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Fluid Resuscitation:

in Trauma and Sepsis

Dita Aditianingsih MD
Department of Anaesthesia and Intensive Care
University of Indonesia - Cipto Mangunkusumo Hospital

The Physiology of
Fluid Shifts

The distribution of total body


water
Distribution of body water
is 60% of body weight

The body water is


equivalent to 60% of
total body weight.

This amounts are


distributed as 40%
intracellular volume
and 20% extracellular
volume of which is 15%
is interstitial and 5% is
plasma volume (red cell
volume is a component
of intracellular volume)
C.H. Svensen et al. / Best Practice & Research Clinical Anaesthesiology 23 (2009) 213224

Physiological basics

Colloids

Capillary tissue fluid


dynamics

Saline, RL, Balanced crystalloids

Glucose

Mg2+
Ca2+
HCO3Proteins
K+
PO42ClNa+

Classic Starling equation with net


efflux of fluid to the interstitial space
interstitial hydrostatic pressure

interstitial oncotic pressure

capillary hydrostatic pressure


capillary oncotic pressure

Jv, net filtration

Distribution of fluids for


increasing the blood volume
Intravascular
Extravascular Intertitial
20%

12

Capillary
membrane

40%
30

6
6

75 kg
BW

Cell membrane
36

9.4 L of
D5W

16

30

5 L of 0.9
NaCl

12

30

1 L of 6%
HES

30

0.6 L of 10%
HES

14.4

Colloid is ideal for


volume therapy

11.6
Body fluid
volume

C.H. Svensen et al. / Best Practice & Research Clinical Anaesthesiology 23 (2009) 213224

The Endothelial Glycocalyx


A double barrier concept : the Endothelial Cell Layer and

Endothelial Glycocalyx Layer play a role in maintaining


the vascular barrier

Jacob M. et al: The endothelial glycocalix affords compatibility of starlings principle and high cardiac interstitial albumin level.
Cardiovasc Res 2007; 73:575-86

Volume Kinetic during Infusion of Fluid


in Healthy and Diseases

Albumin
synthesis

Critical Illness/ High Risk Surgery

Fluid Infusion
Normal glycocalyx
endothelial gap

Albumin
synthesis

lymph

Metabolism
Urinary/ GIT loss

Abnormal glycocalyx endothelial


gap

leakage

Plasma
Plasma

Interstitial

Plasma
Plasma

leakage

Fluid Infusion

lymph
Catabolism
Urinary/ GIT loss
Hemorrhage

Interstitial Edema

Normal condition

Leakage >> lymph flow


tissue edema

What fluid is best for resuscitation ?


the optimal fluid for resuscitation would
combine the volume expansion and
oxygen-carrying capacity of blood, without
the need for crossmatching or the risk of
disease transmission.. and it would restore
and maintain the normal composition and
distribution of body fluid compartments.

Tremblay LN, Rizoli SB, Brenneman FD. Advances in fluid resuscitation of hemorrhagic shock.
Can J Surg.2001;44(3):172-179

Aspects of Fluid Management


Targets :
Intravascular fluid volume or
Extracellular fluid volume or
Both extracellular and intracellular fluid

volumes

Managements :
Volume replacement
Fluid replacement
Electrolyte replacement or osmotherapy

Aim

Definition

Composition

Type of fluid

Volume Replacement

Replace IVFV loss, correct Isooncotic


hypovolemia to maintain Isotonic
hemodynamic and
perfusion

Colloids
Crystalloids

Fluid Replacement

Compensate or replace
ECFV loss due to
cutaneous, enteral or
renal fluid loss

Isotonic

Crystalloids

Electrolyte Replacement
and Osmotherapy

Restore electrolyte
imbalance and a
physiological total body
fluid volume (ECFV and
ICFV)

Hypertonic
Isotonic
H2O base

Nacl 3
Crystalloids
D5W

Case

A 19-year old male was stabbed in the abdomen the patient


awake, but sluggish.

He is speaking and his airway appears patent. Breath sounds


are equal bilaterally.

Peripheral pulses are palpable, and on close inspection, the


wound appears to be bleeding only minimally.

Chest x-ray is normal. The trauma surgeon perform initial


USG FAST (Focus Assessment of Sonography in Trauma)
examination show intraabdominal free fluid level.

The patients initial vital signs are: heart rate of 140


beats per minute, blood pressure of 80/50 mm Hg,
respiratory rate of 20 breaths per minute, temperature
of 97F (36.1C), and SpO2 of 100% on room air.

One 18-G IVs are placed, lab work is drawn,

The patient looks pale, anaemic and starts to


have shortness of breath and become
somnolence.

What is the first


resuscitation action
should be done?

Airway -Ventilation : O2
FM 6lt/min

Circulation : 2 large
bore IV, fluid
resuscitation 1-2 litres

Crystalloid or colloid ?

Transfusion ?

Complete blood count

Blood type and crossmatch

Coagulation profile, including prothrombin time (PT), partial


thromboplastin time (PTT), and international normalized ratio (INR)

Basic metabolic panel : Blood sugar level, Blood gas analysis,


electrolytes

Toxicology studies, including alcohol level and drug screen, as


appropriate

Pregnancy test, as appropriate

Lactate level and base deficit (usually, both can be ascertained


from a blood gas syringe)

Lab findings

Hb 6.0/ Ht 15/ Leu 12.000/ Plt 70.000

Blood type and crossmatch : gol. AB

Coagulation profile : prothrombin time (PT) 2x, partial


thromboplastin time (PTT) 2.5 x, and international
normalized ratio (INR) 2.5x

Basic metabolic panel : Blood sugar level 150, Blood


gas analysis 7.211/26.9/175/-8.1/18.9/98.8, electrolytes
141/3.82/105

Lactate level 5 and base deficit -8.1

Flowchart of initial management of traumatic hemorrhagic shock


Bougl et al. Annals of Intensive Care 2013, 3:1

Fluid Resuscitation based on


Classes of shock by ATLS

Crystalloids

Colloids

Blood transfusions

Fluid option
Blood and components
Crystalloid
Colloid
Hypertonic solution

Isotonic
crystalloids
Advantages
Cheap

Easy to store and warm


Established safety
Predictable rise in cardiac output
Disadvantages14

Large volumes needed


Dilutional coagulopathy
Increase cytokine activation
No oxygen carrying capacity
May Increase ICP

Composition of IV
Crystalloid
Plasma
0.9%NS

Na
Cl
K
141 103 4-5
154 154 ----

Ca
5
----

LR

131 111 2

Buffer
Bicarb
---Lactat
e

pH
7.4
5.7
6.4

LR vs NS
Patients undergoing aortic aneurysm repair
NS
More volume (~1000-6000ml)
Hyperchloremic acidosis
Dilutional coagulopathy

Swine bled via liver injury & resuscitated to MAP 90mmHg


NS
More volume
Hyperchloremic acidosis
Dilutional coagulopathy

Waters 2001 (Aneth Analg)


Todd (J. Trauma 2007; 62:636-9)

LR vs NS
Conclusion

No mortality difference
LR

Lower overall volume


More buffering capacity

NS

Hyperchloremia acidosis
Dilutional coagulopathy

no difference for prehospital or early fluid


Probably
resuscitation.

Colloids
Proposed Benefits
Smaller volume
Less pulmonary edema
Stays in the intravascular space
return to normal
Quicker
hemodynamics
Smaller package
and antinflammatory
Antioxidant
effects

Colloids
Disadvantages
Transmission of diseases

Increased bleeding
Hypersensitivity reactions
Renal failure
Accumulation
Taken up by RES
Dose limit (20-33mL/kg)

Cost

Hypertonic Saline
Rapid plasma volume expansion
of fluid to vascular space secondary to
Pull
increased concentration gradient

Decreases ICP

Potential benefits in TBI patients

Military use
Weighs less

1 liter NS bag=2744 cm3 in volume and 1.1 kg


space for helicopters and ground
Storage
ambulances

Hypertonic Saline
Adverse effects
Hyperosmolar coma
Hypernatremia
Seizures
arrhythmias
Tissue necrosis
Allergic reactions

Hypertonic Saline
Hypertonic saline
7.5% or 7.2%
Dextran 70 (RescueFlow) or HES (HyperHAES)
Osmolarity 2500 mOsm/liter
Na+: 1200 mmol/liter
Total volume 250ml

Natural Colloids :
Albumin
SAFE trial 2004 (N Engl J Med
2004)

blind RCT, 7000 pts, 16 ICUs, 18 month


Double
period
4% albumin v 0.9% normal saline
First 4 days volume albumin to saline (1:1.4)
difference in 2 groups in 28 all day cause
No
mortality
group analysis: difference between trauma
Sub
and sepsis patients

RR of death pts with severe sepsis= 0.87


trauma mortality higher for albumin v
Overall
saline (13.5% v 10%)
TBI increase in mortality

Bio-physiology of Colloids

Crystalloid vs
colloid distribution
Fluids

Plasma

Alb5%

1000

Interstitial

Intracellular

Expafusin 6% 1000
Poligeline

700

300

Dextran 40

1600

-260

-340

Dextran 70

1300

-130

-170

NaCl 0.9%

200

800

NaCl 1.8%

320

1280

-600

NaCl 0.45%

141

567

292

RL

200

800

D5%

83

333

583

Transfusion trigger

Fluid Choice and Blood for Resuscitation


Platelets
Fresh Frozen Plasma

Red blood
cells

Crystalloid +
colloid
Progressive laboratory assessment of hemoglobin level and
hemostasis
50%
Onset of
hemorrhage

100%

150%

200%

% of total blood volume


replaced
Fluid Choice for Resuscitation in Trauma. Joachim Boldt, International TraumaCare (ITACCS). Vol. 18, No. 1, 2008

Protocols of Massive Transfusion

How much fluids to


give

Surviving Sepsis Campaign: International Guidelines for


Management of Severe Sepsis and Septic Shock: 2012
Special Articles

R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal,
Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E.
Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman,
Flavia R. Machado, Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui
Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup*
Critical Care Medicine 2013; 41(2):580-637

Static parameters target

Microcirculation
target

Dynamic parameters target

ASSESMENT for
LOADING RL 2000
CC:
1. takikardia
2. MAP low

89/45 (60)

130
99
89/45
(60)

14
Laboratorium

100
ASSESMENT AFTER
500 CC colloid:
1. HR hampir normal
2. MAP = 65
3. CVP naik 8

99

110/55 (65)

(8)

14
110/57 (65)
NEXT STEP

37.4

Reliability Of Central Venous Pressure to


Assess Blood Volume in Critically Ill Patients
Low Blood Volume
High CVP

High Blood Volume


Low CVP

1500 simultaneous measurements of blood volume and CVP in


188 ICU patients
Correlation CVP - Blood volume r=0.27, Correlation CVP - Blood volume r 2=0.01
Shippy CR and Shoemaker WC - Crit Care Med 1984

CVP measurements are frequently used for the assessment of cardiac preload and volume status / Criticized
because CVP poorly predicts cardiac preload and volume status

CVP is determined by the interaction of 2 functions


Cardiac function
Return function Which defines the return of blood from the vascular reservoir to the heart

CVP

< 0 mmHg

Low CVP

Low CVP

High CVP

High CVP

Volume

Normal

Hypovolemia

Hypervolemic

Hypervolemic

Normal

Normal

Normal

Very dynamic
heart

Normal

Decreased

Return Function
Cardiac
function

Thus, the CVP by itself has little meaning!


A CVP measurement must be interpreted in the light of a measure of cardiac output, or at least
a surrogate of cardiac output, such as venous oxygen saturation or pulse pressure variations.
Crit Care Med

Assessment of Fluid
Responsiveness by ICV diameter
with ultrasound
IVC diameter index variation is an intermittent
measurement and help assessment of volume
by central venous pressure
In spontaneous breathing patient = IVC
colapsibility index
In controlled ventilation patient = IVC
distensibility index
IVC colapsibility index > 50% = fluid responsive, hypovolumefluid loading
IVC colapsibility index < 50% = fluid unresponsive,
IVC
distensibilityoverload
index > 18-20% = fluid unresponsive,
normovolumenormovolume-overload
IVC distensibility index < 18-20% = fluid responsive,
hipovolume- fluid loading

IVC collapsible index = (IVCd exp IVCd insp)/ IVCd


exp
0% is overloaded, 100% is volume depleted
2.04 - 1.51/2.04 = 25%. (Volume overloaded)
IVC distensibility index = (IVCd ins IVCd exp)/ IVCd insp
0% is volume depleted 100% overload
2.04 - 1.51/2.04 = 25%. (Volume overloaded)

Complications of fluid
resuscitation
Allergic and transfusion reactions
(colloids and blood products)

Hemostasis coagulopathy
(hemodilution)

Tissue edema (lung edema, tissue


compartment)
Acid Base Imbalance
Immunity derangements

Conclusion

Goal-directed fluid resuscitation


morbidity

Optimal intravascular volume


with the right type and right
amount of fluid to avoid hypoor hypervolaemia in order to
prevent adverse outcomes

morbidity

Miller T, Gan TJ. Goal-directed fluid therapy. Clinical Fluid Therapy in the Perioperative Setting,2011

Thank You