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. Dorland’s Online Medical Dictionary. Available in website: http://www.dorlands.com
2. McGraw−Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw−Hill 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: 52–59

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): 229−41
 Target of resuscitation
Indicator
Restoration of normal
blood pressure, heart rate,
Definition 1 and urine output (the Uop 0.5 mL/kg BW
standard of care per the
ATLS Course)
The end point is to
increase intravascular
Hemodynamic
Definition 2 volume to augment
parameters
cardiac output and
cellular perfusion
Perfusion:
The end point is to restore Global O2 delivery
Definition 3
cellular perfusion Regional O2
delivery
Target of resuscitation
 Target of resuscitation
Pressure (mmHg)

Pressure (mmHg)
A GFR = 100 mL/min B GFR = 100 mL/min

Glomerular Capillary Length Glomerular Capillary Length

Pressure (mmHg)

Pressure (mmHg)

GFR = 60 mL/min GFR = 90 mL/min

C Glomerular Capillary Length
D 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 Blood Circulation

(IVF, 10%)

Plasma 7.5% of Transcellular 2.5%

TBW, 3.2 liters of TBW, Red cell
Interstitial fluid
volume 1.8 liters
(ISF, 30%)

Exp:
Adult male 80 kg
TBW 48 L
Intracellular fluid Extracellular fluid Circulation 4.8 L
(ICF, 60%) (ECF, 40%)
 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 750 750–1500 1500 –2000 > 2000
Blood loss (%) Up to 15 15 –30 30 –40 > 40
Pulse rate < 100 >100 >120 > 140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal / Decreased Decreased Decreased
increased
Capillary refill Normal Decreased Decreased Decreased
Respiratory rate 14–20 20–30 30–40 > 35
Urine output 30 or more 20–30 5–15 Negligible
(mL/hr)
CNS – mental Slightly Anxious Anxious – Confused –
status anxious confused lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid + Crystalloid +
Blood Blood
 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 I–131

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 Ringer’s 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 Ringer’s 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
Willebrand’s 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 Colloids
MW Protein MW Non Protein MW
Normal saline 25 Dextran 40/70 Plasma protein 30
Albumin 68
Lactated Ringers FFP 65 Gelatine 80
Starch 120
 Fluid management

• Resuscitation
1. Large volume resuscitation (volume
replacement)
ƒ ATLS
ƒ Baxter (Parkland formula)
ƒ 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
ƒ Less is More (Mattox)
ƒ To avoid the complication of large volume
resuscitation
ƒ (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)

ƒ Retaining intravascular fluid shift
ƒ 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:
ƒ Crystalloid 500–1000 mL in 1 hour
ƒ Colloid of 300–500 mL in 1 hour
 Fluid management

• Fluid challenge

Hydration Status
Hypovolemia : CVP ↑ following administration and
(CVP↓) remain at such a targeted point
achieved

Capillary leaks : CVP ↑ following administration and

(CVP↓) 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 non–protein large MW
3. Consider hypertonic saline at the same time with
crystalloid and colloid
Ronald V. Maier. Approach to the patient with shock. Harrison's Principles of Internal Medicine, 17 Part 
11, Section 2.
 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

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and 
published in The Cochrane Library
2007, Issue 3
 Strategy in fluid resuscitation

4. Consider ischemic time (Injury time)

– Adequate resuscitation
ƒ Restoration of perfusion
ƒ 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 pre–hospital management prior to
delivered to secondary / tertiary referral hospital