Fluid Therapy in ICU

Dr. Basuki Rahmat Sp.An

 Fluid Therapy in ER

Objectives

Understand of The Normal Regulation of Fluid Balance

Fluid Imbalance In Shock State
Indices of successful resuscitation
Early Hemodynamic Optimization
Fluid Therapy (Types) & Indication
 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
Obstructive
Pulmonary embolism
Cardiac tamponade
Hypovolemia
Pneumothorax GE
Valvular dysfunction
Acute thrombosis of prosthetic valve Bleeding
Critical aortic stenosis

Cardiogenic
Arrhythmia
Ischemia
rupture

disturbutive
Hyperdynamic sepsis syndrome (early sepsis)
Cellular Poisons Anaphylactic shock
Carbon monoxide Central neurogenic shock
Methemoglobinemia
Drug overdose (dihydropyridines, α1 -
Hydrogen sulfide
Cyanide antagonists)
Adrenal crisis
Regulation of Fluid Balance
Understanding the pathophysiology of circulatory
dysfunction in shock, trauma, and sepsis help to
determine optimum treatment approaches.

Fluid & Electrolyte Balance

 Decreased
Decrease cardiac output myocardial
function

Decrease VR

Decrease Blood Decreased

pressure Coronary
Intracellular Perfusion
fluid Loss

Decreased
Cellular Myocardial
Decrease Tissue Perfusion
hypoxia Contraction

Metabolic Acidosis
Microcirculatory
Damage
Microcirculatory
obstruction

Cellular aggregation
 Hemorrhagic Shock

Rapid reduction in blood volume

Baroreceptor activation

Increased strength
Increased
heart rate + of cardiac
contraction
Vasoconstriction

increase in the diastolic BP narrow

pulse pressure

Cardiac output
Hemorrhagic
Ventricular filling
Shock
 Altered Membrane Potential
SHOCK Altered Ion Distribution (↑ Intracellular
Ca2+ /Na2+ )
PATHOPHYSIOLOGY Cellular Swelling
Cytoskeletal Disorganization
Increased Hypoxanthine
Disruption of
Decreased Adenosine 5′-
cellular Triphosphate (ATP)
metabolism Decreased Phosphocreatine
Decreased Glutathione
Cellular Acidosis
Shock
Cellular ischemia
State
Cellular
Dysfunction
Inflammatory
mediators, and
toxic effects of
DEATH
free radicals
In early shock The American College of Critical Care
Medicine (ACCM) Sep.2004 update

Compensatory Restore pressure and

mechanisms flow to vital organs.
Fail

Irreversible shock
and death

•Damage to cellular membranes

•Loss of ion gradients
•Leakage of lysosomal enzymes
•Proteolysis due to activation of
cellular proteases
•Reductions in cellular energy stores
 Regulation of Fluid Balance

What is the major component of all fluid

compartments within the body.

Water
Regulation of Fluid Balance

TOTAL BODY FLUID

(40) liters;60%TBW

The intracellular and

Plasma volume extracellular compartments
(3 liters,5 %)
are separated by
Red cell volume water-permeable
(2 liters) cell membranes.

Extracellular Intracellular
(15 liters,20%) (25 liters,40%)
Blood volume (5 liters)
 Regulation of Fluid Balance

Is the relative percentage of water the same for every body

or changes??

It changes significantly with age, gender, and adiposity.

 Regulation of Fluid Balance

Extracellular fluid volume is greater in the young and

in the male than in the elderly or the female
 Regulation of Fluid Balance

The extracellular fluid compartment contains high

concentrations of sodium, chloride, and bicarbonate.
 Regulation of Fluid Balance

Plasma and interstitial fluid are rich

in proteins, which determine
plasma colloid osmotic pressure.
 Permeability to ions and proteins varies
in each organ.

Which organ has the most

permeability?? Which organ has the least
Brain permeability??
Heart 1. Brain
Lung 2. Heart
Liver 3. Lung
4. Liver
 Fluid & Electrolyte Balance
IC. WATER ECF
2/3 intrest. 1/3 blood

25 Na 140

150 K 4.5

15 Mg 1.2

0.01 Ca 2.4

2 Cl 100

6 Hco3 25

50 Phos 1.2
 Regulation of Fluid Balance

ECF Osmolarity
ECF Volume

Maintain BP Prevent swelling or

shrinking of the cells
 Regulation of Fluid Balance

THE STARLING EQUATION

The net fluid filtered through a capillary bed is

determined by both the translumenal hydrostatic
pressures and oncotic pressures.
tending to tending to move
keep fluid fluid out of the
Regulation of capillaries
within the
Fluid Balance
capillaries

Oncotic Hydrostatic
pressure pressure

Excess fluid filtered is

collected through the
THE STARLING
lymphatic circulation
EQUATION
and returned to the
Systemic circulation
Indices of Successful Resuscitation in ER

Regulation of Fluid Balance

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

Arteriole Venule

Pnet =(37-1)+(0-25)=11 17
37 Mm
mm Hg
Hg
Oncotic P=25

Interstitial
Hydrostatic P=1 Pnet =(17-1)+(0-25)=-9
 Fluid Imbalance In Shock State
Cellular Pump Failure In Shock

Extracellular
Intracellular

K Na Na.KATPASE
Pump failure
CL

Water
lead to cellular death
 Fluid Imbalance In Shock State

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

COMPONENT INTRACELL. EXTRACELL.

WATER

Na
K
 Regulation of Fluid Balance

Control of body water and its composition involves:

(1) Atrial natriuretic (6) Prostaglandins

peptide (7) dopaminergic receptors
(2) Vasopressin (8) alpha-adrenergic
(3) aldosterone (renin, receptors
angiotensin) (9) the thirst mechanism
(4) parathyroid hormone (10) intrinsic renal
(5) calcitonin properties.
 Shock

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

In approximately 50% of septic patients who

initially present with hypotension, fluids alone
will reverse hypotension and restore
hemodynamic stability
 Shock

In approximately 50% of septic patients who initially

present with hypotension, fluids alone will reverse
hypotension and restore hemodynamic stability

Until restoration of the functional extracellular fluid

volume is completed, normal oxygen and nutrient
delivery to the cells and removal of waste products from
them cannot occur.
 Fluid Imbalance In Shock State

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

The restoration of intravascular volume alone is

insufficient for successful resuscitation.
 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
 Fluid Imbalance In Shock State

A progressive increase in intracellular Na and

water and extracellular K occurs with an
associated decrease in extracellular water.

This accounting for the loss of functional

extracellular fluid volume.
 Indices of successful resuscitation

What is the overall goal of all resuscitation procedures?

• To improve oxygenation and perfusion of body tissues.

 Indices of Successful Resuscitation

V/S
Perfusion End-tidal
CO2
Indirect Fick
equation
Central Venous Oxygen Saturation

Lactate Clearance
• The overall goal of
all resuscitation Lactate concentration
procedures is to
improve oxygenation Clinical Exam
and perfusion of body
tissues. BD
 Indices 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
Is This Patient Hypovolemic? Steven McGee, MD;
JAMA. 1999;281:1022-1029.
 Central Venous Oxygen Saturation

ScvO2 provides an additional method of monitor

adequacy or resuscitative measures.

Studies have shown a close correlation between

ScvO2 and SvO2 during cardiac CPR.
 Central Venous Oxygen Saturation

Because O2 consumption remains relatively constant

during CPR, as does arterial oxygen saturation (SaO2 )
and hg, changes in ScvO2 reflect changes in oxygen
delivery by means of changes in CO.

During cardiac arrest and CPR these values range

from 25% to 35%, indicating the inadequacy of blood
flow produced during CPR.

Failure to achieve a ScvO2 of 40% or greater has a

negative predictive value for ROSC of almost 100%.
 Central Venous Oxygen Saturation

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

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.
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
BD

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 Hemodynamic Optimization

Lactate Clearance Definition.

A positive value denotes a decrease or clearance of

lactate, whereas a negative value denotes an increase
in lactate after 6 hrs of ED intervention.
Early lactate clearance is associated with Early lactate clearance
improved outcome in severe sepsis and
septic shock
H. Bryant Nguyen, MD, MS;

Kaplan-Meier survival analysis between patients with lactate clearance

<10 vs. ≥10% at 6 hrs after emergency department presentation.
Control of body water and Mechanical ventilation :

Mechanical ventilation can decrease the release of

atrial natriuretic hormone and increase the release of
antidiuretic hormone resulting in retention of sodium
and fluids.
 Minimally invasive hemodynamic monitoring

Dynamic Measurements of Fluid Resuscitation 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.
 Indirect Fick equation

The indirect Fick methods are convenient and

relatively easy to apply to mechanically
ventilated patients but may not be accurate
enough for initial diagnostic information in a
patient with significant lung disease or
multiorgan failure
 Indirect Fick equation
Minimally invasive hemodynamic monitoring for the intensivist:
Current and emerging technology
[Review Articles]
Chaney, John C. MD; Derdak, Stephen DO

Substituting CO2 for oxygen in 1 yields the indirect Fick equation

 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.

Minimally invasive hemodynamic monitoring for the intensivist:

Current and emerging technology
[Review Articles]
Chaney, John C. MD; Derdak, Stephen DO
Early Hemodynamic
Optimization
Fluid Therapy
 Fluid Therapy (Types)

Solution Na CL K Mg Ca lactat other PH osm

e
D5W Dex 5 253
5g/dl
0.9NS 154 154 4.2 308

Ring. 130 109 4 3 2.8 6.5 273

Alb5% 145 145 Alb 308

5g/dl
3%n/s 513 513 5 1,02
7
 Fluid Therapy (Types)
Crystalloids

Crystalloids are fluids that contain water and

electrolytes.

Crystalloid solutions are used to both provide

maintenance water and electrolytes and
expand intravascular fluid.

distributed in a ratio 1:4 like extracellular fluid

(i.e., about 20% should remain in the
intravascular space).
 Fluid Therapy (Types)
Ringer Lactate

lactated Ringer solution have an electrolyte composition

similar to extracellular fluid (ECF).

With respect to sodium, they are hypotonic.

If your patient received ringer lactate, would
this affect the lactate level reading???
 Fluid Therapy (Types)
Ringer Lactate

A buffer is included in place of bicarbonate, which

hydrates to carbonic acid, with production of carbon
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
 Fluid Therapy (Types)
Normal Saline

Normal saline, 0.9 percent NaCl, is isotonic and

isoosmotic but contains more chloride than ECF.

When used in large volumes, mild hyperchloremia

(non-anion gap metabolic acidosis) results.

It contains no buffer or other electrolytes.

 Fluid Therapy (Types)
N/S vs RL
It is preferred to lactated Ringer solution (which contains a
hypotonic concentration of sodium) in
brain injury
hypochloremic metabolic alkalosis
hyponatremia

Compared with 0.9 percent NaCl, these solutions

provide small quantities of other electrolytes, which are
inadequate to meet daily maintenance requirements.
What are the indications of using D5
 Fluid Therapy (Types)
Five Percent Dextrose

Five percent dextrose functions as free water.

It may be used to correct hypernatremia, but is most

often used in the prevention of hypoglycemia in
diabetic patients.
 Fluid Therapy (Types)

COLLOID SOLUTIONS

Colloid solutions are generally administered in a

volume equivalent to the volume of blood lost.
The initial volume of distribution is equivalent to the
plasma volume.
The half-life in circulation of albumin is normally 16
hours, but it can be as short as 2 to 3 hours in
pathophysiologic conditions.
 Fluid Therapy (Types)
Five Percent Albumin

Five percent albumin have a colloid osmotic

pressure of about 20 mm Hg (i.e., near-
normal colloid osmotic pressure).
 Fluid Therapy (Types)
Twenty-Five Percent Albumin

A colloid solution of 25 percent, or "salt-poor,"

albumin contains purified albumin at five times the
normal concentration.

When administered, it has the potential to expand

the plasma volume by up to five times the volume
provided.
 Fluid Therapy (Types)
Hydroxyethyl Starch & Pentastarch

Hydroxyethyl starch (hetastarch) is a synthetic colloid

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

It produces dilutional effects.

reduces factor VIII:C levels by 50 percent in a dose

of 1 L with prolongation of the partial thromboplastin
time.

Hetastarch can also interfere with clot formation by

direct movement into the fibrin clot by the hetastarch
molecules.
 Fluid Therapy (Types)
Hydroxyethyl Starch & Pentastarch

Repeated doses can result in accumulation and side

effects, which include allergic reactions and bleeding
with higher doses (20 to 25 mL/kg.)
 Crystalloids Versus Colloids

Crystalloids or colloids in fluid therapy??

 Crystalloids Versus Colloids

The hydrostatic and colloid pressure differences

across capillary walls (Starling forces) cause
movement of water and dissolved solutes into the
interstitial spaces.

The lungs are moderately permeable relative to other

organs and during pathophysiologic processes,
capillary permeability changes, resulting in increased
capillary permeability or leak.
 Crystalloids vs. colloids in fluid resuscitation: a
systematic review.

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.

 Traumatic Brain Injury

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.
Fluid Resuscitation In Anaphylaxis

Increased vascular permeability during anaphylaxis

can result in a transfer of 50% of the intravascular fluid
into the extravascular space within 10 minutes.

This shift in effective blood volume activates the renin-

angiotensin-aldosterone system and causes
compensatory catecholamine release
Fluid Resuscitation In Anaphylaxis

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 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.
Fluid Resuscitation In Neurogenic shock

Effective circulating blood volume decreases

dramatically because of venous pooling.

Decreased sympathetic outflow may be manifested by

bradycardia or hypotension
 Fluid Resuscitation In Neurogenic shock

Fluid resuscitation is usually necessary and typically begins

with several liters of balanced salt solution.

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 In Neurogenic shock

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 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
ventricular 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
 Cardiogenic Shock

Frank-Starling curve with relationship between

ventricular preload and ventricular stroke volume

As a consequence, when the plateau is reached,

vigorous fluid resuscitation carries out the risk of
generating volume overload and pulmonary edema
and/or right-ventricular dysfunction.
 MPE

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

MPE
 MPE

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.
TERIMA KASIH