PATHOPHYSIOLOGY OF FLUID

OVERLOAD IN CRITICALLY ILL

Yohanes george
Head of Emergency and Intensive Care Unit
Pondok Indah Hospital Jakarta

Manado, 26 Okt 2018

 THE HISTORY OF
FLUID
RESUSCITATION IN
CRITICALLY ILL
 THE FIRST FLUID RESUSCITATION IN HUMAN
Dr Thomas Latta , Lancet 1832. Saline infusion to patient with acute Cholera
80 years
 World War I (1914-1918)

Cause of death is hemorrhage shock

5
World War II 1943

6
 FIRST IS FLUID
RESUSCITATION
PEARL HARBOUR ATTACK 1941
 KOREAN WAR 1951

RESUSCITATION WITH COLLOIDS

(ALBUMIN 5%) AND BLOOD

acute renal failure

9
 Vietnam War 1965 - 1970

Extracellular space Need for crystalloids

⇒Renal failure ⇓
Onset of “shock lung” (ARDS)
10
1970
CARDIAC OUTPUT WAS INTRODUCED IN
CLINICAL PRACTICE;

Pulmonary Artery Catheter (Swan-

Dr. William Ganz, a
Ganz Catheter)
cardiologist (1919-2009)
 PERIOPERATIVE HIGH RISK SURGERY
1980

Shoemaker did a series of observational studies

• Previous severe cardio-respiratory
illness
• Late stage vascular disease
• Age> 70 with limited physiological
reserve
• Acute abdominal catastrophe
• Septicaemia
• Respiratory failure
• Acute renal failure
• Massive blood loss > 8 units
• Extensive surgery for carcinoma
Median value of survivors in Shoemaker
observational studies
Cardiac index (CI) 4.5 L/min/m2

Oxygen delivery (DO2I) 600 ml/min/m2

Oxygen consumption (VO2I) 170 ml/min/m2

”SUPRANORMAL” TARGET;
1. Fluid Loading and
2. Inotrope
WHAT ABOUT SEPSIS?
 EGDT IN THE TREATMENT OF
SEVERE SEPSIS AND SEPTIC SHOCK

Rivers. NEJM 2001

Aggressive fluid resuscitation

achieving CVP 8-12 mmHg
using crystalloid then colloid

FLUID FIRST !!

Rivers. NEJM 2001

 (2004-2008)

FLUID FIRST !!
EGDT protocol in
the Bundle EGDT protocol still
in the Bundle

(2012)
 2012

FINALLY;
EGDT had (2015)
removed from
the Bundle

But still fluid

first 😅😍
FLUID FIRST !!
 SSC 2016

Can not
move on ..😅😍
THE CONSEQUENCES
THE CONSEQUENCES
ARDS

PERIPHERAL EDEMA IN DHF

BURST ABD
FLUID BALANCE AND CLINICAL OUTCOME
IN ICU
The lower of total fluids

The lower of mortality

WHY OVERLOAD?
 capillary cell
membrane membrane

ICW Mineral, protein,

40% gycogen, fat
40%

Interstitial o Clearance of crystalloid during anesthesia and

Plasma surgery is 10-20% of that in awake volunteers
Volume 4.3% fluid 15.7%
o Crystalloid leaves the plasma space, equilibrates with
colloids interstitial space after 20-30 min

crystalloid:
75-80% leaves vasculature after 20 minutes
5% dextrose

VOLUME KINETICS FOR INFUSION FLUIDS

Hahn GR, Anesthesiology 2010
 “Pathologic shift” “Pathologic shift”

Interstitial fluid

Delayed clearance
Immediately reaches
shifting equilibrium with
interstitial space during
plasma infusion

Volume Kinetics for Infusion of crystalloid during

surgery and Pre-eclampsia
Hahn GR, Anesthesiology 2010
PATHOPHYSIOLOGY FLUID RESUSCITATION IN
CRITICAL ILLNESS
Healthy Normal

Normal
Crystalloid Glycocalix
infusion & endothelial gap

Interstitial
Normal 15’ 75%
fluid shift
heart
Plasma

Zero Balance

Normal Drainage
kidney
Normal
Lymph
Urine output
 THE IMPACT OF STARLING’S PRELOAD
DEPENDENCY TO FLUID MANAGEMENT
PHYSIOLOGY OF VOLUME
FLUID BOLUS RESUSCITATTION IN CRITICALL ILL
Preload
dependence
Glycocalix damage - Increased
CYSTALLOID permeability/gap
INFUSION

Leakage


Interstitial
hypovolemia
Increase Filling Fluid shift
Plasma

Pressure  Atrial
Natriuretic Peptide
(ANP) launched
Lymph

In critical illness 
Urine output leakage >> lymph flow
decrease  STILL
HYPOPERFUSION  tissue edema
THE CONSEQUENCES OF TISSUE EDEMA
Tissue Normal
edema distance

Celullar
hipoxia

The Importance Of Local Capillary Oxygen Tension And Diffusion Distance

In Determining The Rate Of Oxygen Delivery And The Intracellular PO2

Leach RM. Thorax 2002;57:170–177

 Increase the
DO2crit during
hipoxemia

An increased intercapillary distance, as would occur with tissue oedema, reducing

DO2 by progressive falls in arterial oxygen tension results in a change in the
DO2/VO2 relationship with VO2 falling at much higher levels of global DO2

Leach RM. Thorax 2002;57:170–177

 FLUID ACCUMULATION AND MULTI ORGAN
DYSFUNCTION

Aggressive Fluid Strategies

Adversely Affect Every
System And Organ

Tissue Edema

Diffusion Distance

Celullar damage
Prowle JR et al. Nat Rev Nephrol 2010;6:107
 FLUID ACCUMULATION ON
GASTROINTESTINAL DYSFUNCTION
FLUID ACCUMULATION AND ABDOMINAL
COMPARTEMENT SYNDROME

Vidal et al. Crit Care Med 2008

 THE EFFECT OF FLUID ACCUMULATION
ON GASTROINTESTINAL FUNCTION

Fluid accumulation

Splanchnic edema

Gut Edema

Lower Bursting
pressure

1. Increased gut permeability

2. Impaired wound healing
3. Anastomostic dehiscence
Marjanovic et all. Ann Surg 2009
 THE EFFECT OF FLUID ACCUMULATION ON
GASTROINTESTINAL FUNCTION

1. V(-) = Crystalloid volume restrictive

2. CO = control
3. V(+) = Crystalloid volume overload

Impact of Different Crystalloid Volume

Regimes on Intestinal Anastomotic Stability
Marjanovic et al. Ann Surg 2009
 THE EFFECT OF FLUID ACCUMULATION
ON GASTROINTESTINAL FUNCTION

1. Col- = colloid restrictive

2. Cry- = crystalloid restrictive
3. Col+ = colloid overload
4. Cry+ = crystalloid overload

Colloid vs. crystalloid infusions in gastrointestinal surgery and their different impact on the
healing of intestinal anastomoses
Marjanovic et al. Int J Colorectal Dis (2010) 25:491–498
 THE EFFECT OF FLUID ACCUMULATION
ON GASTROINTESTINAL FUNCTION

1. Col- = colloid restrictive

2. Cry- = crystalloid restrictive
3. Col+ = colloid overload
4. Cry+ = crystalloid overload
Colloid vs. crystalloid infusions in gastrointestinal surgery and their different impact on the
healing of intestinal anastomoses
Marjanovic et al. Int J Colorectal Dis (2010) 25:491–498
FLUID OVERLOAD AND ARDS
 CUMULATIVE FLUID BALANCE

NON-SURVIVOR
NON-SURVIVOR

SURVIVOR

SURVIVOR

DAILY FLUID BALANCE

FLUID OVERLOAD AND AKI

Payen et al. Critical Care 2008. 12:R74

 Zero balance

In septic patients with AKI, positive fluid balance was associated

with decreased survival at 60 days

Payen et al. Critical Care 2008. 12:R74

SO, WHAT WE HAVE TO DO
CONTEXT SENSITIVE; FLUID IS TOXIC

Cordemans et al. Fluid management in critically ill patients: the role of extravascular lung water, adbominal
hypertension, capillary leak, and fluid balance. Annal of Intensive Care 2012
THANK YOU

George 2017
Thank you for
your attention