IV Fluid – Friend or Foe?

Professor Brendan Smith .

School of Biomedical Science, Charles Sturt University,
Medical School, University of Notre Dame, Australia,
Bathurst Private Hospital, Bathurst, NSW, Australia.
Choose a number between 1 and 36.

Remember your number…

Or write it down!
iv fluid is used in every hospital on earth every day!
Why?
We need to rehydrate some patients…
Fluid may be life saving…
But does it have to be intravenous fluid?

What about oral

rehydration?
Basic fluid replacement became
massive therapeutic fluid…How?
How did we get from small volumes of fluid to
4, 5, 7+ litres?

The average volume of blood in a 30kg child

= 2.5 litres
The average plasma volume
= 1.5 Litres

Even if there was no plasma left, why

would we ever need more than
1.5L of fluid for initial resuscitation?
“Despite overwhelming data demonstrating the deleterious effects
of aggressive crystalloid-based resuscitation strategies,
large-volume resuscitations continue to be the standard of care”
Bryan Cotton, Shock 2006; 26 (2): 115 - 121
 Adequate replacement of fluid can be
life-saving in hypovolaemia & dehydration.
BUT …
Excessive fluid is really, really,
really, really, really
bad!
Why? Because it leads to multiple
system dysfunction …
 But some patients with septic shock are
“fluid non-responsive”
Which means that some patients show no
response to 40 or 60 ml/kg of fluid

Which is 85 – 130% of their normal plasma

volume!!

If we give 10ml/kg boluses and

4 – 6 boluses produce no lasting benefit …
 The “Fluid
Non-responder”

“If giving 1 or 2 (or 3 or 4) boluses of

normal saline doesn’t result in a
sustained increase in BP or oxygen
delivery, why would the 5th or 6th
bolus give you a different result?”
The curse of “fluid responsiveness”
The curse of “fluid responsiveness”
The curse of “fluid responsiveness”
3 million+ Google hits for fluid responsiveness!!!
The curse of “fluid responsiveness”
Are you going to give
500ml of crystalloid in 10 minutes
to a child?
What about these patients? …
Are clinical signs reliable indicators
of response to fluid?
It depends on their sensitivity to change,
and
on the measurement error of the method …

If the measurement error is large, e.g. 30%

then the change has to be at least 30%
before we can believe it.
 Can you measure a hair
accurately using a ruler?

No, because measurement error is huge!

Sensitivity to Change
Would you dose medication
using these scales?
No – poor sensitivity!
Sensitivity to Change after Fluid Bolus
BP
Pulse Pressure 15% minimum ∆
(BPsystolic – BPdiastolic)
to be reliable
Heart Rate

What about Cardiac Output and Stroke Volume?

Measurement Error of Methods
Swan-Ganz 20 - 30% Any
PiCCO 20 - 40%
NiCOM (Cheetah) 30 - 50%
clinical
ICG 30 - 80% value?
Sensitivity to Change after Fluid Bolus

Echocardiography / Doppler US

Measurement Error = 3 – 10%

Sensitivity to Change = 2 – 5%
Only Doppler-based methods are sensitive
enough for clinical use.
We give the patient 10ml/kg of fluid

The patient responds to the fluid.

So what? What do we do next?

 Starling Curves and Fluid Loading
Stroke 10ml/kg bolus
Volume Healthy
5%

20%

Mild
2% Heart
8% Failure

LVEDV
 So if the patient responded then
a second bolus may overload them!

If the patient was not responsive then

one bolus may not be enough loading!

So how did knowing that the patient was

fluid responsive help us?
If the minimum detectable change is 15%
for BP / PulsePressure / HR
there may be no detectable response
even in a healthy patient!
And…
Swan-Ganz, PiCCO, NiCOM, ICG, CVP
are no better than simple measures…
“If the patient is fluid responsive
then we can give fluid…”

But why?

Responsiveness
is not the same as
Need!
All of us in this room would respond
to a fluid bolus…

but how many of us need one?

None!

Although one of these would be good…

☺
Lets try this a different way…
The reason we use a fluid bolus is…

To increase Stroke Volume

This leads to increased Cardiac Output

Which improves Perfusion

Which increases Oxygen Delivery (DO2)!

But does it?

And even if it does, for how long?

 We can define need easily:
It is the need for an increase in
tissue perfusion and in
tissue oxygenation
(as measured by an increase in
tissue oxygen tension – PtO2)
Does anybody measure PtO2?
But what about duration
30 mins?
1 hour?
2 hours?
DO2 = 1.34 x [Hb] x SaO2 x CO
100
If fluid increases CO then this looks good but…
Fluid reduces haemoglobin concentration
which reduces DO2.
500ml of fluid reduces [Hb] by ~ 20%.
But how much does CO increase?

If ↑CO <20% then we make a loss on the deal,

DO2 !!
 The average increase in CO
in response to 500ml of fluid is –

11%

So in most cases DO2↓

How many patients are fluid responsive?
Multiple (171) studies have consistently shown
only 50% or less of haemodynamically
unstable patients are fluid responsive!

Therefore 50% of patients given a fluid bolus

immediately have reduced DO2,
i.e. they are directly harmed.

Of patients who do respond to fluid

only 50% increase CO by =>20%

After fluid bolus, 75% of patients have !!

How long does a fluid bolus last for?
=>80% of a crytalloid bolus is
extravascular by 60 minutes…
And that’s on a good day!

(FACTT)

CHEST 2015; 1 48 ( 4 ): 919- 926

 FACTT
569 Fluid bolus doses in 127 patients
(for low BP, low urine output, or both)

Only 23% of patients showed CO increase =>15%

Mean increase in MAP at 1 hour = 2mmHg

No change in urine output.

94% had reduced tissue oxygenation at 1 hour.

“Results show that volume expansion with crystalloids
in patients with circulatory shock has limited success
even in (volume) responders.”
MAP increased by 2.9mmHg (3.9%)
[Hb] decreased from 95.9 g/L 91.1g/L (5%)
 Cardiac Index (L/min/m2) over 45 mins

0 15 30 45 mins
“Responders” - 2.9 L/min, 3.55 L/min, 3.1 L/min, 3.0 L/min
Non-responders - 3.4 L/min, 3.6 L/min, 3.3 L/min, 3.2 L/min
 26 patients
250ml crystalloid rapidly
50% “responders”
Maximal CO was at 1.2 minutes post challenge
CO returned to baseline by 10 minutes
 Septic Shock Patients are NOT
volume depleted in most cases.
The fluid is just in the wrong place…
Squeezing with norepinephrine!
Take Home Messages.
1. Crystalloids do not carry oxygen.
2. Crystalloids do not clot.
3. Excess crystalloid is harmful to multiple systems
4. Water in the lungs (EVLW) is called drowning!
5. Crystalloids do not increase CO & DO2
6. Very few early non-responders benefit from further
fluid boluses…
 Conclusions:
Taking all the research together, the number of non-
responders treated with more fluid who show an
increase in DO2 and tissue oxygenation after 1 hour
is…

2.7%
Or about 1 in 36!

What was your number?

And our lucky patient today is…

# 17
The other 35 all lost…
 Conclusion:
Children with septic shock should
receive as much fluid as they need,
But not one drop more!
 But if anybody wants
to know more about
fluid responsiveness
then join me later and
we can discuss it for
hours!!
Terima kasih untuk mendengarkan !