RESUSCITATION FLUIDSreview article

Critical Care Medicine

SR Finfer, JL Vincent

The new england journal of medicine2013

INTRODUCTION

• Fluid resuscitation ubiquitous intervention in acute medicine– Selection and use based on physiological

principles – Clinical practice clinician preference marked

regional variation

• No ideal resuscitation fluid exists

• Albumin reference colloid solution– Cost is a limitation to its use– Associated with increased mortality among patients with

traumatic brain injury

• Hydroxyethyl starch (HES)– increased rates of renal-replacement therapy

• There is no evidence to recommend the use of other semisynthetic colloid solutions

• Normal saline – associated with the development of metabolic acidosis and

AKI

• All resuscitation fluids – formation of interstitial edema (if used excessively)

• The selection of the specific fluid – based on indications, contraindications, and potential toxic

effects

HISTORY

• 1832, Robert Lewins – effects of the IV administration of alkalinized salt

solution to pts during cholera pandemic

• 1885, Sidney Ringer– physiologic salt solution children with gastroenteritis

• 1941 – blood fractionation human albumin

PHYSIOLOGY OF FLUID RESUSCITATION

• 1896, Ernest Starling

– Capillaries and postcapillary venules semipermeable membrane absorbing fluid from the interstitial space

– hydrostatic and oncotic pressure principal determinants of transvascular exchange

• Recent descriptions questioned these classic models

– A web of membrane-bound glycoproteins and proteoglycans on the luminal side of endothelial cells has been identified as the endothelial glycocalyx layer

The structure and function of the endothelial

glycocalyx layer are key determinants of membrane

permeability

THE IDEAL RESUSCITATION FLUID

• Produces a predictable and sustained increase in intravascular volume

• chemical composition as close as possible to that of extracellular fluid

• metabolized and completely excreted without accumulation in tissues

• No adverse metabolic or systemic effects

• Resuscitation fluids colloid and crystalloid

• Colloid – relatively incapable of crossing the healthy semipermeable capillary membrane

• Crystalloids – freely permeable– contain sodium and chloride determine the tonicity of the fluid– Inexpensive

• volume-sparing effect – Colloid > crystalloid– 1:3 ratio

TYPES OF RESUSCITATION FLUID

• wide variation in clinical practice

• The choice regional and clinician preferences– Institutional protocols– Availability– Cost– Commercial marketing

• Recommendations – Based largely on expert opinion– Low quality clinical evidence

• Resuscitation with one type of fluid as compared with another / Any solution is more effective or safer than any other

LITTLE EVIDENCE

• Albumin

– Human albumin (4 to 5%) in saline reference colloidal solution

– 1998, Meta-analysis albumin vs crystalloid in burns,hypovolemic,hypoalbuminemia pts • Significant increase in the rate of death

– 2004, Saline versus Albumin Fluid Evaluation (SAFE) RCT study albumin 4% vs saline

• No significant difference to the rate of death in 28d

• Significant increase in the rate of death at 2 years in pts with traumatic brain Injury

• Decrease in the adjusted risk of death at 28 days in patients with severe sepsis

– In acute illness hemodynamic effects and effects on patient-centered outcomes of albumin equivalent to saline.

• Semisynthetic Colloids

– HES solutions– Succinylated gelatin– Urealinked gelatin–polygeline preparations– Dextran solutions

• HES solutions – amylopectin obtained from sorghum,maize, or

potatoes

– accumulate in reticuloendothelial tissues skin (resulting in pruritus), liver, and kidney

– alterations in coagulation

– Study reports (10%) HES solutions pts with severe sepsis ↑ rate of death, AKI, Renal replacement therapy

– Currently used (6%) HES solutions • first-line resuscitation fluids in military theaters,

and in pts in the ICU• maximal daily dose 33-50 ml/kg/day

• Scandinavian RCTs pts with severe sepsis (6%) HES solutions vs Ringer acetate – ↑ rate of death at 90 days– ↑ 35% rate of renal-replacement therapy

• Crystalloid versus Hydroxyethyl Starch Trial (CHEST) RCTs – No significant difference in the rate of death at 90 days– ↑ 21% rate of renal-replacement therapy

• gelatin or polygeline preparations – Lack of high quality RCTs

• The use of semisynthetic colloids for fluid resuscitation in critically ill patients is difficult to justify

• Crystalloids– Normal (0.9%) saline most commonly used• strong ion difference (SID) zero• administration of large volumes hyperchloremic

metabolic acidosis

Chemical composition that approximates extracellular fluid “balanced” or “physiologic” solutions Hartmann’s and Ringer’s solutions

– Balanced salt solution • lower sodium concentration

• alternative anions lactate, acetate, gluconate, and malate

• Sodium lactate hyperlactatemia, metabolic alkalosis, and hypotonicity

• Acetate cardiotoxicity

• Calcium microthrombi with citrate containing red-cell transfusions

• Balanced salt solutions – recommended as first-line resuscitation fluids

– Studies Balanced salt solutions vs Normal saline • ↓ incidence of

– postoperative infection– renal-replacement therapy– Acute Kidney Injury– blood transfusion– acidosis-associated investigations

DOSE AND VOLUMES

• The requirements for and response to fluid resuscitation Vary greatly

• Systolic hypotension and oliguria – triggers to “fluid challenge” , 200 to 1000 ml of crystalloid

or colloid for adult pts

• Hypotonic “maintenance” fluids – Cumulative of sodium and water development of

interstitial edema with resultant organ dysfunction

CONCLUSIONS

Although the use of resuscitation fluids is one of the most common interventions in medicine, no currently available resuscitation fluid can be considered to be ideal

THANK YOU

HOW TO UNDERSTAND ACID-BASEA quantitative Acid-Base Primer

For Biology and Medicine Peter A. Stewart

Edward Arnold, London 1981

Stewart PA, 1981

Henderson-Hasselbalch Stewart’s Approach

Gamblegram

Na+

K+ 4Ca++Mg++

Cl-

HCO3-

KATION ANION

SID

STRONG ION DIFFERENCE & WEAK ACID

= {[Na+] + [K+] + [kation divalen]} - {[Cl-] + [As.organik kuat-]}

As. Organik kuat

Weak acid(Alb-,P-)

SID

ClNa

Hubungan SID dgn pH/H+

SID(–) (+)

[H+] ↑↑ [OH-] ↑↑

Dalam cairan biologis (plasma) dgn suhu 370C, SID selalu positif, nilainya berkisar 30-40 mEq/Liter

Asidosis Alkalosis

Konsentrasi H+

Na

SID↓

Cl NaCl

SID↑SID

Na140

KMgCa

Cl102

PO4

Alb

SID = 34

Cl 115

AlbPO4

SID

Asidosis hiperklor

Cl102

Laktat/keto

Asidosis Keto/laktat

CL 95

AlbPO4

Alkalosis hipoklor

SID SID

in SID and Weak Acid

PO4

Alb

Normal

Cl102

SID

Alkalosis hipoalb/ fosfat

Cl102

SID

Alb/PO4

Asidosis hiperalb/

fosfat

George, 2003

Na+ = 140 mEq/LCl- = 102 mEq/LSID = 38 mEq/L

Na+ = 154 mEq/LCl- = 154 mEq/LSID = 0 mEq/L1 liter 1 liter

PLASMA + NaCl 0.9%

SID : 38 pH normal

Plasma NaCl 0.9%

Na+ = 140 mEq/L Cl- = 102 mEq/L SID= 38 mEq/L

Cation+ = 137 mEq/L Cl- = 109 mEq/L

Laktat- = 28 mEq/L SID = 0 mEq/L

1 liter 1 liter

PLASMA + Larutan RINGER LACTATE

SID : 38

Plasma Ringer laktatLaktat cepat dimetabolis

me