This document discusses fluid management in the ICU. It covers assessing volume status through history, exam, and tests. Common types of IV fluids are described including crystalloids like normal saline and lactated Ringer's, as well as colloids like albumin and HES. Normal saline can cause hyperchloremic acidosis while HES is no longer recommended due to safety concerns. Guidelines for fluid resuscitation in hypovolemia and septic shock are provided, emphasizing initial bolus volumes and ongoing reassessment. In general, balanced crystalloids are preferred to normal saline due to safety advantages.

1. Fluid Management in ICUFluid Management in ICU
Ahmed Samir Megahed
Assistant lecturer of Nephrology, Faculty of
Medicine ,Port Said University

2. AgendaAgenda
Introduction
Assessment of Volume Status
Types of Fluids
Choice of Fluids
Amount of Fluids

3. Basic PhysiologyBasic Physiology

5. Movement of fluids () compartments
depend on hydrostatic pressure and
oncotic pressure
Effective circulatory volume: part of ECF
that is in arterial system which perfuse
tissues ( decrease with hypovolemia, N.S,
cirrhosis)

6. Assessment of Fluid statusAssessment of Fluid status
A- History
B- Examination: Vital signs, mucus membranes,
Skin turgor, Capillary refill ,chest auscultation,
neck vein examination, CVP, UOP
C- Investigations: CBC, LFTs, RFTs
Urine ( FENA, Urine Na( both decrease with
hypovolemia)
D- Others:
( ECHO, IVC diameter, PA catheter)

7. Dynamic measures: limited to mechanical ventilated patientsDynamic measures: limited to mechanical ventilated patients

11. Classes of fluid balanceClasses of fluid balance
Dry-Dry
Dehydration
Dry-Wet
Third space loss

12. IV FluidsIV Fluids
IV fluids are the commonest drugs
prescribed in ICU, emergency settings
and operating theatres
 Used to maintain effective blood volume
and maintain organ perfusion also as
diluents for drugs
Types: Crystalloid vs Colloid

15. Composition of commonly used crystalloidComposition of commonly used crystalloid
intravenous fluidsintravenous fluids

16. Composition of commonly used colloidComposition of commonly used colloid
intravenous fluidsintravenous fluids

17. Normal SalineNormal Saline
( Is it normal?)( Is it normal?)
 Composition: highest fluid in chloride content
 Large rapid volume leads to hyperchloremic metabolic
acidosis( that leads to hypotension, coagulopathy, AKI
d2 CL +ve tubuloglomerular feedback so afferent vc
and decrease GFR)
 Some studies compare it with other crystalloid lower in
CL( they found increase surgical complications, AKI,
death among saline group)
 Normal saline is the best resuscitation fluid in
hypovolemia d2 upper GIT loss (CL low, metabolic
alkalosis)
 Normal saline is better than albumin in traumatic brain
injury d2 higher mortality with albumin

18. Human AlbuminHuman Albumin
SAFE trial: albumin has similar outcome with
NS in ICU patients even in patients with
hypoalbuminemia
High cost
C.I in TBI( because carrier mostly hypotonic so
brain edema so increases ICT
Albumin is equivalent to saline in fluid
resuscitation but have beneficial effects in
patients with sepsis, SBP, bacterial infections

19. HESHES
 Older preparations(10%): hypertonic, increase AKI, pruritis and
coagulopathy
 Newer preparations(6%): used in patient resuscitation in patients
with trauma, sepsis and general anesthesia for major surgery
 Studies noted that newer increases also death, AKI( osmotic
nephrosis) vacuolization in tubules and colloid accumulation inside
 Studies stated that HES carry no benefit over crystalloid
 Impair platelet reactivity and decrease circulating plasma
concentrations of coagulation factor VIII and von Willebrand
factor, administration may result in weakening of clot
formation
 EMA(European medicine agency): recommend withdrawal of HES
in critical ill patient with sepsis or burn in European union

20. GelatinGelatin
Two forms( succinylated and urea linked
gelatin)
Expand plasma volume in 1-2 hr till metabolized
and excreted by kidney
S.E: AKI and anaphylaxis
No enough studies for it
Gelatins are not used in the United States
because of their short duration of action
(one to two hours) due to rapid excretion in
the urine, as well as a relatively high
incidence of anaphylaxis

21. Trials comparing different fluidsTrials comparing different fluids

23. Amount of FluidsAmount of Fluids
Hypovolemic shock:
Initial – At least one to two liters of isotonic
crystalloid are initially given as rapidly as possible
in an attempt to restore tissue perfusion
You can give 500 ml bolus then reassess
In cardiac patient: u can give 250 ml bolus then
reassess

24. Maintenance
 Fluid repletion should continue at the initial rapid rate as long as
the systemic blood pressure remains low in the setting of
hypovolemia. Clinical signs, including blood pressure (eg, mean
arterial pressure 65 to 70 mmHg, no greater than 70 mmHg), urine
output, mental status, and peripheral perfusion, are often adequate to
guide resuscitation. The development of peripheral edema is often
due to acute dilutional hypoalbuminemia and should not be used as a
marker for adequate fluid resuscitation or fluid overload
Replace ongoing loss in patient with inadequate oral intake
in adult 70 kg: around 100 ml/hour, and increase it if there is
additional losses as diarrhea and vomiting

25. Adult Na requirement : 2mmol/kg/24 hour
Adult k requirement: 1mmol/kg/24 hour
Typical: alternating N.S with or without K,
D5% and ringer lactate

26. Septic shockSeptic shock
1ST
three hours: 30 ml/kg( average from 2-
3L)
Administered in well-defined (eg, 500
mL), rapidly infused boluses
The clinical and hemodynamic response
and the presence or absence of
pulmonary edema must be assessed
before and after each bolus

27. Take Home MessageTake Home Message
Fluid status assessment sometimes is
difficult and there is no gold standard
available
Balanced crystalloid are more
physiological especially plasmalyte with
decrease incidence of AKI
Colloid don’t offer any advantage over
crystalloid
Choice of IV fluid depend on patient
clinical condition and blood chemistry

29. Thank You