THE CHALLENGES OF THE CHALLENGES OF FLUID THERAPY IN FLUID THERAPY IN

CRITICALLY ILL PATIENTCRITICALLY ILL PATIENT

A.A.El-DawlatlyA.A.El-DawlatlyProfessorProfessor

Dept of AnesthesiaDept of AnesthesiaCollege of MedicineCollege of MedicineKing Saud UniversityKing Saud Universitydawlatly@ksu.edu.sadawlatly@ksu.edu.sa

ObjectivesObjectives

To describe To describe different fluids different fluids componentscomponents

To describe the To describe the challenges of challenges of Fluid therapyFluid therapy

To answer FAQ To answer FAQ about fluids&CIPabout fluids&CIP

FAQFAQ

Crystalloids vs ColloidsCrystalloids vs Colloids

Role of plasma volume Role of plasma volume expander in septic expander in septic shockshock

Why liter limit for colloidsWhy liter limit for colloids

For how long HESFor how long HES

Does HES reduce capillary Does HES reduce capillary leakleak

Renal and liver functionsRenal and liver functions

FLUID LOSSESFLUID LOSSES

TRAUMATRAUMA

BURNSBURNS

PERITONITISPERITONITIS

BLEEDINGBLEEDING

Final Goals of Fluid resuscitationFinal Goals of Fluid resuscitation

--Achievement ofAchievement of normovolemia&hemodynamicnormovolemia&hemodynamic

stabilitystability--Correction of major acid-baseCorrection of major acid-base

disturbancesdisturbances--Compensation of internal fluid fluxesCompensation of internal fluid fluxes

--Maintain an adequate gradientMaintain an adequate gradient between COP&PCWPbetween COP&PCWP

--Improvement of microvascular bloodImprovement of microvascular blood flowflow

--Prevention of cascade system Prevention of cascade system activationactivation

--Normalization of O2 deliveryNormalization of O2 delivery--Prevention of reperfusion cellular Prevention of reperfusion cellular

injuryinjury--Achievement of adequate urine Achievement of adequate urine

outputoutput

Desirable outcome of fluid resuscitationDesirable outcome of fluid resuscitation

- -No peripheral edemaNo peripheral edema

- -No ARDSNo ARDS

Undesirable PMN-EC interactionUndesirable PMN-EC interaction

ActivationActivation

DegranulationDegranulation

Elastase&O2 radicalsElastase&O2 radicals

EC EC damage (lysis & detachment)damage (lysis & detachment)

LeakLeak

Characteristics of different volume Characteristics of different volume substitutessubstitutes

IVVP Cryst<Gel<Dex<HSSIVVP Cryst<Gel<Dex<HSS

Coag Cryst<Alb<Gel=HES<DexCoag Cryst<Alb<Gel=HES<Dex

Anaphyl Cryst<HES=Alb<Dex<GelAnaphyl Cryst<HES=Alb<Dex<Gel

Cost Cryst=Gel<HES<Dex<AlbCost Cryst=Gel<HES<Dex<Alb

Crystalloids in traumaCrystalloids in traumaAdvantagesAdvantages::

Balanced electrolyte Balanced electrolyte solutionssolutions

Buffering capacity (Lactate)Buffering capacity (Lactate)

Easy to administerEasy to administer

No risk of adverse reactionsNo risk of adverse reactions

No disturbance of No disturbance of hemostasishemostasis

Promote diuresisPromote diuresis

InexpensiveInexpensive

Crystalloids contin…Crystalloids contin…DisadvantagesDisadvantages::

Poor plasma volume Poor plasma volume supportsupport

Large quantities Large quantities neededneeded

Risk of HypothermiaRisk of Hypothermia

Reduced plasma COPReduced plasma COP

Risk of edemaRisk of edema

Crystalloid solutionsCrystalloid solutionsNaClNaCl

IsotonicIsotonic 0.9%: 9g/l , Na 154, Cl 0.9%: 9g/l , Na 154, Cl 154154 , ,

Osmolarity:304mosmol/lOsmolarity:304mosmol/l

Disadvantages: Hyperchloremic Disadvantages: Hyperchloremic acidosisacidosis

HCMAHCMA

Diabetic ketoacidosisDiabetic ketoacidosis

Renal tubular acidosisRenal tubular acidosis

Large-volume fluid administrationLarge-volume fluid administration

Exact mechanism of acid-base Exact mechanism of acid-base homeostatsishomeostatsis

-H-H equation-H-H equation

-Stewart approach -Stewart approach

Crystalloids: resuscitation and non-Crystalloids: resuscitation and non-resuscitation fluids.resuscitation fluids.

Saline based are non-physiological: Cl Saline based are non-physiological: Cl level is above plasma, 155 vs 98-level is above plasma, 155 vs 98-102mmol/l, lack electrolytes, lack 102mmol/l, lack electrolytes, lack bicarbonatebicarbonate

Depress myocardiumDepress myocardium

Reduce COReduce CO

Reduce renal, intestinal perfusionReduce renal, intestinal perfusion

CoagulopathyCoagulopathy

HCMA is predictable consequence of HCMA is predictable consequence of saline-based fluid administrationsaline-based fluid administration

Further studies on effect of it in critical Further studies on effect of it in critical ill patients needed ill patients needed

Hypertonic saline:Hypertonic saline: small volume for small volume for resuscitationresuscitation . .

Osmotic effectOsmotic effectInotropic effectInotropic effectDirect vasodilator effectDirect vasodilator effectIncrease MAP, COIncrease MAP, COIncrease renal, mesenteric,splanchnic, Increase renal, mesenteric,splanchnic, coronary blood flowcoronary blood flow..Disadvantages: increase hemorrhage from Disadvantages: increase hemorrhage from open vessels. Hypernatremia. open vessels. Hypernatremia. Hyperchloremia. Metabolic acidosisHyperchloremia. Metabolic acidosis..

CrystalloidsCrystalloidsLactated Ringer'sLactated Ringer's

Composition: Composition: Na 130, cl 109, K 4, ca 3, Na 130, cl 109, K 4, ca 3, Lactate 28, Osmolarity 273mosmol/lLactate 28, Osmolarity 273mosmol/l

--Sydney Ringer 1880Sydney Ringer 1880--Hartmann added Lactate=LRHartmann added Lactate=LR

--Minor advantage over NaClMinor advantage over NaCl--Disadvantages: diluent for blood (CaDisadvantages: diluent for blood (Ca

citratecitrate))Low osmolarity, can lead to high ICPLow osmolarity, can lead to high ICP

CrystalloidsCrystalloidsDextrose 5%Dextrose 5%

Composition: 50g/l, provides 170kcal/lComposition: 50g/l, provides 170kcal/l

DisadvantagesDisadvantages::

--enhance CO2 productionenhance CO2 production

--enhance lactate productionenhance lactate production

--aggravate ischemic brain injuryaggravate ischemic brain injury

ColloidsColloids

AdvantagesAdvantages::

--Good IVVPGood IVVP

--Prolonged plasma volume supportProlonged plasma volume support

--Moderate volume neededModerate volume needed

--minimal risk of tissue edemaminimal risk of tissue edema

--enhances micovascular flowenhances micovascular flow

ColloidsColloids

DisadvantagesDisadvantages::

--Risk of volume overloadRisk of volume overload

--Adverse effect on hemostasisAdverse effect on hemostasis

--Adverse effect on renal functionAdverse effect on renal function

--Anaphylactic reactionAnaphylactic reaction

--ExpensiveExpensive

DextranDextran

Composition: 40/70Composition: 40/70

Inhibit platlet aggregationInhibit platlet aggregation

bleedingbleeding

MRI sagittal view: epid hematoma

T12-T9

MRI Transverse view: epid

hematoma at T12

Medscape 16/09/03

MRI sagittal view: epid hematoma

T12-T9

MRI Transverse view: epid

hematoma at T12

Medscape 16/09/03

GelatinsGelatins

--Derived from hydrolyzed bovine Derived from hydrolyzed bovine collagencollagen

--Metabolized by serum collagenaseMetabolized by serum collagenase--0.5-5hr0.5-5hr

--Histamine release (H1 blockersHistamine release (H1 blockers recommendedrecommended))

--Decreases Von W factor (VWF)Decreases Von W factor (VWF)--Bovine Spongiform EncephalopathyBovine Spongiform Encephalopathy::

1:1,000.0001:1,000.000

AlbuminsAlbumins

--Heat treated preparation of human Heat treated preparation of human serumserum

--5%5%( ( 50g/l50g/l ,) ,)25% (250g/l)25% (250g/l)--Half of infused volume will stayHalf of infused volume will stay

intravascularintravascular --COP=20mmHg=plasmaCOP=20mmHg=plasma

--25%25% , ,COP=70mmHg, it will expand theCOP=70mmHg, it will expand the vascular space by 4-5 times the volumevascular space by 4-5 times the volume infused. (should not be used for volumeinfused. (should not be used for volume

resuscitationresuscitation))

Cochrane studies support mortality Cochrane studies support mortality following albumin infusionfollowing albumin infusion

- -Cardiac decompensation after rapidCardiac decompensation after rapid

infusion of 20-25% albumininfusion of 20-25% albumin

- -Ionized caIonized ca++++- - -Aggravate leak syndrome MOFAggravate leak syndrome MOF

- - -Enhance bleedingEnhance bleeding

- -Imparied Na+&water excretion Imparied Na+&water excretion renalrenal

dysfunctiondysfunction

Hetastarch )Plasmasteril( 6%Hetastarch )Plasmasteril( 6%

Composition: Composition: synthetic colloid, 6% synthetic colloid, 6% preparation in isotonic salinepreparation in isotonic salineMW 240,000 DMW 240,000 DDS 0.7DS 0.7

-AdvantagesAdvantages: low cost, more potent than: low cost, more potent than - 5%5% albumin (COP 30)albumin (COP 30)

DisadvantagesDisadvantages: Hyperamylesemia, allergy: Hyperamylesemia, allergy coagulopathycoagulopathy

Dose: 15-30ml/kg/dayDose: 15-30ml/kg/day

Pentastarch )HES steril( 10%Pentastarch )HES steril( 10%

MW: 200,000 DMW: 200,000 DDS 0.5DS 0.5Low costLow costExtensive clinical use in sepsis, burnsExtensive clinical use in sepsis, burns....

Low permeability indexLow permeability indexGood clinical safetyGood clinical safetyDecreases PMN-EC activationDecreases PMN-EC activationPotential to diminish vascular Potential to diminish vascular permeability and reduces tissue permeability and reduces tissue edemaedema

Tetrastarch )Voluven)Tetrastarch )Voluven)

MW 130,000 DMW 130,000 D

DS 0.4DS 0.4

Used for volume therapy: 50ml/kg/dayUsed for volume therapy: 50ml/kg/day

MW DS Max doseMW DS Max dosePlasmasteril 240,000 0.7 1,500/dayPlasmasteril 240,000 0.7 1,500/day

))HETstarchHETstarch))

Pentastarch 200,000 0.5 2,500/dayPentastarch 200,000 0.5 2,500/day))HESsterilHESsteril))

Tetrastach 130,000 0.4 3,500//dayTetrastach 130,000 0.4 3,500//day))VoluvenVoluven))

Characteristics of colloidsCharacteristics of colloidsProduct name conc% Ooncotic P initial expansion% stay(days) Max dose hemostProduct name conc% Ooncotic P initial expansion% stay(days) Max dose hemost

Albumin 4,5 20 80-100 200-400 0Albumin 4,5 20 80-100 200-400 0

Dext70 Macrod 6 60-70 120 30-40 1.5g/kgDext70 Macrod 6 60-70 120 30-40 1.5g/kg+++ +++

Dext40 Rheom 10 170-190 200 6 1.5g/kgDext40 Rheom 10 170-190 200 6 1.5g/kg+++ +++

Gelatin Gelfusin 3-4 42 70-90 7 0Gelatin Gelfusin 3-4 42 70-90 7 0+-+-

HES450/0.7 Plasmas6 6 24-30 100 120-182 20ml/kgHES450/0.7 Plasmas6 6 24-30 100 120-182 20ml/kg+++ +++

HES200/0.5 Hesteril 6 30-37 100 3-4 33ml/kgHES200/0.5 Hesteril 6 30-37 100 3-4 33ml/kg+ +

HES130/0.4 Voluven 6 36 100-110 50ml/kg 0HES130/0.4 Voluven 6 36 100-110 50ml/kg 0 +- +-

Advantages&Disadvantages of Advantages&Disadvantages of Crystalloids&Colloids in fluid Crystalloids&Colloids in fluid

resuscitationresuscitation Crystalloids ColloidsCrystalloids Colloids

IVVP Poor GoodIVVP Poor Good

Hemod Stability Transient ProlongHemod Stability Transient Prolong

Infusate volume Large ModerateInfusate volume Large Moderate

Plasma COP Reduced MaintainPlasma COP Reduced Maintain

Tissue edema Obvious InsignificTissue edema Obvious Insignific

Anaphylaxis Non-exist low-modAnaphylaxis Non-exist low-mod

Cost Inexpensive ExpensiveCost Inexpensive Expensive

Crystalloids OR ColloidsCrystalloids OR Colloids

ACS protocol for ATLSACS protocol for ATLS: replace each ml : replace each ml of blood loss with 3 ml of crystalloid of blood loss with 3 ml of crystalloid fluid. 3 for 1 rule. Patient responsefluid. 3 for 1 rule. Patient response::

--RapidRapid

--TransientTransient

--Non-responsiveNon-responsive

Blood TransfusionBlood Transfusion))up to 30% of blood volume can be treated with crystalloidsup to 30% of blood volume can be treated with crystalloids))

WhyWhy??

--Improvement of oxygen transportImprovement of oxygen transport

--Restoration of red cell massRestoration of red cell mass

--Correction of bleeding caused by plateletCorrection of bleeding caused by platelet

dysfunctiondysfunction

--Correction of bleeding caused by factorCorrection of bleeding caused by factor

deficienciesdeficiencies

Massive Transfusion )MT)Massive Transfusion )MT)

Transfusion of at least one blood volume Transfusion of at least one blood volume or 10 units of blood in a 24 hr periodor 10 units of blood in a 24 hr period..

Transfusion of 4 or more PRBCs within Transfusion of 4 or more PRBCs within 1hr when ongoing need is foreseeable1hr when ongoing need is foreseeable..

Replacement of 50% of total blood Replacement of 50% of total blood volume within 3hrvolume within 3hr..

Pathophysiology of coagulopathy in Pathophysiology of coagulopathy in MTMT

HemodilutionHemodilution

HypothermiaHypothermia

Blood compotents and alteration of Blood compotents and alteration of hemostasishemostasis

DICDIC

Type Definition Diagnosis LabType Definition Diagnosis LabBiological Biological Hemostatic defect high D-Dimers and Hemostatic defect high D-Dimers and

DD≥500ug/lDD≥500ug/l

without clinical SS major or minor criteria Plat 50-without clinical SS major or minor criteria Plat 50-100,000100,000

of platlet consumptionof platlet consumption

Clinical Clinical Hemostatic defect+He same above+microvasc INR Hemostatic defect+He same above+microvasc INR

1.2-1.51.2-1.5

bleedingbleeding

Complicated Complicated +ischemia +organ failure+ischemia +organ failure“ “

AutotransfusionAutotransfusion

Salvage of shed blood from wounds, body Salvage of shed blood from wounds, body cavities, drains finds use in trauma cavities, drains finds use in trauma patientspatients..

TechniquesTechniques::

--predeposit transfusionpredeposit transfusion

--intraoperative acute normovolemic intraoperative acute normovolemic hemodilutionhemodilution

--intraoperative cell salvageintraoperative cell salvage

Predeposit transfusionPredeposit transfusion::

--blood collection begins 3-5 weeks preopblood collection begins 3-5 weeks preop..

--2-42-4 units storedunits stored

--Eliminates risk of viral transmissionEliminates risk of viral transmission

--Reduces risk of immunological reactionsReduces risk of immunological reactions

--Collection is expensive&time consumingCollection is expensive&time consuming

--Only suitable for elective surgeryOnly suitable for elective surgery

Intraop acute normovolemic Intraop acute normovolemic hemodilutionhemodilution::

--Whole blood removed at start of opWhole blood removed at start of op--1-1.5L can be collected1-1.5L can be collected

--Blood stored in ORBlood stored in OR--Reinfused during or after surgeryReinfused during or after surgery

--Cheaper than predepositCheaper than predepositLittle risk of clerical errorLittle risk of clerical errorSuitable for elective surgerySuitable for elective surgery

Intraop cell salvageIntraop cell salvage::--shed blood is collected from surgical fieldshed blood is collected from surgical field

--heparin addedheparin added--cells washed with saline and concentrated by centrifugationcells washed with saline and concentrated by centrifugation..

--concentrate transfusedconcentrate transfused--large volume could be usedlarge volume could be used

--platlets&clotting factors are consumedplatlets&clotting factors are consumed--suitable for cardiac surgerysuitable for cardiac surgery

--contrindicated in contaminated surgicalcontrindicated in contaminated surgical field&malignancyfield&malignancy..

FFPFFP

Is plasma removed from a unit of whole blood and frozen at or below Is plasma removed from a unit of whole blood and frozen at or below –18C within 8hr of collection–18C within 8hr of collection..

It contains all coagulation factors in normal amounts and is free of It contains all coagulation factors in normal amounts and is free of red cells, leukocytes and platletsred cells, leukocytes and platlets..

It is not a concentrate of clotting factors. One unit is 225ml and must It is not a concentrate of clotting factors. One unit is 225ml and must be ABO compatible, Rh not consideredbe ABO compatible, Rh not considered..

1ml/kg will raise most clotting factors by 1%1ml/kg will raise most clotting factors by 1%..

Should be used within 24hr after thawingShould be used within 24hr after thawing

CryoprecipitateCryoprecipitate

Is low purity concentrate of 3 hemostatic proteins Is low purity concentrate of 3 hemostatic proteins prepared from donated whole bloodprepared from donated whole blood..

A single bag Cryo contains: 100units factor VIII and A single bag Cryo contains: 100units factor VIII and VWF+150-250mg fibrinogen with XIII and VWF+150-250mg fibrinogen with XIII and fibronectinfibronectin..

No compatibilty test requiredNo compatibilty test required

Indication:Indication: hypofibrinogenemia<100mg/dl hypofibrinogenemia<100mg/dl..

Pre-Storage LeukoreductionPre-Storage Leukoreduction

Is the process used to filter white blood cells from Is the process used to filter white blood cells from whole blood before transfusionwhole blood before transfusion..

WBC removed because they provide no benefit to the WBC removed because they provide no benefit to the recipient and can carry bacteria and virusesrecipient and can carry bacteria and viruses..

Problems with leukocytesProblems with leukocytes::--FeverFever

--Alloimmunization:an immune system reaction that Alloimmunization:an immune system reaction that maymay

result in poor transfusion response when the patient isresult in poor transfusion response when the patient is transfused at a later timetransfused at a later time..

Complications of Blood Complications of Blood TransfusionTransfusion

Immune complicationsImmune complications::--hemolytic (acute and delayed)hemolytic (acute and delayed)

--non-hemolytic (febrile, urticaria, anaphylactic, purpura, non-hemolytic (febrile, urticaria, anaphylactic, purpura, immuneimmune

suppressionsuppression))

Non-Immune complicationsNon-Immune complications::--Complications associated with massive blood transfusionComplications associated with massive blood transfusion : :

coagulopathy, citrate toxicity,hypothermia,acid-base balance, coagulopathy, citrate toxicity,hypothermia,acid-base balance, serum Kserum K..

--Infectious complications:hepatitis, AIDS, other viral agentsInfectious complications:hepatitis, AIDS, other viral agents

) ) CMV,EBV,HTLVCMV,EBV,HTLV ,) ,)parasites and bacteriaparasites and bacteria....

THANK YOU FOR YOURTHANK YOU FOR YOUR

PATIENCEPATIENCE