Fluid Therapy in Shock

Multifactorial syndrome leading systemic and localized tissue

hypoperfusion

Presents if evidence of multisystem organ hypoperfusion is

apparent

Often presents as reduced mean blood pressure because blood

pressure is easily measured and extreme hypotension always
result in shock

Keith R. Walley, 2005. Kevin Dwyer, 2006

supplay Demand

Hypovolumic
Febris
heart pumping
Exercise
Gas exchange
Sepsis
pain
 Delivery Oxygen
DO2 = Cardiac Output(CO) x Oxygen content(CaO2 )

CO = Stroke volume x heart rate

Stroke volume = vol. sekuncup = preload = vol. vaskuler

Marini P.C. 2007

Marini P.C. 2007
• CaO2 = ( HB x 1,34 x SaO2 ) + PaO2 x 0,003

Lung Ventilations

Inspiration Oxygen concentration

Marini P.C. 2007

 Classification and Shock Profile
HR CO Preload SVR O2 Ext Pulse pres
Cardiogenic ↑ ↓ ↑ ↑ ↓ ↓

Hypovolemic ↑ ↓ ↓ ↑ ↓ ↓

Distributive ↑ ↓ ↓ ↓ ↑ ↑

Obstructive ↑ ↓ ↑ ↑ ↓ ↓

FCCS 2007
Early Goal directed Resuscitations
Supplement Oxygen

CVC + Artery Line

CVP(8-12)

MAP >65

FCCS 2007
• Pathophysiology respiratory in shock patient :
 Tachypnoe
 Increase work of breathing
Decrease delivery oxygen

• To Improve :
 Oxygen saturations
 Delivery oxygen
 And decrease oxygen consumptions
needs mechanical ventilations
Target of circulatory support :
MAP > 60-65 mmHg
PCWP= 15-18 mmHg
Cardiac index > 2.1 L/min per m2 of body
surface area for cardiogenic and obstructive
shock
Cardiac index > 4.0 L/min per m2 body surface
area for septic, traumatic, or hemorrhagic shock
 Fluid therapy on shock

 How much should we infuse?

 What fluids should we use?
• How should we monitor fluid
replacement?
 How much should we infused ?
 Adequate  what is the parameter ?
 Risks of inadequate resuscitation
− Life-threatening : lactic acidosis, ARF, MOF
 Risks of excessive resuscitation
− Life-threatening : pulmonary edema, cardiac
failure
− Non-fatal; peripheral edema, periorbital edema,
impaired gut function, impaired wound healing
Hypovolemia with insufficient microcirculation
 important factor behind early intestinal
disturbances during SIRS  but compromised
intestinal perfusion and metabolic disturbances
after endotoxin infusion  greatly counteracted
with colloid solution

Albumin, Dextran, HES  no difference

Course of hypovolaemic shock in absence
of therapy
Blood pressure mmHg
Heart rate
150 Bleeding min

100

Blood
pressure
50

0 Compen- Decompen- Irreversi-

sation sation bility

Three Shock phases

 How Much Fluid ?

• Adequate fluid  intravascular, interstitial,

intravascular
• Challenge test : 10 – 20 cc/Kgbb 5 – 10menute
– Clinical sign
– Hemodynamic monitoring principle
– Organ perfusion
– Microcirculation
Challenge test

diguyur
 Starling Capillary Forces
• Two forces regulate bulk flow across capillaries:
– Hydrostatic (HP) and osmotic pressure (OP)
• These forces exist in two fluid compartments:
– Blood (B) and interstitial fluid (IF)
IFOP IFOP
Arterial End Venous End

BOP BOP

BHP BHP

IFHP IFHP

Net Lymphatic Net

system
 Fluid Management
 How much should we infuse?
 What fluids should we use?
• How should we monitor fluid
replacement?
• Crystalloid solutions • Colloid solutions
– Semi-synthetic colloids
– Isotonic – Naturally occurring human
– Hypotonic plasma derivatives
– hypertonic
 Crystalloids and colloids
Crystalliod Colloid
Intravascular persistance Poor Good
Haemodynamic
Transient Prolonged
stabilisation
Required infusion volume Large Moderate
Risk of tissue oedema Obvious Insignificant
Enhancement of capillary
Poor Good
perfusion
Risk of anaphylaxis Nil Low to moderate
Plasma colloid osmotic
Reduced Maintained
pressure
Cost Inexpensive Expensive
Comparison Whole Haemaccel Electrolyte Plasma prot Dextran 40 HES 6% /
blood solutions fraction Voluven
pH 7,3 - 7,4 7,3 (+/- 0,3) 5,5 - 6,5 6,7 -7,3 4,5 - 5,7 3,5 - 6,0
bufferi capacity
Oncotic Iso-oncotic Iso-oncotic Non-oncotic Iso-oncotic Hyper-oncotic Hyper-oncotic
pressure
Intravascular / Restored / Restored Tissue Restored / Tissue Tissue
interstitial Maintained oedema Maintained dehydration dehydration
fluid balance
Cardiovascula Unlikely Unlikely Unlikely Unlikely Risk increased Risk increased
r overload by volume by volume
expand effect expand effect
Plasma half varies from 4-6 hours very short 5-10 days 10 hours 12 hours
life / few hours (min rather
volume effect to svrl days than hours)
Effect on renal usually not improved in not impaired renal renal function use with
function impaired shock but risk of function may be caution in renal
oedema maintained impaired impairment
Effect on Possible Dilution only Dilution only Dilution only Alters platelet Dilutional
coagulation (factor function and effects on
and activation) coagulation fact coagulation
haemostasis Dilution effect mech and CT
Effect on blood Usually None None None Possible Possible
typi and cross- none
match
Accumulation none None none none RES RES
 Fluid Management
 How much should we infuse?
 What fluids should we use?
• How should we monitor fluid
replacement?
 Hemodynamic Monitoring
• Clinical Sign :
– Organ Perfusion : GCS, Urine Out Put, EKG, pulse
oxymetri
• Invasive hemodynamic monitoring :
– Preload : CVP, PA catheter
– oxygen extractions : artery/venous GBA, lactate
• Advance hemodynamic monitoring : TTE,
pulse contour artery