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Principles of intravenous fluid therapy

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Principles of intravenous fluid therapy Jonathan Paddle Consultant in Intensive Care Medicine Royal Cornwall Hospitals NHS Trust 3rd September 2007 – PowerPoint PPT presentation

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Title: Principles of intravenous fluid therapy


1
Principles of intravenous fluid therapy
  • Jonathan Paddle
  • Consultant in Intensive Care Medicine
  • Royal Cornwall Hospitals NHS Trust
  • 3rd September 2007

2

"On the floor lay a girl of slender make and
juvenile height, but with the face of a
superannuated hag... The colour of her
countenance was that of lead - a silver blue,
ghastly tint her eyes were sunk deep into
sockets, as though they had been driven an inch
behind their natural position her mouth was
squared her features flattened her eyelids
black her fingers shrunk, bent, and inky in
their hue In short, Sir, that face and form I
can never forget, were I to live beyond the
period of man's natural age."
3
WILLIAM BROOKE OSHAUGHNESSY Edinburgh graduate,
age 22 from Limerick
  • Investigated cholera outbreak in Sunderland
  • Noted blood ..has lost a large part of its water
    content.. and.. a great proportion of its neutral
    saline ingredients.., leading to venalisation
    (blue, thick and cold) established that the
    stools contained the missing elements in
    proportion
  • Therapeutic conclusions
  • 1. To restore the blood to its natural specific
    gravity
  • 2. To restore its deficient saline matters
  • by the injection of aqueous fluid into the
    veins.

4
She had apparently reached the last moment of
her earthly existence and now nothing could
injure her... Having inserted a tube into the
basilic vein, cautiously, anxiously, I watched
the effects ounce after ounce was injected but
no visible change was produced. Still
persevering, I thought she began to breathe less
laboriously, soon the sharpened features, the
sunken eye and fallen jaw, pale and cold, bearing
the manifest impress of deaths signet, began to
glow with returning animation the pulse, which
had long ceased, returned to the wrist at first
small and quick, by degrees it became more
distinct, fuller, slower and firmer, and in the
short space of half an hour, when six pints had
been injected, she expressed in a firm voice that
she was free from all uneasiness, actually became
jocular, and fancied all she needed was a little
sleep her extremities were warm and every
feature bore the aspect of comfort and health.
This being my first case, I fancied my patient
secure, and from my great need of a little
repose, left her in charge of the Hospital
surgeon

Thomas A Latta, Leith Physician. Lancet June 18th
1832
5

.. But I had not been long gone, ere the
vomiting and purging recurring, soon reduced her
to her former state of disability and she sunk
in five and a half hours after I had left
her I have no doubt, the case would have
issued in complete reaction, had the remedy,
which had already produced such effect, been
repeated.
6
Dr Lattas Saline solution
  • Two to three drachms of muriate of soda (NaCl),
    two scruples of the bicarbonate of soda in six
    pints of water and injected it at temperature 112
    Fah
  • ( approx 58mmol/l Na, 49 mmol/l Cl, 9 mmol/l
    bicarbonate)
  • Ten of the first fifteen patients died

7
The present day
8
Current controversies in fluid therapy
  • How much fluid to give
  • Which fluid to use

9
Assessment of volume status
  • Look at the patient
  • Pulse
  • Blood pressure
  • Capillary refill
  • Mucous membranes
  • Peripheral circulation
  • Thirst

10
Assessment of volume status
  • Try a more invasive approach
  • Urine output
  • Arterial line
  • Central venous line
  • PA catheter
  • Oesophageal doppler

11
Assessment of volume status
  • How about blood tests?
  • UEs
  • Haematocrit
  • Plasma/urine osmolality
  • Arterial blood gases
  • Lactate

12
Assessment of volume status
OK, so the patient needs fluid How much should
we give?
13
Trauma
  • 598 adults with penetrating torso injuries
  • Randomised to standard care or no fluids until
    time of operation

Bickell WH et al. Immediate versus Delayed Fluid
Resuscitation for Hypotensive Patients with
Penetrating Torso Injuries. NEJM 1994 331 1105-9
14
Trauma
  • Cochrane Database of Systematic reviews
  • Six randomised controlled studies
  • No evidence in support or against early
    aggressive fluid resuscitation
  • 52 animal trials hypotensive resuscitation
    reduced risk of death

15
Peri-operative
  • 138 patients undergoing major elective abdominal
    surgery
  • Randomised to one of three groups (one control
    and two goal directed therapy groups

Wilson J et al. Reducing the risk of major
elective surgery randomised controlled trial of
preoperative optimisation of oxygen delivery. BMJ
1999 318 1099-103
16
Peri-operative
  • Goal-directed therapy was aimed at optimising
    oxygen delivery to tissues with
  • Fluids
  • Inotropes
  • Guided by invasive PA catheter monitoring

Extra 1500 ml fluids pre-op
Wilson J et al. Reducing the risk of major
elective surgery randomised controlled trial of
preoperative optimisation of oxygen delivery. BMJ
1999 318 1099-103
17
Peri-operative
Wilson J et al. Reducing the risk of major
elective surgery randomised controlled trial of
preoperative optimisation of oxygen delivery. BMJ
1999 318 1099-103
18
However
  • RCT 172 patients undergoing elective colorectal
    resection
  • Restrictive fluid regime (to maintain neutral
    body weight) vs. standard post-op fluids

Complications 33 versus 51 (P 0.013)
Brandstrup B et al. Effects of intravenous fluid
restriction on postoperative complications
comparison of two perioperative fluid regimens a
randomized assessor-blinded multicenter trial.
Ann Surg. 2003 238(5) 641-8.
19
Early Goal-Directed Therapy in the Treatment of
Severe Sepsis and Septic ShockEmanuel Rivers,
M.D., M.P.H., Bryant Nguyen, M.D., Suzanne
Havstad, M.A., Julie Ressler, B.S., Alexandria
Muzzin, B.S., Bernhard Knoblich, M.D., Edward
Peterson, Ph.D., Michael Tomlanovich, M.D., for
the Early Goal-Directed Therapy Collaborative
Group
Sepsis and the critically ill
  • Volume 345 1368-1377 November 8, 2001

20
Rivers E et al. Early Goal-Directed Therapy in
the Treatment of Severe Sepsis and Septic Shock.
NEJM 2001 345 1368-77
Sepsis and the critically ill
  • 263 patients presenting with severe sepsis
  • Single-centre large American Emergency
    department
  • Randomised to standard therapy or goal-directed
    therapy

21
Protocol group
22
(No Transcript)
23
Treatment given
24
The take-home message!
  • Resuscitate with fluids early and aggressively
  • They wont get overloaded
  • They wont get pulmonary oedema
  • They will be less likely to need ICU
  • Be guided by markers of tissue perfusion
  • Urine output
  • Lactate
  • Consider central venous oxygen saturations

25
FACTT Study
  • Comparison of two fluid management strategies in
    acute lung injury
  • Randomised controlled trial
  • 1001 patients with ARDS or ALI
  • Conservative v liberal fluid therapy
  • Also compared PAC or CVC
  • Mortality at 60 days, vent free days, organ
    failure free days

National Heart, Lung, and Blood Institute Acute
Respiratory Distress Syndrome (ARDS) Clinical
Trials Network Wiedemann HP, Wheeler AP, Bernard
GR, et al. Comparison of two fluid-management
strategies in acute lung injury. N Engl J Med.
20063542564-2575
26
FACTT
  • Fluid restriction 43 hrs post admission
  • 24 hours post ALI/ARDS
  • Renal failure pts excluded
  • Volume replete patients

National Heart, Lung, and Blood Institute Acute
Respiratory Distress Syndrome (ARDS) Clinical
Trials Network Wiedemann HP, Wheeler AP, Bernard
GR, et al. Comparison of two fluid-management
strategies in acute lung injury. N Engl J Med.
20063542564-2575
27
FACTT
  • No significant difference in mortality
  • Restrictive fluid group had
  • Better oxygenation indexes
  • More ventilator free days
  • Less renal failure in conservative group
  • Recommendations Conservative fluid approach
    without PAC
  • But..

National Heart, Lung, and Blood Institute Acute
Respiratory Distress Syndrome (ARDS) Clinical
Trials Network Wiedemann HP, Wheeler AP, Bernard
GR, et al. Comparison of two fluid-management
strategies in acute lung injury. N Engl J Med.
20063542564-2575
28
FACTT
  • Increase in cardiovascular failure days in
    patients in conservative group
  • Caution in fluid depleted patients.
  • Relative young age of patients
  • ? Realistic study population

National Heart, Lung, and Blood Institute Acute
Respiratory Distress Syndrome (ARDS) Clinical
Trials Network Wiedemann HP, Wheeler AP, Bernard
GR, et al. Comparison of two fluid-management
strategies in acute lung injury. N Engl J Med.
20063542564-2575
29
Now for which fluid
30
What is the choice?
Crystalloids Colloids Saline
Albumin Dextrose Gelatins Hartmanns
Starches
31
Fluid distribution
32
Practical differences
Roberts I, Alderson P, Bunn F, P Chinnock, K Ker
and Schierhout G. Colloids versus crystalloids
for fluid resuscitation in critically ill
patients (Cochrane Review). The Cochrane Library,
Issue 4, August 24th, 2004
33
Albumin vs. crystalloid
34
HES vs. crystalloid
35
Gelatin vs. crystalloid
36
Dextran vs. crystalloid
37
There is no evidence from randomised controlled
trials that resuscitation with colloids reduces
the risk of death compared to crystalloids in
patients with trauma, burns and following
surgery. As colloids are not associated with an
improvement in survival, and as they are more
expensive than crystalloids, it is hard to see
how their continued use in these patient types
can be justified outside the context of
randomised controlled trials
38
A Comparison of Albumin and Saline for Fluid
Resuscitation in the Intensive Care Unit The
SAFE Study Investigators 2004 350 2247-2256
39
Study design
  • 16 centres in Australia and New Zealand
  • Randomised, double-blind, trial of 4 albumin
    compared to 0.9 Saline for fluid resuscitation
    in the ICU
  • Study fluid given until death, discharge or 28
    days

40
Study design
  • 6997 Patients enrolled
  • 90 power to detect 3 difference in mortality
    from baseline of 15 mortality
  • A priori sub-groups identified
  • Trauma
  • Severe Sepsis
  • ARDS

41
Fluids administered and effect
42
Outcome
43
Outcome
44
Subgroup Outcome 28 day mortality
45
What about starches?
  • Starches are polymers of glucose
  • a1,6 linkages produce branched chains called
    amylopectins
  • Hydroxyethyl radicals can be substituted on
    glucose units, hence

HYDROXYETHYL STARCH
46
Why might they be useful?
  • Large molecules, so retained in the plasma
  • Stable molecules, so have a sustained effect
  • Some evidence of specific anti-inflammatory
    properties that may be therapeutic

47
Endothelial properties
  • Prospective RCT, single centre
  • 66 patients gt65 years old
  • Major abdominal surgery
  • Ringers lactate (n22)
  • Normal saline (n22)
  • HES 130/0.4 (n22)
  • From induction of anaesthesia until 1st post-op
    day to keep CVP 8-12mmHg

Boldt J. Int Care Med 2004 30 416-22
48
Endothelial properties
Boldt J. Int Care Med 2004 30 416-22
49
Why might they be bad?
  • Potential risk of anaphylaxis
  • Some starch solutions cause coagulation disorders
  • Risk of renal impairment
  • Known incidence of pruritis

50
Incidence of anaphylaxis
  • French multicentre study
  • 49 hospitals
  • 19593 patients
  • Overall 1 in 456 had an anaphylactoid reaction

Laxenaire MC. Ann Fr Anesth Reanim 1994 13
301-10
51
Coagulation disorders
  • Small RCT, 21 patients per group
  • Major abdominal surgery for malignancy
  • Compared blood transfusion requirements according
    to fluid given

Boldt J et al. Br J Anaesth 2002 89 722-8
52
Renal Impairment
Schortgen F, Lacherade J-C, Bruneel F et al.
Effects of hydroxyethylstarch and gelatin on
renal function in severe sepsis a multicentre
randomised study. Lancet 2001 357 911-6
  • 129 patients in three centres
  • Severe sepsis / septic shock
  • 6HES 200/0.6 vs. 3 Gelatin
  • Prospective RCT

53
Renal Impairment
OR 2.57 (1.13 5.83) P0.026
Schortgen F et al. Lancet 2001 357 911-6
54
Renal Impairment
Boldt J, Brenner T, Lehmann A et al. Influence of
two different volume replacement regimens on
renal function in elderly patients undergoing
cardiac surgery comparison of a new starch
preparation with gelatin. Int Care Med 2003 29
763-9
  • 40 patients, single centre
  • HES 130/0.4 vs. Gelatin
  • Prospective RCT

55
Renal Impairment
No significant differences
Boldt J et al. Int Care Med 2003 29 763-9
56
Pruritis
Morgan PW and Berridge JC. Giving long-persistent
starch as volume replacement can cause pruritis
after cardiac surgery.Br J Anaesth 2000 85
696-9.
  • 85 consecutive cardiac patients
  • Structured interview
  • 58 received EloHAES
  • 27 received no HES

57
Pruritis
Morgan PW and Berridge JC. Giving long-persistent
starch as volume replacement can cause pruritis
after cardiac surgery.Br J Anaesth 2000 85
696-9.
  • Pruritis experienced in
  • 13 (22) of EloHAES patients
  • 0 (0) of non-HES patients (P0.007)
  • Median onset (range) 4 (1-12) weeks
  • Greatest duration gt9 months

58
Time to put it all together!
59
How much fluid
  • Trauma
  • Restrictive fluid strategy until bleeding
    controlled
  • Peri-operative
  • Fluids early (?pre-op), then cut back
  • Sepsis
  • Early aggressive fluids to restore perfusion
  • Restrict fluids late to avoid oedema

60
Which fluid
  • It probably doesnt matter!
  • Avoid dextrose (water) as large volumes will be
    required, worsening tissue oedema
  • If using crystalloid, the patient will require
    1.4 times the volume compared to colloid
  • Crystalloid may be better in trauma
  • Colloid (or possibly starches) may be better in
    critically ill / sepsis
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