Fluid Management and Shock Resuscitation Kallie Honeywood UBC Anaesthesia PGY-3.

Fluid Management Fluid Management and Shock and Shock

ResuscitationResuscitation

Kallie HoneywoodKallie Honeywood

UBC Anaesthesia PGY-3UBC Anaesthesia PGY-3

OutlineOutline

Normal Fluid RequirementsNormal Fluid Requirements Definition of ShockDefinition of Shock Types of ShockTypes of Shock

– HypovolemicHypovolemic– CardiogenicCardiogenic– DistributiveDistributive– ObstructiveObstructive

Resuscitation FluidsResuscitation Fluids Goals of ResuscitationGoals of Resuscitation

Body Fluid CompartmentsBody Fluid Compartments

Total Body Water = 60% body weightTotal Body Water = 60% body weight– 70Kg TBW = 42 L70Kg TBW = 42 L

2/3 of TBW is intracellular (ICF)2/3 of TBW is intracellular (ICF)– 40% of body weight, 70Kg = 28 L40% of body weight, 70Kg = 28 L

1/3 of TBW is extracellular (ECF)1/3 of TBW is extracellular (ECF)– 20% of body weight, 70Kg = 14 L20% of body weight, 70Kg = 14 L– Plasma volume is approx 4% of total Plasma volume is approx 4% of total

body weight, but varies by age, gender, body weight, but varies by age, gender, body habitusbody habitus

Blood VolumeBlood Volume

Blood Volume Blood Volume (mL/kg)(mL/kg)

Premature InfantPremature Infant 9090

Term InfantTerm Infant 8080

Slim MaleSlim Male 7575

Obese MaleObese Male 7070

Slim FemaleSlim Female 6565

Obese FemaleObese Female 6060

Peri-operative Maintenance Peri-operative Maintenance FluidsFluids

WaterWater SodiumSodium Potassium replacement can be Potassium replacement can be

omitted for short periods of timeomitted for short periods of time Chloride, Mg, Ca, trace minerals and Chloride, Mg, Ca, trace minerals and

supplementation needed only for supplementation needed only for chronic IV maintenancechronic IV maintenance

Most commonly Saline, Lactated Most commonly Saline, Lactated Ringers, PlasmalyteRingers, Plasmalyte

4 – 2 – 1 Rule4 – 2 – 1 Rule

100 – 50 – 20 Rule for daily fluid 100 – 50 – 20 Rule for daily fluid requirementsrequirements

4 mL/kg for 14 mL/kg for 1stst 10 kg 10 kg 2 mL/kg for 22 mL/kg for 2ndnd 10 kg 10 kg 1 mL/kg for each additional kg1 mL/kg for each additional kg

Maintenance Fluids: Maintenance Fluids: ExampleExample

60 kg female60 kg female 11stst 10 kg: 4 mL/kg x 10 kg = 10 kg: 4 mL/kg x 10 kg = 40 mL40 mL 22ndnd 10 kg: 2 mL/kg x 10 kg = 10 kg: 2 mL/kg x 10 kg = 20 mL20 mL Remaining: Remaining: 60 kg – 20 kg = 40 kg60 kg – 20 kg = 40 kg

1 mL/kg x 40 kg = 1 mL/kg x 40 kg = 40 mL40 mL Maintenance Rate = Maintenance Rate = 120 120

mL/hrmL/hr

Fluid DeficitsFluid Deficits

FastingFasting Bowel Loss (Bowel Loss (Bowel Prep, vomiting, diarrheaBowel Prep, vomiting, diarrhea)) Blood Loss Blood Loss

– TraumaTrauma– FracturesFractures

BurnsBurns SepsisSepsis PancreatitisPancreatitis

Insensible Fluid LossInsensible Fluid Loss

EvaporativeEvaporative ExudativeExudative Tissue Edema (surgical manipulation)Tissue Edema (surgical manipulation) Fluid Sequestration (bowel, lung)Fluid Sequestration (bowel, lung) Extent of fluid loss or redistribution (the Extent of fluid loss or redistribution (the

“Third Space”) dependent on type of “Third Space”) dependent on type of surgical proceduresurgical procedure

Mobilization of Third Space Fluid POD#3Mobilization of Third Space Fluid POD#3

Insensible Fluid LossInsensible Fluid Loss

4 – 6 – 8 Rule4 – 6 – 8 Rule Replace with Crystalloid (NS, LR, Replace with Crystalloid (NS, LR,

Plasmalyte)Plasmalyte) Minor: 4 mL/kg/hrMinor: 4 mL/kg/hr Moderate: 6 mL/kg/hrModerate: 6 mL/kg/hr Major: 8 mL/kg/hrMajor: 8 mL/kg/hr

ExampleExample

68 kg female for laparoscopic 68 kg female for laparoscopic cholecystectomycholecystectomy

Fasted since midnight, OR start at 8amFasted since midnight, OR start at 8am Maintenance = 40 + 20 + 48 = 108 Maintenance = 40 + 20 + 48 = 108

mL/hrmL/hr Deficit = 108 mL/hr x 8hrDeficit = 108 mL/hr x 8hr

= 864 mL = 864 mL 33rdrd Space (4mL/kg/hr) = 272 mL/hr Space (4mL/kg/hr) = 272 mL/hr

ExampleExample

Intra-operative Fluid Replacement of:Intra-operative Fluid Replacement of:– Fluid Deficit 864 mLFluid Deficit 864 mL– Maintenance Fluid 108 mL/hrMaintenance Fluid 108 mL/hr– 33rdrd Space Loss 272 mL/hr Space Loss 272 mL/hr– Ongoing blood loss (crystalloid vs. Ongoing blood loss (crystalloid vs.

colloid)colloid)

ShockShock

Circulatory failure leading to Circulatory failure leading to inadequate perfusion and delivery of inadequate perfusion and delivery of oxygen to vital organsoxygen to vital organs

Blood Pressure is often used as an Blood Pressure is often used as an indirect estimator of tissue perfusionindirect estimator of tissue perfusion

Oxygen delivery is an interaction of Oxygen delivery is an interaction of Cardiac Output, Blood Volume, Cardiac Output, Blood Volume, Systemic Vascular ResistanceSystemic Vascular Resistance

DO2

CaO2

CO

Sat %

PaO2

Hgb

HR

SV

Preload

Contractility

Afterload

Types of ShockTypes of Shock

Hypovolemic – most commonHypovolemic – most common Hemorrhagic, occult fluid lossHemorrhagic, occult fluid loss

CardiogenicCardiogenic Ischemia, arrhythmia, valvular, myocardial Ischemia, arrhythmia, valvular, myocardial

depressiondepression

DistributiveDistributive Anaphylaxis, sepsis, neurogenicAnaphylaxis, sepsis, neurogenic

ObstructiveObstructive Tension pneumo, pericardial tamponade, PETension pneumo, pericardial tamponade, PE

Shock StatesShock States

BPBP CVPCVP PCWPPCWP COCO SVRSVR

HypovolemHypovolemiaia

CardiogeniCardiogenic - LVc - LV

- RV- RV

DistributiveDistributive

ObstructiveObstructive

DO2

CaO2

CO

Sat %

PaO2

Hgb

HR

SV

Preload

Contractility

Afterload

Hypovolemic ShockHypovolemic Shock

Most commonMost common TraumaTrauma Blood LossBlood Loss Occult fluid loss (GI)Occult fluid loss (GI) BurnsBurns PancreatitisPancreatitis Sepsis (distributive, relative Sepsis (distributive, relative

hypovolemia)hypovolemia)

Assessment of Stages of ShockAssessment of Stages of Shock% Blood % Blood Volume Volume lossloss

< 15%< 15% 15 – 30%15 – 30% 30 – 40%30 – 40% >40%>40%

HRHR <100<100 >100>100 >120>120 >140>140

SBPSBP NN N, DBP, N, DBP, postural droppostural drop

Pulse Pulse PressurePressure

N or N or

Cap RefillCap Refill < 3 sec< 3 sec > 3 sec> 3 sec >3 sec or >3 sec or absentabsent

absentabsent

RespResp 14 - 2014 - 20 20 - 3020 - 30 30 - 4030 - 40 >35>35

CNSCNS anxiousanxious v. anxiousv. anxious confusedconfused lethargiclethargic

TreatmentTreatment 1 – 2 L 1 – 2 L crystalloid, crystalloid, + + maintenancmaintenancee

2 L 2 L crystalloid, crystalloid, re-evaluatere-evaluate

2 L crystalloid, re-2 L crystalloid, re-evaluate, replace blood evaluate, replace blood loss 1:3 crystalloid, 1:1 loss 1:3 crystalloid, 1:1 colloid or blood products. colloid or blood products. Urine output >0.5 Urine output >0.5 mL/kg/hrmL/kg/hr

Fluid Resuscitation of ShockFluid Resuscitation of Shock

Crystalloid SolutionsCrystalloid Solutions– Normal salineNormal saline– Ringers Lactate solutionRingers Lactate solution– PlasmalytePlasmalyte

Colloid SolutionsColloid Solutions– PentastarchPentastarch– Blood products (albumin, RBC, plasma)Blood products (albumin, RBC, plasma)

Crystalloid SolutionsCrystalloid Solutions

Normal SalineNormal Saline Lactated Ringers SolutionLactated Ringers Solution PlasmalytePlasmalyte Require 3:1 replacement of volume Require 3:1 replacement of volume

lossloss e.g. estimate 1 L blood loss, require e.g. estimate 1 L blood loss, require

3 L of crystalloid to replace volume3 L of crystalloid to replace volume

Colloid SolutionsColloid Solutions

PentaspanPentaspan Albumin 5% Albumin 5% Red Blood CellsRed Blood Cells Fresh Frozen PlasmaFresh Frozen Plasma Replacement of lost volume in 1:1 Replacement of lost volume in 1:1

ratioratio

Oxygen Carrying CapacityOxygen Carrying Capacity

Only RBC contribute to oxygen Only RBC contribute to oxygen carrying capacity (hemoglobin)carrying capacity (hemoglobin)

Replacement with all other solutions Replacement with all other solutions willwill– support volumesupport volume– Improve end organ perfusionImprove end organ perfusion– Will NOT provide additional oxygen Will NOT provide additional oxygen

carrying capacitycarrying capacity

RBC TransfusionRBC Transfusion

BC Red Cell Transfusion Guidelines BC Red Cell Transfusion Guidelines recommend transfusion only to keep recommend transfusion only to keep Hgb >70 g/dL unlessHgb >70 g/dL unless– Comorbid disease necessitating higher Comorbid disease necessitating higher

transfusion trigger (CAD, pulmonary transfusion trigger (CAD, pulmonary disease, sepsis)disease, sepsis)

– Hemodynamic instability despite Hemodynamic instability despite adequate fluid resuscitationadequate fluid resuscitation

Crystalloid vs. ColloidCrystalloid vs. Colloid

SAFE study (Saline vs. Albumin Fluid SAFE study (Saline vs. Albumin Fluid Evaluation)Evaluation)– Critically ill patients in ICUCritically ill patients in ICU– Randomized to Saline vs. 4% Albumin for Randomized to Saline vs. 4% Albumin for

fluid resuscitationfluid resuscitation– No difference in 28 day all cause No difference in 28 day all cause

mortalitymortality– No difference in length of ICU stay, No difference in length of ICU stay,

mechanical ventilation, RRT, other organ mechanical ventilation, RRT, other organ failurefailure

NEJM 2004; 350 (22), 2247- 2256NEJM 2004; 350 (22), 2247- 2256

Goals of Fluid ResuscitationGoals of Fluid Resuscitation

Easily measuredEasily measured

– MentationMentation– Blood PressureBlood Pressure– Heart RateHeart Rate– Jugular Venous PressureJugular Venous Pressure– Urine OutputUrine Output

Goals of Fluid ResuscitationGoals of Fluid Resuscitation

A little less easily measuredA little less easily measured

– Central Venous Pressure (CVP)Central Venous Pressure (CVP)– Left Atrial PressureLeft Atrial Pressure

– Central Venous Oxygen Saturation SCentral Venous Oxygen Saturation SCVCVOO22

Goals of Fluid ResuscitationGoals of Fluid Resuscitation

A bit more of a pain to measureA bit more of a pain to measure

– Pulmonary Capillary Wedge Pressure Pulmonary Capillary Wedge Pressure (PCWP)(PCWP)

– Systemic Vascular Resistance (SVR)Systemic Vascular Resistance (SVR)– Cardiac Output / Cardiac IndexCardiac Output / Cardiac Index

Mixed Venous OxygenationMixed Venous Oxygenation

Used as a surrogate marker of end organ Used as a surrogate marker of end organ perfusion and oxygen deliveryperfusion and oxygen delivery

Should be interpreted in context of other Should be interpreted in context of other clinical informationclinical information

True mixed venous is drawn from the True mixed venous is drawn from the pulmonary artery (mixing of venous blood pulmonary artery (mixing of venous blood from upper and lower body)from upper and lower body)

Often sample will be drawn from central Often sample will be drawn from central venous catheter (superior vena cava, R venous catheter (superior vena cava, R atrium)atrium)

Mixed Venous OxygenationMixed Venous Oxygenation

Normal oxygen saturation of venous Normal oxygen saturation of venous blood 68% – 77%blood 68% – 77%

Low SLow SCVCVOO22

– Tissues are extracting far more oxygen Tissues are extracting far more oxygen than usual, reflecting sub-optimal tissue than usual, reflecting sub-optimal tissue perfusion (and oxygenation)perfusion (and oxygenation)

Following trends of SFollowing trends of SCVCVOO2 2 to guide to guide resuscitation (fluids, RBC, inotropes, resuscitation (fluids, RBC, inotropes, vasopressors)vasopressors)

Goals of ResuscitationGoals of Resuscitation

Rivers Study- Early Goal Directed Rivers Study- Early Goal Directed Therapy in Sepsis and Septic ShockTherapy in Sepsis and Septic Shock– Emergency department with severe Emergency department with severe

sepsis or septic shock, randomized to sepsis or septic shock, randomized to goal directed protocol vs standard goal directed protocol vs standard therapy prior to admission to ICUtherapy prior to admission to ICU

– Early goal directed therapy conferred Early goal directed therapy conferred lower APACHE scores, incidating less lower APACHE scores, incidating less severe organ dysfunctionsevere organ dysfunction

DO2

CaO2

CO

Sat %

PaO2

Hgb

HR

SV

Preload

Contractility

Afterload

Bottom LineBottom Line

Resuscitation of Shock is all about getting Resuscitation of Shock is all about getting oxygen to the tissuesoxygen to the tissues

Initial assessment of volume deficit, Initial assessment of volume deficit, replace that (with crystalloid), and replace that (with crystalloid), and reassessreassess

Continue volume resuscitation to target Continue volume resuscitation to target endpoints endpoints

Can use mixed venous oxygen saturation Can use mixed venous oxygen saturation to estimate tissue perfusion and to estimate tissue perfusion and oxygenationoxygenation

ReferencesReferences

Clinical Anesthesia 3Clinical Anesthesia 3rdrd Ed. Morgan et Ed. Morgan et al. Lange Medical / McGraw Hill, 2002al. Lange Medical / McGraw Hill, 2002

Anesthesiology Review 3Anesthesiology Review 3rdrd Ed. Faust, Ed. Faust, R. Churchill-Livingstone, 2002R. Churchill-Livingstone, 2002

Rivers, E. et al. NEJM 2001; 345 (19): Rivers, E. et al. NEJM 2001; 345 (19): 1368 – 771368 – 77

SAFE Investigators. NEJM 2004; 350: SAFE Investigators. NEJM 2004; 350: 2247 - 562247 - 56