CONCEPTS IN

FLUID
RESUSCITATION

DR RAJASHEKHAR MULIMANI
CONSULTANT PHYSICIAN
WHAT YOU (SHOULD) ALREADY KNOW..??

1. BODY FLUIDS COMPARTMENT

WHAT YOU (SHOULD) ALREADY KNOW..??

1. BODY FLUIDS COMPARTMENT

2. ENDOTHELIUM & GLYCOCALYX

WHAT YOU (SHOULD) ALREADY KNOW..??

1. BODY FLUIDS COMPARTMENT

2. ENDOTHELIUM & GLYCOCALYX

3. HYDROSTATIC & ONCOTIC PRESSURES

WHAT YOU (SHOULD) ALREADY KNOW..??

1. BODY FLUIDS COMPARTMENT

2. ENDOTHELIUM & GLYCOCALYX

3. HYDROSTATIC & ONCOTIC PRESSURES

4. OSMOSIS & SEMIPERMEABLE MEMBRANE

WHAT YOU (SHOULD) ALREADY KNOW..??

1. BODY FLUIDS COMPARTMENT

2. ENDOTHELIUM & GLYCOCALYX

3. HYDROSTATIC & ONCOTIC PRESSURES

4. OSMOSIS & SEMIPERMEABLE MEMBRANE

5. FLUID MOVEMENT IN RBC

• I.V. fluid therapy plays a fundamental role in the management of hospitalized patients.

• While the correct use of i.v. fluids can be lifesaving, recent literature demonstrates that
fluid therapy is not without risks.

• Indeed, the use of certain types and volumes of fluid can increase the risk of harm, and
even death, in some patient groups.

• When used appropriately i.v. fluids can obviously improve outcomes.

• However, in view of the physiological complexity of the considerations underpinning

the use of fluid resuscitation, many physicians prescribing fluid therapy appear to lack
appropriate expertise or an appreciation for its potential to cause harm.

• It has been recommended that the use of fluid therapy should be accorded similar
status as drug prescribing
DEFINITIONS
 TIME DEPENDENT CONSIDERATION
• Administration of fluid for immediate
RESUSCITATION management of life threatening condition
associated with impaired tissue perfusion.

• Adjustment of fluid type, rate and amount based

TITRATION upon the context to achieve optimisation of
tissue perfusion

• Minimisation of fluid administration

DE-ESCALATION • Mobilisation of extra fluid to optimise fluid
balance
 • A rapid infusion to correct hypotensive shock
FLUID BOLUS • It typically includes the infusion of at-least a 500mL over a
maximum of 15 mins.

FLUID • 100 – 200 mL over 5-10 min with reassessment to optimise tissue
perfusion
CHALLENGE
FLUID • Continuous delivery of iv fluids
• To maintain homeostasis, replace losses, or prevent organ injury
INFUSION (pre-hydration before surgery or to prevent contrast nephropathy)
 • Fluid administration for the provision of fluids for patients who
cannot meet their needs by oral route.
MAINTENANCE • This should be titrated for patient need and context and
should include replacement of ongoing losses.
• In a patient without ongoing losses it is usually 1-2 ml/kg/hour

DAILY FLUID • Daily sum of all intakes and outputs

BALANCE

CUMULATIVE • Sum total of fluid accumulation over a

FLUID BALANCE set period of time
 • Cumulative fluid balance expressed as
FLUID proportion of baseline body weight
• Fluid overload is defined by a cut-off
OVERLOAD value of 10% of fluid accumulation, as
this is associated with worse outcome
STAGES (PHASES) OF
FLUID THERAPY
 RESCUE OPTIMISATION STABILISATION DE-ESCALATION
PRINCIPLES LIFE SAVING ORGAN RESCUE ORGAN SUPPORT ORGAN RECOVERY

GOALS TO CORRECT SHOCK OPTIMISE & MAINTAIN AIM FOR SERO OR MOBILISE FLUID
TISSUE PERFUSION NEGATIVE FLUID ACCUMALATED
BALANCE

TIME (USUAL) MINUTES HOURS DAYS DAYS - WEEKS

PHENOTYPE SEVERE SHOCK UNSTABLE STABLE RECOVERING

 RESCUE OPTIMISATION STABILISATION DE-ESCALATION
PRINCIPLES LIFE SAVING ORGAN RESCUE ORGAN SUPPORT ORGAN RECOVERY

GOALS TO CORRECT SHOCK OPTIMISE & MAINTAIN AIM FOR ZERO OR MOBILISE FLUID
TISSUE PERFUSION NEGATIVE FLUID ACCUMALATED
BALANCE

TIME (USUAL) MINUTES HOURS DAYS DAYS - WEEKS

PHENOTYPE SEVERE SHOCK UNSTABLE STABLE RECOVERING

FLUID THERAPY RAPID BOLUSES TITRATE FLUID INFUSION & MINIMAL ORAL INTAKE IF
CONSERVATIVE USE OF MAINTENANCE POSSIBLE, AVOID
FLUID CHALLENGES INFUSION ONLY if ORAL UNNCESSARY FLUIDS
INTAKE IS INADEQUATE
 RESCUE OPTIMISATION STABILISATION DE-ESCALATION
PRINCIPLES LIFE SAVING ORGAN RESCUE ORGAN SUPPORT ORGAN RECOVERY

GOALS TO CORRECT SHOCK OPTIMISE & MAINTAIN AIM FOR SERO OR MOBILISE FLUID
TISSUE PERFUSION NEGATIVE FLUID ACCUMALATED
BALANCE

TIME (USUAL) MINUTES HOURS DAYS DAYS - WEEKS

PHENOTYPE SEVERE SHOCK UNSTABLE STABLE RECOVERING

FLUID THERAPY RAPID BOLUSES TITRATE FLUID INFUSION & MINIMAL ORAL INTAKE IF
CONSERVATIVE USE OF MAINTENANCE POSSIBLE, AVOID
FLUID CHALLENGES INFUSION ONLY if ORAL UNNCESSARY FLUIDS
INTAKE IS INADEQUATE

TYPICAL • SEPTIC SHOCK • INTRAOPERATIVE GDT • NPO • PATIENT ON

CLINICAL • MAJOR TRAUMA • BURNS POSTOPERTAIVE ENTERAL FEED
• DKA PATIENT DURING RECOVERY
SCENARIO • DRIP & SUCK PHASE
MANAGEMENT OF • RECOVERING ATN
PANCREATITIS
 INADEQUATE
AGGRESSIVE
MONITORING
RESUSCITATION
FLUID
FLUIDS RESPONSIVENESS

FLUID
OVERLOAD

ROLE OF PERSISTENCE USE OF

HIDDEN FLUIDS MAINTENANCE FLUIDS
 IV FLUID STEWARDSHIP

RIGHT RIGHT RIGHT RIGHT

PATIENT DRUG ROUTE DOSE
(FLUID)
 • Patient identification is critical to fluid stewardship.

• ROSE/ROS-D model for hemodynamic optimisation

identifies patient in need of IVF.

RIGHT • Need for assessment of volume responsiveness.

PATIENT • Routine m-IVF therapy is rarely indicated.

• Replacement fluids should be driven by the site

and volume of fluid losses.
 • Patient identification is critical to fluid stewardship.

• ROSE/ROS-D model for hemodynamic optimisation

identifies patient in need of IVF.

RIGHT • Need for assessment of fluid responsiveness.

PATIENT • Routine m-IVF therapy is rarely indicated.

• Replacement fluids should be driven by the site

and volume of fluid losses.
  A Patient is considered to be fluid responsive if
their stroke volume increases by at least 10%
FLUID CHALLENGE
after fluid administration (usually 500cc of
crystalloids) as quickly as possible (usually over
10 minutes).

 Only patients who are fluid responsive should

receive additional fluids.

 Patients who have decreased systolic or diastolic

function (on the descending limb of the Frank
Starling curve) will not respond to a fluid
challenge, even if they are intravascularly
depleted.
 STATIC TESTS DYNAMIC TESTS USG BASED
 Less sensitive
 Less specific
 Less useful

CLINICAL STATIC PLR + REAL TIME SV ECHOCARDIOGRAPHY

ENDPOINTS (HR, BP, CRT, UO) MONITORING
END EXPIRATORY
CVP/PCWP OCCLUSION TEST LUNG ULTRSOUND

CXR IVC ULTRASOUND

PiCCO
 STATIC TESTS DYNAMIC TESTS USG BASED
 Less sensitive
 Less specific
 Less useful

CLINICAL STATIC PLR + REAL TIME SV ECHOCARDIOGRAPHY

ENDPOINTS (HR, BP, CRT, UO) MONITORING
END EXPIRATORY
CVP/PCWP OCCLUSION TEST LUNG ULTRSOUND

CXR IVC ULTRASOUND

PiCCO
 • Patient-specific factors and the phase of fluid
management dictate fluid choice.

• Factors to be considered
 Composition
 Osmotic effect
RIGHT  Adverse effects
DRUG  Storage life
 Cost
 UN-BALANCED SOLUTIONS

Do not contain all electrolytes essential for proper body functioning

Concentration of electrolytes is not plasma like

Tonicity of fluids is not isotonic

Do not contain a buffered base

 0.9% NORMAL SALINE
• ITS NOT AT ALL NORMAL

• HYPERTONIC

• ACIDOTIC

•IT’S CHEAP.

•IT’S WHAT WE HAVE ALWAYS DONE.

•EVERYONE IN THE DEPARTMENT USES

IT.

•IT'S HOW I WAS TRAINED.

•IT SEEMS TO WORK.

•THE NURSES START IT AUTOMATICALLY.

0.9% NORMAL
SALINE • CAUSES AND EXACERBATES HYPERCHLOREMIC
ACIDOSIS

• MAY BE DANGEROUS IN HYPERKALEMIA

• HYPERCHLOREMIC ACIDOSIS IS HARMFUL

• NS MAY INCREASE THE NEED OF VASOPRESSORS

• NORMAL SALINE ------- INFLAMMATION

• SALINE – KIDNEY INJURY

 RINGER LACTATE
• VOLUME RESUSCITATION (GREAT FLUID FOR
AGGRESSIVE FLUID REPLACEMENT).

• PROVIDES BODY WITH SODIUM LACATE, which

might act as bioenergetic fuel during ischemic
conditions.

1. THEORETICAL RISK OF HYPERKALEMIA

2. LACTIC ACIDOSIS

3. CANNOT BE USED ALONG WITH BLOOD PRODUCTS

PLASMA-LYTE
 COLLOIDS - ALBUMIN
ALBUMIN 4% ALBUMIN 20%
PREPERATION (4g/100mL) (20g/100mL)

1g human albumin in 25
Concentration mL 1g human albumin in 5 mL

Iso-oncotic with human Hyper-oncotic and hypo-

Description serum and isotonic osmotic to plasma

Hypovolaema and intra- Used in patients with fluid

Uses vascularly depleted and salt restriction
patients
 IV FLUID STEWARDSHIP

RIGHT RIGHT RIGHT RIGHT

PATIENT DRUG ROUTE DOSE
(FLUID)
 FLUID RESUSCITATION
IN HYPOVELOMEIC SHOCK
 HEMORRHAGIC NON-HEMORRHAGIC
HYPOVOLEMIC SHOCK HYPOVOLEMIC SHOCK

1. BLOOD PRODUCTS 1. FIRST LINE : CRYSTALLOID SOLUTION

 Mainstay of therapy in volume loss with
bleeding. 0.9% NS VS BALANCED CRYSTALLOIDS
 Typically PRBC • LACTATED RINGER
 Patient may receive fluids, usually • PLASMALYTE-A
• 0.45% NS + 75 NaHCO3
crystalloid, while waiting for blood
products.
2. SECOND LINE : COLLOID SOLUTIONS
2. BLOOD SUBSTITUTES  ALBUMIN
 Acellular, oxygen carrying fluids.
 When blood is not immediately available.  OTHERS
 When patient refuses blood products

3. AVOID : HYPERTONIC STARCH

 PREVENTION OF
CONTRAST INDUCED NEPHROPATHY
 CALCULATE CCR USING
MDRD or CKD-EPI EQUATION

If <60 ml/min/ If >60 ml/min/

1.73 m2 or AKI 1.73 m2

Drugs to stop 48 hr before HYDRATION NO FURTHER

and reassess 48 hr after D5W 850 ml + 3 amp of 50 MEASURES REQUIRED
procedure based on creat mmol NaHCO3 3ml/kg/hr
 NSAIDs before scan then 1mg/kg/hr
 Metformin for 6 hrs
 Diuretics if feasible Or
 ACEI ?? ARB ?? Isotonic saline 1ml/kg/hr for
Avoid iodinated contrast for 12 hours before scan then 1
next 72 hour if feasible ml/kg/hr for 12 hours
POST-OPERATIVE
FLUID THERAPY
POST-OPERATIVE
FLUID THERAPY
• SIMPLE TO COMPLEX

• ENSURES ADEQUATE ORGAN PERFUSION,

PREVENTS CATABOLISM, ENSURES PH-AND-
ELECTROLYTE BALANCE
 FLUID LOSS IN
POST-OP

THIRD SPACE
BLEEDING DRAINAGE INSENSIBLE LOSS
LOSS
 REPLACEMENT
FLUIDS

BLOOD
CRYSTALLOIDS COLLOIDS
PRODUCTS

0.9% NS ALBUMIN 5%

RINGER
LACTATE

PLASMALYTE
• NORMAL SALINE – particularly useful in cases of chloride and volume loss as well as alkalosis (ex; vomiting).

• NORMAL SALINE – can be used in associatin with blood transfusion, particularly rapid transfusion, because it does not
contain any additives like calcium, potassium, or magnesium. RL & palsmalyte contain these additives, which may not be
compatible with all blood products and can result in redd cell lysis, clot formation in tubing, and electrolyte chelation.

• NORMAL SALINE – is used for head injuries, in whom hypernatremia is preferable to hyponatremia; maintaining a normal
(or liitle elevated) sodium ensures that cerebral edema is minimised.

• AVOID LARGE VOLUMES OF NORMAL SALINE.

• CONSIDER ADDING BICARBONATE TO REPLACEMENT FLUID (pancreatic fistula, bladder-drained pancreas transplant)

• 3% NS – used for the resuscitation of trauma patients whose abdomens are maintained open with a temporary abdominal
closure device.
s should be administered with the sa
on that is used with any intravenous

• TYPE

• DOSE

• INDICATIONS

• CONTRAINDICATIONS

• POTENTIAL FOR TOXICITY

• COST
uid resuscitation is a component of
Complex Physiological process

• Identify the fluid that is most likely to be lost and replace the fluid lost in equivalent
volumes

• Consider serum sodium, osmolarity, and acid-base status when selecting a resuscitation
fluid.

• Consider cumulative fluid balance and actual body weight when selecting the dose of
resuscitation fluid.

• Consider the early use of catecholamines as concomitant treatment of shock

Fluid requirements change over time
In critically ill patients

• Positive fluid balance and pathological edema is associated with an adverse outcome.

• The use of fluid challenge in the post-resuscitation period (> 24 hour) is questionable.

• The use hypotonic maintenance fluids is questionable once dehydration has been
corrected.
ecific considerations apply to differe
Categories of patients
• Bleeding patients require control of hemorrhage and transfusion with red cells and blood components as indicated.

• Isotonic, balanced salt solutions are a pragmatic initial resuscitation fluid for the majority of acutely ill patients.

• Caonsider 0.9% saline in patients with hypovolemia with alkalosis

• Consider albumin during early resuscitation of patients with severe sepsis.

• Saline or isotonic crystalloids are indicated in TBI. Albumin is not recommended in TBI.

• H-starch is not indicated in patients with sepsis or AKI.

• The safety of other semisynthetic colloids has not been established, so the use of these solutions is not indicated.

• The appropriate type and dose of resuscitation fluid in patients with burns has not been determined