1. Fluids Management Jamal A. Alhashemi, MBBS, MSc, FRPC, FCCP, FCCM Professor of Anesthesiology & Critical Care Medicine Faculty of Medicine, King Abdulaziz University

2. Objectives By the end of the lecture, students should be able to: Compare crystalloids with colloids Compare crystalloids with colloids Determine the volume status of patients based on clinical exam & invasive monitors Determine the volume status of patients based on clinical exam & invasive monitors Institute appropriate fluid therapy for the resuscitation of trauma patients Institute appropriate fluid therapy for the resuscitation of trauma patients

3. Case History A 24 yr old male involved in an MVC 1/2 h ago as an unrestrained driver. His primary survey revealed fractured left femur but no other injuries. In ER, his HR 120/min, BP 70/40, RR 24, SpO 2 100% on FiO 2 0.5 by facemask.

4. What are the issues? ShockTachypnea Fractured femur, ongoing bleeding Potential C-spine injury Potential closed head injury

5. What should you do next? ABC Volume resuscitation Which type of fluid? Which type of fluid? How fast? How fast? How much? How do we know? How much? How do we know? ? Vasopressors

6. Types of Fluids Crystalloids: 0.9% NaCl (NS) 0.9% NaCl (NS) 0.45% NaCl 0.45% NaCl 0.225% NaCl 0.225% NaCl 3% NaCl 3% NaCl Lactated Ringer Lactated Ringer 5% Dextrose (D5W) 5% Dextrose (D5W) D5 LR D5 LR D5 NS D5 1/2NS D5 1/4NS 10% Dextrose (D10) 25% Dextrose (D25) 50% Dextrose (D50)

7. Types of Fluids Colloids: 6% HES 6% HES 5% Albumin 5% Albumin Plasma Protein Fraction (PPF) Plasma Protein Fraction (PPF) Fresh Frozen Plasma (FFP) Whole Blood Gelatins

8. Body Fluid Composition ICF (2/3) ECF (1/3) ISF (2/3)IVF (1/3) H2OH2OH2OH2O H2OH2O Na + Cl - HES

9. Crystalloids vs. Colloids Crystalloids Cheap Cheap Readily available Readily available Large volume Large volume Maintenance & resuscitation fluid Maintenance & resuscitation fluid No allergic potentials No allergic potentials No infectious risk No infectious riskColloids Expensive Not readily available Small volume Resuscitation fluid Not for maintenance Potential for allergy Risk of infection

10. Fluid Therapy Maintenance Therapy 4 ml/kg/h 4 ml/kg/h 2 ml/kg/h 2 ml/kg/h 1 ml/kg/h 1 ml/kg/hDeficit Replace as fast as possible Replace as fast as possible 3:1 rule when giving crystalloids 3:1 rule when giving crystalloids Ongoing losses including “third spacing” Ongoing losses including “third spacing” Fluid therapy = maintenance + deficit + losses

11. Monitoring of Fluid Therapy Clinical exam HR HR MAP MAP ?JVP and “postural drop” ?JVP and “postural drop” Urine output Urine output Central venous pressure (CVP) Pulmonary artery catheter (PAOP) Serum lactate & ScvO 2

12. Goals of Therapy - I MAP ≥ 65 mmHg HR < 100/min Urine output Adults ≥ 0.5 ml/kg/h Adults ≥ 0.5 ml/kg/h Pediatrics ≥ 1 ml/kg/h Pediatrics ≥ 1 ml/kg/h ScvO 2 ≥ 70% Serum lactate ≤ 2 mmol/l

13. Goals of Therapy - II CVP CVP 8-12 mmHg CVP 8-12 mmHg 5, 7 rule 5, 7 rule PA catheter PAOP 10-12 mmHg PAOP 10-12 mmHg 2, 5 rule 2, 5 rule Trends are more important than absolute numbers

14. Complications of Fluid Therapy Fluid overload Generalized edema Generalized edema Pulmonary edema Pulmonary edema Electrolyte disturbances Na + Na + K + K + Ca ++ Ca ++HypothermiaCoagulopathy

15. Case Management - I ABC Two large-bore iv cannulae CBC, coags, urea & electrolytes X-match 4-6 units of PRBCs LR for initial resuscitation

16. Case Management - II HES may be added subsequently Blood may be needed later Early blood administration if there is ongoing uncontrolled hemorrhage FFPs only for documented coagulopathy

17. Conclusion - I Most of the hypotension encountered in the surgical patient is due to hypovolemia Never use hypotonic solutions for fluid resuscitation Never use dextrose-containing solutions for fluid resuscitation

18. Conclusion - II Never use FFP for fluid resuscitation Blood may be used for severe hemorrhage or uncontrolled bleeding Always monitor the adequacy of fluid resuscitation