Upload
mohamed-sember
View
231
Download
5
Tags:
Embed Size (px)
Citation preview
Fluid Management Fluid Management and Shock and Shock
ResuscitationResuscitation
Kallie HoneywoodKallie Honeywood
UBC Anaesthesia PGY-3UBC Anaesthesia PGY-3
OutlineOutline
Normal Fluid RequirementsNormal Fluid Requirements Definition of ShockDefinition of Shock Types of ShockTypes of Shock
– HypovolemicHypovolemic– CardiogenicCardiogenic– DistributiveDistributive– ObstructiveObstructive
Resuscitation FluidsResuscitation Fluids Goals of ResuscitationGoals of Resuscitation
Body Fluid CompartmentsBody Fluid Compartments
Total Body Water = 60% body weightTotal Body Water = 60% body weight– 70Kg TBW = 42 L70Kg TBW = 42 L
2/3 of TBW is intracellular (ICF)2/3 of TBW is intracellular (ICF)– 40% of body weight, 70Kg = 28 L40% of body weight, 70Kg = 28 L
1/3 of TBW is extracellular (ECF)1/3 of TBW is extracellular (ECF)– 20% of body weight, 70Kg = 14 L20% of body weight, 70Kg = 14 L– Plasma volume is approx 4% of total Plasma volume is approx 4% of total
body weight, but varies by age, gender, body weight, but varies by age, gender, body habitusbody habitus
Blood VolumeBlood Volume
Blood Volume Blood Volume (mL/kg)(mL/kg)
Premature InfantPremature Infant 9090
Term InfantTerm Infant 8080
Slim MaleSlim Male 7575
Obese MaleObese Male 7070
Slim FemaleSlim Female 6565
Obese FemaleObese Female 6060
Peri-operative Maintenance Peri-operative Maintenance FluidsFluids
WaterWater SodiumSodium Potassium replacement can be Potassium replacement can be
omitted for short periods of timeomitted for short periods of time Chloride, Mg, Ca, trace minerals and Chloride, Mg, Ca, trace minerals and
supplementation needed only for supplementation needed only for chronic IV maintenancechronic IV maintenance
Most commonly Saline, Lactated Most commonly Saline, Lactated Ringers, PlasmalyteRingers, Plasmalyte
4 – 2 – 1 Rule4 – 2 – 1 Rule
100 – 50 – 20 Rule for daily fluid 100 – 50 – 20 Rule for daily fluid requirementsrequirements
4 mL/kg for 14 mL/kg for 1stst 10 kg 10 kg 2 mL/kg for 22 mL/kg for 2ndnd 10 kg 10 kg 1 mL/kg for each additional kg1 mL/kg for each additional kg
Maintenance Fluids: Maintenance Fluids: ExampleExample
60 kg female60 kg female 11stst 10 kg: 4 mL/kg x 10 kg = 10 kg: 4 mL/kg x 10 kg = 40 mL40 mL 22ndnd 10 kg: 2 mL/kg x 10 kg = 10 kg: 2 mL/kg x 10 kg = 20 mL20 mL Remaining: Remaining: 60 kg – 20 kg = 40 kg60 kg – 20 kg = 40 kg
1 mL/kg x 40 kg = 1 mL/kg x 40 kg = 40 mL40 mL Maintenance Rate = Maintenance Rate = 120 120
mL/hrmL/hr
Fluid DeficitsFluid Deficits
FastingFasting Bowel Loss (Bowel Loss (Bowel Prep, vomiting, diarrheaBowel Prep, vomiting, diarrhea)) Blood Loss Blood Loss
– TraumaTrauma– FracturesFractures
BurnsBurns SepsisSepsis PancreatitisPancreatitis
Insensible Fluid LossInsensible Fluid Loss
EvaporativeEvaporative ExudativeExudative Tissue Edema (surgical manipulation)Tissue Edema (surgical manipulation) Fluid Sequestration (bowel, lung)Fluid Sequestration (bowel, lung) Extent of fluid loss or redistribution (the Extent of fluid loss or redistribution (the
“Third Space”) dependent on type of “Third Space”) dependent on type of surgical proceduresurgical procedure
Mobilization of Third Space Fluid POD#3Mobilization of Third Space Fluid POD#3
Insensible Fluid LossInsensible Fluid Loss
4 – 6 – 8 Rule4 – 6 – 8 Rule Replace with Crystalloid (NS, LR, Replace with Crystalloid (NS, LR,
Plasmalyte)Plasmalyte) Minor: 4 mL/kg/hrMinor: 4 mL/kg/hr Moderate: 6 mL/kg/hrModerate: 6 mL/kg/hr Major: 8 mL/kg/hrMajor: 8 mL/kg/hr
ExampleExample
68 kg female for laparoscopic 68 kg female for laparoscopic cholecystectomycholecystectomy
Fasted since midnight, OR start at 8amFasted since midnight, OR start at 8am Maintenance = 40 + 20 + 48 = 108 Maintenance = 40 + 20 + 48 = 108
mL/hrmL/hr Deficit = 108 mL/hr x 8hrDeficit = 108 mL/hr x 8hr
= 864 mL = 864 mL 33rdrd Space (4mL/kg/hr) = 272 mL/hr Space (4mL/kg/hr) = 272 mL/hr
ExampleExample
Intra-operative Fluid Replacement of:Intra-operative Fluid Replacement of:– Fluid Deficit 864 mLFluid Deficit 864 mL– Maintenance Fluid 108 mL/hrMaintenance Fluid 108 mL/hr– 33rdrd Space Loss 272 mL/hr Space Loss 272 mL/hr– Ongoing blood loss (crystalloid vs. Ongoing blood loss (crystalloid vs.
colloid)colloid)
ShockShock
Circulatory failure leading to Circulatory failure leading to inadequate perfusion and delivery of inadequate perfusion and delivery of oxygen to vital organsoxygen to vital organs
Blood Pressure is often used as an Blood Pressure is often used as an indirect estimator of tissue perfusionindirect estimator of tissue perfusion
Oxygen delivery is an interaction of Oxygen delivery is an interaction of Cardiac Output, Blood Volume, Cardiac Output, Blood Volume, Systemic Vascular ResistanceSystemic Vascular Resistance
DO2
CaO2
CO
Sat %
PaO2
Hgb
HR
SV
Preload
Contractility
Afterload
Types of ShockTypes of Shock
Hypovolemic – most commonHypovolemic – most common Hemorrhagic, occult fluid lossHemorrhagic, occult fluid loss
CardiogenicCardiogenic Ischemia, arrhythmia, valvular, myocardial Ischemia, arrhythmia, valvular, myocardial
depressiondepression
DistributiveDistributive Anaphylaxis, sepsis, neurogenicAnaphylaxis, sepsis, neurogenic
ObstructiveObstructive Tension pneumo, pericardial tamponade, PETension pneumo, pericardial tamponade, PE
Shock StatesShock States
BPBP CVPCVP PCWPPCWP COCO SVRSVR
HypovolemHypovolemiaia
CardiogeniCardiogenic - LVc - LV
- RV- RV
DistributiveDistributive
ObstructiveObstructive
DO2
CaO2
CO
Sat %
PaO2
Hgb
HR
SV
Preload
Contractility
Afterload
Hypovolemic ShockHypovolemic Shock
Most commonMost common TraumaTrauma Blood LossBlood Loss Occult fluid loss (GI)Occult fluid loss (GI) BurnsBurns PancreatitisPancreatitis Sepsis (distributive, relative Sepsis (distributive, relative
hypovolemia)hypovolemia)
Assessment of Stages of ShockAssessment of Stages of Shock% Blood % Blood Volume Volume lossloss
< 15%< 15% 15 – 30%15 – 30% 30 – 40%30 – 40% >40%>40%
HRHR <100<100 >100>100 >120>120 >140>140
SBPSBP NN N, DBP, N, DBP, postural droppostural drop
Pulse Pulse PressurePressure
N or N or
Cap RefillCap Refill < 3 sec< 3 sec > 3 sec> 3 sec >3 sec or >3 sec or absentabsent
absentabsent
RespResp 14 - 2014 - 20 20 - 3020 - 30 30 - 4030 - 40 >35>35
CNSCNS anxiousanxious v. anxiousv. anxious confusedconfused lethargiclethargic
TreatmentTreatment 1 – 2 L 1 – 2 L crystalloid, crystalloid, + + maintenancmaintenancee
2 L 2 L crystalloid, crystalloid, re-evaluatere-evaluate
2 L crystalloid, re-2 L crystalloid, re-evaluate, replace blood evaluate, replace blood loss 1:3 crystalloid, 1:1 loss 1:3 crystalloid, 1:1 colloid or blood products. colloid or blood products. Urine output >0.5 Urine output >0.5 mL/kg/hrmL/kg/hr
Fluid Resuscitation of ShockFluid Resuscitation of Shock
Crystalloid SolutionsCrystalloid Solutions– Normal salineNormal saline– Ringers Lactate solutionRingers Lactate solution– PlasmalytePlasmalyte
Colloid SolutionsColloid Solutions– PentastarchPentastarch– Blood products (albumin, RBC, plasma)Blood products (albumin, RBC, plasma)
Crystalloid SolutionsCrystalloid Solutions
Normal SalineNormal Saline Lactated Ringers SolutionLactated Ringers Solution PlasmalytePlasmalyte Require 3:1 replacement of volume Require 3:1 replacement of volume
lossloss e.g. estimate 1 L blood loss, require e.g. estimate 1 L blood loss, require
3 L of crystalloid to replace volume3 L of crystalloid to replace volume
Colloid SolutionsColloid Solutions
PentaspanPentaspan Albumin 5% Albumin 5% Red Blood CellsRed Blood Cells Fresh Frozen PlasmaFresh Frozen Plasma Replacement of lost volume in 1:1 Replacement of lost volume in 1:1
ratioratio
Oxygen Carrying CapacityOxygen Carrying Capacity
Only RBC contribute to oxygen Only RBC contribute to oxygen carrying capacity (hemoglobin)carrying capacity (hemoglobin)
Replacement with all other solutions Replacement with all other solutions willwill– support volumesupport volume– Improve end organ perfusionImprove end organ perfusion– Will NOT provide additional oxygen Will NOT provide additional oxygen
carrying capacitycarrying capacity
RBC TransfusionRBC Transfusion
BC Red Cell Transfusion Guidelines BC Red Cell Transfusion Guidelines recommend transfusion only to keep recommend transfusion only to keep Hgb >70 g/dL unlessHgb >70 g/dL unless– Comorbid disease necessitating higher Comorbid disease necessitating higher
transfusion trigger (CAD, pulmonary transfusion trigger (CAD, pulmonary disease, sepsis)disease, sepsis)
– Hemodynamic instability despite Hemodynamic instability despite adequate fluid resuscitationadequate fluid resuscitation
Crystalloid vs. ColloidCrystalloid vs. Colloid
SAFE study (Saline vs. Albumin Fluid SAFE study (Saline vs. Albumin Fluid Evaluation)Evaluation)– Critically ill patients in ICUCritically ill patients in ICU– Randomized to Saline vs. 4% Albumin for Randomized to Saline vs. 4% Albumin for
fluid resuscitationfluid resuscitation– No difference in 28 day all cause No difference in 28 day all cause
mortalitymortality– No difference in length of ICU stay, No difference in length of ICU stay,
mechanical ventilation, RRT, other organ mechanical ventilation, RRT, other organ failurefailure
NEJM 2004; 350 (22), 2247- 2256NEJM 2004; 350 (22), 2247- 2256
Goals of Fluid ResuscitationGoals of Fluid Resuscitation
Easily measuredEasily measured
– MentationMentation– Blood PressureBlood Pressure– Heart RateHeart Rate– Jugular Venous PressureJugular Venous Pressure– Urine OutputUrine Output
Goals of Fluid ResuscitationGoals of Fluid Resuscitation
A little less easily measuredA little less easily measured
– Central Venous Pressure (CVP)Central Venous Pressure (CVP)– Left Atrial PressureLeft Atrial Pressure
– Central Venous Oxygen Saturation SCentral Venous Oxygen Saturation SCVCVOO22
Goals of Fluid ResuscitationGoals of Fluid Resuscitation
A bit more of a pain to measureA bit more of a pain to measure
– Pulmonary Capillary Wedge Pressure Pulmonary Capillary Wedge Pressure (PCWP)(PCWP)
– Systemic Vascular Resistance (SVR)Systemic Vascular Resistance (SVR)– Cardiac Output / Cardiac IndexCardiac Output / Cardiac Index
Mixed Venous OxygenationMixed Venous Oxygenation
Used as a surrogate marker of end organ Used as a surrogate marker of end organ perfusion and oxygen deliveryperfusion and oxygen delivery
Should be interpreted in context of other Should be interpreted in context of other clinical informationclinical information
True mixed venous is drawn from the True mixed venous is drawn from the pulmonary artery (mixing of venous blood pulmonary artery (mixing of venous blood from upper and lower body)from upper and lower body)
Often sample will be drawn from central Often sample will be drawn from central venous catheter (superior vena cava, R venous catheter (superior vena cava, R atrium)atrium)
Mixed Venous OxygenationMixed Venous Oxygenation
Normal oxygen saturation of venous Normal oxygen saturation of venous blood 68% – 77%blood 68% – 77%
Low SLow SCVCVOO22
– Tissues are extracting far more oxygen Tissues are extracting far more oxygen than usual, reflecting sub-optimal tissue than usual, reflecting sub-optimal tissue perfusion (and oxygenation)perfusion (and oxygenation)
Following trends of SFollowing trends of SCVCVOO2 2 to guide to guide resuscitation (fluids, RBC, inotropes, resuscitation (fluids, RBC, inotropes, vasopressors)vasopressors)
Goals of ResuscitationGoals of Resuscitation
Rivers Study- Early Goal Directed Rivers Study- Early Goal Directed Therapy in Sepsis and Septic ShockTherapy in Sepsis and Septic Shock– Emergency department with severe Emergency department with severe
sepsis or septic shock, randomized to sepsis or septic shock, randomized to goal directed protocol vs standard goal directed protocol vs standard therapy prior to admission to ICUtherapy prior to admission to ICU
– Early goal directed therapy conferred Early goal directed therapy conferred lower APACHE scores, incidating less lower APACHE scores, incidating less severe organ dysfunctionsevere organ dysfunction
DO2
CaO2
CO
Sat %
PaO2
Hgb
HR
SV
Preload
Contractility
Afterload
Bottom LineBottom Line
Resuscitation of Shock is all about getting Resuscitation of Shock is all about getting oxygen to the tissuesoxygen to the tissues
Initial assessment of volume deficit, Initial assessment of volume deficit, replace that (with crystalloid), and replace that (with crystalloid), and reassessreassess
Continue volume resuscitation to target Continue volume resuscitation to target endpoints endpoints
Can use mixed venous oxygen saturation Can use mixed venous oxygen saturation to estimate tissue perfusion and to estimate tissue perfusion and oxygenationoxygenation
ReferencesReferences
Clinical Anesthesia 3Clinical Anesthesia 3rdrd Ed. Morgan et Ed. Morgan et al. Lange Medical / McGraw Hill, 2002al. Lange Medical / McGraw Hill, 2002
Anesthesiology Review 3Anesthesiology Review 3rdrd Ed. Faust, Ed. Faust, R. Churchill-Livingstone, 2002R. Churchill-Livingstone, 2002
Rivers, E. et al. NEJM 2001; 345 (19): Rivers, E. et al. NEJM 2001; 345 (19): 1368 – 771368 – 77
SAFE Investigators. NEJM 2004; 350: SAFE Investigators. NEJM 2004; 350: 2247 - 562247 - 56