routine day to day use

1. !!!
!
!
Fluid!Management!and!Shock!
Resuscita5on!
DR!.!KAWITA!BAPAT!
!KAWITABAPAT

2. Outline!
• Normal!Fluid!Requirements!
• Defini5on!of!Shock!
• Types!of!Shock!
– Hypovolemic!
– Cardiogenic!
– Distribu5ve!
– Obstruc5ve!
• Resuscita5on!Fluids!
• Goals!of!Resuscita5on!
KAWITABAPAT

3. Body!Fluid!Compartments!
• Total!Body!Water!=!60%!body!weight!
– 70Kg!TBW!=!42!L!
• 2/3!of!TBW!is!intracellular!(ICF)!
– 40%!of!body!weight,!70Kg!=!28!L!
• 1/3!of!TBW!is!extracellular!(ECF)!
– 20%!of!body!weight,!70Kg!=!14!L!
– Plasma!volume!is!approx!4%!of!total!body!weight,!
but!varies!by!age,!gender,!body!habitus!
KAWITABAPAT

4. Blood!Volume!
BloodVolume(mL/kg)
PrematureInfant90
TermInfant80
SlimMale75
ObeseMale70
SlimFemale65
ObeseFemale60
KAWITABAPAT

5. Peri_opera5ve!Maintenance!Fluids!
• Water!
• Sodium!
• Potassium!replacement!can!be!omi`ed!for!
short!periods!of!5me!
• Chloride,!Mg,!Ca,!trace!minerals!and!
supplementa5on!needed!only!for!chronic!IV!
maintenance!
• Most!commonly!Saline,!Lactated!Ringers,!
Plasmalyte!
KAWITABAPAT

6. 4!–!2!–!1!Rule!
• 100!–!50!–!20!Rule!for!daily!fluid!requirements!
• 4!mL/kg!for!1st!10!kg!
• 2!mL/kg!for!2nd!10!kg!
• 1!mL/kg!for!each!addi5onal!kg!
KAWITABAPAT

7. Maintenance!Fluids:!!Example!
• 60!kg!female!
• 1st!10!kg:!!4!mL/kg!x!10!kg!=!40!mL!
• 2nd!10!kg:!!2!mL/kg!x!10!kg!=!20!mL!
• Remaining:!!60!kg!–!20!kg!=!!40!kg!
!!!!!!!!!!!!!!!!!!!1!mL/kg!x!40!kg!=!40!mL!
• Maintenance!Rate!!!!!!!!!!!!!!!=!120!mL/hr!
KAWITABAPAT

8. Fluid!Deficits!
• Fas5ng!
• Bowel!Loss!(Bowel!Prep,!vomi5ng,!diarrhea)!
• Blood!Loss!!
– Trauma!
– Fractures!
• Burns!
• Sepsis!
• Pancrea55s!
KAWITABAPAT

9. Insensible!Fluid!Loss!
• Evapora5ve!
• Exuda5ve!
• Tissue!Edema!(surgical!manipula5on)!
• Fluid!Sequestra5on!(bowel,!lung)!
• Extent!of!fluid!loss!or!redistribu5on!(the!
Third!Space)!dependent!on!type!of!surgical!
procedure!
• Mobiliza5on!of!Third!Space!Fluid!POD#3!
KAWITABAPAT

10. Insensible!Fluid!Loss!
• 4!–!6!–!8!Rule!
• Replace!with!Crystalloid!(NS,!LR,!Plasmalyte)!
• Minor:!!4!mL/kg/hr!
• Moderate:!6!mL/kg/hr!
• Major:!8!mL/kg/hr!
!
KAWITABAPAT

11. Example!
• 68!kg!female!for!laparoscopic!
cholecystectomy!
• Fasted!since!midnight,!OR!start!at!8am!
• Maintenance!=!40!+!20!+!48!=!108!mL/hr!
• Deficit!=!108!mL/hr!x!8hr!
!!!!!!!!!!!!!!=!864!mL!!
• 3rd!Space!(4mL/kg/hr)!=!272!mL/hr!
KAWITABAPAT

12. Example!
• Intra_opera5ve!Fluid!Replacement!of:!
– Fluid!Deficit!!864!mL!
– Maintenance!Fluid!108!mL/hr!
– 3rd!Space!Loss!272!mL/hr!
– Ongoing!blood!loss!(crystalloid!vs.!colloid)!
KAWITABAPAT

13. Shock!
• Circulatory!failure!leading!to!inadequate!
perfusion!and!delivery!of!oxygen!to!vital!
organs!
• Blood!Pressure!is!oien!used!as!an!indirect!
es5mator!of!5ssue!perfusion!
• Oxygen!delivery!is!an!interac5on!of!Cardiac!
Output,!Blood!Volume,!Systemic!Vascular!
Resistance!
!
KAWITABAPAT

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

15. Types!of!Shock!
• Hypovolemic!–!most!common!
• Hemorrhagic,!occult!fluid!loss!
• Cardiogenic!
• Ischemia,!arrhythmia,!valvular,!myocardial!depression!
• Distribu5ve!
• Anaphylaxis,!sepsis,!neurogenic!
• Obstruc5ve!
• Tension!pneumo,!pericardial!tamponade,!PE!
KAWITABAPAT

16. Shock!States!
BPCVPPCWPCOSVR
Hypovolemia
Cardiogenic-
LV
-RV
Distributive
Obstructive
KAWITABAPAT

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

18. Hypovolemic!Shock!
• Most!common!
• Trauma!
• Blood!Loss!
• Occult!fluid!loss!(GI)!
• Burns!
• Pancrea55s!
• Sepsis!(distribu5ve,!rela5ve!hypovolemia)!
KAWITABAPAT

19. Assessment!of!Stages!of!Shock!
%Blood
Volumeloss
<15%15–30%30–40%>40%
HR<100>100>120>140
SBPNN,DBP,
posturaldrop
Pulse
Pressure
Nor
CapRefill<3sec>3sec>3secor
absent
absent
Resp14-2020-3030-40>35
CNSanxiousv.anxiousconfusedlethargic
Treatment1–2L
crystalloid,+
maintenance
2Lcrystalloid,
re-evaluate
2Lcrystalloid,re-evaluate,
replacebloodloss1:3
crystalloid,1:1colloidorblood
products.Urineoutput>0.5
mL/kg/hrKAWITABAPAT

20. Fluid!Resuscita5on!of!Shock!
• Crystalloid!Solu5ons!
– Normal!saline!
– Ringers!Lactate!solu5on!
– Plasmalyte!
• Colloid!Solu5ons!
– Pentastarch!
– Blood!products!(albumin,!RBC,!plasma)!
KAWITABAPAT

21. Crystalloid!Solu5ons!
• Normal!Saline!
• Lactated!Ringers!Solu5on!
• Plasmalyte!
• Require!3:1!replacement!of!volume!loss!
• e.g.!es5mate!1!L!blood!loss,!require!3!L!of!
crystalloid!to!replace!volume!
KAWITABAPAT

22. Colloid!Solu5ons!
• Pentaspan!
• Albumin!5%!!
• Red!Blood!Cells!
• Fresh!Frozen!Plasma!
• Replacement!of!lost!volume!in!1:1!ra5o!
KAWITABAPAT

23. Oxygen!Carrying!Capacity!
• Only!RBC!contribute!to!oxygen!carrying!
capacity!(hemoglobin)!
• Replacement!with!all!other!solu5ons!will!
– support!volume!
– Improve!end!organ!perfusion!
– Will!NOT!provide!addi5onal!oxygen!carrying!
capacity!
KAWITABAPAT

24. RBC!Transfusion!
• BC!Red!Cell!Transfusion!Guidelines!
recommend!transfusion!only!to!keep!Hgb!>70!
g/dL!unless!
– Comorbid!disease!necessita5ng!higher!transfusion!
trigger!(CAD,!pulmonary!disease,!sepsis)!
– Hemodynamic!instability!despite!adequate!fluid!
resuscita5on!
KAWITABAPAT

25. Crystalloid!vs.!Colloid!
• SAFE!study!(Saline!vs.!Albumin!Fluid!
Evalua5on)!
– Cri5cally!ill!pa5ents!in!ICU!
– Randomized!to!Saline!vs.!4%!Albumin!for!fluid!
resuscita5on!
– No!difference!in!28!day!all!cause!mortality!
– No!difference!in!length!of!ICU!stay,!mechanical!
ven5la5on,!RRT,!other!organ!failure!
NEJM%2004;%350%(22),%22470%2256%
!
KAWITABAPAT

26. Goals!of!Fluid!Resuscita5on!
• Easily!measured!
– Menta5on!
– Blood!Pressure!
– Heart!Rate!
– Jugular!Venous!Pressure!
– Urine!Output!
!
KAWITABAPAT

27. Goals!of!Fluid!Resuscita5on!
• A!li`le!less!easily!measured!
!
– Central!Venous!Pressure!(CVP)!
– Lei!Atrial!Pressure!
– Central!Venous!Oxygen!Satura5on!SCVO2!
KAWITABAPAT

28. Goals!of!Fluid!Resuscita5on!
• A!bit!more!of!a!pain!to!measure!
!
– Pulmonary!Capillary!Wedge!Pressure!(PCWP)!
– Systemic!Vascular!Resistance!(SVR)!
– Cardiac!Output!/!Cardiac!Index!
!
KAWITABAPAT

29. Mixed!Venous!Oxygena5on!
• Used!as!a!surrogate!marker!of!end!organ!perfusion!
and!oxygen!delivery!
• Should!be!interpreted!in!context!of!other!clinical!
informa5on!
• True!mixed!venous!is!drawn!from!the!pulmonary!
artery!(mixing!of!venous!blood!from!upper!and!lower!
body)!
• Oien!sample!will!be!drawn!from!central!venous!
catheter!(superior!vena!cava,!R!atrium)!
KAWITABAPAT

30. Mixed!Venous!Oxygena5on!
• Normal!oxygen!satura5on!of!venous!blood!!
68%!–!77%!
• Low!SCVO2!
– Tissues!are!extrac5ng!far!more!oxygen!than!usual,!
reflec5ng!sub_op5mal!5ssue!perfusion!(and!
oxygena5on)!
• Following!trends!of!SCVO2!to!guide!
resuscita5on!(fluids,!RBC,!inotropes,!
vasopressors)!
KAWITABAPAT

31. Goals!of!Resuscita5on!
• Rivers!Study_!Early!Goal!Directed!Therapy!in!
Sepsis!and!Sep5c!Shock!
– Emergency!department!with!severe!sepsis!or!
sep5c!shock,!randomized!to!goal!directed!
protocol!vs!standard!therapy!prior!to!admission!to!
ICU!
– Early!goal!directed!therapy!conferred!lower!
APACHE!scores,!incida5ng!less!severe!organ!
dysfunc5on!
KAWITABAPAT

32. KAWITABAPAT

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

34. Bo`om!Line!
• Resuscita5on!of!Shock!is!all!about!genng!oxygen!to!
the!5ssues!
• Ini5al!assessment!of!volume!deficit,!replace!that!
(with!crystalloid),!and!reassess!
• Con5nue!volume!resuscita5on!to!target!endpoints!!
• Can!use!mixed!venous!oxygen!satura5on!to!es5mate!
5ssue!perfusion!and!oxygena5on!
!
KAWITABAPAT

35. KAWITABAPAT