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Transcript of Fluid Resuscitation
By: Arlen Brickman MSIV
Assessment of Volume Status
Look at the patient:
Assessment of Volume Status
Try a more invasive approach:
Central venous line
In 1832, Robert Lewins described the effects of the intravenous administration of an alkalinized salt solution in treating patients during the cholera pandemic.
Alexis Hartmann, modified a physiologic salt solution developed in 1885 by Sidney Ringer for rehydration of children with gastroenteritis.
Lactated Ringers Solution
Require 3:1 replacement of volume loss
e.g. estimate 1 L blood loss, require
3 L of crystalloid to replace volume
Hartmann's or Ringer's Lactate
Crystalloids with a chemical composition that approximates extracellular fluid have been termed “balanced” or “physiologic” solutions and are derivatives of the original Hartmann’s and Ringer’s solutions. However, none of the proprietary solutions are either truly balanced or physiologic
“the quantity necessary to be injected will probably depend upon on the quantity of serum lost; the object being to place the patient in nearly his ordinary state"
The observations of Lewins are as relevant today as they were nearly 200 years ago.
In 1941, human albumin was used for the first time in large quantities for resuscitation of patients who were burned during the attack on Pearl Harbor in the same year.
Current Controversies in Fluid Therapy
How much fluid to give
Which fluid to use
Human albumin (4 to 5%) in saline is considered to be the reference colloidal solution. It is produced by the fractionation of blood and is heat- treated to prevent transmission of pathogenic viruses. It is an expensive solution to produce and distribute, and its availability is limited in low- and middle-income countries.
Sodium chloride (saline) is the most commonly used crystalloid solution on a global basis, par- ticularly in the United States. Normal (0.9%) sa- line contains sodium and chloride in equal con- centrations, which makes it isotonic as compared with extracellular fluid.
Dutch physiologist Hartog Hamburger studied red cell lysis in 1882 and 1883, suggested that 0.9% was the concentration of salt in human blood, rather than the actual concentration of 0 0.6%
The limited availability and relative expense of human albumin have prompted the development and increasing use of semisynthetic colloid solutions during the past 40 years.
Globally, HES solutions are the most commonly used semisynthetic colloids, particularly in Europe.
Assessment of Volume Status
How about blood tests?
Arterial blood gases
The Ideal Resuscitation Fluid
Should be one that;
produces a predictable and sustained increase in intravascular volume,
has a chemical composition as close as possible to that of extracellular fluid,
is metabolized and completely excreted without accumulation in tissues,
does not produce adverse metabolic or systemic effects, and is cost-effective in terms of improving patient outcomes.
Currently, there is no such fluid available for clinical use.
Red Blood Cells
Fresh Frozen Plasma
Replacement of lost volume in 1:1 ratio
A matched-cohort observational study compared the rate of major complications in 213 patients who received only 0.9% saline and 714 patients who received only a calcium-free balanced salt solution (PlasmaLyte) for replacement of fluid losses on the day of surgery.
The use of balanced salt solution was associated with a significant decrease in the rate of major complications (odds ratio, 0.79; 95% CI, 0.66 to 0.97; P<0.05), including a lower incidence of postoperative infection, renal-replacement therapy, blood transfusion, and acidosis-associated investigations.
Balanced salt solutions are relatively hypotonic because they have a lower sodium concentration than extracellular fluid.
Because of the instability of bicarbonate-containing solutions in plastic containers, alternative anions, such as lactate, acetate, gluconate, and malate, have been used.
Excessive administration of balanced salt solutions may result in
hyperlactatemia, metabolic alkalosis, and hypotonicity (with compounded sodium lactate) and cardiotoxicity (with acetate).
The addition of calcium in some solutions may generate microthrombi with citrate- containing r red-cell transfusions.
Ringer's saline solution was invented in the early 1880s by Sydney Ringer, a British physician and physiologist. Ringer was studying the beating of an isolated frog heart outside of the body. He hoped to identify the substances in blood that would allow the isolated heart to beat normally for a time.
130 mEq of sodium ion = 130 mmol/L
109 mEq of chloride ion = 109 mmol/L
28 mEq of lactate = 28 mmol/L
4 mEq of potassium ion = 4 mmol/L
3 mEq of calcium ion = 1.5 mmol/L
The lactate is metabolized into bicarbonate by the liver, which can help correct metabolic acidosis.
SAFE study (Saline vs. Albumin Fluid Evaluation)
6997 adults, Critically ill patients in ICU
Randomized to Saline vs. 4% Albumin for fluid resuscitation
No difference in 28 day all cause mortality
No difference in length of ICU stay, mechanical ventilation, RRT, other organ failure
NEJM 2004; 350 (22), 2247- 2256
Crystaloid vs Colloid
Resuscitation with albumin was associated with a significant increase in the rate of death at 2 years among patients with traumatic brain injury (relative risk, 1.63; 95% CI, 1.17 to 2.26; P=0.003).
This outcome has been attributed to increased intracranial pressure, particularly during the first week after injury.
Resuscitation with albumin was associated with a decrease in the adjusted risk of death at 28 days in patients with severe sepsis (odds ratio, 0.71; 95% CI, 0.52 to 0.97; P = 0.03), suggesting a potential, but unsubstantiated, benefit in patients with s severe sepsis
In a single-center, sequential, observational ICU study, use of a chloride-restrictive fluid strategy (using lactated and calcium-free balanced solutions) to replace chloride-rich intravenous fluids (0.9% saline, succinylated gelatin, or 4% albumin) was associated with a significant decrease in the incidence of acute kidney injury and the rate of renal-replacement therapy.
Given the widespread use of saline (>200 million liters per year in the United States alone), these data suggest that a randomized, controlled trial is
Body Fluid Compartments
Total Body Water = 60% body weight
- 70Kg TBW = 42 L
2/3 of TBW is intracellular (ICF)
- 40% of body weight, 70Kg = 28 L
1/3 of TBW is extracellular (ECF)
- 20% of body weight, 70Kg = 14 L
Plasma volume is approx 4% of total body weight, but varies by age, gender, body habitus
Blood Volume (mL/kg)
Premature infant 90
Term infant 80
Slim Male 75
Obese Male 70
Slim Female 65
Obese Female 60
Peri-operative Maintenance Fluids
Potassium replacement can be omitted for short periods of time
Chloride, Mg, Ca, trace minerals and supplementation needed only for chronic IV maintenance
Most commonly Saline, Lactated Ringers, Plasmalyte
4 – 2 – 1 Rule
100 – 50 – 20 Rule for daily fluid requirements
4 mL/kg for 1st 10 kg
2 mL/kg for 2nd 10 kg
1 mL/kg for each additional kg
Maintenance Fluids: Example
60 kg female
1st 10 kg: 4 mL/kg x 10 kg = 40 mL
2nd 10 kg: 2 mL/kg x 10 kg = 20 mL
Remaining: 60 kg – 20 kg = 40 kg
1 mL/kg x 40 kg = 40 mL
Maintenance Rate = 120 mL/hr
Bowel Loss (Bowel Prep, vomiting, diarrhea)
Insensible Fluid Loss
Tissue Edema (surgical manipulation)
Fluid Sequestration (bowel, lung)
Extent of fluid loss or redistribution (the “Third Space”) dependent on type of surgical procedure
Mobilization of Third Space Fluid POD#3
Insensible Fluid Loss
4 – 6 – 8 Rule
Replace with Crystalloid (NS, LR, Plasmalyte)
Minor: 4 mL/kg/hr
Moderate: 6 mL/kg/hr
Major: 8 mL/kg/hr
The strong ion difference of 0.9% saline is zero, with the result that the administration of large volumes of saline results in a
hyperchloremic metabolic acidosis
Adverse effects such as immune and renal dysfunction have been attributed to this phenomenon, although the clinical consequences of these effects is unclear.
Concern about sodium and water overload associated with saline resuscitation has resulted in the concept of “small volume” crystalloid resuscitation with the use of hypertonic saline (3%, 5%, and 7.5%) solutions.
However, the early use of hypertonic saline for resuscitation, particularly in patients with traumatic brain injury, has not improved either short-term or long- term outcomes.
HES solutions are produced by hydroxyethyl substitution of amylopectin obtained from sorghum, maize, or potatoes.
A high degree of substitution on glucose molecules protects against hydrolysis by nonspecific amylases in the blood, thereby prolonging intravascular expansion.
This action increases the potential for HES to
accumulate in reticuloendothelial tissues, such as skin (resulting in pruritus), liver, and kidney.
The use of HES, particularly high-molecular- weight preparations, is associated with
alterations in coagulation — specifically, changes in visco- elastic measurements and fibrinolysis
— although the clinical consequences of these effects in specific patient populations, such as those undergoing surgery or patients with trauma, are undetermined.
HES solutions are widely used in patients undergoing anesthesia for major surgery, particularly as a component of goal-directed perioperative fluid strategies, as a first-line resuscitation fluid in military theaters, and in patients in the ICU.
Because of the potential that such solutions may accumu- late in tissues, the recommended maximal daily dose of HES is 33 to 50 ml per kilogram of body weight per day.