
isoosmotic but contains more chloride than ECF.isoosmotic but contains more chloride than ECF.
 When used in large volumes, mild hyperchloremiaWhen used in large volumes, mild hyperchloremia
(non-anion gap metabolic acidosis) results.(non-anion gap metabolic acidosis) results.
 It contains no buffer or other electrolytes.It contains no buffer or other electrolytes.

It is preferred to lactated Ringer solution (which contains aIt is preferred to lactated Ringer solution (which contains a
hypotonic concentration of sodium) inhypotonic concentration of sodium) in
brain injurybrain injury
hypochloremic metabolic alkalosishypochloremic metabolic alkalosis
Hyponatremia.Hyponatremia.
Normal SalineNormal Saline

 •• 0.9% NaCl is better known as“AbNormal0.9% NaCl is better known as“AbNormal
Saline,” is associated with the followingSaline,” is associated with the following
complications, and is best avoidedcomplications, and is best avoided
.. Decreased glomerular filtration rateDecreased glomerular filtration rate
(GFR)(GFR)
. Metabolic acidosis; both hyperchloremic. Metabolic acidosis; both hyperchloremic
non-AG as well as AG acidosisnon-AG as well as AG acidosis
• Coagulopathy with increasedCoagulopathy with increased bleedingbleeding

Five percent dextrose functions as free water.Five percent dextrose functions as free water.
It may be used to correctIt may be used to correct hypernatremia,hypernatremia, but is mostbut is most
often used in the prevention of hypoglycemia inoften used in the prevention of hypoglycemia in
diabetic patients.diabetic patients.
•• A glucose (5 or 10%) containing solution should beA glucose (5 or 10%) containing solution should be
used in patientsused in patients
with cirrhosis (high risk of hypoglycemia)with cirrhosis (high risk of hypoglycemia)
Five Percent DextroseFive Percent Dextrose

COLLOID SOLUTIONSCOLLOID SOLUTIONS
 Colloid solutions are generally administered in aColloid solutions are generally administered in a
volume equivalent to the volume of blood lost.volume equivalent to the volume of blood lost.
 The initial volume of distribution is equivalent to theThe initial volume of distribution is equivalent to the
plasma volume.plasma volume.
 The half-life in circulation of albumin is normally 16The half-life in circulation of albumin is normally 16
hours, but it can be as short as 2 to 3 hours inhours, but it can be as short as 2 to 3 hours in
pathophysiologic conditions.pathophysiologic conditions.

Five percent albumin have a colloid osmoticFive percent albumin have a colloid osmotic
pressure of about 20 mm Hg (i.e., near-pressure of about 20 mm Hg (i.e., near-
normal colloid osmotic pressure).normal colloid osmotic pressure).
•• Albumin (5% in NaCl) is SAFE and mayAlbumin (5% in NaCl) is SAFE and may
have a role (together with lactated Ringer’shave a role (together with lactated Ringer’s
solution) in the resuscitation of patients withsolution) in the resuscitation of patients with
–– SepsisSepsis
–– CirrhosisCirrhosis
–– PancreatitisPancreatitis
–– BurnsBurns
Five Percent AlbuminFive Percent Albumin

 Albumin should be considered the volumeAlbumin should be considered the volume
expander of choice in patients withexpander of choice in patients with
underlying liver disease (cirrhosis).underlying liver disease (cirrhosis).
 Albumin is particularly useful in patientsAlbumin is particularly useful in patients
with spontaneous bacterial peritonitis,with spontaneous bacterial peritonitis,
hepatorenal syndrome, and following ahepatorenal syndrome, and following a
paracentesisparacentesis..

Hydroxyethyl StarchHydroxyethyl Starch && PentastarchPentastarch
 Hydroxyethyl starch (hetastarch) is a synthetic colloidHydroxyethyl starch (hetastarch) is a synthetic colloid
solution in which the molecular weight of at least 80solution in which the molecular weight of at least 80
percent of the polymers ranges from 10,000 topercent of the polymers ranges from 10,000 to
2,000,000.).2,000,000.).
 The pH of hetastarch is about 5.5 and the osmolarity isThe pH of hetastarch is about 5.5 and the osmolarity is
near 310 mOsm/L.near 310 mOsm/L.
 The larger molecules are degraded enzymatically byThe larger molecules are degraded enzymatically by
amylase.amylase.
 It is stored in the reticuloendothelial system for severalIt is stored in the reticuloendothelial system for several
hours and is believed to be ultimately renally excreted.hours and is believed to be ultimately renally excreted.

 It produces dilutional effectsIt produces dilutional effects..
 reduces factor VIII:C levels by 50 percent in a dosereduces factor VIII:C levels by 50 percent in a dose
of 1 L with prolongation of the partial thromboplastinof 1 L with prolongation of the partial thromboplastin
time.time.
 Hetastarch can also interfere with clot formation byHetastarch can also interfere with clot formation by
direct movement into the fibrin clot by the hetastarchdirect movement into the fibrin clot by the hetastarch
molecules.molecules.

 Repeated doses can result in accumulation and sideRepeated doses can result in accumulation and side
effects, which include allergic reactions and bleedingeffects, which include allergic reactions and bleeding
with higher doses (20 to 25 mL/kg.)with higher doses (20 to 25 mL/kg.)
 Hydroxyethyl starch (HES) solutions are associatedHydroxyethyl starch (HES) solutions are associated
with an increased risk of renal failure (and death) andwith an increased risk of renal failure (and death) and
have a “limited” role in critical care medicine.have a “limited” role in critical care medicine.

The SAFE StudyThe SAFE Study
AA multicenter, randomized, double-blind trialmulticenter, randomized, double-blind trial
toto compare the effect of fluid resuscitationcompare the effect of fluid resuscitation
with albumin or salinewith albumin or saline on mortality in aon mortality in a
heterogeneous population of patients in theheterogeneous population of patients in the
ICU.ICU.

Subgroup Analyses traumaSubgroup Analyses trauma
Among all the patients who had trauma (596 in theAmong all the patients who had trauma (596 in the
albumin groupalbumin group and 590 in the saline group), there were 81and 590 in the saline group), there were 81
(13.6(13.6%%) deaths) deaths in the albumin group and 59(10.0in the albumin group and 59(10.0%%) in the) in the
saline groupsaline group
(relative risk, 1.36; 95 percent confidence interval, 0.99 to(relative risk, 1.36; 95 percent confidence interval, 0.99 to
1.86; P=0.06)1.86; P=0.06)
The SAFE StudyThe SAFE Study

Subgroup Analyses traumaSubgroup Analyses trauma
Among patients who had traumaAmong patients who had trauma
withoutwithout brain injury, there was nobrain injury, there was no
difference between the groups indifference between the groups in termsterms
of mortalityof mortality

HHypoalbuminemiaypoalbuminemia & Lung inj.& Lung inj.

Albumin and furosemide therapy in hypoproteinemic
patients with acute lung injury.
Martin GS
Thirty-seven mechanically-ventilated patients with acute lung
injury and serum total protein </=5.0 g/dL
Five-day protocolized regimen of 25 g of human serum
albumin every 8 hrs with continuous infusion furosemide,
or dual placebo, targeted to diuresis, weight loss, and serum
total protein

CONCLUSIONS:
Albumin and furosemide therapy improves fluid balance,
oxygenation, and hemodynamics in hypoproteinemic
Albumin and furosemide therapy in hypoproteinemic
2002
Martin GS

The Patient With Cerebral EdemaThe Patient With Cerebral Edema
 Isotonic crystalloids or colloids do not cause edemaIsotonic crystalloids or colloids do not cause edema
in normal brainin normal brain..
 HHyponatremia is often due to hypovolemia withyponatremia is often due to hypovolemia with
inappropriate sodium loss and subsequent waterinappropriate sodium loss and subsequent water
retention.retention.
 This should be treated with intravascular volumeThis should be treated with intravascular volume
expansion with isotonic or hypertonic sodium chloride.expansion with isotonic or hypertonic sodium chloride.
 Hypovolemia must be carefully avoided.Hypovolemia must be carefully avoided.

The Patient With Cerebral EdemaThe Patient With Cerebral Edema
Fluid management of patients with cerebralFluid management of patients with cerebral
edema is directed at maintainingedema is directed at maintaining CPPCPP,,
avoiding elevations ofavoiding elevations of cerebral venouscerebral venous
pressure andpressure and HTNHTN, preventing large, preventing large
changes inchanges in plasma osmolalityplasma osmolality (particularly(particularly
depression of plasma osmolality),depression of plasma osmolality),
and avoidingand avoiding hyperglycemia.hyperglycemia.

BLOOD PRODUCTSBLOOD PRODUCTS
 Packed –red blood cells AND lactatedPacked –red blood cells AND lactated
Ringer’s (LR) are the volume expanders ofRinger’s (LR) are the volume expanders of
choice in hemorrhagic shockchoice in hemorrhagic shock
 In traumatic blood loss, RBCIn traumatic blood loss, RBC
should be given with FFP andshould be given with FFP and
platelets in a ratio of 1:1:1platelets in a ratio of 1:1:1
 Patients with traumatic head injury shouldPatients with traumatic head injury should
be resuscitated with crystalloids (LR);be resuscitated with crystalloids (LR);
albumin should be avoidedalbumin should be avoided..

The Patient With Liver FailureThe Patient With Liver Failure
 HypoalbuminemiaHypoalbuminemia
 Low COP favors loss of fluid from the vascular spaceLow COP favors loss of fluid from the vascular space
into the interstitial space, producing intravascularinto the interstitial space, producing intravascular
hypovolemia.hypovolemia.
 The goals in these patients are to avoid increasingThe goals in these patients are to avoid increasing
interstitial fluid overload, maintain normal potassiuminterstitial fluid overload, maintain normal potassium
concentration, and maintain intravascular volume.concentration, and maintain intravascular volume.

If the patient is acutely hypovolemic, 5 percentIf the patient is acutely hypovolemic, 5 percent
albumin solutions should be preferred toalbumin solutions should be preferred to
crystalloid, which will tend to further expand thecrystalloid, which will tend to further expand the
already overexpanded ECF volume (i.e., producealready overexpanded ECF volume (i.e., produce
more edema and ascites).more edema and ascites).
Patient With Liver FailurePatient With Liver Failure

Adequate volume replacement decreases the
morbidity and mortality associated with severe
burn injury.
The goal of initial fluid resuscitation is to restore
and maintain vital organ perfusion.
Initial Fluid Resuscitation in Burn Pt.Initial Fluid Resuscitation in Burn Pt.

A delay in starting fluid resuscitation is
associated with greater than predicted fluid
requirements.

In adults, IV fluid resuscitation is usually
necessary in second- or third-degree burns
involving greater than 20% TBSA.
In pediatric patients, fluid resuscitation
should be initiated in all infants with burns
of 10% or greater TBSA and in older
children with burns greater than 15% or
greater TBSA.

Urine output is a measure of renal
perfusion and can help assess fluid
balance. In adults, a urine output of 0.5-
1.0 mL/kg/h should be maintained
Lactated Ringer's solution is the most
commonly used fluid for burn
resuscitation.

The Parkland formula is most commonlyThe Parkland formula is most commonly
4 cc/kg/TBSA burn (second and third degree) of4 cc/kg/TBSA burn (second and third degree) of
lactated Ringer's solution over the first 24 hours.lactated Ringer's solution over the first 24 hours.
half over the first eight hours post burn, and halfhalf over the first eight hours post burn, and half
over the next 16 hours.over the next 16 hours.
Initial Fluid Resuscitation in Burn Pt.

Patients with high-voltage electrical
injuries frequently require more
resuscitation fluid than that
predicted based on the extent of
cutaneous injury.

Fluid Resuscitation InFluid Resuscitation In AnaphylaxisAnaphylaxis
 Increased vascular permeability during anaphylaxisIncreased vascular permeability during anaphylaxis
can result in a transfer of 50% of the intravascular fluidcan result in a transfer of 50% of the intravascular fluid
into the extravascular space within 10 minutes.into the extravascular space within 10 minutes.
 This shift in effective blood volume activates the renin-This shift in effective blood volume activates the renin-
angiotensin-aldosterone system and causesangiotensin-aldosterone system and causes
compensatory catecholamine releasecompensatory catecholamine release

Volume expansion is important as part of the
resuscitation with epinephrine to treat acute
hypotension.
Initially, 2 to 4 L of RL ,NS or colloid
Fluid Resuscitation InFluid Resuscitation In
AnaphylaxisAnaphylaxis

Fluid Resuscitation In Neurogenic shockFluid Resuscitation In Neurogenic shock
Neurogenic shock is produced by loss of
peripheral vasomotor tone as a result of
spinal cord injury. Blood becomes pooled
in the periphery, venous return is
decreased, and cardiac output falls.
All patients who have sustained spinal
trauma should be assumed to have
hypovolemic shock from associated injuries
until proved otherwise.

Fluid Resuscitation In Neurogenic shockFluid Resuscitation In Neurogenic shock
Atropine, though short-acting, may rapidly reverse hypotension
associated with bradycardia. Placement of a temporary cardiac
pacemaker may be required for severe bradycardia.
Fluid resuscitation is usually necessary and typically
begins with several liters of balanced salt solution.

•Is a therapeutical option for victims of penetrating
injuries,provided fast evacuation to definite (surgical)
intervention.
Permissive hypotension by means of fluid re-
striction is not recommended in case of blunt
trauma.
Permissive hypotension in severe traumaPermissive hypotension in severe trauma

Cardiogenic ShockCardiogenic Shock
Although cardiogenic shock may occur in patients
with whole body fluid overload, they may be
effectively hypovolemic.
If PCWP is less than 10-12 mm Hg, fluid should be
administered in an attempt to increase filling
pressures.
Cardiac output should be measured after each change
of 2-3 mm Hg in PCWP. Filling pressures near 20 mm
Hg may be required before cardiac output increases.

Frank-Starling curve with relationship betweenFrank-Starling curve with relationship between
ventricular preload and ventricular stroke volumeventricular preload and ventricular stroke volume
After volume expansion the same magnitude of change in preload
recruit less SV, because the plateau of the curve is reached which
characterize a condition of preload independency

Frank-Starling curve with relationship betweenFrank-Starling curve with relationship between
ventricular preload and ventricular stroke volumeventricular preload and ventricular stroke volume
 As a consequence, when the plateau is reached,As a consequence, when the plateau is reached,
vigorous fluid resuscitation carries out the risk ofvigorous fluid resuscitation carries out the risk of
generating volume overload and pulmonary edemagenerating volume overload and pulmonary edema
and/or right-ventricular dysfunction.and/or right-ventricular dysfunction.
Cardiogenic ShockCardiogenic Shock

· Decreased cerebral perfusion causes agitation followed by
altered mental status.
· Myocardial ischemia occurs in individuals with underlying
coronary artery disease.
Uncompensated shock causes end organs hypoperfusion :

When hemorrhage is uncontrolled, aggressive fluid
resuscitation increases arterial pressure and bleeding
rate, thereby shortening the time before cardiac arrest.
This occurs for several interrelated reasons:

Elevated systemic pressure dislodges or prevents the
formation of a protective thrombus once intraluminal
driving pressure exceeds tamponading pressure.
Hemodilution lowers blood viscosity, decreasing
resistance to flow around an incomplete thrombus.
Hemodilution causes progressive anemia and washout
of coagulation factors

• The problems limiting widespread acceptance of this
concept are:
• the need for prompt definitive intervention to minimize the
oxygen debt;
• delays in surgery, e.g. in rural area may be better with
‘normal’ resuscitation

• this approach is inappropriate for patients who
also have head injury.
• The biggest problem is that this study was
performed in penetrating
injuries. Patients with blunt trauma (the majority)
are not so likely to
have definitive surgical interventions

• contraindicated inpatients with traumatic brain
injury (TBI),
even in case of penetrating trauma, or inspinal
cord injury due to worse neurological outcome.

Elderly patients or those with preexisting
compromised cardiovascular function will
probably not benefit from the concept due
to fast exhaustion of physiologic compensa-
tory mechanisms.

Immediate versus delayed fluid resuscitation for
hypotensive patients with penetrating torso injuries.
AU - Bickell WH N Engl J Med 1994 Oct
Prospective trial comparing immediate and delayed
fluid resuscitation in 598 adults with penetrating torso
injuries who presented with a pre-hospital systolic
blood pressure of < or = 90 mm Hg.

CLINICAL PEARLSCLINICAL PEARLS
 The initial treatment of hypotension is a fluid challengeThe initial treatment of hypotension is a fluid challenge
(lactated Ringer’s solution)(lactated Ringer’s solution)
 The initial treatment of oliguria is a fluid challengeThe initial treatment of oliguria is a fluid challenge
(lactated Ringer’s solution)(lactated Ringer’s solution)
 Lactated Ringer’s is the replacement fluid of choice inLactated Ringer’s is the replacement fluid of choice in
most clinical scenariosmost clinical scenarios
 Pulse pressure variation (on mechanical ventilation)Pulse pressure variation (on mechanical ventilation)
should be used to determine “fluid responsiveness”should be used to determine “fluid responsiveness”
 The measurement of extravascular lung water and intra-The measurement of extravascular lung water and intra-
abdominalabdominal pressure should be used to preventpressure should be used to prevent
volume overload during “large volume”volume overload during “large volume”
resuscitationresuscitation

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