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

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Presentation on theme: "Fluid Management and Shock Resuscitation Kallie Honeywood UBC Anaesthesia PGY-3."— Presentation transcript:

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

2 Outline Normal Fluid Requirements Normal Fluid Requirements Definition of Shock Definition of Shock Types of Shock Types of Shock –Hypovolemic –Cardiogenic –Distributive –Obstructive Resuscitation Fluids Resuscitation Fluids Goals of Resuscitation Goals of Resuscitation

3 Body Fluid Compartments Total Body Water = 60% body weight Total Body Water = 60% body weight –70Kg TBW = 42 L 2/3 of TBW is intracellular (ICF) 2/3 of TBW is intracellular (ICF) –40% 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 L –Plasma volume is approx 4% of total body weight, but varies by age, gender, body habitus

4 Blood Volume Blood Volume (mL/kg) Premature Infant 90 Term Infant 80 Slim Male 75 Obese Male 70 Slim Female 65 Obese Female 60

5 Peri-operative Maintenance Fluids Water Water Sodium Sodium Potassium replacement can be omitted for short periods of time Potassium replacement can be omitted for short periods of time Chloride, Mg, Ca, trace minerals and supplementation needed only for chronic IV maintenance Chloride, Mg, Ca, trace minerals and supplementation needed only for chronic IV maintenance Most commonly Saline, Lactated Ringers, Plasmalyte Most commonly Saline, Lactated Ringers, Plasmalyte

6 4 – 2 – 1 Rule 100 – 50 – 20 Rule for daily fluid requirements 100 – 50 – 20 Rule for daily fluid requirements 4 mL/kg for 1 st 10 kg 4 mL/kg for 1 st 10 kg 2 mL/kg for 2 nd 10 kg 2 mL/kg for 2 nd 10 kg 1 mL/kg for each additional kg 1 mL/kg for each additional kg

7 Maintenance Fluids: Example 60 kg female 60 kg female 1 st 10 kg: 4 mL/kg x 10 kg = 40 mL 1 st 10 kg: 4 mL/kg x 10 kg = 40 mL 2 nd 10 kg: 2 mL/kg x 10 kg = 20 mL 2 nd 10 kg: 2 mL/kg x 10 kg = 20 mL Remaining: 60 kg – 20 kg = 40 kg Remaining: 60 kg – 20 kg = 40 kg 1 mL/kg x 40 kg = 40 mL 1 mL/kg x 40 kg = 40 mL Maintenance Rate = 120 mL/hr Maintenance Rate = 120 mL/hr

8 Fluid Deficits Fasting Fasting Bowel Loss ( Bowel Prep, vomiting, diarrhea ) Bowel Loss ( Bowel Prep, vomiting, diarrhea ) Blood Loss Blood Loss –Trauma –Fractures Burns Burns Sepsis Sepsis Pancreatitis Pancreatitis

9 Insensible Fluid Loss Evaporative Evaporative Exudative Exudative Tissue Edema (surgical manipulation) Tissue Edema (surgical manipulation) Fluid Sequestration (bowel, lung) Fluid Sequestration (bowel, lung) Extent of fluid loss or redistribution (the Third Space) dependent on type of surgical procedure Extent of fluid loss or redistribution (the Third Space) dependent on type of surgical procedure Mobilization of Third Space Fluid POD#3 Mobilization of Third Space Fluid POD#3

10 Insensible Fluid Loss 4 – 6 – 8 Rule 4 – 6 – 8 Rule Replace with Crystalloid (NS, LR, Plasmalyte) Replace with Crystalloid (NS, LR, Plasmalyte) Minor: 4 mL/kg/hr Minor: 4 mL/kg/hr Moderate: 6 mL/kg/hr Moderate: 6 mL/kg/hr Major: 8 mL/kg/hr Major: 8 mL/kg/hr

11 Example 68 kg female for laparoscopic cholecystectomy 68 kg female for laparoscopic cholecystectomy Fasted since midnight, OR start at 8am Fasted since midnight, OR start at 8am Maintenance = = 108 mL/hr Maintenance = = 108 mL/hr Deficit = 108 mL/hr x 8hr Deficit = 108 mL/hr x 8hr = 864 mL = 864 mL 3 rd Space (4mL/kg/hr) = 272 mL/hr 3 rd Space (4mL/kg/hr) = 272 mL/hr

12 Example Intra-operative Fluid Replacement of: Intra-operative Fluid Replacement of: –Fluid Deficit 864 mL –Maintenance Fluid 108 mL/hr –3 rd Space Loss 272 mL/hr –Ongoing blood loss (crystalloid vs. colloid)

13 Shock Circulatory failure leading to inadequate perfusion and delivery of oxygen to vital organs Circulatory failure leading to inadequate perfusion and delivery of oxygen to vital organs Blood Pressure is often used as an indirect estimator of tissue perfusion Blood Pressure is often used as an indirect estimator of tissue perfusion Oxygen delivery is an interaction of Cardiac Output, Blood Volume, Systemic Vascular Resistance Oxygen delivery is an interaction of Cardiac Output, Blood Volume, Systemic Vascular Resistance

14 DO 2 CaO 2 CO Sat % PaO 2 Hgb HR SV Preload Contractility Afterload

15 Types of Shock Hypovolemic – most common Hypovolemic – most common Hemorrhagic, occult fluid loss Hemorrhagic, occult fluid loss Cardiogenic Cardiogenic Ischemia, arrhythmia, valvular, myocardial depression Ischemia, arrhythmia, valvular, myocardial depression Distributive Distributive Anaphylaxis, sepsis, neurogenic Anaphylaxis, sepsis, neurogenic Obstructive Obstructive Tension pneumo, pericardial tamponade, PE Tension pneumo, pericardial tamponade, PE

16 Shock States BPCVPPCWPCOSVR Hypovolemia Cardiogenic - LV - RV Distributive Obstructive

17 DO 2 CaO 2 CO Sat % PaO 2 Hgb HR SV Preload Contractility Afterload

18 Hypovolemic Shock Most common Most common Trauma Trauma Blood Loss Blood Loss Occult fluid loss (GI) Occult fluid loss (GI) Burns Burns Pancreatitis Pancreatitis Sepsis (distributive, relative hypovolemia) Sepsis (distributive, relative hypovolemia)

19 Assessment of Stages of Shock % Blood Volume loss < 15% 15 – 30% 30 – 40% >40% HR<100>100>120>140 SBPN N, DBP, postural drop Pulse Pressure N or Cap Refill < 3 sec > 3 sec >3 sec or absent absent Resp >35 CNSanxious v. anxious confusedlethargic Treatment 1 – 2 L crystalloid, + maintenance 2 L crystalloid, re- evaluate 2 L crystalloid, re-evaluate, replace blood loss 1:3 crystalloid, 1:1 colloid or blood products. Urine output >0.5 mL/kg/hr

20 Fluid Resuscitation of Shock Crystalloid Solutions Crystalloid Solutions –Normal saline –Ringers Lactate solution –Plasmalyte Colloid Solutions Colloid Solutions –Pentastarch –Blood products (albumin, RBC, plasma)

21 Crystalloid Solutions Normal Saline Normal Saline Lactated Ringers Solution Lactated Ringers Solution Plasmalyte Plasmalyte Require 3:1 replacement of volume loss Require 3:1 replacement of volume loss e.g. estimate 1 L blood loss, require 3 L of crystalloid to replace volume e.g. estimate 1 L blood loss, require 3 L of crystalloid to replace volume

22 Colloid Solutions Pentaspan Pentaspan Albumin 5% Albumin 5% Red Blood Cells Red Blood Cells Fresh Frozen Plasma Fresh Frozen Plasma Replacement of lost volume in 1:1 ratio Replacement of lost volume in 1:1 ratio

23 Oxygen Carrying Capacity Only RBC contribute to oxygen carrying capacity (hemoglobin) Only RBC contribute to oxygen carrying capacity (hemoglobin) Replacement with all other solutions will Replacement with all other solutions will –support volume –Improve end organ perfusion –Will NOT provide additional oxygen carrying capacity

24 RBC Transfusion BC Red Cell Transfusion Guidelines recommend transfusion only to keep Hgb >70 g/dL unless BC Red Cell Transfusion Guidelines recommend transfusion only to keep Hgb >70 g/dL unless –Comorbid disease necessitating higher transfusion trigger (CAD, pulmonary disease, sepsis) –Hemodynamic instability despite adequate fluid resuscitation

25 Crystalloid vs. Colloid SAFE study (Saline vs. Albumin Fluid Evaluation) SAFE study (Saline vs. Albumin Fluid Evaluation) –Critically ill patients in ICU –Randomized to Saline vs. 4% Albumin for fluid resuscitation –No difference in 28 day all cause mortality –No difference in length of ICU stay, mechanical ventilation, RRT, other organ failure NEJM 2004; 350 (22),

26 Goals of Fluid Resuscitation Easily measured Easily measured –Mentation –Blood Pressure –Heart Rate –Jugular Venous Pressure –Urine Output

27 Goals of Fluid Resuscitation A little less easily measured A little less easily measured –Central Venous Pressure (CVP) –Left Atrial Pressure –Central Venous Oxygen Saturation S CV O 2

28 Goals of Fluid Resuscitation A bit more of a pain to measure A bit more of a pain to measure –Pulmonary Capillary Wedge Pressure (PCWP) –Systemic Vascular Resistance (SVR) –Cardiac Output / Cardiac Index

29 Mixed Venous Oxygenation Used as a surrogate marker of end organ perfusion and oxygen delivery Used as a surrogate marker of end organ perfusion and oxygen delivery Should be interpreted in context of other clinical information Should be interpreted in context of other clinical information True mixed venous is drawn from the pulmonary artery (mixing of venous blood from upper and lower body) True mixed venous is drawn from the pulmonary artery (mixing of venous blood from upper and lower body) Often sample will be drawn from central venous catheter (superior vena cava, R atrium) Often sample will be drawn from central venous catheter (superior vena cava, R atrium)

30 Mixed Venous Oxygenation Normal oxygen saturation of venous blood 68% – 77% Normal oxygen saturation of venous blood 68% – 77% Low S CV O 2 Low S CV O 2 –Tissues are extracting far more oxygen than usual, reflecting sub-optimal tissue perfusion (and oxygenation) Following trends of S CV O 2 to guide resuscitation (fluids, RBC, inotropes, vasopressors) Following trends of S CV O 2 to guide resuscitation (fluids, RBC, inotropes, vasopressors)

31 Goals of Resuscitation Rivers Study- Early Goal Directed Therapy in Sepsis and Septic Shock Rivers Study- Early Goal Directed Therapy in Sepsis and Septic Shock –Emergency department with severe sepsis or septic shock, randomized to goal directed protocol vs standard therapy prior to admission to ICU –Early goal directed therapy conferred lower APACHE scores, incidating less severe organ dysfunction

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33 DO 2 CaO 2 CO Sat % PaO 2 Hgb HR SV Preload Contractility Afterload

34 Bottom Line Resuscitation of Shock is all about getting oxygen to the tissues Resuscitation of Shock is all about getting oxygen to the tissues Initial assessment of volume deficit, replace that (with crystalloid), and reassess Initial assessment of volume deficit, replace that (with crystalloid), and reassess Continue volume resuscitation to target endpoints Continue volume resuscitation to target endpoints Can use mixed venous oxygen saturation to estimate tissue perfusion and oxygenation Can use mixed venous oxygen saturation to estimate tissue perfusion and oxygenation

35 References Clinical Anesthesia 3 rd Ed. Morgan et al. Lange Medical / McGraw Hill, 2002 Clinical Anesthesia 3 rd Ed. Morgan et al. Lange Medical / McGraw Hill, 2002 Anesthesiology Review 3 rd Ed. Faust, R. Churchill-Livingstone, 2002 Anesthesiology Review 3 rd Ed. Faust, R. Churchill-Livingstone, 2002 Rivers, E. et al. NEJM 2001; 345 (19): 1368 – 77 Rivers, E. et al. NEJM 2001; 345 (19): 1368 – 77 SAFE Investigators. NEJM 2004; 350: SAFE Investigators. NEJM 2004; 350:


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