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CLINICAL PRACTICE
OF FLUID RESUSCITATION

Ririe F Malisie

The Fluid Management Concept

Specific treatment, necessary in patients with volume (Blood) losses

target: intravascular space

indication: plasma and blood losses
colloid + crystalloid

crystalloid
Fluid replacement
target: tissues, interstitium

Fluid management

Fluid management

Volume replacement

indication: dehydration, maintenance

Basic treatment, necessary in all patients
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Distribution of Fluids
The distribution of fluids within the body
depends on the physico-chemical properties
of the administered solution.
The major properties,
which influence the distribution are:
Colloid osmotic pressure (COP)
Tonicity, i. e. the sodium concentration

share of water: 60 %
IVS
ISS

ICS

Infusion Fluids
Basically we can distinguish two different types of preparations
used
in fluid therapy:

Crystalloids

&

Colloids

Crystalloids are mainly electrolyte solutions like normal

saline (0.9% NaCl), Ringer s solution, or balanced solutions
(eg. Ringerfundin).
Colloids are preparations containing macromolecules like
gelatin (eg. Gelofusine) or hydroxyethyl starches (eg.
Venofundin and Tetraspan).

Targeted fluid compartment in the body

Crystalloids
! They administer fluid MAINLY to the whole extracellular space (ECS),

which is the IVS (intravascular space) and ISS (interstitial space)

Colloids
! They administer fluid MAINLY to the intravascular space (IVS)

Fluid Therapy
Crystalloids

Colloids

Other fluids

Electrolyte
solutions like:

Albumin

Glucose 5%

NaCl 0.9%/ 0,45%

Dextran

Mannitol

Ringer s solution

Gelatin

Electrolyte
concentrates

Lactated Ringer s

HES

Ringerfundin

(Hydroxyethyl

etc.

starch)

Advantages/ disadvantages of crystalloid fluid resuscitation

Advantages

Disadvantages

Balanced electrolyte composition

Buffering capacity, lactate/ acetate
No risk of adverse reactions
No disturbance of hemostasis
Promoting diuresis
Inexpensive

Poor plasma volume support

Large quantities needed
Reduced plasma COP
Risk of overhydration
Risk of edema formation
Risk of hypothermia

Boldt et al. (2004), Table 3.1

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Problems in Colloid Therapy

We are just giving colloidto the patient!
What should happen?
Possible side effects amongst others can be:
! Influence on Renal Function
! Influence on coagulation
! Anaphylaxis reaction
! Tissue accumulation
! Acid base balance disturbances

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Hydroxethylstarch (HES) Classification

(Based on the degree of substitution)
Tetrastarch (0.4)

Pentastarch (0.5)

HES 130 /0.4

HES 130/0.42

HES 200 /0.5

Hetastarch (0.7)

HES 450 /0.7

(Based on In Vitro Molecular weight)

High molecular weight
HES

Medium Molecular weight

HES

HES 450 / 0.7

HES 470 /0.7

HES 200 /0.5

HES 200 /0.62
Hemohes,
Haes-steril,

Low molecular weight

HES
HES 40 /0.5
HES 70 /0,5
HES 110 /0.5
HES 130 /0.4
HES 130/0.42
Voluven
Venofundin
Tetraspan

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Effects of colloids on kidney function

Gelatins:

No negative effect! Improved kidney function!

Dextrans: Renal insufficiency is possible after Dextran 40

HES:

Acute renal failure after HES is possible

Decrease of glomerular
filtration
Dextran
concentration
in proximal
tubuli

Latent
increase of
urine viscosity

Enhanced
flow
resistance

Stop of
filtration

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Effect on coagulation

Gelatins
Factor VIII, vWF

No effect

Platelets
adhesion
aggregation

No effect

Thrombus
formation time
Blood typing

HES

Dextrans

No clinical
effect
No effect

In emergency situations
blood typing prior to infusion

Gelatin dlm dosis besar tidak memperpanjang perdarahan

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Take Home Message

Ringers Ringerplasma 0.9% NaCl solution fundin

Tetraspan
Electrolytes:
sodium, calcium, potassium,
magnesium and chloride
The blood buffer is mainly
composed of bicarbonate acetate/malate are
precursors of bicarbonate.
Plasma proteins keep the
COP of the circulatory system
- this can be taken over by
colloids like HES or Gelatin.
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