DR: Zohair AlAseri EM/CCM Fluid Therapy in ED & ICU

DR: Zohair AlAseri DR: Zohair AlAseri

EM/CEM/CCCMM

Fluid Therapy in ED & ICUFluid Therapy in ED & ICU

Fluid Therapy in ER Fluid Therapy in ER

ObjectivesObjectives

Understand of The Normal Regulation of Fluid Balance Understand of The Normal Regulation of Fluid Balance Fluid Imbalance In Shock State

Indices of successful resuscitation Indices of successful resuscitation Early Hemodynamic Optimization

Fluid Therapy (Types) & IndicationFluid Therapy (Types) & Indication

Permissive hypotensionPermissive hypotension

Fluid Resuscitation InFluid Resuscitation In Special situation ( burn, MPE, brain injury, electrolyte dist. AAA, etc. ( burn, MPE, brain injury, electrolyte dist. AAA, etc.

Early Hemodynamic Optimization

The unavoidable duration of stay frequently necessitates diagnostic and therapeutic interventions to attain hemodynamic stability that

would otherwise be performed in the ICU.

The ED is becoming an integral part of the chain of survival as it has been shown that the progression or resolution of organ

dysfunction in critical illness is significant during the ED stay

Cellular PoisonsCarbon monoxideMethemoglobinemiaHydrogen sulfideCyanide

disturbutive Hyperdynamic sepsis syndrome (early sepsis)Anaphylactic shockCentral neurogenic shockDrug overdose (dihydropyridines, α1 -antagonists)Adrenal crisis

ObstructivePulmonary embolismCardiac tamponadePneumothoraxValvular dysfunctionAcute thrombosis of prosthetic valveCritical aortic stenosis

CardiogenicArrhythmiaIschemiarupture

Hypovolemia

GE

Bleeding

Regulation of Fluid Regulation of Fluid BalanceBalance

Fluid & Electrolyte Fluid & Electrolyte BalanceBalance

Understanding the pathophysiology of circulatory dysfunction in shock, trauma, and sepsis help to

determine optimum treatment approaches.

Decrease VR

Decrease Tissue Perfusion

Decrease Blood pressure

Decrease cardiac output

Intracellular fluid Loss

Cellular hypoxia

Metabolic Acidosis

Decreased Myocardial Contraction

Microcirculatory Damage

Cellular aggregation

Microcirculatory obstruction

Decreased myocardial function

Decreased Coronary Perfusion

Hemorrhagic Shock

Rapid reduction in blood volume

Baroreceptor activation

VasoconstrictionIncreased

strength of cardiac

contraction

Increased heart rate +

increase in the diastolic BP narrowpulse pressure

Ventricular filling Cardiac output Hemorrhagic Shock

Cellular Dysfunction

Cellular ischemia

Disruption of cellular

metabolism

Inflammatory mediators, and toxic effects of free radicals

Shock State

DEATH DEATH

SHOCK PATHOPHYSIOLOGY

SHOCK PATHOPHYSIOLOGY

Altered Membrane Potential

Altered Ion Distribution (↑ Intracellular Ca2+ /Na2+ )

Cellular Swelling

Cytoskeletal Disorganization

Increased Hypoxanthine

Decreased Adenosine 5′-Triphosphate (ATP)

Decreased Phosphocreatine

Decreased Glutathione Cellular Acidosis

The American College of Critical Care Medicine (ACCM) Sep.2004 update

Compensatory mechanisms

Restore pressure and flow to vital organs.

In early shock

•Damage to cellular membranes•Loss of ion gradients•Leakage of lysosomal enzymes•Proteolysis due to activation of cellular proteases•Reductions in cellular energy stores

Irreversible shock and death

Fail

What is the major component of all fluid What is the major component of all fluid compartments within the body.compartments within the body.

Regulation of Fluid BalanceRegulation of Fluid Balance

Water

Regulation of Fluid Balance

TOTAL BODY FLUID(40) liters;60%TBW

Red cell volume(2 liters)

Plasma volume(3 liters,5 %)

Extracellular(15 liters,20%)

Blood volume (5 liters)

Intracellular(25 liters,40%)

The intracellular and The intracellular and extracellular compartments extracellular compartments

are separated by are separated by water-permeable water-permeable cell membranes.cell membranes.

Is the relative percentage of water the same for every body Is the relative percentage of water the same for every body or changes??or changes??

It changes significantly with age, gender, and adiposity.It changes significantly with age, gender, and adiposity.


Extracellular fluid volume is greater in the young and Extracellular fluid volume is greater in the young and in the male than in the elderly or the femalein the male than in the elderly or the female


The extracellular fluid compartment contains high The extracellular fluid compartment contains high concentrations of sodium, chloride, and bicarbonate. concentrations of sodium, chloride, and bicarbonate.


Plasma and interstitial fluid are rich Plasma and interstitial fluid are rich in proteins, which determine in proteins, which determine plasma colloid osmotic pressure. plasma colloid osmotic pressure.


Permeability to ions and proteins varies Permeability to ions and proteins varies in each organ.in each organ.

Which organ has Which organ has the least the least permeability??permeability??

1.1. BrainBrain2.2. HeartHeart3.3. LungLung4.4. LiverLiver

Which organ has Which organ has the most the most permeability??permeability??BrainBrainHeartHeartLungLungLiverLiver

IC. WATER ECF2/3 intrest. 1/3 blood

25 150 15 0.01 2 6 50

Na K Mg Ca Cl Hco3 Phos

140 4.5 1.2 2.4 100 25 1.2

Fluid & Electrolyte Balance


ECC OsmolarityECC OsmolarityECF VolumeECF Volume

Prevent swelling or Prevent swelling or shrinking of the cellsshrinking of the cells

Maintain BPMaintain BP


The net fluid filtered through a capillary bed is The net fluid filtered through a capillary bed is determined by both the translumenal hydrostatic determined by both the translumenal hydrostatic pressures and oncotic pressures. pressures and oncotic pressures.

THE STARLING EQUATION

Hydrostatic Hydrostatic pressurepressure

Oncotic Oncotic pressurepressure

tending to move tending to move fluid out of the fluid out of the capillariescapillaries

tending to tending to keep fluid keep fluid within the within the capillariescapillaries

THE STARLING EQUATION

Excess fluid filtered is collected through the lymphatic circulation and returned to the Systemic circulation



Q=K[(Pc-Pi)-@(Oc-Oi)]Q=K[(Pc-Pi)-@(Oc-Oi)]

Indices of Successful Resuscitation in ER

17Mm Hg

Oncotic P=25

37mm Hg

VenuleArteriole

Pnet =(37-1)+(0-25)=11

InterstitialHydrostatic P=1 Pnet =(17-1)+(0-25)=-9

Fluid Imbalance In Shock State Cellular Pump Failure In Shock

K Na.KATPASE

Pump failure

lead to cellular death

CL

Na

K

Intracellular

Extracellular

Water

Changes in Sk. Muscle Fluid & Elect. In Shock StateChanges in Sk. Muscle Fluid & Elect. In Shock State

INTRACELL. EXTRACELL.COMPONENT

WATER

Na

K

Fluid Imbalance In Shock State

Control of body water and its composition involvesControl of body water and its composition involves::


(1) Atrial natriuretic peptide

(2) Vasopressin(3) aldosterone (renin,

angiotensin)(4) parathyroid hormone(5) calcitonin

(6) Prostaglandins(7) dopaminergic receptors(8) alpha-adrenergic receptors(9) the thirst mechanism(10) intrinsic renal properties.

The diagnosis and management of shock are among the most common challenges we must deal with.

Shock may be broadly grouped into five pathophysiologic categories: (1) Hypovolemic

(2) Distributive

(3) Cardiac

(4) Obstructive

(6) cytotoxic

Failure of end-organ cellular metabolism is a feature of all five.

Shock Shock

In approximately 50% of septic patients who initially present with hypotension, fluids alone will reverse hypotension and restore hemodynamic stability

Shock Shock

ShockShock

Until restoration of the functional extracellular fluid Until restoration of the functional extracellular fluid volume is completed, normal oxygen and nutrient volume is completed, normal oxygen and nutrient delivery to the cells and removal of waste products from delivery to the cells and removal of waste products from them cannot occur.them cannot occur.

In approximately 50% of septic patients who initially In approximately 50% of septic patients who initially present with hypotension, fluids alone will reverse present with hypotension, fluids alone will reverse hypotension and restore hemodynamic stability hypotension and restore hemodynamic stability

In severe (ED) or long-standing (ICU) shock :In severe (ED) or long-standing (ICU) shock :

The restoration of intravascular volume alone is insufficient The restoration of intravascular volume alone is insufficient for successful resuscitation. for successful resuscitation.


Cellular effects of ischemia. Cellular effects of ischemia.

• Altered Membrane Potential

• Altered Ion Distribution (↑ Intracellular Ca2+ /Na2+ )

• Cellular Swelling

• Cytoskeletal Disorganization

• Increased Hypoxanthine

• Decreased Adenosine 5′-Triphosphate (ATP)

• Decreased Phosphocreatine

• Decreased Glutathione • Cellular Acidosis

A progressive increase in intracellular A progressive increase in intracellular Na Na and and water and extracellular water and extracellular K K occurs with an occurs with an

associated decrease in extracellular water.associated decrease in extracellular water.

ThThis is accounting for the loss of functional accounting for the loss of functional extracellular fluid volume. extracellular fluid volume.


Indices of successful resuscitation Indices of successful resuscitation in ERin ER

• To improve oxygenation and perfusion of body tissues.

Indices of successful resuscitation in ERIndices of successful resuscitation in ER

What is the overall goal of all resuscitation procedures?

• The overall goal of all

resuscitation procedures is to

improve oxygenation and perfusion of body

tissues.

Perfusion

Indices of Successful Resuscitation in ER

End-tidal CO2

Indirect Fick equation

Central Venous Oxygen Saturation

Lactate Clearance

BD

Lactate concentration

Clinical Exam

V/S

Indices of successful resuscitationIndices of successful resuscitation

Improved blood pressure

Diminished tachy. Falling lactate Normalizing pH

Increasing central venous 02 saturation

Urine output > 0.5 mL/kg/h or improving (in children, > 1 mL/kg/h; in infants, > 2 mL/kg/h)LOC

Peripheral perfusion improving, Cardiac output increasing (normal ≥ 3.5 L/min in adults)

Blood Pressure

A normal blood pressure can be sustained despite loss of up to 30% of blood volume.

A decrease in MAP should be regarded as a late finding in hemorrhagic shock

After blood loss of 450 to 630 mL, only 1 in 5 patients demonstrate these findings. The sensitivity increases to 97% (95% CI, 91%-100%) after 630 mL to 1150 mL blood loss.

Postural pulse increment of 30/min or more or the inability of the patient to stand for vital signs because of severe

dizziness

Steven McGee, MD;

JAMA. 1999;281:1022-1029.

Postural V/S

Is This Patient Hypovolemic?

If the patient sits instead of stands up from the supine position, the sensitivity decreases, being 39%and 78%in 2 studies after 1000 mL of hemorrhage postural hypotension (a more than 20-mm Hg decrease in systolic BP) has little additional predictive value.

Its sensitivity for 450 to 630 mL of blood loss is only 9% in those younger than 65 years and 27% in those older than 65 years.

Steven McGee, MD; JAMA. 1999;281:1022-1029.

Is This Patient Hypovolemic?

Postural V/S

Is This Patient Hypovolemic? Steven McGee, MD;

JAMA. 1999;281:1022-1029.

Study Design: Data were collected from all trauma patients, 16 to 49 years old, presenting to university-based trauma center between July

1988 and January 1997.

Moribund patients with a systolic blood pressure < or =50 or heart rate < or = 40 and patients with significant head or spinal cord injuries were excluded. Tachycardia was defined as a

heart rate > or = 90 and hypotension as a systolic blood pressure < 90.

Does tachycardia correlate with hypotension after trauma?Victorino GP, Battistella FD, Wisner DH.J Am Coll Surg. 2003; 196: 679-84

Heart Rate

The correlation between heart rate and hypotension remains unproved.

Hypotension was present in 489 of the 14,325 admitted patients that met the entry criteria.

Of the hypotensive patients, 35% (169) were not tachycardic.

Tachycardia was present in 39% of patients with systolic blood pressure 120 mmHg.

Hypotensive patients with tachycardia had a higher mortality (15%) compared with hypotensive patients who were not tachycardic (2%, P = 0.003).


•Logistic regression analysis revealed tachycardia to be independently associated with hypotension (p = 0.0004)

•The sensitivity and specificity of heart rate for predicting hypotension is poor.


Conclusions:

• Tachycardia is not a reliable sign of hypotension after trauma.

• Although tachycardia was independently associated with hypotension, its sensitivity and specificity limit its usefulness in the initial evaluation of trauma victims.

• Absence of tachycardia should not reassure the clinician about the absence of significant blood loss after trauma.

• Patients who are both hypotensive and tachycardic have an associated increased mortality and warrant careful evaluation.


Central Venous Oxygen SaturationCentral Venous Oxygen Saturation

ScvO2 provides an additional method of monitor ScvO2 provides an additional method of monitor adequacy or resuscitative measures.adequacy or resuscitative measures.

Studies have shown a close correlation between Studies have shown a close correlation between ScvO2 and SvO2 during cardiac CPR.ScvO2 and SvO2 during cardiac CPR.


Because Because OO2 consumption remains relatively constant 2 consumption remains relatively constant during CPR, as does arterial oxygen saturation (SaO2 ) during CPR, as does arterial oxygen saturation (SaO2 ) and hg, changes in ScvO2 reflect changes in oxygen and hg, changes in ScvO2 reflect changes in oxygen delivery by means of changes in CO.delivery by means of changes in CO.

During cardiac arrest and CPR these values range During cardiac arrest and CPR these values range from 25% to 35%, indicating the inadequacy of blood from 25% to 35%, indicating the inadequacy of blood flow produced during CPR.flow produced during CPR.

Failure to achieve a ScvO2 of 40% or greater has a Failure to achieve a ScvO2 of 40% or greater has a negative predictive value for ROSC of almost 100%.negative predictive value for ROSC of almost 100%.


ScvO2 also helps to confirm ROSC rapidly.

ScvO2 monitoring is also useful in the postresuscitation period to help titrate therapy and recognize any sudden

deteriorations in the patient’s clinical condition.


Venous hyperoxia after cardiac arrest. Characterization of a defect in systemic oxygen utilizationEP Rivers

In spite of a lower DO2 than survivors, the OER in nonsurvivors remained lower than expected. Venous hyperoxia is a clinical manifestation of this derangement. Epinephrine dose may have a causal relationship.

additional therapy is required in the majority of critically ill patients to restore adequate systemic

oxygenation after initial resuscitation and hemodynamic stabilization in the ED. Additional therapy to increase ScvO2 and decrease Lact may not produce substantial

responses in SBP, DBP, MAP, HR, and SI.

The measurement of ScvO2 and Lact can be utilized to guide this phase of additional therapy in the ED.

Resuscitation of the critically III in the ED: Responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactateMohamed Y. Rady

Monitoring of central venous oxygen saturation versus mixed venous oxygen saturation in critically ill patients.Martin C Intensive Care Med. 1992;18(2):101-4.

Continuous monitoring of mixed venous (SvO2) and central venous (ScO2) oxygen saturation was compared in 7 critically-ill patients

Better, but still less than ideal, correlations were obtained with changes in SvO2 and ScO2 during periods without (r = 0.70) and with therapeutic interventions (r = 0.77). Although there is a need to develop a simple technique to monitor mixed venous oxygen saturation, the present study indicates that ScO2 monitoring was not reliable in the study patients

Monitoring of central venous oxygen saturation versus mixed venous oxygen saturation in critically ill patients.Martin C

Intensive Care Med. 1992;18(2):101-4.

Mixed and Central Venous O2 Saturations

Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically illKonrad Reinhart

Objective To compare the course of continuously measured mixed and central venous O2 saturations in high-risk patients and to evaluate the impact of various factors that might interfere with reflection spectrophotometry.

Patients 32 critically ill patients with triple-lumen central vein catheters, including 29 patients requiring pulmonary artery catheterization.

Intensive Care Medicine(aug.2004) 30

The average value (bias) for ScvO2 was 7.05±3.98% higher than The average value (bias) for ScvO2 was 7.05±3.98% higher than the SvO2 (precision 7.95%). the SvO2 (precision 7.95%). highest in patients with elevated ICP (mean SO2=10.7±4.0%,highest in patients with elevated ICP (mean SO2=10.7±4.0%, pp<0.001) <0.001) lowest in the postop group (7.25±5.92%,lowest in the postop group (7.25±5.92%, p p<0.001). <0.001). Among sepsis patients the mean SO2 was 7.90±4.27% (Among sepsis patients the mean SO2 was 7.90±4.27% (pp<0.001). <0.001). The accuracy of continuous ScvO2 measurement was not The accuracy of continuous ScvO2 measurement was not impaired by simultaneous administration of various solutions impaired by simultaneous administration of various solutions through the same central venous catheter through the same central venous catheter



Studies carried out in cardiac and shock patients have observed Studies carried out in cardiac and shock patients have observed differences between 5% and 18% differences between 5% and 18%



•This data confirm the findings of others that in critically ill patients with circulatory failure from various causes ScvO2 is generally higher than SvO2 measured in the pulmonary artery. •In healthy individuals ScvO2 is typically slightly lower than SvO2

•This data confirm the findings of others that in critically ill patients with circulatory failure from various causes ScvO2 is generally higher than SvO2 measured in the pulmonary artery. •In healthy individuals ScvO2 is typically slightly lower than SvO2



The data suggest that the presence of a pathologically low ScvO2 very likely indicates an even lower SvO2.

The data suggest that the presence of a pathologically low ScvO2 very likely indicates an even lower SvO2.

Conclusions Conclusions Continuous fiberoptic measurement of Continuous fiberoptic measurement of central vein O2 saturation has potential to be a reliable central vein O2 saturation has potential to be a reliable and convenient tool which could rapidly warn of acute and convenient tool which could rapidly warn of acute

change in the oxygen supply/demand ratio of critically ill change in the oxygen supply/demand ratio of critically ill patients.patients.



The objective of this study was to determine whether in cardiac arrest with pulseless electrical activity (PEA), EtCO2 indicates the mechanism (cause) of arrest

METHODS:Design: A prospective observational study measuring initial EtCO2 and EtCO2 after 1 minute of CPR.

EtCO2 levels were compared between the group of

patients with asphyxial cardiac arrest and the group with

cardiac arrest following MI or pulmonary embolism. Only patients with initial PEA were included in the study.

End-tidal CO2

Does End-tidal CO2 Indicate the Mechanism of Cardiac Arrest with Pulseless Electrical Activity? tefek Grmec

End-tidal CO2

RESULTS: Data from 76 patients A significant difference was found between EtCO2 of patients with asphyxial compared to MI/PE cardiac arrest (initial EtCO2 49.9 ± 31.4 vs. 17.2 ± 8.3 mmHg, respectively [p < 0.05]; EtCO2 after 1 minute of CPR 38.7 ± 20.3 mmHg vs. 18.9 ± 9.2 mmHg, respectively [p < 0.05].

CONCLUSION: EtCO2 in PEA possibly indicates the mechanism of cardiac arrest. In combination with other signs, the level of EtCO2 might influence approach to and treatment of PEA in the out-of-hospital setting.

Does End-tidal CO2 Indicate the Mechanism of Cardiac Arrest with Pulseless Electrical Activity? tefek Grmec

ETCO2

Objectives: Sidestream ETCO2 (SSETCO2) might be a

non-invasive, rapid, and reliable predictor of arterial

PCO2 in non-intubated patients in respiratory distress.

The aim of this study was to verify whether SSETCO2

can accurately predict the arterial PCO2 and to detect

variables that may affect this correlation.

End tidal carbon dioxide as a predictor of the arterial PCO2 in the emergency department setting C Yosefy

Emerg Med J 2004; 21:557-559

Methods: A prospective semi-blind study. The participants were 73 patients (47 men, 26 women) referred to the ED for respiratory distress. Arterial blood gas pressures and SSETCO2 measurements were performed and recorded for all patients.

Results: A significant correlation was found between SSETCO2 and arterial PCO2 (r = 0.792).


Emerg Med J 2004; 21:557-559

Conclusions: There is a good correlation between SSETCO2 and arterial PCO2 in the ED setting. Young age may increase the arterial PCO2/SSETCO2 gradient while raised temperature may decrease this gradient. Further studies are needed to confirm these findings in the normal healthy population.


Emerg Med J 2004; 21:557-559

To test the ability of SLCO2 to detect acute hemorrhage.

Comparison of SLCO2 with arterial base deficit (BD) and

lactate (LAC) in patients with suspected blood loss.

Prospective, observational study of patients with penetrating torso trauma in an urban trauma center.

Baron BJ, Inerrt R, Zehtabchi S, Stavile KL, Scalea TM: Diagnostic utility of sublingual for detecting hemorrhage in pCO2 patients with penetrating trauma.Acad Emerg Med 2002, 9:492

SLCO2 (mm Hg) was measured at triage using a sublingual capnometer

Predictor variables: SLCO2, BD, and LAC.

Outcome variables: Blood loss (BL) was estimated

BL groups were defined as (1) minimal (<1.0 prbc), (2) moderate (1-6 prbc), and (3) severe (>6 prbc).


Results: 87 patients

There was a significant difference (p < 0.001) in SLCO2 between BL groups: (1) 48 ± 7 (n = 57), (2) 55 ± 11 (n = 23), and (3) 71 ± 16 (n = 7).

SLCO2 of nonsurvivors was 79 ± 15 (n = 4). Correlation between SLCO2 and BL was r = 0.56 (p < 0.0001).


No significant (p > 0.05) differences between predictor variables.

SLCO2 (46 mm Hg) was appropriate for triage, with a sensitivity of 90%, which yielded a negative predictive value of 88%.


Conclusions: •SLCO2 correlated with degree of blood loss. •The diagnostic performance of SLCO2 was equivalent to that of BD and LAC. •SLCO2 is noninvasive, fast, and easy to use and may be advantageous in the triage of patients with penetrating trauma.

•To compare sublingual PCO2 (PslCO2) measurements with gastric intramucosal PCO2 (PimCO2) as well as with the traditional indexes of tissue oxygenation in hemodynamically unstable ICU patients. Design: A prospective, validation study.

•Patients: Consecutive patients with severe sepsis, septic shock, or cardiogenic shock requiring pulmonary artery catheterization for hemodynamic management.

•Interventions: During the first 24 h of ICU admission, the PslCO2, PimCO2, and blood lactate concentrations were recorded every 4 to 6 h.

•The PslCO2-PaCO2 and PimCO2-PaCO2 differences were used as indexes of tissue dysoxia.

Results: Seventy-six data sets were obtained on 22 patients. Fifteen patients had severe sepsis/septic shock, and 7 patients did not have sepsis. Conclusion: In this study, sublingual capnometry yielded measurements that correlated well with those of gastric tonometry. PslCO2 may serve as a technically simple and noninvasive clinical measurement of tissue dysoxia in critically ill and injured patients.

Chest. 2001;120:923-927.Sublingual Capnography A Clinical Validation Study Paul E. Marik, MD, FCCP * From Critical Care Medicine, The Mercy Hospital of Pittsburgh, Pittsburgh, PA.

Increase in PetCO2

Increase in cardiac outputAdministration of bicarbonateAddition of CO2 (eg, during laparoscopy)HypoventilationHyperthermia

Decrease in PetCO2

Esophageal intubation Decrease in cardiac output and pulmonary blood flow Cardiac arrest Pulmonary embolism Air embolism Hyperventilation Hypothermia

Meta-analysis of hemodynamic optimization in high-risk patients

Conclusion:

Review of 21 randomized controlled trials with various approaches to treatment revealed statistically significant

mortality reductions, with hemodynamic optimization, when patients with acute critical illness were treated early to achieve optimal goals before the development of organ

failure, when there were control group mortalities of >20% and when therapy produced differences in oxygen delivery between

the control and protocol groups.

Jack W Critical Care Medicine 30 August 2002



Studies have shown that a lactate concentration >4 mmol/L in Studies have shown that a lactate concentration >4 mmol/L in the presence of the systemic inflammatory response syndrome the presence of the systemic inflammatory response syndrome (SIRS) criteria significantly increases intensive care unit (ICU) (SIRS) criteria significantly increases intensive care unit (ICU) admission rates and mortality rate in normotensive patients admission rates and mortality rate in normotensive patients

•Grzybowski M : Systemic inflammatory response syndrome criteria and lactic acidosis in the detection of critical illness among patients presenting to the emergency department . Chest 1996 ; 110 : 145S. •Moore RB The value of SIRS criteria in ED patients with presumed infection in predicting mortality . Acad Emerg Med 2001 ; 8 : 477 •Aduen J The use and clinical importance of a substrate-specific electrode for rapid determination of blood lactate concentrations . JAMA 1994 ; 272 : 1678–1685

Lactate

As a product of anaerobic glycolysis, lactate is an indirect measure of oxygen debt. As tissue oxygen delivery falls below the threshold required for efficient oxidative phosphorylation, cells metabolize glucose into pyruvate and then lactate rather than entering the Krebs cycle.

Lactate

The trend of lactate concentrations is a better indicator than a single value and it is a better prognostic indicator than oxygen-derived variables. It is more sensitive than blood pressure or CO in predicting mortality in a dog model of hemorrhage

BDBD

2 to −5 (mild), −6 to −14 (moderate), and −15 or less (severe).

BD predicted MAP and fluid requirements during resuscitation. In addition, 65% of patients who had a further decrease in BD despite resuscitation had ongoing hemorrhage

The problem is there is no good correlation between lactate and BD and concluded that serum lactate was preferred to more accurately assess tissue perfusion.

J.W. Davis, S.R. Shackford, R.C. Mackersie and D.B. Hoyt, Base deficit as a guide to volume resuscitation. J Trauma 28 (1988), pp. 1464–1467


Early lactate clearance is associated with improved outcome in severe sepsis and septic shock

H. Bryant Nguyen, MD, MS;

Prospective observational study

Critical Care MedicineVolume 32 • Number 8 • August 2004


A positive value denotes a decrease or clearance of A positive value denotes a decrease or clearance of lactate, whereas a negative value denotes an lactate, whereas a negative value denotes an

increase in lactate after 6 hrs of ED intervention.increase in lactate after 6 hrs of ED intervention.

Lactate Clearance Definition.Lactate Clearance Definition.


In severe sepsis patients, those with high lactate In severe sepsis patients, those with high lactate clearance had significantly lower mortality rate than clearance had significantly lower mortality rate than patients with low clearance (patients with low clearance (pp = .03). = .03).




Kaplan-Meier survival analysis between patients with lactate clearance <10 vs. ≥10% at 6 hrs after emergency department presentation.

Early lactate clearance is associated with improved outcome in severe sepsis and septic shockH. Bryant Nguyen, MD, MS;

Early lactate clearanceEarly lactate clearance


Conclusions:

Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance.




To test whether increasing oxygen delivery immediately after cardiac surgery would shorten hospital and intensive

care unit (ICU) stay.

Four hundred three elective cardiac surgical patients enrolled to either the control or the protocol group.

Goals of the protocol group were to maintain SvO(2) >70% and lactate concentration < or =2.0 mmol/L from admission

to the ICU and up to 8 h thereafter.

P. Polonen, E. Ruokonen, M. Hippelainen, M. Poyhonen, and J. TakalaA Prospective, Randomized Study of Goal-Oriented Hemodynamic Therapy in Cardiac Surgical PatientsAnesth. Analg., May 1, 2000; 90(5): 1052 - 1059.

Increasing oxygen delivery to achieve normal SvO(2) values and lactate concentration during the

immediate postoperative period after cardiac surgery can shorten the length of hospital stay

A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients.2000 Polonen P

Targeting a specific threshold of high oxygen delivery is not high oxygen delivery is not recommendedrecommended as therapy of circulatory shock.

Gattinoni L, Brazzi L, Pelosi P, et al: A trial of goal-oriented hemodynamic therapy in critically ill patients. N Engl J Med 1995; 333: 1025–1032

Hayes MA, Timmins AC, Yau EHS, et al: Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 1994; 330: 1717–1722

Target

Mechanical ventilation can decrease the release of Mechanical ventilation can decrease the release of atrial natriuretic hormone and increase the release of atrial natriuretic hormone and increase the release of antidiuretic hormone resulting in retention of sodium antidiuretic hormone resulting in retention of sodium

and fluids.and fluids.

Control of body water and Mechanical ventilation Control of body water and Mechanical ventilation ::

Minimally invasive hemodynamic monitoring Minimally invasive hemodynamic monitoring

Dynamic Measurements of Fluid ResuscitationDynamic Measurements of Fluid Resuscitation in MV in MV

SPV and PP, which are dynamic measurements, have been shown to identify hypotension related to decrease in preload, to distinguish between responders and nonresponders to fluid challenge , and to permit titration of Fluid ressuscitation in various patient populations.

Systolic pressure variation (SPV) after one mechanical breath followed by an end-expiratory pause. Reference line permits the measurement of up and down. Bold Maximal and minimal pulse pressure. AP Airway pressure; SAP systolic arterial pressure

Dynamic Measurements of Fluid Resuscitation in in MVMV

Minimally invasive hemodynamic Minimally invasive hemodynamic monitoring (SPV)monitoring (SPV)

Systolic pressure variation as a guide to fluid therapy in patients with Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension.sepsis-induced hypotension.Tavernier B.(1998). Tavernier B.(1998). AnesthesiologyAnesthesiology

prospective study tested the correlation of the PAOP, the left ventricular end-diastolic area index measured by transesophageal echocardiography, the ASP variation (the difference between maximal and minimal systolic blood pressure values during one mechanical breath), and its delta down (dDown) component (= apneic - minimum systolic blood pressure) with the response of cardiac output to volume expansion during sepsis.

The down threshold value of 5 mm Hg was able to

discriminate responders and nonresponders with a

positive predictive value of 95% and a negative predictive

value of 93%

In sedated patients receiving mechanical ventilation with sepsis-induced hypotension :

Minimally invasive hemodynamic Minimally invasive hemodynamic monitoring (SPV)monitoring (SPV)

Relation between Respiratory Changes in Arterial Pulse Relation between Respiratory Changes in Arterial Pulse Pressure and Fluid Responsiveness in Septic Patients with Pressure and Fluid Responsiveness in Septic Patients with Acute Circulatory FailureAcute Circulatory Failure

40 pt instrumented with indwelling systemic and pulmonary artery catheters were studied before and after VE.

Maximal and minimal values of pulse pressure (Ppmax and Ppmin) and systolic pressure (Psmax and Psmin) were determined over one respiratory cycle

Michard, F (2000) Am J Respir Crit Care Med 162,134-138

Minimally invasive hemodynamic Minimally invasive hemodynamic monitoring monitoring Pulse PressurePulse Pressure

Pp was a more accurate indicator of fluid responsiveness Pp was a more accurate indicator of fluid responsiveness than Ps. than Ps.

They concluded that in mechanically ventilated patients with acute circulatory failure related to sepsis, analysis of Pp is a simple method for predicting and assessing the hemodynamic effects of Fluid Resuscitation in MV in MV and that Pp is a more reliable indicator of fluid responsiveness than Ps.

Minimally invasive hemodynamic Minimally invasive hemodynamic monitoring monitoring Pulse PressurePulse Pressure

Pulse pressure variations to predict fluid responsiveness: influence of tidal volumeDaniel De Backer, Sarah Heenen, Michael Piagnerelli, Marc Koch and Jean-Louis VincentIntensive Care Medicine April 2005 31, Number 4 517 - 523

Objective To evaluate the influence of tidal volume on the capacity of pulse pressure variation ( PP) to predict fluid responsiveness.Design Prospective interventional study.Setting A 31-bed university hospital medico-surgical ICU.Patients and participants Sixty mechanically ventilated critically ill patients requiring fluid challenge, separated according to their tidal volume.

•Intervention Fluid challenge with either 1,000 ml crystalloids or 500 ml colloids.

•Measurements and results Complete hemodynamic measurements including PP were obtained before and after fluid challenge.

•Tidal volume was lower than 7 ml/kg in 26 patients, between 7–8 ml/kg in 9 patients, and greater than 8 ml/kg in 27 patients.

•The CI increased from 2.66 to 3.04 l/min m2 ( P <0.001). It increased by more than 15% in 33 patients (fluid responders).

•PAOP was lower and PP higher in responders than in non-responders.

Fluid responsiveness was better predicted with PP (ROC curve area 0.76±0.06) than with PAWP(0.71±0.07) and right atrial (0.56±0.08) pressures.

Conclusions PP is a reliable predictor of fluid responsiveness in mechanically ventilated patients only when tidal volume is at least 8 ml/kg.

Daniel De Backer, Sarah Heenen, Michael Piagnerelli, Marc Koch and

Jean-Louis Vincent Pulse pressure variations to predict fluid responsiveness: influence of tidal volume Intensive Care Medicine April 2005 31, Number 4 517 - 523

The indirect Fick methods are convenient and The indirect Fick methods are convenient and relatively easy to apply to mechanically relatively easy to apply to mechanically

ventilated patients but may not be accurate ventilated patients but may not be accurate enough for initial diagnostic information in a enough for initial diagnostic information in a

patient with significant lung disease or patient with significant lung disease or multiorgan failuremultiorgan failure


Minimally invasive hemodynamic monitoring for the intensivist: Minimally invasive hemodynamic monitoring for the intensivist: Current and emerging technologyCurrent and emerging technology

[Review Articles][Review Articles]Chaney, John C. MD; Derdak, Stephen DOChaney, John C. MD; Derdak, Stephen DO

Substituting CO2 for oxygen in 1 yields the indirect Fick equation


Vco2 is the clearance of CO2, Cvco2 is the mixed venous content of CO2, and Caco2 is the arterial content of CO2.

Vco2 can be calculated by the difference in CO2 content between expired and inspired gasses. Caco2 can be obtained

from arterial blood gas or estimated from end-tidal CO2

A partial rebreathing technique has been used to eliminate the need to directly measure Cvco2.






First, the difference between Pvco2 and Paco2 is usually only about 6 mm Hg; consequently, small errors in the measurement of either of these values results in a

large change in calculated cardiac output.

Second, the relationships assumed are only valid when the Paco2 is >30 torr when the CO2-hemoglobin

dissociation curve is linear

If the patient hyperventilates and the Paco2 is <30 torr, the relationship is no longer valid.

Minimally invasive hemodynamic monitoring for the intensivist: Current and Minimally invasive hemodynamic monitoring for the intensivist: Current and emerging technologyemerging technology

[Review Articles][Review Articles]


Third, shunted blood is not measured.

Fourth, changes in mechanical ventilator settings that alter dead space or

ventilation/perfusion relationships may produce a calculated alteration in cardiac output when in

fact none has occurred.


[Review Articles]Chaney[Review Articles]Chaney



[Review Articles]Chaney[Review Articles]Chaney



Fluid TherapyFluid Therapy

Fluid Therapy (Types)Fluid Therapy (Types)

SolutionSolution NaNa CLCL KK MgMg CaCa lactatlactatee

otherother PHPH osmosm

D5WD5W Dex Dex 5g/dl5g/dl

55 253253

0.9NS0.9NS 154154 154154 4.24.2 308308

Ring.Ring. 130130 109109 44 33 2.82.8 6.56.5 273273

Alb5%Alb5% 145145 145145 AlbAlb

5g/dl5g/dl

308308

3%n/s3%n/s 513513 513513 55 1,021,0277

Fluid Therapy (Types)Fluid Therapy (Types)CrystalloidsCrystalloids

Crystalloids are fluids that contain water and Crystalloids are fluids that contain water and electrolytes.electrolytes.

Crystalloid solutions are used to both provide Crystalloid solutions are used to both provide maintenance water and electrolytes and maintenance water and electrolytes and expand intravascular fluid. expand intravascular fluid.

distributed in a ratio 1:4 like extracellular fluiddistributed in a ratio 1:4 like extracellular fluid (i.e., about 20% should remain in the (i.e., about 20% should remain in the intravascular space).intravascular space).

Fluid Therapy (Types)Fluid Therapy (Types) RingerRinger Lactate Lactate

lactated Ringer solution have an electrolyte composition lactated Ringer solution have an electrolyte composition similar to extracellular fluid (ECF). similar to extracellular fluid (ECF).

With respect to sodium, they are With respect to sodium, they are hypotonic. hypotonic.

If your patient received ringer lactate, would If your patient received ringer lactate, would this affect the lactate level reading???this affect the lactate level reading???

Fluid Therapy (Types)Fluid Therapy (Types) RingerRinger Lactate Lactate

A buffer is included in place of bicarbonate, which A buffer is included in place of bicarbonate, which hydrates to carbonic acid, with production of carbon hydrates to carbonic acid, with production of carbon dioxide, which diffuses from the solution. dioxide, which diffuses from the solution.

•The lactate content of Ringer’s solution is rapidly metabolized during resuscitation and does not significantly affect the use of arterial lactate concentration as a marker of tissue hypoperfusion

Normal saline, 0.9 percent NaCl, is isotonic and Normal saline, 0.9 percent NaCl, is isotonic and isoosmotic but contains more chloride than ECF. isoosmotic but contains more chloride than ECF.

When used in large volumes, mild hyperchloremia When used in large volumes, mild hyperchloremia (non-anion gap metabolic acidosis) results.(non-anion gap metabolic acidosis) results.

It contains no buffer or other electrolytes.It contains no buffer or other electrolytes.

Fluid Therapy (Types)Fluid Therapy (Types)Normal SalineNormal Saline

Fluid Therapy (Types)Fluid Therapy (Types)N/S vs RLN/S vs RL

It is preferred to lactated Ringer solution (which contains a It is preferred to lactated Ringer solution (which contains a hypotonic concentration of sodium) in hypotonic concentration of sodium) in brain injurybrain injuryhypochloremic metabolic alkalosishypochloremic metabolic alkalosishyponatremiahyponatremia

Compared with 0.9 percent NaCl, these solutions Compared with 0.9 percent NaCl, these solutions provide small quantities of other electrolytes, which are provide small quantities of other electrolytes, which are inadequate to meet daily maintenance requirements.inadequate to meet daily maintenance requirements.

What are the indications of using D5 in What are the indications of using D5 in ED??ED??

Fluid Therapy (Types)Fluid Therapy (Types)Five Percent DextroseFive Percent Dextrose

Five percent dextrose functions as free water.Five percent dextrose functions as free water.

It may be used to correct hypernatremia, but is most It may be used to correct hypernatremia, but is most often used in the prevention of hypoglycemia in often used in the prevention of hypoglycemia in

diabetic patients. diabetic patients.

Fluid Therapy (Types)Fluid Therapy (Types)

COLLOID SOLUTIONSCOLLOID SOLUTIONS

Colloid solutions are generally administered in a Colloid solutions are generally administered in a volume equivalent to the volume of blood lost. volume equivalent to the volume of blood lost. The initial volume of distribution is equivalent to the The initial volume of distribution is equivalent to the plasma volume. plasma volume. The half-life in circulation of albumin is normally 16 The half-life in circulation of albumin is normally 16 hours, but it can be as short as 2 to 3 hours in hours, but it can be as short as 2 to 3 hours in pathophysiologic conditions. pathophysiologic conditions.

Fluid Therapy (Types)Fluid Therapy (Types)Five Percent AlbuminFive Percent Albumin

Five percent albumin have a colloid osmotic Five percent albumin have a colloid osmotic pressure of about 20 mm Hg (i.e., near-pressure of about 20 mm Hg (i.e., near-

normal colloid osmotic pressure). normal colloid osmotic pressure).

Fluid Therapy (Types)Fluid Therapy (Types)Twenty-Five Percent AlbuminTwenty-Five Percent Albumin

A colloid solution of 25 percent, or "salt-poor," A colloid solution of 25 percent, or "salt-poor," albumin contains purified albumin at five times the albumin contains purified albumin at five times the normal concentration.normal concentration.

When administered, it has the potential to expand When administered, it has the potential to expand the plasma volume by up to five times the volume the plasma volume by up to five times the volume provided. provided.

Fluid Therapy (Types)Fluid Therapy (Types)Hydroxyethyl StarchHydroxyethyl Starch & & PentastarchPentastarch

Hydroxyethyl starch (hetastarch) is a synthetic colloid Hydroxyethyl starch (hetastarch) is a synthetic colloid solution in which the molecular weight of at least 80 solution in which the molecular weight of at least 80 percent of the polymers ranges from 10,000 to percent of the polymers ranges from 10,000 to 2,000,000.). 2,000,000.). The pH of hetastarch is about 5.5 and the osmolarity is The pH of hetastarch is about 5.5 and the osmolarity is near 310 mOsm/L. near 310 mOsm/L. The larger molecules are degraded enzymatically by The larger molecules are degraded enzymatically by amylase. amylase. It is stored in the reticuloendothelial system for several It is stored in the reticuloendothelial system for several hours and is believed to be ultimately renally excreted.hours and is believed to be ultimately renally excreted.

It produces dilutional effectsIt produces dilutional effects..

reduces factor VIII:C levels by 50 percent in a dose reduces factor VIII:C levels by 50 percent in a dose of 1 L with prolongation of the partial thromboplastin of 1 L with prolongation of the partial thromboplastin time. time.

Hetastarch can also interfere with clot formation by Hetastarch can also interfere with clot formation by direct movement into the fibrin clot by the hetastarch direct movement into the fibrin clot by the hetastarch molecules. molecules.


Repeated doses can result in accumulation and side Repeated doses can result in accumulation and side effects, which include allergic reactions and bleeding effects, which include allergic reactions and bleeding with higher doses (20 to 25 mL/kg.)with higher doses (20 to 25 mL/kg.)


Crystalloids Versus ColloidsCrystalloids Versus Colloids

Crystalloids or colloids in fluid therapy?? Crystalloids or colloids in fluid therapy??

The hydrostatic and colloid pressure differences The hydrostatic and colloid pressure differences across capillary walls (Starling forces) cause across capillary walls (Starling forces) cause movement of water and dissolved solutes into the movement of water and dissolved solutes into the interstitial spaces. interstitial spaces.

The lungs are moderately permeable relative to other The lungs are moderately permeable relative to other organs and during pathophysiologic processes, organs and during pathophysiologic processes, capillary permeability changes, resulting in increased capillary permeability changes, resulting in increased capillary permeability or leak. capillary permeability or leak.


Animal studies have documented that oncotic Animal studies have documented that oncotic forces play a significant role only when hydrostatic forces play a significant role only when hydrostatic pressure increases.pressure increases.

If the hydrostatic pressure is normal, oncotic If the hydrostatic pressure is normal, oncotic pressure is not particularly important, as illustrated pressure is not particularly important, as illustrated by patients who have liver cirrhosis or nephrotic by patients who have liver cirrhosis or nephrotic syndrome and do not develop pulmonary edema. syndrome and do not develop pulmonary edema.


CrystalloidsCrystalloids

Those who suggest that administering albumin Those who suggest that administering albumin adversely affects patients who have adversely affects patients who have hypoalbuminemia hypothesize that the hypoalbuminemia hypothesize that the exogenous albumin leaking from the exogenous albumin leaking from the intravascular compartment may worsen edema. intravascular compartment may worsen edema.



They suggest that dilution of plasma by balanced They suggest that dilution of plasma by balanced electrolyte solutions decreases the colloid oncotic electrolyte solutions decreases the colloid oncotic pressure and enhances water flux into the pulmonary pressure and enhances water flux into the pulmonary interstitiuminterstitium


"a decrease in plasma protein concentration, even to "a decrease in plasma protein concentration, even to low levels, should not produce pulmonary edema low levels, should not produce pulmonary edema because it would be accompanied by similar because it would be accompanied by similar decreases in perimicrovascular protein concentration decreases in perimicrovascular protein concentration of the pulmonary interstitium."of the pulmonary interstitium."



TThe administration of plasma solutions is associated with an he administration of plasma solutions is associated with an increased flux of albumin into the pulmonary interstitium increased flux of albumin into the pulmonary interstitium compared with that occurring during crystalloid resuscitation. compared with that occurring during crystalloid resuscitation.

This albumin flux is accompanied by an increase of This albumin flux is accompanied by an increase of extravascular lung water (interstitial pulmonary edema). extravascular lung water (interstitial pulmonary edema).



An attempt to increase plasma oncotic pressure An attempt to increase plasma oncotic pressure with colloid solutions in order to prevent with colloid solutions in order to prevent pulmonary edema is not based on sound pulmonary edema is not based on sound physiologic observationsphysiologic observations




Proponents of colloid fluid point out that Proponents of colloid fluid point out that resuscitation with crystalloid solution dilutes the resuscitation with crystalloid solution dilutes the plasma proteins, with a subsequent reduction of plasma proteins, with a subsequent reduction of plasma oncotic pressure resulting in fluid filtration plasma oncotic pressure resulting in fluid filtration from the intravascular to the interstitial compartment from the intravascular to the interstitial compartment and the development of interstitial pulmonary and the development of interstitial pulmonary edema. edema.

ColloidsColloids


Proponents of crystalloid solutions have argued that Proponents of crystalloid solutions have argued that albumin molecules normally enter the pulmonary albumin molecules normally enter the pulmonary interstitial compartment freely and then are cleared via interstitial compartment freely and then are cleared via the lymphatic system returning to the systemic the lymphatic system returning to the systemic circulation. Thus, additional albumin should merely circulation. Thus, additional albumin should merely increase the albumin pool cleared by the lymphatics.increase the albumin pool cleared by the lymphatics.

ColloidsColloids

In this setting, colloids move more easily into the In this setting, colloids move more easily into the interstitium and increase interstitial edema.interstitium and increase interstitial edema.

With leakage of colloid molecules into the interstitial With leakage of colloid molecules into the interstitial space, further swelling of tissues occurs due to the space, further swelling of tissues occurs due to the unfavorable oncotic pressure gradient, and these unfavorable oncotic pressure gradient, and these molecules are removed by the lymphatic system. molecules are removed by the lymphatic system.



Removal of colloids requires longer periods than Removal of colloids requires longer periods than for crystalloids and is a significant problem in burn for crystalloids and is a significant problem in burn and major surgical patients. and major surgical patients.



The additional cost and The additional cost and potential risks of colloids potential risks of colloids

compared with crystalloids is compared with crystalloids is another argument against another argument against

colloid administration.colloid administration.


Human albumin administration in critically ill patients: systematic Human albumin administration in critically ill patients: systematic review of randomised controlled trials review of randomised controlled trials

Cochrane Injuries Group Cochrane Injuries Group Albumin ReviewersAlbumin Reviewers

BMJ - 25-JUL-1998; 317(7153): 235-40


Systematic review of randomised controlled trials comparing Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fractionadministration of albumin or plasma protein fraction with no with no administration or with administration of crystalloid solutionadministration or with administration of crystalloid solution in in critically ill patients with hypovolaemia, burns, orcritically ill patients with hypovolaemia, burns, or

hypoalbuminaemia. hypoalbuminaemia.

Human albumin administration in critically ill Human albumin administration in critically ill patients: systematic review of randomised patients: systematic review of randomised

controlled trials controlled trials

Cochrane Injuries Group Albumin ReviewersCochrane Injuries Group Albumin Reviewers

BMJ - 25-JUL-1998; 317(7153): 235-40

SubjectsSubjects: : 30 randomised controlled trials including 30 randomised controlled trials including 1419 randomised patients.1419 randomised patients.

Conclusions: There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia.

Human albumin administration in critically ill patients: systematic review of randomised controlled trials


BMJ - 25-JUL-1998; 317(7153): 235-40

Strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials.


BMJ - 25-JUL-1998; 317(7153): 235-40

Human albumin administration in critically ill patients: systematic review of randomised controlled trials

Patient Survival after Human Albumin Administration Patient Survival after Human Albumin Administration

A Meta-Analysis of Randomized, Controlled A Meta-Analysis of Randomized, Controlled Trials Trials

Mahlon M. Wilkes, PhD and Roberta J. Navickis, PhD

Study SelectionStudy Selection55 55 Randomized, controlled trials comparing Randomized, controlled trials comparing albumin therapy with crystalloid therapy, no albumin therapy with crystalloid therapy, no albumin, or lower doses of albumin.albumin, or lower doses of albumin.

Conclusions: Overall, no effect of albumin on mortality was detected; any such effect may therefore be small. This finding supports the safety of albumin

Patient Survival after Human Albumin Patient Survival after Human Albumin Administration Administration

Mahlon M. Wilkes, PhD and Roberta J. Navickis, PhD


Crystalloids vs. colloids in fluid Crystalloids vs. colloids in fluid resuscitation: a systematic review.resuscitation: a systematic review.

Choi PT, Yip G, Quinonez LG, Cook DJ.Choi PT, Yip G, Quinonez LG, Cook DJ.

CONCLUSIONS: Overall, there is no apparent difference in pulmonary edema, mortality, or length of stay between isotonic crystalloid and colloid resuscitation.

Crystalloid resuscitation is associated with a lower mortality in trauma patients..

Choi PT, Yip G, Quinonez LG, Cook DJ.

Crystalloids vs. colloids in fluid resuscitation: a Crystalloids vs. colloids in fluid resuscitation: a systematic review.systematic review.

Colloid solutions for fluid resuscitation.Colloid solutions for fluid resuscitation.20022002

Bunn F, Alderson P, Hawkins V.Bunn F, Alderson P, Hawkins V.

OBJECTIVES: To compare the effects of different colloid solutions in patients thought to need volume replacement.

ColloidColloid

Fifty-seven trials met the inclusion criteria, with a total of 3659 participants

REVIEWER'S CONCLUSIONS: From this review, there is no evidence that one colloid solution is more effective or safe than any other.

Colloid solutions for fluid resuscitation.2002

ColloidColloid

Bunn F, Alderson P, Hawkins V.Bunn F, Alderson P, Hawkins V.

A Systematic Review of the Comparative A Systematic Review of the Comparative Safety of Colloids Safety of Colloids

Michael E. Barron, MD; Michael E. Barron, MD; MahlonMahlon M. Wilkes, PhD; Roberta J. M. Wilkes, PhD; Roberta J. NavickisNavickis, PhD, PhD

Arch Surg. 2004;139:552-563

Conclusions Significant safety differences exist among colloids. Therefore, conclusions regarding the clinical usefulness of colloids as a fluid class should be formed with caution.

ColloidColloid

A Comparison of A Comparison of Albumin and Saline Albumin and Saline

for Fluid for Fluid Resuscitation in the Resuscitation in the Intensive Care UnitIntensive Care Unit

The SAFE StudyThe SAFE Study


A A multicenter, randomized, double-blind trial multicenter, randomized, double-blind trial toto compare the effect of fluid resuscitation compare the effect of fluid resuscitation

with albumin or salinewith albumin or saline on mortality in a on mortality in a heterogeneous population of patients in theheterogeneous population of patients in the

ICU.ICU.



ICUs of 16 academic tertiary hospitalsICUs of 16 academic tertiary hospitals in Australia and New in Australia and New Zealand between November 2001 and JuneZealand between November 2001 and June 20032003


patients who had been admittedpatients who had been admitted to the ICU to the ICU were were randomly randomly assigned to receive either 4 percent albumin or normal assigned to receive either 4 percent albumin or normal salinesaline for intravascular-fluid resuscitation during the next for intravascular-fluid resuscitation during the next 28 days 28 days

The primary outcome measure was death from any cause during the 28-day period after randomization.


Patients are eligible for inclusion in the study if ALL the Patients are eligible for inclusion in the study if ALL the following requirements are met: following requirements are met:

1.1. Fluid resuscitation is required for intravascular fluid Fluid resuscitation is required for intravascular fluid depletion that is in addition to intravenous fluid that is depletion that is in addition to intravenous fluid that is required for nutrition or to replace ongoing insensible required for nutrition or to replace ongoing insensible losses, urinary losses, ongoing losses from other sites losses, urinary losses, ongoing losses from other sites (eg. fistula losses from the gastrointestinal tract, urinary (eg. fistula losses from the gastrointestinal tract, urinary losses from diabetes insipidus, cerebral salt wasting losses from diabetes insipidus, cerebral salt wasting syndrome or the polyuric phase of acute renal failure) syndrome or the polyuric phase of acute renal failure) or to restore normonatraemia. or to restore normonatraemia.

2.2. The ICU clinician considers that both 4% human The ICU clinician considers that both 4% human albumin solution and 0.9% sodium chloride are equally albumin solution and 0.9% sodium chloride are equally appropriate for the patient and that no specific appropriate for the patient and that no specific indication or contraindication for either exists. indication or contraindication for either exists.

The SAFE Study

3. 3. The requirement for fluid resuscitation must be The requirement for fluid resuscitation must be supported by AT LEAST ONE of the following clinical supported by AT LEAST ONE of the following clinical signs: signs:

a.a. Heart rate > 90 beats per minute Heart rate > 90 beats per minute

b. b. (SBP) < 100mmHg or (MAP) < 75mmHg or a 40mmHg (SBP) < 100mmHg or (MAP) < 75mmHg or a 40mmHg decrease in SBP or MAP from the baseline recording. decrease in SBP or MAP from the baseline recording. Or requirement for inotropes or vasopressors to Or requirement for inotropes or vasopressors to maintain maintain bp bp at those levels. at those levels.

Patients are eligible for inclusion in the study if ALL Patients are eligible for inclusion in the study if ALL the following requirements are met:the following requirements are met:

The SAFE Study

c. c. Central venous pressure < 10mmHg Central venous pressure < 10mmHg d. d. Pawp < 12 mmHg Pawp < 12 mmHg e. e. Respiratory variation in systolic or mean arterial blood Respiratory variation in systolic or mean arterial blood

pressure of >5 mmHg pressure of >5 mmHg f. f. Capillary refill time > one second Capillary refill time > one second g. g. Urine output < 0.5 ml/kg for one hour Urine output < 0.5 ml/kg for one hour

Patients are eligible for inclusion in the study if ALL Patients are eligible for inclusion in the study if ALL the following requirements are met:the following requirements are met:

The SAFE Study

Patients are excluded from the study if ONE OR Patients are excluded from the study if ONE OR MORE of the following are presentMORE of the following are present

1.1. A known previous adverse reaction to human albumin A known previous adverse reaction to human albumin solution solution

2.2. Any known religious objection to the administration of Any known religious objection to the administration of human blood products (for example if patient is a human blood products (for example if patient is a Jehovah’s Witness) Jehovah’s Witness)

3.3. A requirement for the patient to receive A requirement for the patient to receive plasmapheresis during this ICU admission plasmapheresis during this ICU admission

4.4. An admission to the ICU following cardiac surgery. An admission to the ICU following cardiac surgery. 5.5. An admission to the ICU for the treatment of body An admission to the ICU for the treatment of body

burn. burn. 6.6. An admission to the ICU following liver transplantation An admission to the ICU following liver transplantation

surgery. surgery.

7. 7. Age less than 18 years. Age less than 18 years. 8. 8. Brain death or brain death that is likely to be diagnosed within in the Brain death or brain death that is likely to be diagnosed within in the

next 24 hours of fluid resuscitation being required. next 24 hours of fluid resuscitation being required. 9. 9. If the patient is moribund and expected to die within the next 24 If the patient is moribund and expected to die within the next 24

hours - defined as having a treatment limitation order in place that hours - defined as having a treatment limitation order in place that exceedsexceeds a ‘not for resuscitation’ order and that indicates the a ‘not for resuscitation’ order and that indicates the treating clinicians are not committed to full supportive care. treating clinicians are not committed to full supportive care.

10. 10. If the patient has previously been enrolled and has completed If the patient has previously been enrolled and has completed follow up in the SAFE study. follow up in the SAFE study.

11. 11. If the patient has previously received fluid resuscitation that was If the patient has previously received fluid resuscitation that was prescribed within the study ICU and during this current ICU prescribed within the study ICU and during this current ICU admission. admission.

12. 12. If the patient has been transferred to the study ICU from a non-If the patient has been transferred to the study ICU from a non-study ICU and received a fluid bolus or fluid resuscitation for the study ICU and received a fluid bolus or fluid resuscitation for the treatment of volume depletion in that non-study ICU.treatment of volume depletion in that non-study ICU.

Patients are excluded from the study if ONE OR Patients are excluded from the study if ONE OR MORE of the following are presentMORE of the following are present

3500 to receive saline;3500 to receive saline;

729 deaths729 deaths in the saline in the saline groupgroup(21.1)(21.1)

3497 were assigned to receive albumin

There were 726 deaths in the albumin group (20.9)

(relative risk of death, 0.99; 95 percent confidence interval, 0.91 to 1.09; P=0.87).

The SAFE StudyThe SAFE Study (Results)(Results)

TThe two groups had similar baseline characteristics.he two groups had similar baseline characteristics.

New single-organ and multiple-organ failure wasNew single-organ and multiple-organ failure was similar similar in the two groups (P=0.85). in the two groups (P=0.85).

There were no significantThere were no significant differences between the differences between the groups in the mean (±SD) numbersgroups in the mean (±SD) numbers of days spent in of days spent in the ICU (6.5±6.6 in the albumin groupthe ICU (6.5±6.6 in the albumin group and 6.2±6.2 in and 6.2±6.2 in the saline group, P=0.44), the saline group, P=0.44),

days spentdays spent in the hospital , days of mechanical in the hospital , days of mechanical ventilationventilation, , or days of renal-replacementor days of renal-replacement therapytherapy

The SAFE StudyThe SAFE Study (Results)(Results)

Was the assignment of patients to treatments randomized?Was the assignment of patients to treatments randomized?

YesYes

Randomization was carried out centrally with the use of a minimization algorithm, and the service was accessed on the Internet through a secure Web site.

Web page showing successful randomisationWeb page showing successful randomisation

The SAFE Study

Was Was followupfollowup complete? complete?

NoNo

At the completionAt the completion of the trial, information on vital status 28 of the trial, information on vital status 28 days after randomizationdays after randomization was unavailable for 67 was unavailable for 67 patients (1.0 percent), including 26patients (1.0 percent), including 26 in the albumin group in the albumin group and 41 in the saline group. and 41 in the saline group.

In 56 of theseIn 56 of these 67 cases, vital status was missing because 67 cases, vital status was missing because the patient or histhe patient or his or her legal surrogate had withheld or or her legal surrogate had withheld or withdrawn consent.withdrawn consent.

Were patients analyzed in the groups to which they were raWere patients analyzed in the groups to which they were randomized?ndomized?

Three patients mistakenly underwent Three patients mistakenly underwent randomization twice withinrandomization twice within 28 days28 days..

MMore than 97 percent of patients received their ore than 97 percent of patients received their assigned fluidassigned fluid

Were patients, health workers, and study personnel "blind" Were patients, health workers, and study personnel "blind" to treatment?to treatment?

YESYES

Study fluids were suppliedStudy fluids were supplied in identical 500-ml bottlesin identical 500-ml bottles..BBlinding was ensured throughlinding was ensured through the use of specially designed the use of specially designed

masking cartons and speciallymasking cartons and specially designed and designed and manufactured administration setsmanufactured administration sets

Study fluid in masking cartonStudy fluid in masking carton.. Study giving set.

The SAFE Study

Were the groups similar at the start of the trial?Were the groups similar at the start of the trial?

YES & NOYES & NO

At baseline, the only statistically significant difference between the two groups was a higher mean (±SD) CVP in the albumin group (9.0±4.7 mm Hg, vs. 8.6±4.6 mm Hg in the saline group; P=0.03).

Can’t tellCan’t tell

Resuscitation fluids in addition to the study fluid were administered to 309 patients in the albumin group (8.8 percent) and 375 in the saline group (10.7 percent).

On average, during the first four days, patients assigned to receive albumin received 71.0 ml more packed red cells than those assigned to receive saline

Aside from the experimental intervention, were the grouAside from the experimental intervention, were the groups treated equally?ps treated equally?

(relative risk of death, 0.99; 95 percent confidence interval, 0.91 to 1.09; P=0.87).

How large was the treatment effect?How large was the treatment effect?

How precise was the estimate of the treatment eHow precise was the estimate of the treatment effect?ffect?

For the albumin groupFor the albumin group as compared with the saline as compared with the saline group, the absolute difference ingroup, the absolute difference in mortality was –0.2 mortality was –0.2 percent (95 percent confidence interval,percent (95 percent confidence interval, –2.1 to +1.8 –2.1 to +1.8

percent). percent).

Can the results be applied to my patient care?Can the results be applied to my patient care?

Were all clinically important outcomes considered?Were all clinically important outcomes considered?

YesYes

The primary outcome measure was death from any cause within 28 days after randomization.

Secondary outcome measures wereSecondary outcome measures were the survival time the survival time during the first 28 days, during the first 28 days,

NNew organ failuresew organ failures

TThe duration of mechanical ventilation, he duration of mechanical ventilation,

TThe duration of renal-replacementhe duration of renal-replacement therapy, therapy,

TThe duration of the ICU and hospital stay.he duration of the ICU and hospital stay.

Were all clinically important outcomes considered?Were all clinically important outcomes considered?

Conclusions In patients in the ICU, use of either 4 Conclusions In patients in the ICU, use of either 4 percentpercent albumin or normal saline for fluid resuscitation albumin or normal saline for fluid resuscitation

results inresults in similar outcomes at 28 days.similar outcomes at 28 days.


During the 28-day During the 28-day , , relative risk of death amongrelative risk of death among patients patients with trauma in the albumin group as compared with suchwith trauma in the albumin group as compared with such

patients in the saline group was 1.36; patients in the saline group was 1.36;

TThe corresponding relativehe corresponding relative risk of death among patients risk of death among patients without trauma was 0.96 (P=0.04without trauma was 0.96 (P=0.04 by the test for a by the test for a common relative risk). common relative risk).

Subgroup AnalysesSubgroup Analyses, , traumatrauma


???? ???? due to the greater number ofdue to the greater number of patients with trauma patients with trauma and an associated brain injury who diedand an associated brain injury who died after random after random assignment to albumin as opposed to saline: assignment to albumin as opposed to saline:

5959 of 241 such patients in the albumin group died (24.5 of 241 such patients in the albumin group died (24.5 percent),percent), as compared with 38 of 251 such patients in as compared with 38 of 251 such patients in the saline groupthe saline group (15.1 percent) (relative risk, 1.62; 95 (15.1 percent) (relative risk, 1.62; 95 percent confidence interval,percent confidence interval, 1.12 to 2.34; P=0.009)1.12 to 2.34; P=0.009)

Subgroup Analyses trauma Subgroup Analyses trauma


Among all the patients who had trauma (596 in the Among all the patients who had trauma (596 in the albumin groupalbumin group and 590 in the saline group), there were 81 and 590 in the saline group), there were 81 (13.6(13.6%%) deaths) deaths in the albumin group and 59(10.0in the albumin group and 59(10.0%%) in the ) in the

saline groupsaline group

(relative risk, 1.36; 95 percent confidence interval, 0.99 to(relative risk, 1.36; 95 percent confidence interval, 0.99 to

1.86; P=0.06) 1.86; P=0.06)



TThe relativehe relative risk of death 0.87, asrisk of death 0.87, as compared with a compared with a corresponding relative risk of 1.05 among patientscorresponding relative risk of 1.05 among patients

without severe sepsis (P=0.06 by the test for a without severe sepsis (P=0.06 by the test for a common relativecommon relative risk). risk).

Of the 603 Of the 603 in in albuminalbumin group group , 185 (30.7 percent) , 185 (30.7 percent) dieddied..

Of Of 615615 patients with severe sepsis who had been patients with severe sepsis who had been assigned to receiveassigned to receive saline, 217 (35.3 percent) died saline, 217 (35.3 percent) died (relative risk, 0.87; 95 percent(relative risk, 0.87; 95 percent confidence interval, confidence interval, 0.74 to 1.02; P=0.09)0.74 to 1.02; P=0.09)

Subgroup Analyses severe sepsis Subgroup Analyses severe sepsis


Among patients who had trauma Among patients who had trauma withoutwithout brain injury, there was no brain injury, there was no difference between the groups indifference between the groups in

terms of mortalityterms of mortality


In a subgroupIn a subgroup analysis of patients with theanalysis of patients with the ARSD ARSD,, the the RR RR of death among those assigned to receive albuminof death among those assigned to receive albumin as as opposed to saline was 0.93; the corresponding relative opposed to saline was 0.93; the corresponding relative riskrisk among patients without this syndrome was 1.00 among patients without this syndrome was 1.00 (P=0.74 by the(P=0.74 by the test for a common relative risk).test for a common relative risk).

Subgroup AnalysesSubgroup Analyses ARDS ARDS

Subgroup AnalysesSubgroup Analyses guide guide Subgroup AnalysesSubgroup Analyses guide guide

The The magnitude of the differencemagnitude of the difference.. TThe statistical significance of the differencehe statistical significance of the difference.. whether whether the hypothesis preceded or followed the analysisthe hypothesis preceded or followed the analysis..WWhether the subgroup analysis was one of a small hether the subgroup analysis was one of a small number of hypotheses testednumber of hypotheses tested.. WWhether the difference was suggested by hether the difference was suggested by comparisons within or between studiescomparisons within or between studies.. TThe consistency of the difference, and the existence he consistency of the difference, and the existence of indirect evidence that supports the difference. of indirect evidence that supports the difference.

Therefore,Therefore, cautious interpretation of these cautious interpretation of these findings is warranted.findings is warranted.

Subgroup Analyses guide

Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury.Martin GS

Thirty-seven mechanically-ventilated patients with acute lung injury and serum total protein </=5.0 g/dL

Five-day protocolized regimen of 25 g of human serum albumin every 8 hrs with continuous infusion furosemide, or dual placebo, targeted to diuresis, weight loss, and serum total protein

CONCLUSIONS:

Albumin and furosemide therapy improves fluid balance, oxygenation, and hemodynamics in hypoproteinemic patients with acute lung injury.

Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury.2002 Martin GS

HHypoalbuminemiaypoalbuminemia & Lung inj. & Lung inj.

A meta-analysis of cohort studies in controlled A meta-analysis of cohort studies in controlled trials of hypoalbuminemia in acute illness trials of hypoalbuminemia in acute illness reviewed by Dr. Vincent reviewed by Dr. Vincent

concluded that there is no evidence that hypoalbuminemia can be protective

There is no prospective, randomized, controlled study has documented the need to correct hypoalbuminemia.

Diuretic and Colloid Replacement Therapy Diuretic and Colloid Replacement Therapy in Acute Lung Injuryin Acute Lung Injury

(Humphrey. (Humphrey. Chest.Chest. 1999;97:1176) 1999;97:1176)

In one observational study, patients whose wedge In one observational study, patients whose wedge pressures were reduced by more than 25% had a pressures were reduced by more than 25% had a mortality rate of approximately 20% compared mortality rate of approximately 20% compared with a 70% mortality rate among those in whom with a 70% mortality rate among those in whom the wedge pressures could not be reduced. the wedge pressures could not be reduced.

Dr. Bernard's group examined the role of Dr. Bernard's group examined the role of plasma albumin and total protein plasma albumin and total protein concentrations in adult respiratory distress concentrations in adult respiratory distress syndrome (ARDS) by evaluating data from the syndrome (ARDS) by evaluating data from the Ibuprofen in Human Sepsis Trial. Ibuprofen in Human Sepsis Trial.

(Bernard. (Bernard. N Engl J Med.N Engl J Med. 1998;336:912; 1998;336:912; Mangialardi. Mangialardi. Am J Respir Crit Care Med.Am J Respir Crit Care Med. 1997;155:A504) 1997;155:A504)


HHypoalbuminemiaypoalbuminemia & Lung inj & Lung inj


The Patient With Cerebral EdemaThe Patient With Cerebral Edema Fluid Therapy (Types) Fluid Therapy (Types)

The normal brain capillary bed is essentially The normal brain capillary bed is essentially impermeable to sodium, mannitol, and protein, impermeable to sodium, mannitol, and protein, although water crosses freely. although water crosses freely.

The damaged capillary bed becomes excessively The damaged capillary bed becomes excessively permeable, with conductivity being greatest for the permeable, with conductivity being greatest for the smallest molecules, but less for colloids. smallest molecules, but less for colloids.

The vessel wall is permeable to both water (H2O) and small ions, but not to proteins (P), in the brain. (B) The blood–brain barrier is permeable only to water.

The Patient With Cerebral EdemaThe Patient With Cerebral Edema Fluid Therapy (Types) Fluid Therapy (Types)

Isotonic crystalloids or colloids do not cause edema Isotonic crystalloids or colloids do not cause edema in normal brainin normal brain..

HHyponatremia is often due to hypovolemia with yponatremia is often due to hypovolemia with inappropriate sodium loss and subsequent water inappropriate sodium loss and subsequent water retention. retention.

This should be treated with intravascular volume This should be treated with intravascular volume expansion with isotonic or hypertonic sodium chloride. expansion with isotonic or hypertonic sodium chloride.

Hypovolemia must be carefully avoided. Hypovolemia must be carefully avoided.

The Patient With Cerebral Edema The Patient With Cerebral Edema Fluid Therapy (Types)Fluid Therapy (Types)

The Patient With Cerebral EdemaThe Patient With Cerebral Edema Fluid Therapy (Types)Fluid Therapy (Types)

Fluid management of patients with cerebral Fluid management of patients with cerebral edema is directed at maintaining edema is directed at maintaining CPPCPP,, avoiding elevations of avoiding elevations of cerebral venous cerebral venous

pressure and pressure and HTNHTN, preventing large changes , preventing large changes in in plasma osmolalityplasma osmolality (particularly depression (particularly depression

of plasma osmolality),of plasma osmolality), and avoiding and avoiding hyperglycemia.hyperglycemia.

Because the blood-brain barrier enhances the influence of brain water on changes in serum sodium, hypotonic solutions, including lactated Ringer’s solution, are more likely to increase brain water content than 0.9% saline or colloids.

Traumatic Brain Injury Traumatic Brain Injury

Individual patient cohort analysis of the efficacy of hypertonic Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and saline/dextran in patients with traumatic brain injury and

hypotension.hypotension.

Wade CE, Grady JJ, Kramer GC, Younes RN, Gehlsen K, Holcroft JW. J TraumaJ Trauma 1997;42(5 Suppl):S61-5. 1997;42(5 Suppl):S61-5.

Cohort analysis from six previous PRCTs

Brain Injury and HypotensionBrain Injury and Hypotension

Fluid Therapy (Types) Fluid Therapy (Types) ..

CONCLUSIONS: Patients who have traumatic brain CONCLUSIONS: Patients who have traumatic brain injuries in the presence of hypotension and receive injuries in the presence of hypotension and receive HSD are about twice as likely to survive as those HSD are about twice as likely to survive as those

who receive standard of care.who receive standard of care.




Fluid Therapy (Types) Fluid Therapy (Types)


Hetrogeneous trials, which were not all designed to assess head injured patients

Long term outcome not assessed

Study weaknesses




Fluid Therapy (Types) Fluid Therapy (Types)


Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial

34 patients with severe head injuries and undergoing ICP monitoring. 1.6% NaCl (HS) vs Ringer's lactate (RL) to treat "episodes of haemodynamic instability" during initial resuscitation and for 5 days.

Brain Injury and HypotensionBrain Injury and HypotensionFluid Therapy (Types) Fluid Therapy (Types)

Shackford SR, Bourguignon PR, Wald SL et al.. J Trauma 1998;44(1):50-8.

Number of interventions to control elevated ICP

Glasgow Outcome Score at discharge

Outcomes

No significant difference between groups.

Results




CPP not addressed

HS group had more severe injuries

Small numbers: a power study indicated the need for 320 patients but only 34 were enrolled

Study weaknesses




Prehospital Hypertonic Saline Resuscitation of Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Traumatic Patients With Hypotension and Severe Traumatic

Brain Injury Brain Injury A Randomized Controlled TrialA Randomized Controlled Trial

Interventions Interventions Patients were randomly Patients were randomly assigned to receiveassigned to receive a rapid intravenous a rapid intravenous infusion of either 250 mL of 7.5% salineinfusion of either 250 mL of 7.5% saline

(n = 114) or 250 mL of Ringer's lactate (n = 114) or 250 mL of Ringer's lactate solution (n = 115; controls)solution (n = 115; controls)

..

JAMA.JAMA. 2004;291:1350-1357. 2004;291:1350-1357. D. James Cooper


Main Outcome Measure Main Outcome Measure Neurological Neurological function at 6 months,function at 6 months, measured by the measured by the extended Glasgow Outcome Score (GOSE).extended Glasgow Outcome Score (GOSE).

Conclusion Conclusion Both Both hadhad almost identical almost identical neurological function 6 months after injuryneurological function 6 months after injury

as patients who received conventional fluid.as patients who received conventional fluid.

Prehospital Hypertonic Saline Resuscitation of Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Patients With Hypotension and Severe


JAMA.JAMA. 2004;291:1350-1357 2004;291:1350-1357 D. James Cooper


There is insufficient evidence at present to justify the use of hypertonic saline as resuscitation fluid in

patients with severe head injury.



•Clinical studies have not shown any benefit from the use of Colloid for resuscitation from trauma. •crystalloid resuscitation has been associated with a lower mortality rate in trauma patients.

In the ATLS guidelines RL is recommended as part of the emergency resuscitation of the trauma patient, proceeding to blood products as required.

The American College of Surgeons Classes of Acute Hemorrhages specify four classes of acute hemorrhage using a blood loss ranging from up to 750 mL to > 2,000 mL.

Fluid replacement should be performed with crystalloids exclusively (3:1 rule) - there is no place for infusing (synthetic) colloids in their recommendations.

Fluid Replacement In Trauma Patient

7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport.

To evaluate the use of hypertonic saline/dextran solutions in the prehospital resuscitation of severely injured patients

Fluid Replacement In Trauma Patient Hypertonic versus isotonicHypertonic versus isotonic

Vassar MJ - Arch Surg - 01-SEP-1991; 126(9): 1065-72

250 mL of either 7.5% sodium chloride/dextran 70 (HSD) (n = 83) or lactated Ringer's solution (n = 83),

followed by conventional isotonic fluids

Trauma patients with systolic blood pressures less than or equal to 100 mm Hg,




The rate of survival to hospital discharge for the patients with severe head injuries was 32% vs 16% for the lactated Ringer's solution group.

The rate of survival to hospital discharge was 64% vs 59% for patients in the lactated Ringer's solution group.



..Fluid Replacement In Trauma Patient Hypertonic versus isotonicHypertonic versus isotonic

A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride. The effect of

added dextran 70.

To evaluate the use of 250 mL of a 7.5% sodium chloride solution, both with and without added dextran 70, for the prehospital resuscitation

Vassar MJ - Arch Surg - 01-SEP-1993; 128(9(


(1) lactated Ringer's; (2) 7.5% sodium chloride (hypertonic saline); (3) 7.5% sodium chloride combined with 6% dextran 70; and (4) 7.5% sodium chloride combined with 12% dextran 70

A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride. The effect of added dextran 70.

Survival in the hypertonic saline solution group, however, was significantly higher than other g.

Vassar MJ - Arch Surg - 01-SEP-1993; 128(9(


Hypertonic versus isotonic crystalloid for fluid Hypertonic versus isotonic crystalloid for fluid resuscitation in critically ill patients (Cochrane resuscitation in critically ill patients (Cochrane

Review)Review)

Objectives: To determine whether hypertonic Objectives: To determine whether hypertonic crystalloid decreases mortality in patients with crystalloid decreases mortality in patients with hypovolaemia with and without head injuries.hypovolaemia with and without head injuries.


Bunn F, Roberts I, Tasker R, Akpa EBunn F, Roberts I, Tasker R, Akpa EThe Cochrane Library, The Cochrane Library, Issue 3, 2004.Issue 3, 2004.

Selection criteriaSelection criteria: Randomised trials comparing : Randomised trials comparing hypertonic to isotonic crystalloid in patients with hypertonic to isotonic crystalloid in patients with trauma, burns or undergoing surgery.trauma, burns or undergoing surgery.

Reviewers' conclusions: This review does not give us enough data to be able to say whether hypertonic crystalloid is better than isotonic crystalloid for the resuscitation of patients with trauma, burns, or those undergoing surgery


Bunn F, Roberts I, Tasker R, Akpa EBunn F, Roberts I, Tasker R, Akpa EThe Cochrane Library, The Cochrane Library, Issue 3, 2004.Issue 3, 2004.

•Is a therapeutical option for victims of penetrating injuries,provided fast evacuation to definite (surgical) intervention.

Permissive hypotension by means of fluid re-

striction is not recommended in case of blunt

trauma.

Permissive hypotension in severe traumaPermissive hypotension in severe trauma

· Decreased cerebral perfusion causes agitation followed by altered mental status.

· Myocardial ischemia occurs in individuals with underlying coronary artery disease.

Uncompensated shock causes end organs hypoperfusion :



· Hypoventilation and hypoxia occurs in individuals with underlying pulmonary disease.

· Selective vasoconstriction of the kidneys, skin, gut, and muscles causes lactic acidosis.

· Irreversible damage to vital organs leads to death within hours to days.

Uncompensated shock causes end organs hypoperfusion :

When hemorrhage is uncontrolled, aggressive fluid resuscitation increases arterial pressure and bleeding rate, thereby shortening the time before cardiac arrest. This occurs for several interrelated reasons:


Elevated systemic pressure dislodges or prevents the formation of a protective thrombus once intraluminal driving pressure exceeds tamponading pressure.

Hemodilution lowers blood viscosity, decreasing resistance to flow around an incomplete thrombus.

Hemodilution causes progressive anemia and washout of coagulation factors


The recommendation has, therefore, been made to limit fluids to main-tain a MAP ≤ 50 until bleeding has been surgically controlled, then proceed to full resuscitation.


• The problems limiting widespread acceptance of this concept are:

• the need for prompt definitive intervention to minimize the oxygen debt;

• delays in surgery, e.g. in rural area may be better with ‘normal’ resuscitation


• this approach is inappropriate for patients who also have head injury.

• The biggest problem is that this study was performed in penetrating

injuries. Patients with blunt trauma (the majority) are not so likely to

have definitive surgical interventions


• contraindicated inpatients with traumatic brain injury (TBI),

even in case of penetrating trauma, or inspinal cord injury due to worse neurological outcome.



Elderly patients or those with preexisting

compromised cardiovascular function will

probably not benefit from the concept due

to fast exhaustion of physiologic compensa-

tory mechanisms.

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.

AU - Bickell WH N Engl J Med 1994 Oct

Prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre-hospital systolic blood pressure of < or = 90 mm Hg.


RESULTS. 70 percent survived and were discharged from the hospital, as compared with 62 % who received immediate fluid

resuscitation (P = 0.04).

Hospitalization was shorter in the delayed-resuscitation group.

CONCLUSIONS. For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative

intervention improves the outcome.

Hypotensive resuscitation during TraumaHypotensive resuscitation during Trauma

AU - Bickell WH N Engl J Med 1994 Oct

Commentary: Interestingly, the BP in the OR was the same in both groups even though by

that point both groups had received significantly different volumes of resuscitation physiologic mechanisms kicking in in the delayed group?

Lack of standardized protocol for fluid administration in prehospital setting: what were the paramedics titrating fluids to?

Did not report final diagnoses in both groups – were they similar? Pt assignment not random alternate day assignment. Longer intraoperative period delay in the delayed resuscitation group

does this indicate greater need for initial intraop resuscitation in the delayed resuscitation gp?

Need for large RTC’s to confirm these findings.

In response to letters to the editor questioning the severity of injuries:

Posthoc analysis excluding all minor injuries by analyzing only data from pts with ISS >25 showed survival rate of 48% vs. 61% (p=0.02) favoring the delayed resuscitation group confirming that baseline differences in severity of injury is unlikely to account for the difference in outcome.

In response to letters to the editor(Bickell et al. NEJM, 1995)

Hypotensive resuscitation during active hemorrhage Hypotensive resuscitation during active hemorrhage

METHODS: Patients presenting in hemorrhagic shock were randomized to one of two fluid resuscitation protocols: target

SBP > 100 mm Hg (conventional) or target SBP of 70 mm Hg (low).

Impact on in-hospital mortality.

Hypothesis fluid resuscitation titrated to a lower than normal SBP during the period of active hemorrhage would improve survival in trauma patients presenting to the hospital in hemorrhagic shock.

Dutton RP; Mackenzie CF; Scalea TMSO - J Trauma 2002 Jun;52(6):1141-6.

RESULTS: 110 patients were enrolled over 20 months, 55 in each group.

Overall survival was 92.7%, with four deaths in each group.

CONCLUSION: Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality in this study.

Hypotensive resuscitation during active hemorrhage Hypotensive resuscitation during active hemorrhage

Impact on in-hospital mortality.

Dutton RP; Mackenzie CF; Scalea TMSO - J Trauma 2002 Jun;52(6):1141-6.

Hypotensive resuscitation during active hemorrhage Hypotensive resuscitation during active hemorrhage Dutton RP; Mackenzie CF; Scalea TMSO - J Trauma 2002 Jun;52(6):1141-6.

Commentary: Did not reach goal of hypotensive resusc – the

hypotensive gp was normotensive on arrival to trauma center this alone could explain lack of positive result.

Small study, limited power. Analgesics & sedatives given to “hypertensive pts”. How much fluids in prehospital? How much fluids in the

trauma center? Lower mortality than in the Houston trial: does

hypotensive resusc only make a difference in sick pts? Treating physicians NOT BLINDED. Lower mortality may require larger studies in future to

detect significant differences in survival.

Hypotensive resuscitation during active hemorrhage Hypotensive resuscitation during active hemorrhage Dutton RP; Mackenzie CF; Scalea TMSO - J Trauma 2002 Jun;52(6):1141-6.

RedistributionRedistribution Conditions Conditions

Third-space losses, are due primarily to tissue edema Third-space losses, are due primarily to tissue edema and transcellular fluid displacement.and transcellular fluid displacement.

Functionally, this fluid is not available to the vascular Functionally, this fluid is not available to the vascular space.space.

The composition of third-space losses is The composition of third-space losses is equivalent to the ECF volume electrolyte equivalent to the ECF volume electrolyte concentration plus a smaller amount of concentration plus a smaller amount of protein. protein.

Therefore, balanced salt solution is the most Therefore, balanced salt solution is the most appropriate replacement fluid. appropriate replacement fluid.

RedistributionRedistribution Conditions Conditions

The Patient With Liver FailureThe Patient With Liver Failure

Hypoalbuminemia Hypoalbuminemia Low COP favors loss of fluid from the vascular space Low COP favors loss of fluid from the vascular space into the interstitial space, producing intravascular into the interstitial space, producing intravascular hypovolemia. hypovolemia.

The goals in these patients are to avoid increasing The goals in these patients are to avoid increasing interstitial fluid overload, maintain normal potassium interstitial fluid overload, maintain normal potassium concentration, and maintain intravascular volume.concentration, and maintain intravascular volume.

Restore intravascular COP by infusion of 25 percent Restore intravascular COP by infusion of 25 percent albumin when possible. albumin when possible.


If the patient is acutely hypovolemic, 5 percent albumin If the patient is acutely hypovolemic, 5 percent albumin solutions should be preferred to crystalloid, which will solutions should be preferred to crystalloid, which will tend to further expand the already overexpanded ECF tend to further expand the already overexpanded ECF volume (i.e., produce more edema and ascites). volume (i.e., produce more edema and ascites).


If the patient is acutely hypovolemic, 5 percent If the patient is acutely hypovolemic, 5 percent albumin solutions should be preferred to albumin solutions should be preferred to

crystalloid, which will tend to further expand the crystalloid, which will tend to further expand the already overexpanded ECF volume (i.e., produce already overexpanded ECF volume (i.e., produce

more edema and ascites). more edema and ascites).

Patient With Liver FailurePatient With Liver Failure

Adequate volume replacement decreases the morbidity and mortality associated with severe burn injury.

The goal of initial fluid resuscitation is to restore and maintain vital organ perfusion.

Initial Fluid Resuscitation in Burn Pt.Initial Fluid Resuscitation in Burn Pt.

A delay in starting fluid resuscitation is associated with greater than predicted fluid requirements.


In adults, IV fluid resuscitation is usually necessary in second- or third-degree burns involving greater than 20% TBSA.

In pediatric patients, fluid resuscitation should be initiated in all infants with burns of 10% or greater TBSA and in older children with burns greater than 15% or greater TBSA.


Urine output is a measure of renal perfusion and can help assess fluid balance. In adults, a urine output of 0.5-1.0 mL/kg/h should be maintained

Lactated Ringer's solution is the most commonly used fluid for burn resuscitation.


The Parkland formula is most commonly The Parkland formula is most commonly

4 cc/kg/TBSA burn (second and third degree) of 4 cc/kg/TBSA burn (second and third degree) of lactated Ringer's solution over the first 24 hours.lactated Ringer's solution over the first 24 hours.

half over the first eight hours post burn, and half half over the first eight hours post burn, and half over the next 16 hours. over the next 16 hours.

Initial Fluid Resuscitation in Burn Pt.

Half of the resuscitative volume is given in the Half of the resuscitative volume is given in the first eight hours post burn to adjust for edema first eight hours post burn to adjust for edema formation and plasma fluid loss.formation and plasma fluid loss.

The volume of fluid given to a burn patient is The volume of fluid given to a burn patient is based on the time elapsed since the burn.based on the time elapsed since the burn.


Patients with high-voltage electrical injuries frequently require more resuscitation fluid than that predicted based on the extent of cutaneous injury.


Hypertonic saline has been evaluated whether it limits burn edema.

Although fluid requirements have been decreased, studies have shown mixed results.

Benefits have yet to be clearly realized, and the optimal amount of these solutions required is unclear.


Colloid-containing solutions are no more effective than crystalloids

Initial Fluid Resuscitation in Burn Pt.

Increased vascular permeability during anaphylaxis Increased vascular permeability during anaphylaxis can result in a transfer of 50% of the intravascular fluid can result in a transfer of 50% of the intravascular fluid into the extravascular space within 10 minutes. into the extravascular space within 10 minutes.

This shift in effective blood volume activates the renin-This shift in effective blood volume activates the renin-angiotensin-aldosterone system and causes angiotensin-aldosterone system and causes compensatory catecholamine releasecompensatory catecholamine release

Fluid Resuscitation In Fluid Resuscitation In AnaphylaxisAnaphylaxis

Volume expansion is important as part of the resuscitation with epinephrine to treat acute hypotension.

Initially, 2 to 4 L of RL ,NS or colloid

Fluid Resuscitation In Fluid Resuscitation In AnaphylaxisAnaphylaxis

Fluid Resuscitation In Neurogenic shock Fluid Resuscitation In Neurogenic shock

Neurogenic shock is produced by loss of peripheral vasomotor tone as a result of spinal cord injury. Blood becomes pooled in the periphery, venous return is decreased, and cardiac output falls.

All patients who have sustained spinal trauma should be assumed to have hypovolemic shock from associated injuries until proved otherwise.

Effective circulating blood volume decreases dramatically because of venous pooling.

Decreased sympathetic outflow may be manifested by bradycardia or hypotension



Atropine, though short-acting, may rapidly reverse hypotension associated with bradycardia. Placement of a temporary cardiac pacemaker may be required for severe bradycardia.

Fluid resuscitation is usually necessary and typically begins with several liters of balanced salt solution.


Following recovery from spinal shock, reflex hypertension, sweating, pilomotor erection, or, rarely, bradycardia or cardiac arrest (autonomic dysreflexia)

may occur.

This is usually precipitated by painful stimuli such as bladder catheterization, respiratory suctioning, or

colorectal manipulation. Hypertensive crises, which can be life-threatening, should be treated .

Cardiogenic ShockCardiogenic Shock

Although cardiogenic shock may occur in patients with whole body fluid overload, they may be effectively hypovolemic.

If PCWP is less than 10-12 mm Hg, fluid should be administered in an attempt to increase filling pressures.

Cardiac output should be measured after each change of 2-3 mm Hg in PCWP. Filling pressures near 20 mm Hg may be required before cardiac output increases.

Frank-Starling curve with relationship between Frank-Starling curve with relationship between ventricular preload and ventricular stroke volumeventricular preload and ventricular stroke volume

After volume expansion the same magnitude of change in preload recruit less SV, because the plateau of the curve is reached which characterize a condition of preload independency

As a consequence, when the plateau is reached, As a consequence, when the plateau is reached, vigorous fluid resuscitation carries out the risk of vigorous fluid resuscitation carries out the risk of generating volume overload and pulmonary edema generating volume overload and pulmonary edema and/or right-ventricular dysfunction. and/or right-ventricular dysfunction.

Frank-Starling curve with relationship between Frank-Starling curve with relationship between ventricular preload and ventricular stroke volumeventricular preload and ventricular stroke volume

Cardiogenic ShockCardiogenic Shock

MPEMPE

Hemodynamic effects of fluid loading in acute massive pulmonary embolism.Mercat A

Thirteen patients free of previous cardiopulmonary disease with angiographically proven AMPE , with acute circulatory failure defined by a cardiac

Infusion of 500 mL of dextran 40 over 20 mins

Crit Care Med. 1999 Mar;27(3):540-4

MPEMPE

CONCLUSIONS: These results suggest that fluid loading can improve hemodynamic status in patients with acute circulatory failure caused by AMPE

Hemodynamic effects of fluid loading in acute massive pulmonary embolism.Mercat A

Crit Care Med. 1999 Mar;27(3):540-4

MPEMPE

Excessive fluid may be counterproductive in massive PE and has been reported to worsen

hypotension.

MPEMPE

Since right ventricular pressure is already elevated, volume administration further raises pressure that compromises coronary diastolic filling and left ventricular function.

MPEMPE

Overdistension of the right ventricle causes a shift of the septum towards the left ventricle. This limits left ventricular filling and subsequent

cardiac output.

Therefore, cautious, judicious administration of fluids is recommended.

MPEMPE

Fluid Resuscitation Fluid Resuscitation Pulmonary contusionPulmonary contusion

Bruised lung like any other bruised tissue becomes moreBruised lung like any other bruised tissue becomes moreoedematous with time, i.e. pulmonary function will oedematous with time, i.e. pulmonary function will

deteriorate over 48 h and IPPV may become necessary.deteriorate over 48 h and IPPV may become necessary.

Avoid over hydration’ is good advice but the choice of fluid Avoid over hydration’ is good advice but the choice of fluid and the end points of fluid therapy are difficult and and the end points of fluid therapy are difficult and controversial.controversial.

Volume expansion is used often in critically ill patients to improve hemodynamics.

However, volume expansion may be ineffective or even induce deleterious effects (increasing extravascular lung water)

Ruptured AAA in the Unstable PatientRuptured AAA in the Unstable Patient


• Preoperative hypotension is strongly correlated with risk of death in these patients

Some argue that preoperative hypotension slows bloods loss and allows clot

formation.

Giving the patient a large volume of crystalloid can promote a dilutional

coagulopathy as well.


Prolonged hypotension in these elderly patients can contribute to end organ problems, such as renal failure and cardiac ischemia.

Indeed, most patients die in the early postoperative stage from MI or respiratory or renal failure, which may represent complications of inadequate organ perfusion.


No studies on varying resuscitation strategies in these patients have been published.

There is no blood pressure “number” to aim. Adequate blood pressure should be maintained to preserve mental status and prevent cardiac

ischemia.

Blood products should be used early in the resuscitation efforts in order to reduce dilutional

coagulopathy.


Fluid deficits (Toxin-Induced))

(1) vomiting or diarrhea

(2) injure tissue with resultant third spacing (caustic agents)

(3) increase urination, sweating, or

respiratory rate

Salicylate Poisoning Salicylate Poisoning

For shock, perfusion and vascular volume should be established with 5% dextrose in 0.9% saline, then the treatment can proceed with correction of dehydration and alkalinization.

Salicylates enhance insulin secretion from pancreatic islet cells and thus can cause hypoglycemia, but they also decrease peripheral glucose utilization, which can cause hyperglycemia

Hypoglycemia often occurs, particularly in children. Even in the normoglycemic state, the cerebrospinal fluid glucose level has been shown to be reduced.

Patients with altered mental status should receive a bolus of 50 per cent dextrose even if normoglycemic

Salicylate PoisoningSalicylate Poisoning

Using isotonic sodium chloride solution, stabilize Using isotonic sodium chloride solution, stabilize hypovolemic patients who have unstable vital signs hypovolemic patients who have unstable vital signs before correcting free water deficits because hypotonic before correcting free water deficits because hypotonic fluids quickly leave the intravascular space and do not fluids quickly leave the intravascular space and do not help to correct hemodynamics. help to correct hemodynamics.

Once stabilization has occurred, free water deficits can Once stabilization has occurred, free water deficits can be replaced either orally or intravenously. be replaced either orally or intravenously.

Treatment of hypernatremiaTreatment of hypernatremia


WATER DEFICIT = CBW x (NA/ 140)-1

For patients in whom hypernatremia is induced by water loss.

The total body water is normally about 60 and 50 percent of lean body weight in men and women, respectively


This formula estimates the amount of positive water balance required to return the plasma sodium concentration to 140 meq/L.

Insensible losses and some part of urine and gastrointestinal losses must be added to the calculation


In patients with hypernatremia that has developed over a In patients with hypernatremia that has developed over a period of hours (e.g., those with accidental sodium period of hours (e.g., those with accidental sodium loading) rapid correction improves the prognosis without loading) rapid correction improves the prognosis without increasing the risk of cerebral edema, because increasing the risk of cerebral edema, because accumulated electrolytes are rapidly extruded from brain accumulated electrolytes are rapidly extruded from brain cells. In such patients, reducing the serum sodium cells. In such patients, reducing the serum sodium concentration by 1 mmol per liter per hour is appropriate.concentration by 1 mmol per liter per hour is appropriate.

Adrogué and Madias 342 (20): 1493, Table 2 May 18, 2000


The more hypotonic the infusate, the lower the infusion rate required.

Because the risk of cerebral edema increases with the volume of the infusate, the volume should be restricted to that required to correct hypertonicity


RATE OF CORRECTIONRATE OF CORRECTION — —

Overly rapid correction is potentially dangerous in hypernatremia

Hypernatremia initially causes fluid movement out of the brain and cerebral contraction that is primarily

responsible for the associated symptoms.

Within one to three days, however, brain volume is largely restored due both to water movement from the cerebrospinal fluid into the brain (thereby increasing

the interstitial volume) and to the uptake of solutes by the cells (thereby pulling water into the cells and

restoring the cell volume) .



Water lossH. osmola.

Accumulation of electrolyteH osmolality

Norm brainNormalosmolality

Cerebral edema

Accumulation of organic osmolesH.osm.

Rapid adaptation

Water

Slow adaptation

Immediate effect of hypertonic state

Proper therapy

Slow correction

Improper therapy

Rapidly lowering the plasma sodium concentration once Rapidly lowering the plasma sodium concentration once this adaptation has occurred causes osmotic water this adaptation has occurred causes osmotic water movement into the brain, increasing brain size above movement into the brain, increasing brain size above normal. normal. This sequence of an adverse response to therapy has This sequence of an adverse response to therapy has been primarily described in children in whom the been primarily described in children in whom the hypernatremia was corrected at a rate exceeding 0.7 hypernatremia was corrected at a rate exceeding 0.7 meq/L per h. meq/L per h. In comparison, no neurologic sequelae were induced if In comparison, no neurologic sequelae were induced if the plasma sodium concentration were lowered at 0.5 the plasma sodium concentration were lowered at 0.5 meq/L per h meq/L per h


This fluid is usually administered intravenously as dextrose in water; if the patient is able to drink, oral fluid

resuscitation is an alternative.

Sodium and/or potassium can be added to the intravenous fluid as necessary.


The addition of solutes decreases the amount of free water that is being given.

For example, one-quarter isotonic saline is infused, then only three-quarters of the solution is free water. As a

result, 160 mL must be given to provide 120 mL of free water. If potassium is also added, then even less free

water is present and a further adjustment to the rate must be made .


•The Adrogue and Madias formula

•The "1" in the denominator represents the extra liter of infusate added to TBW.


Change in serum Na per litre = Infusate Na – Serum Na / (weight in Kg x 0.6) +1


Q If the Na in 60 Kg female pt is 150 how much D5W you will give?

D5W - Change =

= 0-150/(60*0.6)+1 = - 3.4mmol

That mean for each l of d5 you give there w’ll be 3.4 drop in serum Na.

& because you want the change to be 1 mmol/h so the rate is 10 mmol/10h, 10/3.4 give you the amount in L of D5 you should give over 10 hs With 1.5 liters added to compensate for average obligatory water losses over the 24-hour period


(infusate Na –seruum Na) / tbw+1

If D5W is chosen to avoid fluid overload, an infusion rate of 250 mL/h results in a

correction just over 1 mEq/h.

(Note: This assumes the patient has no other losses during this time. Intrinsic losses make

the correction slower [more conservative] than calculated.)


HyponatremiaHyponatremia

Symptomatic 70 kg pt with new onset of Symptomatic 70 kg pt with new onset of hyponatremia (Na of 120mmol/l) how much fluid you hyponatremia (Na of 120mmol/l) how much fluid you want to give him?want to give him?

How fast ?How fast ?

Symptoms of severe hyponatremia include nausea, headache, lethargy, coma and respiratory arrest.


It is usual to correct only half the sodium deficit (NaD): (hence the deficit/2)

NaD = (Desired Sodium - Patients Sodium /2)

If the patient’s weight is 70kg, and the serum sodium is 120, then the desired change is 10 mEq/L

Total body deficit of sodium is the sodium deficit x total body water (TBW)

NaD x (weight in Kg x 0.6) = Total deficit (TD)

Using the formula: 10 x (70 x 0.6) = 420 mEq.


calculate the rate of replacement

Most physicians replace the deficit at no more than 0.5mEq per hour.

Rate of Replacement (RoR) in hours = NaD/ 0.5


Replace the sodium deficit with the fluid of your choice

TD / [Na Fluid/ml] / RoR = per hour fluid replacement

If we are using 3% saline :(420/0.513) / 20 = 41ml/hour

That is, after 20 hours, assuming no other fluids are given, the patient's serum sodium will rise to 130mEq/L.

If 0.9% saline is given:(420/0.13) / 20 = 160 ml/hour

N Engl J Med 2000; 342:1581-1589, May 25, 2000. Review Articles

Treatment of severe euvolemic hyponatremia. (From Thurman J, Halterman R, Berl T: Therapy of dysnatremic disorders. In Brady H, Wilcox C: Therapy in Nephrology and Hypertension, 2nd ed.

Philadelphia, Saunders, 2003.)

A Randomized, Controlled Trial of Albumin versus Saline for the Treatment of Intradialytic Hypotension

Greg A. Knoll*, Jenny A. Grabowski, Geoffrey F. Dervin and Keith O’Rourke

Conclusion: 5% albumin is no more effective than N/S for the treatment of IDH in chronic hemodialysis patients. Normal saline should be used as the initial fluid for the treatment of IDH.

A randomized, double-blind, crossover trial was performed in 72 chronic hemodialysis patients to determine whether 5% albumin was more effective

than normal saline for the treatment of IDH.

Prevention of Contrast-Induced Nephropathy With Sodium Prevention of Contrast-Induced Nephropathy With Sodium Bicarbonate A Randomized Controlled Trial Bicarbonate A Randomized Controlled Trial

Objective To examine the efficacy of sodium bicarbonate compared with sodium chloride for preventive hydration before and after radiographic contrast.

119 patients with stable serum creatinine levels of at least 1.1 mg/dL ( 97.2 µmol/L) who were randomized to receive a 154-mEq/L infusion of either sodium chloride (n = 59) or sodium bicarbonate (n = 60) before and after iopamidol administration (370 mg iodine/mL). Serum creatinine levels were measured at baseline and 1 and 2 days after contrast.

Gregory J. MertenGregory J. MertenJAMA.JAMA. 2004;291:2328-2334. 2004;291:2328-2334.

Patients received 154 mEq/L of either sodium chloride or sodium bicarbonate, as a bolus of 3 mL/kg per hour for 1 hour before iopamidol contrast, followed by an infusion of 1 mL/kg per hour for 6 hours after the procedure.

Main Outcome Measure Contrast-induced nephropathy, defined as an increase of 25% or more in serum creatinine within 2 days of contrast.




Results The primary end point of contrast-induced nephropathy occurred in 8 patients (13.6%) infused with sodium chloride but in only 1 (1.7%) of those receiving sodium bicarbonate(mean difference, 11.9%; 95% confidence interval [CI], 2.6%-21.2%; P = .02).

Conclusion Hydration with sodium bicarbonate before contrast exposure is more effective than hydration with sodium chloride for prophylaxis of contrast-induced renal failure.


The major complications of fluid resuscitation are pulmonary and systemic edema. these are related to three principal factors:

1. increases in hydrostatic pressures; 2. decreases in colloid osmotic pressure; 3. increases in microvascular permeability associated with septic

shock.

Data suggest that when lower filling pressures are maintained there is no significant difference in the development of pulmonary edema with crystalloids or colloids

THANK YOU

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Shock

From left to right: oxygen is delivered by convection or bulk flow from environment to vascularized surface, oxygen diffuses across into the blood, oxygen is delivered by convection or bulk flow to the various tissues of the body, and oxygen diffuses into the individual cells of the tissues.

the interpretation of blood lactate concentration is complicated by additional factors:

(1) the blood lactate concentration depends on the balance between tissue lactate production and hepatic removal. The liver has a large capacity for lactate removal, and therefore lactate production has to be substantially increased before the metabolic threshold of the liver is exceeded, and increased blood concentrations occur. Therefore, tissue dysoxia may be present despite a normal lactate concentration, (2) due to delayed hepatic clearance of lactate, tissue hypoxia may have resolved, yet the blood lactate concentration may remain elevated; and (3) other conditions interfere with lactate production, so that despite tissue hypoxia, blood lactate concentration will be normal. In severe malnutrition, for example, glucose stores are insufficient to sustain glycolysis.

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DR: Zohair AlAseri EM/CCM Fluid Therapy in ED & ICU