Yefta Moenadjat

Objectives
Target of resuscitation
Fluids for resuscitation
Fluid management
Monitoring
Strategy in resuscitation

Fluid resuscitation
Definition
1. Rapid intravenous administration of isotonic fluid
to treat volume deficit (volume replacement)
1. Dorlands Online Medical Dictionary. Available in website: http://www.dorlands.com
2. McGrawHill Concise Dictionary of Modern Medicine. 2002 by The McGrawHill Companies, Inc.

2. Intravenous administration of isotonic fluid in

traumatized, burn injured, and hypotensive patients
Boldt J. Clinical review: Hemodynamic monitoring in the intensive care unit. Crit Care. 2002; 6: 5259

3. The procedure of intravenous fluid administration

to achieve restoration, revival and renewal.
Santry HP, Alam HB. Fluid resuscitation: past, present, and the future. Shock. 2010; 33(3): 22941

Target of resuscitation
Indicator

Definition 1

Restoration of normal
blood pressure, heart rate,
and urine output (the
Uop 0.5 mL/kg BW
standard of care per the
ATLS Course)

Definition 2

The end point is to

increase intravascular
volume to augment
cardiac output and
cellular perfusion

Definition 3

Perfusion:
The end point is to restore Global O2 delivery
cellular perfusion
Regional O2
delivery

Hemodynamic
parameters

Target of resuscitation

Pressure (mmHg)

Pressure (mmHg)

Target of resuscitation

GFR = 100 mL/min

Glomerular Capillary Length

Pressure (mmHg)

Pressure (mmHg)

Glomerular Capillary Length

GFR = 60 mL/min

GFR = 100 mL/min

Glomerular Capillary Length

GFR = 90 mL/min

Glomerular Capillary Length

Fig 1. Schematic (A and B) and pathologic kidney with decrease of the total ultrafiltration surface (C and
D) representation of the glomerular capillary hydraulic and oncotic pressure in normal kidney

Target of resuscitation

Target of resuscitation

Target of resuscitation

Target of resuscitation
1. Global O2 delivery

Mean arterial pressure (MAP)

Mixed venous O2 saturation (SvO2)*
O2 Consumption (VO2)
Other hemodynamic parameters (incl. Global acid-base
status: base deficit* and lactate levels*.

2. Regional O2 delivery
Gastric ischemia (gastric tonometry: pHim)*.
Intramuscular pH and pCO2
Near infrared spectroscopy (NIRS) or tissue electrodes)
*) Prognostic value

Fluids
Total Body Water
Intravascular fluid
(IVF, 10%)

Interstitial fluid
(ISF, 30%)

Intracellular fluid
(ICF, 60%)

Extracellular fluid
(ECF, 40%)

Blood Circulation

Plasma 7.5% of Transcellular 2.5%

TBW, 3.2 liters of TBW, Red cell
volume 1.8 liters

Exp:
Adult male 80 kg
TBW 48 L
Circulation 4.8 L

Shock
Classification of shock
Committee on Trauma. American College of Surgeon, 1975
Class I

Class II

Class III

Class IV

Blood loss (mL)

Up to 750

7501500

1500 2000

> 2000

Blood loss (%)

Up to 15

15 30

30 40

> 40

< 100

>100

>120

> 140

Blood pressure

Normal

Normal

Decreased

Decreased

Pulse pressure

Normal /
increased

Decreased

Decreased

Decreased

Capillary refill

Normal

Decreased

Decreased

Decreased

1420

2030

3040

> 35

Urine output
(mL/hr)

30 or more

2030

515

Negligible

CNS mental
status

Slightly
anxious

Anxious

Anxious
confused

Confused
lethargic

Crystalloid

Crystalloid

Crystalloid +
Blood

Crystalloid +
Blood

Pulse rate

Respiratory rate

Fluid replacement

Intravascular volume
Assessment
Clinical (empirical)
Clinical (objective): hemodynamic parameters
Oxygen delivery utilization
Blood volume :
BVA-100 blood volume analyzer (Daxor Corporation)
- Quantitative method (PCR)

A. Data entry: Height, weight (BVA

computes predicted normal blood
volume for patient)

PCR
Blood sample collection
(Saline lock)
B. Injection of Albumin I131
Tracer from Volumex
quantitative injection
syringe
C. Multi-sample collection
of blood Utilizing Saline
lock)

Fluids
Crystalloids
A substance that in solution can pass through a
semipermeable membrane and completely dissolved in
water (Thomas Graham, 1861).
Resembling a crystal in shape or structure
Molecular weight of 25 kDa
Isotonic
infusion of 1 L of 0.9% sodium chloride (isotonic saline)
adds 275 mL to the plasma volume and 825 mL to the
interstitial volume
Only about a third remains intravascularly.

Fluids
1. Replacement Solutions

To replace ECF.
Isotonic.
Have a [Na+] similar to that of the extracellular fluid which
effectively limits their fluid distribution to the ECF.
Distributes between the ISF and the plasma in proportion to
their volumes.
Intracellular fluid volume does not change.

Fluids
1. Replacement Solutions

If used to replace blood loss, 3 to 4 times the volume lost must

be administered as only 1/3 to 1/4 remains intravascularly.
Administration of 1,000 mL:
The ISF volume 750 mL
The plasma volume 250 mL

In healthy adults with a normal initial haemoglobin level, up to

20% loss of blood volume (loss of approx 1,000 mL) can be
safely replaced with a 3,000-4,000 mL infusion of replacement
solution without any adverse effects.

Fluids
1. Replacement Solutions

Normal saline
The prototype crystalloid fluid is 0.9% sodium chloride (NaCl),
also called isotonic saline or normal saline. The latter term is
inappropriate because a one normal (1 N) NaCl solution contains
58 g NaCl per liter (the combined molecular weights of sodium
and chloride), whereas isotonic (0.9%) NaCl contains only 9 g
NaCl per liter

Lactated Ringers
These anions (eg lactate) are the conjugate base to the corresponding
acid (eg lactic acid) and do not contribute to development of an acidosis
as they are administered with Na+ rather than H+ as the cation.

Fluids
2. Maintenance Solutions

To provide maintenance fluids

Iso-osmotic as administered and do not cause hemolysis.
Following administration, the glucose is rapidly taken up by
cells so the net effect is of administering pure water.
Dextrose 5% contains no Na+ so it is distributed throughout the
total body water with each compartment receiving fluid in
proportion to its contribution to the TBW

Fluids
3. Special Solutions

Some crystalloid solutions used for special purposes are

grouped together here:
Hypertonic (3%) saline
Half normal saline
8.4% Bicarbonate solution
Mannitol 20%

Fluids
Complication of crystalloid administration

The chloride content of isotonic saline is particularly high

relative to plasma (154 mEq/L vs 103 mEq/L, respectively).
Hyperchloremic metabolic acidosis (fatal), is a potential
risk with large-volume isotonic saline resuscitation.

Administration of >2,000 mL crystalloid lead to metabolic

acidosis:
pH of isotonic saline < plasma pH
(Strong ion difference)

Fluids
Complication of crystalloid administration

Hemodilution: Plasma oncotic pressure causes

glomerulotubular imbalance.

Haemostatic effect: The calcium in lactated Ringers can bind

to certain drugs and reduce their bioavailability and efficacy.
Of particular note is calcium binding to the citrated
anticoagulant in blood products. This can inactivate the
anticoagulant and promote the formation of clots in donor
blood. For this reason, lactated Ringers solution is
contraindicated as a diluent for blood transfusions

Fluids
Complication of crystalloid administration

Large volume resuscitation lead to massive interstitial edema

particularly in burns (endothelial dysfunction)
Third space syndrome
Lung edema (Da Nang lung)
Abdominal compartment syndrome

Fluid resuscitation for

Burns

Fluids
Colloids
A substance microscopically evenly dispersed throughout
another (Greek: glue).
Large molecular weight (nominally MW > 30,000) substances
Two molecular weights are quoted for colloid solutions:
Mw = Weight average molecular weight viscosity
Mn = Number average molecular weight oncotic pressure
Monodisperse: Mw = Mn (exp, Albumin)
Polydisperse : varies (artificial, synthetic)

Fluids
Colloids
Isooncotic
: plasma substitute (Mw >30 80 kDa)
Hyperoncotic : plasma expander (Mw > 80 120 kDa)
Duration of action of 6 to 8 hours
Interferes with haemostasis; it induces an acquired von
Willebrands state (protein colloid)
Max dose recommendation of 20 mL/kg (about 1,500 mL)

Fluids
Complication of colloid administration
Intravascular volume overload
Anaphylactoid reactions can occur
No coagulation factors and its use contributes to dilutional
coagulopathy
Extravascular axtravasation: Colloids of molecular weight < 80
kDa leaks as capillary hyperpermeability occurs during acute
phase
Cochrane study: hazardous administration of Albumin
Renal dysfunction (dextran 40)
Hyperamylasemia (Hetastarch)

Crystalloids
Normalsaline
LactatedRingers

Colloids
MW

Protein

MW

Non Protein

MW

25

Dextran
Albumin

40/70
68

Plasmaprotein

30

FFP

65

Gelatine

80

Starch

120

Fluid management
Resuscitation
1. Large volume resuscitation (volume
replacement)
ATLS
Baxter (Parkland formula)
3 to 4 times the volume lost must be administered
WARNING:
Volume (replacement) is NOT improved the perfusion

None proven helpful, some deleterious

Englehart; Curr Op Crit Care; Vol 12(6), Dec 06, p 579-574

Fluid management
Resuscitation
2. Small volume resuscitation
Less is More (Mattox)
To avoid the complication of large volume
resuscitation
(hi Mw solution)
The Pro and Con:
Crystalloids vs. Colloid

None proven helpful, some deleterious

Englehart; Curr Op Crit Care; Vol 12(6), Dec 06, p 579-574

Fluid management
Slow resuscitation
Hypertonic Saline (tonicity)
Retaining intravascular fluid shift
Intracellular dehydration lead to
hypernatremia (intracellular Na+ efflux)
WARNING:
Rapid administration lead to demyelinated pontine (fatal)

Fluid management
Fluid challenge
Bolus administration (loading)
Assessment tool of volume status as well as
capillary leaks
The procedure:
Crystalloid 5001000 mL in 1 hour
Colloid of 300500 mL in 1 hour

Fluid management
Fluid challenge
Hydration Status
Hypovolemia
(CVP)

: CVP following administration and

remain at such a targeted point
achieved

Capillary leaks
(CVP)

: CVP following administration and

then soon decreased, or
CVP is not respond to fluid
administration

Fluid management
Fluid treatment
Treatment of negative effects of fluid management:
Osmotic diuretic
: mannitol 20%
Cellular edema
: hypertonic saline 3-7.5%

Monitoring
Volume
Intravascular volume monitoring is indirectly
carried out by pressure measurement
(hemodynamic parameters)

Monitoring
Volume

Monitoring
1. Global O2 delivery

Mean arterial pressure (MAP)

Mixed venous O2 saturation (SvO2)*
O2 Consumption (VO2)
Other hemodynamic parameters (incl. Global acid-base
status: base deficit* and lactate levels*.

2. Regional O2 delivery
Gastric ischemia (gastric tonometry: pHim)*.
Intramuscular pH and pCO2
Near infrared spectroscopy (NIRS) or tissue electrodes)
Paul E Marik, Xavier Monnet, Jean-Louis Teboul. Hemodynamic parameters to guide fluid therapy. Annals of
Intensive Care 2011, 1:1. http://www.annalsofintensivecare.com/content/1/1/1

Strategy in fluid resuscitation

1. Crystalloid as the 1st line fluid resuscitation

2. Consider Colloid:
a) Large volume crystalloid is required
b) Capillary leaks syndrome
c) Use colloid of nonprotein large MW
3. Consider hypertonic saline at the same time with
crystalloid and colloid
Ronald V. Maier. Approach to the patient with shock.Harrison'sPrinciplesofInternalMedicine,17Part
11,Section2.

Colloids versus crystalloids for fluid

resuscitation in critically
ill patients (Review)
Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G

.it was argued that large molecular weight colloids such as

hydroxyethyl starch may be better retained in the vascular
compartment than albumin and gelatins, and would therefore
be more likely to show a favorable effect on mortality (Gosling
1998). In response to these concerns, the review has been
stratified by type of colloid.
However, the pooled relative risks fail to show a mortality
benefit for resuscitation with any type of colloid.

Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review) 2
Copyright 2007 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationand
publishedinTheCochraneLibrary
2007,Issue3

Strategy in fluid resuscitation

4. Consider ischemic time (Injury time)

Adequate resuscitation
Restoration of perfusion
Minimal injury time (<2 hours period)

Strategy in fluid resuscitation

Implementation
Hyperdynamic resuscitation (supranormal O2
delivery)
Early goal directed therapy (EGDT)
Hypotensive resuscitation

Surviving sepsis campaign

Message(s)

Resuscitation should be addressed to treat shock,

which is individualistic (casuistic) rather than
protocol
Consider prehospital management prior to
delivered to secondary / tertiary referral hospital