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fluid resuscitation

in shock:
the role of colloids

Nur Samsu

Divisi Ginjal dan Hipertensi


Departemen Ilmu Penyakit Dalam FKUB – RSU Dr Saiful Anwar Malang
Homeostasis Cairan & Elektrolit
Regulasi Osmolalitas (Air)
H2O Osm ADH Ginjal meretensi H2O

Osmolaritas = solut/(solut+pelarut)
Osmolalitas = solut/pelarut (280~290 mOsm/L)
Tonisitas = osmolalitas efektif (270-285 mOsm/L)
Osmolalitas Plasma = 2 x (Na) + (Glukosa/18) + (Urea/2.8)
Tonisitas Plasma = 2 x (Na) + (Glukosa/18)

Regulasi Volume (Na+)

Na+ GFR Renin Angiotensin


Aldosteron Retensi Na+ oleh Ginjal
Why does fluid stay within the vasculature ?

Two opposing major factors governing fluid


movement between vascular and interstitial space:

Plasma colloid
oncotic pressure
The Endothelial Glycocalyx

 Membrane coating endothelium


(“double barrier concept”)
 Affect endothelial permeability.
 Prevent leukocyte and platelet
adhesion.
 Decreases inflammation.
 Bounds plasma proteins and fluids.
 700 ~ 1000 mL of “non-circulatory” plasma
fixed within.
 Maintains “oncotic gradient”

Myburgh JA, Resuscitation fluids, NEJM, 369, 2013: 1243-1249 A: Healthy, B: Damaged
Vascular Barrier Dysfunction

Ischemia/reperfusion injury, and Fluid loading


TNF-ᾱ, cytokines, proteases, mediated by ↑ ANP
heparanase (actors in sepsis)

↓ ESL thickness, Glycocalyx Degradation,


↑ Vascular Permeability

↑ leucocyte adhesion and


A starting point of the
trans-endothelial vicious circle
permeability
of vascular leakage and organ failure
Tissue Edema Formation
Stages of shock
Compensated (Early Shock)
Vasoconstriction (renin & carotid sinus baroreceptor)
Increase in HR and RR (sympathetic activation)
Normotensive usually (aldosterone/ADH Na+/H20 retention)

Decompensated (Late Shock)


Decreased Blood Flow to Brain and Heart
Restless, agitated, confused, lethargy
Hypotension, Tachycardia, Tachypnea

Irreversible (end-stage shock)


Bradycardia
MULTI ORGAN FAILURE
Impending death, death
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course
Multiple Organ Dysfunction Syndrome
Number of Mortality (%)
Organs
0 0.8
1 6.8
2 26.2
3 48.5
4 68.8
5 83.3

*Adapted from Irwin and Rippe’s Critical Care Medicine 5 th Edition, pg 1837
Circumferential Shock
Subendocardial Lung
Infarction due
to Shock
Intestinal mucosal
hemorrhages due to shock

Acute tubular necrosis Acute congestion


of the kidney due to shock of liver due to shock
Fluid Resuscitation
 “How much” is primary importance.
 Further consideration is “What fluid”
 Considerations when using “Colloid”

The right amount


of the right fluid
at the right time
Avoid the “Lethal Triad”
 Coagulopathy
 Consumption of clotting factor
 Dilution of platelets and clotting factors

 Hypothermia
 Perpetuates coagulopathy
 Most forgotten vital sign in resuscitation

 Acidosis
 Inadequate resuscitation and tissue perfusion
 Anaerobic metabolism and of lactic acid production
“How much”
Goals of Resuscitation Fluid Therapy

 Restore blood Therapeutic end point


pressure
• CRT < 2 seconds
 Normalize systemic
• MAP 65 – 70 mmHg
The principle of fluid therapy is
perfusion
• Urine output > 0.5
Preserve organ

to maintain tissue perfusion
function
ml/kg/hour (adults); > 1
ml/kg/hour (children)
• Shock index = HR/SBP
(normal 0.5 – 0.7)
Volume  Fluids
 • CVP 8 to 12 mmHg
 Pressure  Vasopressor • O2 sat > 95%
 Flow  Inotrope • ScvO2 > 70%
No therapeutic end point
is universally effective
“Hypoperfusion can be present in the absence
of significant hypotension.”
(Don’t only relay on BP for diagnosing shock)

CVP: Poor Target for Fluid Rx

No longer recommended as lone guiding


principles as they carry limited value for measuring
fluid responsiveness

use of dynamic variables (ie passive leg raise, pulse


pressure variation, stroke volume variation)
Deficit or Excess Blood Volume
Fluid Resuscitation
Marik PE, et al. Chest. 2008;134(1):172-178. Surviving Sepsis 2017 Guidelines
Initial Resuscitation

Modificated by Rivers, NEJM 2001


Surviving Sepsis Guidelines 2017
Small Volume Resuscitation
 Rapid infusion of a small dose (4 ml/kg
B.W.) of 7.2%-7.5% NaCl/colloid solution.
 Endogenous fluid shift along the osmotic
gradient from the intracellular to the
intravascular compartment.
 Immediate BP, SVR.
 Reduction of post-ischemic reperfusion
injury.
 Patients with head injury benefit more
Hypotensive Resuscitation

 Target MAP was 50 mmHg


 The use of small volumes of fluid 
avoids hemodilution and reduces the risk
of coagulopathy.
 A lower SBP  formation of primary blood
clots more easily and reduces the risk of
secondary hemorrhage.
Auto-correction
of the serum sodium
 The administration of saline to patients
with true volume depletion.
 The administration of glucocorticoids to
patients with adrenal insufficiency.
 Spontaneous resolution of a transient
cause for SIADH (eg, surgical stress,
nausea, pneumonia).

Lakhmir S Chawla, 1 st Asia Pacific AKI-CRRT 2017


Rationale for Hypotensive Resuscitation

 Excessive fluid resuscitation increases the chances of developing


abdominal compartment syndrome in critically ill surgical/trauma, burn,
and medical patients.
 In a multicenter study of burn patients, administration of excessive fluids
(in excess of 25% of predicted) increased the odds of ARDS (OR 1.7),
pneumonia (OR 5.7), multiple organ failure (OR 1.6), bloodstream
infections (OR 2.9), and death (OR 5.3).
 Hypotensive resuscitation strategy reduces transfusion requirements
and severe postoperative coagulopathy in trauma patients with
hemorrhagic shock.
 A systematic review of 52 animal trials concluded that fluid resuscitation
appeared to decrease the risk of death in models of severe hemorrhage
(RR = 0.48), but increased the risk of death in those with less severe
hemorrhage (RR = 1.86).

Parenteral fluid and nutrition therapy, 2012


“What Fluid”
Which fluid to Choose?

1: What is your goal for therapy?


 Maintenance
 Rehydration
 Volume resuscitation
2: Any baseline electrolyte abnormalities?
 Look at basic chemistry prior to ordering
fluids.
3: Where is the fluid going to go?
Which Fluid to Choose?
 Hypovolemia: primary goal is volume expansion.
 Use the fluid that will put the most volume into the
intravascular space.
 Dehydration (= hyperosmolality): primary goal is
free water replacement.
 Use a hypotonic fluid usually 0.45% saline or D5W.
 Post-operative patients  pain can be powerful
stimulants of inappropriate ADH secretion
(SIADH).
 Giving hypotonic fluids can cause dangerous
hyponatremia.
Advantages and Disadvantages
of Colloids and Crystalloids
Colloids
Advantages Disadvantages
1. Plasma volume expansion without 1. Anaphylaxis
concomitant ISF expansion
2. Greater intravascular volume expansion for 2. Expensive
a given volume
3. Longer duration of action 3. Albumin can aggravate myocardial
depression in shock patient, owing to albumin
4. Better tissue oxygenation binding to Ca++, which in turn decreases ionic
calcium
5. Less alveolar-arterial O2 gradient 4. Possible coagulopathy, impaired cross
matching
Crystalloids
1. Easily available 1. Weaker and shorter volume effect compared
to colloid
2. Composition resembling plasma (acetated 2. Decreased tissue oxygenation, owing to
ringer, lactated ringer) increased distance between microcirculation
3. Easy storage at room temperature and tissue
4. Free of anaphylactic reaction
5. Economical
Parenteral fluid and nutrition therapy, 2012
Pengaruh cairan koloid dan kristaloid terhadap volume kompartemen
cairan ekstraseluler
Colloid fluids
Commonly used colloids include:
 Hetastarch
 Gelatins
 Dextran
 Albumin
 Plasma protein fraction
Accepted indications
for colloids
 Fluid resuscitation in patients with severe
intravascular fluid deficits (eg, hemorrhagic
shock) prior to the arrival of blood for transfusion
 Fluid resuscitation in the presence of severe
hypoalbuminemia or conditions associated with
large protein losses such as burns
 Volumes infused should be limited because of
side effects and lack of evidence for their continued
use in the acutely ill.
Recommendations
 Do not use HES solutions in critically ill adult patients,
including those with sepsis.
 Avoid use in patients with pre-existing renal dysfunction.
 Discontinue use of HES at the first sign of renal injury.
 Need for RRT has been reported up to 90 days after HES
administration. Continue to monitor renal function for at least
90 days in all hospitalized patients.
 Monitor the coagulation status of patients undergoing open
heart surgery in association with cardiopulmonary bypass as
excess bleeding has been reported with HES solutions in this
population.
 Do not use HES products in patients with severe liver disease.
Sweeney RM et al. Ulster Med J 2013;82:171-8
Gelatin
 Degradation product of collagen
 Generally, gelatin solutions are considered to have
no dosage-related side effects, specifically not
impairing surgical hemostasis and being less
harmful to the kidneys than other non-protein
colloids.
 Cumulative effects of gelatin on mortality:
 Perel et al compared gelatin to crystalloid fluids in 506 critically ill
adult patients, and..
 Bunn et al compared gelatin with albumin 636 patients thought to
need volume replacement  No review found a significant effect on
mortality.
Specific Considerations apply
to different categories of patients
 Bleeding pts required control of hemorrhage and transfusion
with RBCs and blood components as indicated
 Isotonic, balanced salt solutions are pragmatic initial
resuscitation fluid for the majority of acutely ill pts
 Consider saline in pts with hypovolemia and alkalosis
 Consider albumin during the early resuscitation of pts with
severe sepsis
 Saline or isotonic crystalloids are indicated in pts with
traumatic brain injury
 Albumin is not indicated in pts with traumatic brain injury
 HES is not indicated in pts with sepsis, risk for AKI
Take Home Points
 Shock = poor tissue perfusion/oxygenation
 Resuscitate with fluids early and
aggressively
 The first few hours are vital.
 Primary goal in hypovolemia is volume
expansion.
 Use the fluid that will put the most volume into
the intravascular space.
 Gelatin : several advantages
The right amount
of the right fluid
at the right time