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To p i c s i n Progressive


Third-spacing: When body fluid shifts
By Susan Simmons Holcomb, ARNP-BC, PhD


In a healthy adult, nearly all fluid is contained in the intracellular, intravascular, or interstitial spaces, with the intracellular space holding about two-thirds of total body water. Normally, fluid moves freely between these three spaces to maintain fluid balance (see Water, water everywhere). Third-spacing occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or “third” space—the nonfunctional area between cells. This can cause potentially serious problems such as edema, reduced cardiac output, and hypotension. In this article, I’ll describe why third-spacing occurs and how to intervene to restore balance. Let’s start with a brief physiology review.

Water, water everywhere
Intracellular fluid

Intravascular fluid

Interstitial fluid

What’s behind third-spacing? Fluid volume, pressure, and levels of sodium and albumin are the keys to maintaining fluid balance between the intracellular and extracellular (intravascular and interstitial) spaces. Capillary permeability and the lymphatic system also play a role. A problem with any of these components can cause fluid to shift from the intravascular space to the interstitial space. Let’s look more closely at each component. • Increased fluid volume can be caused by overzealous fluid replacement or renal dysfunction. Volume overload can lead to peripheral edema, pulmonary edema, hepatic dysfunction, cerebral edema and mental changes, and decreased cardiac output. Other signs of fluid overload include jugular vein distension, hypertension, and a pathologic S3. • Increased capillary hydrostatic pressure often accompanies heart failure. Right-sided heart failure is characterized by an increase in venous pressure that causes edema in the liver and the periphery. Left-sided heart failure causes pulmonary edema. • Decreased sodium level, or hyponatremia, may result from sodium loss; for example, gastrointestinal

Body fluids are distributed between the intracellular and extracellular fluid compartments. The intracellular compartment consists of fluid contained within all the body cells. The extracellular compartment contains all the fluids outside the cells, including fluid in the interstitial (tissue) spaces, and that in the intravascular space (blood vessels).

losses during diarrhea or fluid losses caused by medications such as diuretics. Hyponatremia can also arise from volume overload. Also called dilutional or hypervolemic hyponatremia, this can occur with overzealous fluid replacement, heart failure, hepatic cirrhosis, renal disease, hypothyroidism, or administration of vasopressin. • Albumin losses disrupt colloidal osmotic pressure. Plasma proteins are crucial to maintaining colloidal osmotic pressure. Albumin, the major protein constituent of the intravascular space, accounts for up to 60% of total protein. Any condition that destroys tissue or reduces protein intake can lead to protein losses and third-spacing. Some examples are hypocalcemia, decreased iron intake, severe liver diseases, alcoholism, hypothyroidism, malabsorption, malnutrition, renal disease, diarrhea, immobility, burns, and cancer.
March l Nursing2009Critical Care l


To p i c s i n Progressive Care • Increased capillary permeability results from burns and other forms of tissue trauma. or bleeding can be measured. urine output increases. The metabolic panel will give clues to renal and hepatic function as well as electrolyte balance (especially sodium). The albumin-to-globulin ratio (normally slightly greater than 1:1) will elicit more information about colloidal osmotic pressure than total protein and albumin levels alone. Fluid loss from diarrhea. and some facilities aren’t equipped for this type of monitoring. complete metabolic profile. Venous end Arterial end Capillary Excess fluid and proteins accumulate in interstitial space Obstructed lymphatic vessel Phases of third-spacing Third-spacing has two distinct phases—loss and reabsorption. which can lead to shock and renal failure. decreased values may indicate hypervolemia. which can lead to pulmonary edema. Elevated hemoglobin and hematocrit values may indicate 10 hypovolemia. Number 2 .com l Nursing2009Critical Care l Volume 4. The lymphatic system usually returns excess fluids and osmotically active plasma proteins to the circulation. the cause of third-spacing may be subtle and require a diagnostic workup. including a complete blood cell count (CBC). and weighing the patient daily. or sepsis). the patient’s weight stabilizes. During the reabsorption phase. Postmastectomy lymphedema is an example of this type of third-spacing. In the loss phase. such as infection or necrosis. and signs of shock (if any) begin to reverse. tissues begin to heal and fluid is transported back into the intravascular space. and the factors involved. decreased urinary output. vomiting. Determining the cause In some cases. Edema due to an increase in capillary permeability can be local. which may yield information on cardiac function and volume status. such as tachycardia and hypotension. your focus is on preventing hypovolemia and hypotension. and levels of protein. Signs and symptoms include weight gain. but fluid loss from third-spacing isn’t so easy to quantify. fluid and plasma proteins accumulate in the interstitial space. www. The role of the lymph system Normally the forces moving fluid out of the capillaries into the interstitial space are greater than those returning fluid to the capillaries. and serum osmolality. Invasive hemodynamic monitoring of central venous pressure. fluid and plasma proteins accumulate and can’t be drained into the general circulation because of the lymphatic obstruction (see The role of the lymph system). surgery. right atrial pressure. Stabilizing your patient’s hemodynamic status is the first priority. Treatment of third-spacing depends on the cause. Noninvasive assessment tools include an echocardiogram. • Lymphatic system obstruction is commonly caused by lymph node removal to treat cancer. the phase. Signs of hypovolemia resolve. An obstruction typically leads to localized edema. However. and pulmonary artery occlusive pressure also help track volume status and the patient’s response to treatment for hypervolemia or hypovolemia. or systemic as with anaphylaxis or disseminated intravascular coagulation. During the reabsorption phase. burns. including albumin. and signs of hypovolemia. If the patient was given fluid resuscitation during the loss phase. trauma. some patients aren’t candidates for hemodynamic monitoring. During the loss phase. The CBC may give clues to volume status and factors contributing to third-spacing. increased capillary permeability leads to a loss of proteins and fluids from the intravascular space to the interstitial space. focus on preventing circulatory overload and hypertension.nursingcenter. monitor for fluid overload as interstitial fluid shifts back to the intravascular space. But if the lymphatic system is obstructed. This phase lasts 24 to 72 hours after the initial insult that led to the increased capillary permeability (for example. as with a localized trauma. making this protein a major source of plasma colloid osmotic pressures. Albumin molecules are large and don’t diffuse freely through the vascular endothelium.

Which fluid is best? To stabilize the patient’s volume status.A. with 0. isotonic. Hy •Tape is friendly to both patients and health care professionals.hytape. there wasn’t enough evidence to determine whether hypertonic solutions were safer or more effective than isotonic THE GENTLE GIANT There’s always been a genuine comfort level between health care professionals and the powerful pink presence of Hy •Tape. not deplete the third space. and patients with cardiovascular or pulmonary disease. yet flexible.9% sodium chloride solution preferred if the patient is hyponatremic. Box Hy•Tape and “The Original Pink Tape” are registered trademarks of Hy•Tape International Inc.45% sodium chloride solution. Isotonic solutions such as lactated Ringer’s solution and 0. March l Nursing2009Critical Care l 11 . so it’s perfect for extended wearing while it gently accommodates underlying tissue shifts. patients with associated traumatic brain injury. the SAFE (saline versus albumin fluid evaluation) study evaluated fluid resuscitation with albumin. Hy •Tape is durable. And with good reason. Crystalloids replace electrolytes and restore normal serum osmolality.4 At present. resuscitation with albumin or 0.2 In 2004. a recent study found that hypertonic crystalloids were better than isotonic crystalloids for reducing abdominal thirdspacing and abdominal compartment syndrome that often occur with massive fluid resuscitation in patients with extensive burns.nursingcenter. Hypertonic solutions. colloid use was found to be associated with increased morbidity and mortality compared with crystalloid use. are used for resuscitation. or hypertonic. you’ll administer crystalloids. such as 3% sodium chloride solution. No other surgical tape sizes up to the formidable array of easy working properties neatly rolled into every spool. Remember.1 Another study of critically ill patients found that even though smaller volumes of hypertonic solutions are needed for fluid resuscitation. Crystalloids are most commonly used. P. aren’t appropriate for volume resuscitation because very little of the fluid would remain in the intravascular space.9% sodium chloride solution may not make a difference except in cost: Albumin is considerably more expensive. NY 12563-0540 • Toll Free: 1-800-248-0101 Fax: 845-878-4104 • Visit our Web site: www. oily or hairy surfaces. with older adults. This industry giant is all about sensitivity.S. contain large amounts of sodium and have been rarely used for resuscitation because of their potential for cellular dehydration and overexpansion of the intravascular space. you’re trying to replenish intravascular volume. Hypotonic solutions. Remarkably. colloids. However.O. Patterson. or a combination of these. Crystalloid fluids can be hypotonic. which are similar to plasma in tonicity and osmolality. colloids replace the proteins responsible for maintaining plasma colloid osmotic pressure. Latex-free and non-allergenic. Its waterproof surface can be washed with soap and water without slipping or detaching from wet.9% sodium chloride solution. Made in the U. and can also treat hyponatremia. such as 0. compared with crystalloid. However. In young adult trauma patients without preexisting cardiovascular or pulmonary disease. it’s just as easily removed from sensitive post-operative skin. a colloid.3 The study found that albumin wasn’t associated with higher morbidity and mortality in critically ill patients. It’s not surprising that they’ve grown so attached to this gentle giant. There’s a lot to like about Hy •Tape. due to www.

PA 19106 © Wolters Kluwer Health/Lippincott Williams & Wilkins Now includes FREE online access to full-text articles since 2001 with your individual paid subscription.60(1):64-71. monitor your patient’s response to treatment to determine if the goals of intravascular resuscitation have been met.13(5):304-311.):S82-S88. Vincent JL. research doesn’t support using colloids instead of crystalloids. especially if human albumin is used. Crit Care Med. 2004. Keeping up with rapid change in infusion nursing takes a reliable and measured challenges you face every day • maximize the effectiveness of the therapy you provide.38(7):50-53. et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit.) Medical • discover practical solutions to the or LWW. Boyce N. DeBacker D.. et al. Third spacing: when body fluid shifts. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. J Trauma. Ueyama M. Breton C. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Bunn F. 3.):S451-S454.11(3):240-244. Norton R. Perioperative influences on fluid distribution. van Wissen K.24(4):182-191.54(5 suppl. Gerlach H.4 No matter which type of fluid he receives. vital signs. critical. Tasker R. Rizoli S. Adapted from: Holcomb SS. 2005. Cur Opin Crit Care. weight. continuous infusion of new knowledge. and home health care. 2006. The SAFE Study Investigators. The Official Publication of the Infusion Nurses Society F7NGK437 A7K437ZZ . French J. Bellomo R. J Trauma. Finfer S. Cochrane Database Syst Rev. New Engl J Med. 2003. you can learn evidence-based developments – as judged most helpful to you by your peers – in one. 2. we may be able to not only monitor capillary health at the bedside.the cost of colloids and the potential for adverse reactions. and urine output don’t tell us what’s going on at the capillary level.18(4):CD000567. Roberts I. What the future holds Although they’re valuable indicators of a patient’s condition. Roberts I. long-term. Crystalloids and colloids in trauma resuscitation: A brief overview of the current debate. oncology. Verdant C. Oda J. Someday soon. 2004. 2004(3):CD002045. Inc. Now. but also to determine which factor or combination of factors led to third-spacing so that interventions can be tailored more precisely to the patient’s condition. call TOLL FREE • grow with brand-new advice from today’s infusion experts 1-800-638-3030 or visit NursingCenter. 530 Walnut Street Philadelphia. 2004. RESOURCES Redden M. Future goals for treating third-spacing may focus less on the type of fluid given than the patient’s capillary health as defined by capillary permeability and perfusion.) Community College. To subscribe. 2004. Myburgh J.32 (11 suppl. Cochrane Database Syst Rev.350(22):2247-2256. Hypertonic lactated saline resuscitation reduces the risk of abdominal compartment syndrome in severely burned patients. Yamashita K. Medsurg Nurs. Wotton K. Nursing. ❖ REFERENCES 1. Fluid resuscitation in severe sepsis and septic shock: An evidence based review. How monitoring of the microcirculation may help us at the bedside. and a consultant in continuing nursing education at Kansas City (Kan. 2008. Clinical decision making by nurses when faced with third-space fluid shift: How well do they fare? Gastroenterology Nurs. including med-surgical. 4. Susan Simmons Holcomb is a nurse practitioner at Olathe (Kan. You will … • apply the latest tools and techniques that are ideal for your health care setting. 2001. Akpa E.