Fluid balance and therapy in critically ill
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IV fluids in critically ill patients,composition,osmolarity,uses evidence based
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Fluid balance and therapy in critically ill
- 1. Dr Anand.M.Tiwari F.N.B critical care medicine Intensivist
- 2. Revision of the known facts
- 3. What is the water content of human body? Male female
- 4. 50 to 60% of body weight Higher in neonates and children Lower in elderly Lower in women
- 7. 40% is intracellular. 20% extracellular 15% is interstitial 5% is intravascular 28 L 14L 3.5 L
- 8. Diffusion Facilitated diffusion Active transport Osmosis Osmolality Calculation 2na+glu/18+ bun/2.8 Freezing point depression method
- 9. Hypotonic (cell swells) 200mosm/litre Hypertonic cell shrink –360 mosm/l Isotonic nochange 280mosm/l
- 11. Intracellular Interstitial Intravascular 2/3 1/3 3/4 1/4 ECF osmolality = ICF osmolality K, ATP Creatinine PO4 phospholipids Na, Cl HCO3
- 20. Intake and output must be balanced. Intake---N fluid ingested—2100 +from metabolism(200)=2300ml output—urine-1400+feces(100) -sweat-100 - insensible loses—skin- 350+lungs350ml Subject to variation environmental condition and disease states
- 21. Weight Water requirement 0-10 kg 4mL/kg/hr 10-20 kg 40mL/hr +2ml/kg/hr for each kg>10kg >20kg 60ml/hr +1ml/kg/hr for each kg>20kg for 60kg man this = 100ml/hr or 2400 ml/24 hrs for normal people!!
- 22. Solutions Volumes Na+ K+ Ca2+ Mg2+ Cl- HCO3 - Dextrose mOsm/L ECF 142 4 5 103 27 280-310 Lactated Ringer’ s 130 4 3 109 28 273 0.9% NaCl 154 154 308 0.45% NaCl 77 77 154 D5W 50 250 D5/0.45% NaCl 77 77 50 406 3% NaCl 513 513 1026 6% Hetasta rch 500 154 154 310 5% Albumin 250,500 130 - 1 6 0 <2.5 130-160 330 25% Albumin 20,50,100 130 - 1 <2.5 130-160 330
- 24. Crystalloids relatively large volume for resus Ideal for repleshing third space loss Less fear of allergic reaction Used as diluent for ionotropic adminstration Colloids Lesser volume better expander more duration Allergic reaction seen as well interfearance with blood crossmatch
- 25. R.L hartmen “solution, balanced salt solution Isotonic -isobaric- iso- osmolar- crystalloid solution. Concentrations of ions— Na-131mEq/l calcium-2mEq/l bicarbonate-29mEQ/L AS LACTATE K+ 5MeQ/L, CL- 110mEq/l Ph-6.5,osmolarity-279 mosm/L Normal saline Isotonic isobaric 0.9% w/vsolution Na+/cl- =154mEq/l Ph-5.0 0smolarity -308mosm/L --common maintainence fluid till other are made available ---in treatment of diabetic ketoacidosis—2 litres --upper intestinal obstruction and hypochloremia
- 26. RL-Solutions provides electrolytes with lactate. Lactate is rapidly metabolized in liver to bicarbonate helps in correction of acidosis Mild to moderate hypovolemia due to any cause As a maintainence fluid Preloading before spinal anaesthesia Risk—Lactic acidosis hyperkalemia NS-Only fluid compatible with blood. Flushing of dialysis set with saline Surgeons use for – washing crush injuries peritoneal lavage under water seal bottle Can be used as diluent for medication NS-RISK-Hyperchloraemic metabolic acidosis more likely with renal insufficiency
- 27. FULFILLS INDICATIONS OF BOTH 5% DEX AND .9% SALINE Useful particularly in pediatric patient Safely be used as maintainence fluid. Avoid for surgical procedures as dex best media for bacterial growth Can be used along with blood
- 28. It provides calories –each gm of glucose 4 kcal. --used to correct water deficit --used to correct hypoglycemia --used as carrier for giving drugs dopamine, aminophylline,noradrenaline,insulin,SNP
- 29. Higher concentration is irritant to vien. Avoid extravasation Water intoxication,odema states Should not be given along with blood transfusion Avoid in known hyperglycemic as maintainence fluid
- 30. Hemaccel 3.5% poly gelatin Na 145/cl 145 k-5.1, ca++-6.25mEq/l Mol wt 30,000 pH 7.3 Half life 4-6hr Use in mod to severe shock. Priming solution
- 31. Citrated blood should not be mixed. Produces histamine release/anaphylactic Dose should not increase 1000ml in 24 hrs. Careful in digitalized patient Avoid in hepatic renal and CCF However unlike other colloids does not cause agglutination and Rolex formation
- 32. 6% SOLUTION mol wt-2,00,000da Dose 20ml/kg in 24 h These are hyperoncotic and cause intravascular volume expansion Duration 12-24 hrs The incidence of anphylactoid reaction is low
- 33. IT interferes PL Aggregation and coagulation. Thermo osmalarity-308mosm/l Ability to with draw fluid from interstital space in to intravascular compartment It should be cautiously used in presence of renal failure
- 34. Dextran 40/ rheomacrodex --IT decreases viscosity of blood. --it improves micro circulation. --plasma half life 6-12hrs --dose 20 cc/kg/24hrs --it does not interfere with blood gp and crossmatch
- 35. Accumulation and tissue storage Effects on renal function Coagulopathy and bleeding risk Increase in amylase levels Anaphylactic potentials Cost factors
- 36. New generation colloids-0.4 Molar substitution==degradation factor hydroxyl ethyl group No risk of accumulation even with dosages increased from 20ml/kg---50ml/kg No effects on renal and coagulopathy Quest for the new colloid-- Balanced colloid solution like volulyte will end the debate
- 37. HES therapy was associated with higher HES therapy was associated with higher rates of acute renal failure and renal -replacement therapy than was Ringer’s lactate. N Engl J Med 2008;358:125-39. Copyright © 2008 Massachusetts Medical Society
- 39. What is the first sign of shock? a. Tachycardia b. hypotension c. narrow pulse pressure d. low urine output
- 40. paramet er class1 clqss2 class3 class4 %blood vol/cns <15% anxious 15-30% agitated 30-40% confuse >40% lethargic Pulse rate <100 >100 >120 >140 Supine b.p n n decrease decreas Urine output >30ml/hr .20-30ml 5-15ml <5ml
- 41. Fluid resuscitation in uncontrolled bleeding is deleterious Delayed resuscitation is valid in trauma systems with short response times (<20 minutes to hospital from injury) Attempts to control bleed should be given greater importance
- 42. Fluids (pre-op) 2.4 L 0.4 L (p<0.001) Survival 62% 70% (p=0.04) ARDS/ renal failure 30% 23% (p=0.08) Sepsis/ infection Hospital days 14+24 11+19 (p=0.006) N Engl J Med 1994; 331:1105-1109. 598 patients; penetrating torso injury Field systolic BP <90 mm Hg (58+35) 309 289 Immediate fluids Delayed until induction
- 44. Restores volume +o2 carrying capacity Indicated in severe hemorrhagic shock eg pelvic trauma ,variceal bleed Pre-operative measure Blood products for replenishing coagulation/factors eg FFP, PL Conc,
- 45. Pyrexial reaction,allergy Transmission of disease-syphilis ,viral hepatitis,HIV,malaria Hemolytic reactions Citrate intoxication Hyperkalemia ,hypothermia Volume overload TRIM,TRALI
- 46. PERIPHERIAL INTRACATH 16G Same gauze central line Hagen poiseuille equation rate @{radius} 4th power inversely proportional to length :;; infusion through central catheter will be as much as 75% less than infusion rate through peripheral cathter of equal diameter
- 47. Fluid resuscitation may consist of natural or artificial colloids or crystalloids No evidenced-based support for one type of fluid over another •Crystalloids have a much larger volume of distribution compared to colloids •Crystalloid resuscitation requires more fluid to achieve the same endpoints as colloid •Crystalloids result in more edema Choi PTL. Crit Care Med 1999;27:200-210. Cook D. Ann Intern Med 2001;135:205-208. Schierhout G. BMJ 1998;316:961-964. Fluid Therapy: Choice of FluidFluid Therapy: Choice of Fluid Grade C Dellinger, et. al. Crit Care Med 2004, 32: 858-873.
- 48. Fluid challenge in patients with suspected hypovolemia may be given 500 - 1000 mL of crystalloids over 30 mins 300 - 500 mL of colloids over 30 mins Repeat based on response and tolerance Input is typically greater than output due to venodilation and capillary leak Most patients require continuing aggressive fluid resuscitation during the first 24 hours of management Fluid Therapy: Fluid ChallengeFluid Therapy: Fluid Challenge Grade E Dellinger, et. al. Crit Care Med 2004, 32: 858-873.
- 49. Central venous pressure (CVP) 8–12 mmHg – Mean arterial pressure (MAP) 65 mmHg – Urine output 0.5 ml/kg h1 – Central venous (superior vena cava) or mixed venous oxygen saturation 70%. Rationale. Early goal-directed therapy (EGDT)
- 51. Blood Pressure—not a sensitive marker until blood loss >30% NIBP-spuriously low measurement in patient with hypovolemia (vasoconstrictor response) Direct IAP better ? Cardiac filling pressures CVP—limitation—Indirect measure
- 52. Change in CVP measured before and 5 mins after bolus of fluid ◦0-3 mmHg: underfilled ◦3-5 mmHg: adequately filled ◦5-7 mmHg: overfilled
- 53. 1 a wave is due to atrial contraction 2.c wave due to buldging of tricuspid valve in rt atrium 3 x descent depicts atrial relaxation 4 v due to rise in atrial pressure before the tricuspid valve opens 5 y decent is due to atrial emptying as blood enters ventricles
- 54. Watch out for Systolic pressure variation
Editor's Notes
- No evidence-based support for one type of crystalloid over another No studies that are specific to sepsis population Note: since development of these guidelines the preliminary results of the SAFE (Fluid resuscitation with Albumin vs. Saline) study results have been reported at the Society of Critical Care Medicine National Scientific Meeting held in Feb. 2004. This randomized controlled trial of over 7,000 patients demonstrated that in the subset of severe sepsis patients there was a mortality benefit with albumin over saline (RR .087; CI 0.74-1.02). This data set was locked in late 2003; therefore, final manuscript publication is pending.
- Fluid Challenge describes the initial volume expansion period in which the patient’s response is closely monitored. Fluid Challenge must be clearly separated from an increase in maintenance fluid administration Response may be measured by increase in blood pressure and urine output Tolerance may be measured by evidence of intravascular volume overload Input/output ratio is of no utility to judge fluid resuscitation during this time period