Principles of Intravenous Fluid Therapy for HandoutsPrinciples of Intravenous Fluid Therapy for Handouts

8/23/2019 Principles of Intravenous Fluid Therapy for HandoutsPrinciples of Intravenous Fluid Therapy for Handouts

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Principles of intravenous fluid

therapy

Jonathan Paddle

Consultant in Intensive Care Medicine

Royal Cornwall Hospitals NHS Trust

3rd September 2007


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"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."


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Investigated cholera outbreak in Sunderland:

Noted blood ..has lost a large part of itswater content.. and.. a great proportion of itsneutral saline ingredients.., leading to

venalisation (blue, thick and cold);established that the stools contained themissing elements in proportion

Therapeutic conclusions:1. To restore the blood to its naturalspecific gravity;2. To restore its deficient saline matters

by the injection of aqueous fluid into theveins.

WILLIAM BROOKE OSHAUGHNESSYEdinburgh graduate, age 22 from Limerick


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She had apparently reached the last moment of her earthly existence and nownothing 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 spaceof half an hour, when six pints had been injected, she expressed in a firmvoice 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. LancetJune 18th 1832


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.. 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.


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Two to three drachms of muriate of soda (NaCl), two

scruples of the bicarbonate of soda in six pints of water andinjected it at temperature 112 Fah

( approx 58mmol/l Na, 49 mmol/l Cl, 9 mmol/l bicarbonate)

Ten of the first fifteen patients died

Dr Lattas Saline solution


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The present day


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Current controversies in fluid therapy

How much fluid to give

Which fluid to use


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Assessment of volume status

Look at the patient:

Pulse

Blood pressure

Capillary refill

Mucous membranes

Peripheral circulation Thirst


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Try a more invasive approach:

Urine output Arterial line

Central venous line

PA catheter Oesophageal doppler


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How about blood tests?

U&Es Haematocrit

Plasma/urine osmolality

Arterial blood gases Lactate


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OK, so the patient

needs fluid

How much should

we give?


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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. NEJM1994; 331: 1105-9

50%

55%

60%

65%

70%

75%

Standard Restrictive

Mortality

P=0.04


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Trauma

Cochrane Database of Systematic

reviews

Six randomised controlled studies No evidence in support or against early

aggressive fluid resuscitation

52 animal trials hypotensive resuscitationreduced risk of death


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Peri-operative

138 patients undergoing major elective

abdominal surgery

Randomised to one of three groups (onecontrol 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. BMJ1999; 318: 1099-103


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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


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Peri-operative




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However RCT 172 patients undergoing elective colorectal

resection Restrictive fluid regime (to maintain neutral body

weight) vs. standard post-op fluids

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.

Complications: 33% versus 51% (P= 0.013)


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Early Goal-Directed Therapy in the Treatmentof Severe Sepsis and Septic Shock

Emanuel 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

Volume 345: 1368-1377 November 8, 2001

Sepsis and the critically ill


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Rivers E et al. Early Goal-Directed Therapy in the Treatment of

Severe Sepsis and Septic Shock. NEJM2001; 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


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Protocol group


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Treatment given0-6 hours 7-72 hours 0-72 hours

Fluids (ml)

EGDT 4991 8625 13443

Standard 3499 10602 13358

P value


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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


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FACTT Study

Comparison of two fluid management strategiesin 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 failurefree 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. 2006;354:2564-2575


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FACTT

Fluid restriction 43 hrs post admission

24 hours post ALI/ARDS

Renal failure pts excluded Volume replete patients






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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 approachwithout PAC

But..






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FACTT

Increase in cardiovascular failure days in

patients in conservative group

Caution in fluid depleted patients.

Relative young age of patients

? Realistic study population






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Now for which fluid


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What is the choice?

Crystalloids Colloids

Saline Albumin

Dextrose Gelatins

Hartmanns Starches


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Fluid distribution

Capillary wallCell membrane


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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

Practical differences


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Albumin vs. crystalloid


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HES vs. crystalloid


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Gelatin vs. crystalloid


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Dextran vs. crystalloid


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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


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A Comparison of Albumin and

Saline for Fluid Resuscitation inthe Intensive Care Unit

The SAFE Study Investigators

2004; 350: 2247-2256


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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


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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


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Total administered study fluid

Albumin Saline Ratio2247 ml 3096 ml 1 : 1.4

Fluids administered and effect


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Outcome

ALBUMIN SALINERelative risk

(95% CI)

Absolute diff

(95% CI)P value

28 day

mortality

726/3473

(20.9%)

729/3460

(21.1%)

0.99

(0.91 to 1.09)0.87

ICU LOS(days)

6.5 6.6 6.2 6.2 0.24(-0.06 to 0.54)

0.44

Hospital LOS

(days)15.3 9.6 15.6 9.6

-0.24

(-0.70 to 0.21)0.30

Duration of

mech. Vent. 4.5 6.1 4.3 5.7

0.19

(-0.08 to 0.47) 0.74

Duration of

RRT0.48 2.28 0.39 2.0

0.09

(-0.0 to 0.19)0.41


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Outcome


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Subgroup Outcome: 28 day mortality

ALBUMIN SALINERelative risk

(95% CI)P value

Trauma 81/596(13.6%)

59/590(10.0%)

1.36(0.99 to 1.86)

0.06

Severe Sepsis185/603

(30.7%)

217/615

(35.3%)

0.87

(0.74 to 1.02)0.09

ARDS

24/61

(39.3%)

28/66

(42.4%)

0.93

(0.61 to 1.41) 0.72


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What about starches?

Starches are polymers of

glucose

1,6 linkages produce

branched chains calledamylopectins

Hydroxyethyl radicals can

be substituted on glucose

units, hence

HYDROXYETHYL STARCH


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Why might they be useful?

Large molecules, so retained in the

plasma

Stable molecules, so have a sustainedeffect

Some evidence of specific anti-

inflammatory properties that may be

therapeutic


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Endothelial properties

Prospective RCT, single centre

66 patients >65 years old

Major abdominal surgery

Ringers lactate (n=22)

Normal saline (n=22)

HES 130/0.4 (n=22)

From induction of anaesthesia until 1stpost-op day to keep CVP 8-12mmHg

Boldt J. Int Care Med2004; 30: 416-22


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Endothelial properties

Boldt J. Int Care Med2004; 30: 416-22


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Why might they be bad?

Potential risk of anaphylaxis

Some starch solutions cause

coagulation disorders

Risk of renal impairment

Known incidence of pruritis


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Incidence of anaphylaxis

French multicentre

study

49 hospitals

19593 patients Overall 1 in 456 had

an anaphylactoid

reaction

0.00

0.10

0.20

0.30

0.40

0.50

Gelatin Dextran Albumin Starch

%ageofanaphylactoid

reaction

Laxenaire MC.Ann Fr Anesth Reanim 1994; 13: 301-10


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Coagulation disorders

Boldt J et al. Br J Anaesth 2002; 89: 722-8

0

500

1000

1500

2000

Post op 5 hr 1st day 2 day (tot)

RL HES 140/0.4 Hextend

*

*

**

Small RCT, 21 patients

per group

Major abdominal surgeryfor malignancy

Compared blood

transfusion requirements

according to fluid given


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Renal Impairment

129 patients in three centres

Severe sepsis / septic shock

6%HES 200/0.6 vs. 3% Gelatin

Prospective RCT

Schortgen F, Lacherade J-C, Bruneel F et al. Effects ofhydroxyethylstarch and gelatin on renal function in severe sepsis:

a multicentre randomised study. Lancet2001; 357: 911-6


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Renal Impairment

Schortgen F et al. Lancet2001; 357: 911-6

OR 2.57 (1.13 5.83) P=0.026


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Renal Impairment

40 patients, single centre

HES 130/0.4 vs. Gelatin

Prospective RCT

Boldt J, Brenner T, Lehmann A et al. Influence of two differentvolume replacement regimens on renal function in elderly

patients undergoing cardiac surgery: comparison of a new

starch preparation with gelatin. Int Care Med2003; 29: 763-9


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Renal Impairment

Boldt J et al. Int Care Med2003; 29: 763-9

No significant differences


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Pruritis

85 consecutive cardiac patients Structured interview

58 received EloHAES

27 received no HES

Morgan PW and Berridge JC. Giving long-persistent starch asvolume replacement can cause pruritis after cardiac surgery.

Br J Anaesth 2000; 85: 696-9.


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Pruritis

Pruritis experienced in: 13 (22%) of EloHAES patients

0 (0%) of non-HES patients (P=0.007)

Median onset (range) 4 (1-12) weeks

Greatest duration >9 months

Morgan PW and Berridge JC. Giving long-persistent starch asvolume replacement can cause pruritis after cardiac surgery.

Br J Anaesth 2000; 85: 696-9.


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Time to put it all together!


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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


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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) maybe

better in critically ill / sepsis

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Principles of Intravenous Fluid Therapy for HandoutsPrinciples of Intravenous Fluid Therapy for Handouts