Download Fluids and Fluid Resuscitation

Fluids and Fluid
Resuscitation
Mariusz Bral
Marcel Abouassaly
Alisha Mills
NOSM
Outline
Overview of total body fluids and
assessment of fluid status
„ Colloids
„ Crystalloids
„ Resuscitation
„
Why do we worry about fluids?
„
Body water used in a variety of
mechanisms to maintain homeostasis
Metabolism
„ Excretion of solutes
„ Maintenance of intravascular volume
„
How much do we need?
Maintenance fluid replacement
„ Approximately 1600cc/day in normal
healthy adult
„
„
Sensible losses
• Stool: 200cc/day
• Urine: 500cc/day (minimum)
• Sweating: 100cc/day
„
Insensible losses
• Skin and respiratory tract: 800cc/day
Review of Total Body Water
„Total body water = 60% of weight (50%
in females)
„Intracellular water = 2/3
„Extracellular water = 1/3
•
•
interstitial = 75%
intravascular = 25%
Assessing fluid status
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SSx
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Tachycardia
Supine Hypotension
Postural Hypotension
Postural Pulse Increment
JVP
Pedal edema
Dry mucous membranes
Concentrated urine
Passive leg raise
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Numerical values
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Urine output
CXR for pulm edema
CVP
MAP
Cardiac filling
pressures
Elevated BUN
Persistent metabolic
alkalosis
Colloids
„
Dictates
movement of
fluid between
compartments
What are Colloids?
„Large molecules that do not move out
of vascular compartment
Create osmostic pressure called
Colloid Osmotic Pressure
Favours retention of water in vascular
compartment
„
„
Colloid Osmotic Pressure
Q=(Pc-COP)
How good are Colloids?
„Colloid fluid is approximately 3 times
more effective than crystalloid fluid for
increasing plasma volume.
Available colloids
„Voluven
„Pentaspan
„5% Albumin
„25% Albumin
„Blood
Voluven
„6% Hydroxyethyl starch 130/0.4 in 0.9%NS
„Osmolarity 308 mosm/L
„pH: 4.0-5.5
„Plasma expansion of 1.3 x volume infused
„What is it made of?
„Sodium 154 mmol
„Chloride 154 mmol
„Polystarch 6.00g
Voluven
„Duration of action: 6 hours
„Half-life elimination: 12 hours
„Excreted by the urine
„Endothelial membrane acts as a barrier
to large molecules therefore stays
intravascular
Voluven
„Max dose: 50mL/kg/day
„Children <2yrs: 7-25mL/kg
„Children 2-12 not studied
„Children >12 yrs: max dose of 50mL/kg/day
„Contraindicated in renal failure/hemodialysis
„Caution in hypernatremia or hyperchloremia
„Contraindicated in intracranial bleeding
Reference: Product monograph
Voluven and the kidney
Cochrane Review: Hydroxyethyl starch
(HES) versus other fluid therapies:
effects on kidney function (Review)
„ 34 randomized trials reviewed
„ In surgical or trauma patients, no
difference in renal failure
„ Increased renal failure in sepsis
„
Pentaspan
„ 10% Pentastarch in 0.9% NaCl
„ Osmolality: 326mOsm/Kg
„ pH 5.o
„ Plasma expansion approximately 1:1 infused volume
„ What is it made of?
„ Pentastarch 10.0g
„ Sodium 154 mmol
„ Chloride 154 mmol
Pentaspan
„Duraction of action 18-24 hours
„Half-life elimination: 1.9 days
„Renally excreted
„Max dose: 2000mL/24hrs or
28mL/kg/day
Pentaspan
„Major adverse reactions: coagulopathy
„Contraindicated in renal disease with
oliguria or anuria
No established safety in children
Use beyond 72 hours has not been
studied
„
„
Reference: Product monograph
5% Albumin
„Isotonic, iso-oncotic
„Osmolarity: 308
„What is it made of?
„Sodium 154 mmol
„Chloride 154 mmol
„Albumin 5gm/100mL = 5gm/L
5% Albumin
„Blood Product Derived
„Plasma expansion 1:1 with volume infused
„Initial dose: 25g, may be repeated in 15-30
minutes if response inadequate
„Max dose: 250g in 48hrs
„Can also be given for hypoproteinemia at
0.5-1g/kg/dose, repeated every 1-2 days as
needed
5% Albumin
„Use in patients unresponsive to
crystalloid therapy and when nonprotein
colloids are contraindicated
25% Albumin
„Osmolarity: 308
„Isotonic, hyper-oncotic
„What is it made of?
„Sodium 154 mmol
„Chloride 154 mmol
„Albumin 25gm/100mL = 25gm/L
25% Albumin
„High oncotic pressure
„Draws fluid into interstitial space
„Incremental increase in plasma volume
4-5 times greater than volume infused
Interstitial fluid decreases 4 times
greater than volume infused
„
25% Albumin
„Use is indicated in patients in whom
fluid and sodium intake is restricted or
when needing to shift interstitial fluid
into plasma where hypovolemia
associated with edema
Same dosing as 5% (25g initial dose,
max dose 250g/48hrs)
May dilute in normal saline
„
„
Blood Products
„FFP: contains plasma with a few cells
„pRBC: RBC with some plasma
„Fluid in blood products are
isotonic/oncotic/osmotic therefore no
shifting of fluid
All transfusions stay in intravascular
space
„
What are crystalloids?
IV Fluids comprising of various amounts
of electrolytes and sugar
„ Used for fluid expansion, maintenance
infusion, correction of electrolytes
„ Divided into isotonic, hypotonic,
hypertonic fluids
„
Advantages of crystalloids
Inexpensive
„ Little risk of allergy/transfusion reaction
„
Available crystalloids
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Isotonic
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Hypertonic
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Normal Saline (0.9%)
Ringer’s Lactate
Hypertonic Saline (3%)
Hypotonic
„
„
0.45% NaCl
D5W
Isotonic crystalloids
Workhorse of shock resuscitation
„ Distributes equally through all fluid
compartments
„ Larger volumes (3:1) for intravascular
filling
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Normal Saline (0.9%)
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Sodium - 154 mmol
Chloride - 154 mmol
Osmolarity =154 x 2 = 308
Iso-osmolar, Isotonic, Hypo-oncotic
pH=5
Normal Saline Bolus of 1L
Na keeps fluid in extracellular space
„ Distributes proportionally in extracellular
space
„
Normal Saline
Potential adverse effects: Hypernatremia
and hyperchloremic metabolic acidosis
„ Preferred in the presence of
hyperkalemia, hypercalcemia,
hyponatremia, hypochloremia, or
metabolic alkalosis
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Ringer’s Lactate
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Sodium 130 mmol
Potassium 4 mmol
Calcium 1.4 mmol
Chloride 109 mmol
Lactate 28 mmol
Osmolarity=130+4+1.4+109+28 = 273
Hypotonic, Hypo-oncotic
pH=6.5
Ringer’s Lactate Bolus
Similar to NS
„ Distributes proportionally in extracellular
compartment
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Ringer’s Lactate
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Balanced salt solution despite similar
tonicity as NS
Designed to mimic extracellular fluid
Provides a HCO3- precursor
Useful for GI losses and extracellular fluid
volume deficits
Ringer’s Lactate
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Lactate may provide a buffer to metabolic
acidosis
Implicated in promoting respiratory acidosis
Possible immune-modulating function
Hypertonic saline solutions
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Combines ease of crystalloid with the
tonicity of colloids
Promotes influx of fluid from the interstitial
space
Rapid, low-volume resuscitation for
hypovolemic shock
Hypertonic Saline
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3% NaCl
Sodium: 513
Chloride: 513
pH: 5.0
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7.5% NaCl
Sodium: 1,283
Chloride: 1,283
Hypertonic saline solutions
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Possible hypernatremia and
hyperosmolarity
Reports of hypokalemia, metabolic
acidosis, and impaired platelet aggregation
Risks:
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Central pontine myelinolysis with rapid infusion
Renal compromise with high sodium and
osmolar loads
Hypotonic solutions
Distribute throughout the TBW
compartment
„ Not for volume expansion
„ Replace free water deficits
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D5W
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Dextrose - 5gm/100ml = 50gm/litre
Osmolarity=252 = hypo-osmolar
Hypotonic, Hypo-oncotic
pH=4.0
Bolus of D5W
Distributed proportionally between ICF
and ECF
„ Water crosses cellular membrane
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D5-1/2NS
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Sodium 77 mmol
Chloride 77 mmol
Dextrose 50gm/litre
Osmolarity=252 + 77 +77 = 406
Hypotonic, Hypo-oncotic
Bolus of 1L D5-1/2NS
500 cc NS and 500 cc D5
„ D5 redistributes everywhere
„ NS extracellular
„ ICF up 300cc, ECF up 600 cc
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Resuscitation.
„ Does
it matter what fluid I give?
„ How do I fluid resuscitate a…?
„ Trauma
patient?
„ Septic patient?
„ Burn patient?
„ Pediatric patient?
Choice of fluid.
„ Intuitively
crystalloids or hypertonic saline,
BUT…
„ The bulk of available evidence indicates
that neither colloids or crystalloids provide
a survival benefit in ICU patients
„ But
not in patients with traumatic brain
injury
Choice of fluid.
A comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit
„ Conclusion:
“In patients
in the ICU, use of either 4
percent albumin or
normal saline for fluid
resuscitation results in
similar outcomes at 28
days”
„ The primary outcome
measure was death from
ANY cause within 28
days after randomization
The SAFE Study Investigators. (2004). A comparison of Albumin and Saline
for Fluid Resuscitation in the Intensive Care Unit. New England Journal
Medicine, 350, 2247-2256.
Choice of Fluid.
„ Plain
language
summary:
„ “No
evidence that
colloids are more
effective than
crystalloids in reducing
mortality in people
who are critically ill or
injured”
Perel et al. (2007). Cochrane Database of Systematic Reviews,
4
Choice of Fluid.
„ Conclusions:
“In this
post hoc study of
critically ill patients
with traumatic brain
injury, fluid
resuscitation with
albumin was
associated with higher
mortality rates than
was resuscitation with
saline.”
Myburgh J, et al., (2007). Saline or albumin for fluid resuscitation in patients with
traumatic brain injury. New England Journal Medicine, 357, 874-884
„ Hypertonic
saline:
- have greater ability to
expand blood volume,
and thus elevate blood
pressure
Plain language
summary: “more
evidence needed as to
the best concentration of
crystalloid to use in
resuscitation fluids”.
Bunn, Roberts, Tasker, & Trivedi (2008). Cochrane Database of Systemic Reviews, 3
Choice of fluid.
„A
reasonable approach:
„ Tailor the type of resuscitation fluid to the
specific clinical condition
„ Hypovolemia
secondary to dehydration
(uniform loss of extracellular fluid)- crystalloid
fluid
„ Hypovolemia secondary to hypoalbuminemia
(fluid shift)- colloid fluid (25% albumin)
Trauma
Traditional resuscitation approach:
Establish vascular access with 2 large bore IV’s, and:
„ (At the moment) warmed crystalloid solutions are
recommended for initial resuscitation
„ Alternative is hypertonic saline, but no evidence
„ Initial warmed fluid bolus given as rapidly as possible;
„ 1 to 2 L for adults, 20 ml/kg for pediatric patients
„ Initial fluid and blood requirement is difficult to predict
on initial evaluation of the patient
„ Important to asses the patient’s response!
Estimated Blood Loss Based on Patient’s Initial Presentation
“Class I”
“Class II”
“Class III”
“Class IV”
EBL
EBL
EBL
EBL
<750cc
<15% of TBV
750cc – 1500cc
15 – 30% of TBV
1.5L – 2L
30 – 40% of TBV
>2L
>40% of TBV
S&S
S&S
HR: increased
Pulse Pressure: decreased
BP: no change
HR: increased
BP: decreased
MS: agitated
Urine Output: decreased
Tx
Tx
S&S
None/minimal
Tx
Crystalloids
Crystalloids
1. Crystalloid (1 – 2L)
2. Transfusion (1 – 2units)
3. Identify source of Bleed(*5)
S&S
HR: increased
BP: decreased (<60)
MS: decreased
Tx
1.
2.
3.
4.
Crystalloid (2L)
Transfusion (2 – 4 units)
Identify source of Bleed(*5)
OR
American College of Surgeon’s Committee on Trauma (2008). Advance Trauma Life Support for
Doctors, 8th Ed. Chicago, IL: American College of Surgeons
Trauma cont.
„ In
penetrating trauma with hemorrhage,
delaying aggressive fluid resuscitation
until definitive control may prevent
additional bleeding
„ Bickell
et al. (1994). Immediate versus delayed fluid
resuscitation for hypotensive patients with penetrating
torso injuries. New England Journal of Medicine, 331,
1105-1109
Trauma, cont.
„ Concept
of “Permisive Hypotension”:
„ AKA
hypotensive resuscitation
„ Balancing goal of organ perfusion with the
risks of rebleeding by accepting lower than
normal blood pressure
„ strategy to bridge to definitive surgical control
„ Does not apply to patients with head injury
„ Supported by many animal studies
• Mapstone, Roberts, & Evans (2003). Fluid resuscitation
strategies: A systematic review of animal trials. Journal of
Trauma, 55, 571-587
„ Plain
language
summary: No
evidence from trials
to support or not to
support the use of
early or larger
volume intravenous
fluid in uncontrolled
bleeding
Kwan, Bunn, & Roberts (2003). Cochrane Database of Systematic Reviews, 3
Trauma, cont.
„ Severe
injury and hemorrhage result in
consumption of coagulation factors
„ Measure INR, PTT, platelet count, and
fibrinogen levels
„ Major brain injury-tissue thromboplastin
„ Massive fluid resuscitation worsens
coagulopathy
„
Maegele et al. (2007). Early coagulopathy in multiple injury: An
analysis from the German Trauma Registry on 8724 patients. Injury,
38, 298-304.
Trauma, cont.
„ Patients
transiently responding, or not
responding to resuscitation need blood!
„ Recent trend towards administering blood
component therapy in equal proportions
• Conclusions: “The transfusion of plasma to RBCs
in a 1:1 ratio is a rapid treatment that improves
survival for patients at risk of hemorrhagick shock.
We suggest that the empiric ratio of plasma to RBC
should approximate 1:1 for patients with traumatic
injuries requiring massive transfusions.”
Borgman MA, et al. (2007). The ratio of blood products transfused affects mortality in
patients receiving massive tranfusions at a combat support hospital. Journal of Trauma,
63, 805-813.
Evaluation of Fluid
Resuscitation
„ evaluate
blood pressure, pulse pressure,
and pulse rate
„ Improvements in CVP, skin circulation are
difficult to quantitate
„ Base deficit/lactate
„ Urinary output sensitive indicator of renal
perfusion
„ 0.5
ml/kg/hr in adults, 1 ml/kg/hr in pediatric
patients, children under 1 yr 2 ml/kg/hr
Sepsis
„ SIRS-
tachycardia (HR>90), tachypnea
(RR>20 or PacO2,32 mmHg),
leukocytosis (WBC>12) or leukopenia
„ “Time is tissue”
„ Use “Early Goal Directed Therapy” as a
guideline
„ CVP of 8-12, MAP >65, urine output >0.5
ml/kg/hr, ScvO2=70%
„
Rivers, E. et al. 2005 CMAJ. 173(9) 1054-1065.
Sepsis, cont.
„ Rapid,
repeated 500 mL boluses of
crystalloid or colloid up to an initial
resuscitation volume of 20-40 mL/kg body
weight
„ If Scv02 remains below 70% after
attempted optimization, give PRBC’s to
achieve a hematocrit above 30%
„ But.. as always, treat the patient, not the
numbers!
„ Frequently re-asses progress!
Burns
„ Burns
covering more than 15% of the total
body surface area in adults and more than 10%
in children warrant formal resuscitation
„ Most commonly used resuscitation formula is
the Parkland formula
„ Titrate rate against urine output:
„ Starting point for resuscitation is the time of
injury, not the time of admission
Wallace Rule of Nines
Burns, cont.
„ Parkland
formula for burn resuscitation:
„ Total fluid requirement in 24 hours=
„4
ml X (TBSA)(%)) X (body weight (kg)).
„ 50% given in the first 8 hours, 50% given in the
next 16 hours.
„ Children receive maintenance fluid in addition
End Point:
• Urine output of 0.5-1.0 ml/kg/hour in adults, 1.0-1.5
ml/kg/hour in children
Pediatric Fluid Therapy
„
„
„
„
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Goals = prevention of dehydration, electrolyte
disorders, ketoacidosis and protein
degradation
Glucose should be added to prevent
ketoacidosis
Kids have small amounts of glycogen stores
Maintenance fluid: 4-2-1 rule
Bolus dose: start with 20cc/kg
Pediatric Fluid Therapy
„
„
Bolus: Normal saline OR Ringer’s Lactate
D5-1/2NS + 20mEq/l KCl provides
17calories/100mL, 20% of caloric need
„
„
Prevents ketoacidosis and minimizes protein
degredation
D5-0.2NS + 20mEq/l KCl good in children
<10kg
„
High water need/kg
Morbidity Associated with Over
Resuscitation
„ Decreased
wound healing, difficulty with wound
closure,
„ Decreased gut mobility, abdominal compartment
syndrome, bacterial translocation
„ Cellular level: acidosis, large fluid shifts
„ Hemodilution; hemoglobin, clotting actors
„ Coagulopathy; decreased clotting factors,
increased bleeding time
„ Cytokine activation; inflammatory cascade,
ARDS, renal failure
Conclusions
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Multiple ways to fluid resuscitate individuals
Key = frequent reassessment of fluid
resuscitation and fluid balance
Crystalloids and Colloids are drugs and have
complications associated with their use
Cater your fluid resuscitation to the patient
Watch for signs of fluid overload
Conclusions
„ If
a patient is not bleeding;
„ Resuscitate
according to etiology of illness
„ Evidence to date does not support any
crystalloid/colloid more than any other
-may consider use of hypertonic saline 7.5%
Can use Early Goal Directed Therapy as a
guideline
Conclusions
„ If
the patient is bleeding:
„ Judicious
use of fluids: Concept of permissive
hypotension until definitive repair
„ In
a patient with a head injury:
„ Do
not give Albumin!
„ - Avoid hypotension
„ If significant blood loss:
• Administer blood products
Cater your fluid resuscitation to the
patient
„ Watch for signs of fluid overload
„
References
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American College of Surgeon’s Committee on Trauma (2008). Advance Trauma Life Support for Doctors, 8th Ed. Chicago, IL: American College of Surgeons.
Bickell et al. (1994). Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New England Journal of Medicine, 331, 1105‐
1109.
Borgman et al. (2007). The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. Journal of Trauma, 63, 805‐
813.
Bunn, Roberts, Tasker, & Trivedi (2004). Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database of Systemic Reviews, 3,CD002045.
Civetta, Taylor, & Kirby's critical care / edited by Andrea Gabrielli, A. Joseph
Layon, Mihae Yu. — 4th ed.
Dart, AB., Mutter, TC., Ruth, CA., Taback, SP., Hydroxyethyl starch (HES) versus
other fluid therapies: effects on kidney function. The Cochrane Collaboration
2010, Issue 1
Fluid and Electrolyte administration. Policies & Procedures Database, The
hospital for Sick Kids, 2008.
Hettiaratchy & Papini (2004). Initial management of a major burn: II – Assessment and resuscitation. British Medical Journal, 329,101‐103.
Kliegman: Nelson Textbook of Pediatrics, 18th ed. 2007 Saunders, Elsevier
References
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Klingensmith, Mary E.; Chen, Li Ern; Glasgow, Sean C.; Goers, Trudie A.; Melby, Spencer J.
Washington Manual of Surgery, 5th Edition, 2008 Lippincott Williams & Wilkins
Kwan, Bunn, & Roberts (2003). Timing and volume of fluid administration for patients with bleeding. Cochrane Database of Systematic Reviews, 3, CD002245. Maegele et al. (2007). Early coagulopathy in multiple injury: An analysis from the German Trauma Registry on 8724 patients. Injury, 38, 298‐304.
Mapstone, Roberts, & Evans (2003). Fluid resuscitation strategies: A systematic review of animal trials. Journal of Trauma, 55, 571‐587.
Marino (2007). The ICU Book, 3rd Ed. Philadelphia, PA: Lippincott Williams & Wilkins.
Myburgh J, et al. (2007). Saline or albumin for fluid resuscitation in patients with traumatic brain injury. New England Journal Medicine, 357, 874‐884.
Pentaspan Product Monograph
Perel et al. (2007). Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews, 4, CD000567.
Rivers et al. (2005). Early and innovative interventions for severe sepsis and septic shock: Taking advantage of a window of opportunity. Canadian Medical Association Journal, 173(9) 1054‐1065.
The SAFE Study Investigators (2004). A comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. New England Journal Medicine, 350, 2247‐2256.
Townsend, CM., Beauchamp, RD., Evers, BM., Mattox, KL., Sabiston’s Textbook of Surgery, 18th
ed., Saunders, 2007
Vincent, J., Weil, H., Fluid challenge revisted. Crit Care Med 2006 Vol. 34, No. 5
Voluven Product Monograph