Fluid Resuscitation and

Organ Perfusion
Evaluation
Departemen Anestesiologi dan Terapi Intensif
Fakultas Kedokteran UMSU
2014

Body Fluid
The volume of total body fluid (in liters)

Male : 60% of lean body weight (kg)

600 ml/kg
Female: 50% of lean body weight (kg)
500 ml/kg

 A healthy adult male who weighs 75

kg will then have 0.6 75 = 45 liters
of total body fluid
A healthy adult female who weighs
60 kg will have 0.5 60 = 30 liters
of total body fluid

Blood Volume
The volume of blood accounts for 67% of body weight
Male : 66 ml/kg
Female : 60 ml/kg

The volumes of blood 11-12% of

total body fluid

Body Fluid
Body fluid

Men

Women

ml/kg

75 Kg

ml/kg

60 kg

Total body
fluid

600

45 L

500

30 L

Interstitial
fluid

150

11,3 L

125

7,5 L

Blood

66

5L

60

3,6 L

Red Cell

26

2L

24

1,4 L

Plasma

40

3L

36

2,2 L

Plasma and Interstitial

Fluid
Extracellular fluid accounts for about
40% of TBF:
Extravascular (interstitial)
Intravascular (plasma)

Plasma volume is about 25% of

interstitial fluid volume

Physiologic principles of
fluid management

Perdarahan

ISF

IVF

ICF

Compensatory
Responses
earliest
Acute Blood
loss
late

Movement of
interstitial fluid
in to the
bloodstream
Activation of
RAA system

Fully compensate for

the loss of 15-20% BV

Restoring
volume
deficits

10

Trauma 7th Ed, 2013

Clinical Evaluation

Clinical Evaluation
Pulse rate

CNS/men
tal status

Blood
pressure

Clinical
Evaluat
ion
Urine
output

Pulse
pressure

Respirato
ry rate

Postural Changes
Moving from the supine to the standing
position causes a shift of 7 to 8 mL/kg
of blood to the lower extremities
In healthy subjects, this change in
body position is associated with a
small increase in heart rate (about 10
beats/min) and a small decrease in
systolic blood pressure (about 3 to 4
mm Hg)
These changes can be
exaggerated in the
hypovolemic patient

 A significant postural (orthostatic)

change is defined as any of the
following:
an increase in pulse rate of at least 30
beats/minute,
a decrease in systolic pressure > 20 mm
Hg, or dizziness on standing.
The only tests with a sensitivity high enough to
be of any value are postural
dizziness and postural increments in heart rate in
severe blood loss (630 to 1,150 mL of blood).

Hematocrit
The hematocrit (and hemoglobin concentration
in blood) to determine the extent of acute blood
loss is both common and inappropriate.
Acute blood loss the loss of whole blood
the volume of plasma and erythrocytes
hematocrit will not change significantly
Activating RAA system leading to renal
conservation of sodium and water and expansion
of the plasma volume the hematocrit.
This process begins 8 to 12 hours after acute
blood loss

Chemical Markers of
Dysoxia
Two
measures
of
acid-base
balance can provide information
about the adequacy of tissue
oxygenation:
serum lactate concentration
arterial base deficit

Both are used as markers of

impaired tissue oxygenation.

glucose

38 Mol ATP

oksigen

glucose

oksigen

2 Mol ATP
+
36 Mol Lactate

Serum Lactate
> 2 mM/L abnormal.
> 4mM/L more predictive
of increased mortality lifethreatening elevations of
serum lactate

Arterial Base Deficite

The base deficit is the amount (in
millimoles) of base needed to titrate
one liter of whole blood to a pH of
7.40 (at temperature of 37C and
PCO2 = 40 mm Hg).
The normal range for base deficit is
+2 to 22 mmol/L.

 Abnormal elevations in base

deficit are classified
mild 22 to 25 mmol/L
moderate 26 to 214 mmol/L
severe <215 mmol/L.

Resuscitation Strategies

GOAL

Promote cardiac output

Promote oxygen
delivery

Promote aerobic
metabolisme

Promote Hemostasis

END-POINTS
1. CI > L/min/m2
2. MABP > 65 mmHg or < 65
mmHg, if tolerated, untill
bleeding is controlled
3. UOP > 0,5 ml/kg/hr
1. DO2 > 500 ml/min/m2
2. Hb > 7-9 g/dl
3. SaO2 > 90%
1. VO2 > 100 ml/min/m2
2. SvO2 > 70%
3. Serum lactate < 2 mM/L within
24 hr
1. INR < 1,5
2. aPTT < 1,5 x control
3. Platelet count > 50 x 109/L

Promoting Cardiac
Output
The consequences of a low cardiac
output are far more threatening
than the consequences of anemia,
so the first priority in the
bleeding patient is to support
cardiac output.

Resuscitation Fluid
The fluids used to promote cardiac
output:
Crystalloid fluids
Colloid fluids

Plasma provide clotting factors

NOT USED as a volume expander

Crystalloid >< Colloid

CRYSTALLOID FLUIDS
COLLOID FLUIDS
Sodium-rich electrolyte Sodium-rich electrolyte
solutions
solutions
large
Distribute throughout Contain
the extracellular space
molecules do not
the
pass readily out of the
Expand
extracellular volume
bloodstream
Retained molecule
hold water in the
intravascular
compartment
the
Expand
intravascular (plasma)
volume.

Different Type of Resuscitation

Fluid
Type of fluid

Products

Principal use or result

Colloid fluid

Albumin (5%, 25%)

Hetastarch (6%)
Dextrans

Expands the plasma volume

Crystalloid fluid

Isotonic saline
Ringers lactate
Normosol

Expands
volume

the

extracellular

RBC concentrate Packed RBCs

Increases O2 content of blood

Stored plasma

FFP

Provide coagulation factors

Procoagulant
mixture

Cryoprecipitate

Low-volume
fibrinogen

Platelet
concentrate

Pooled platelet
Apharesis platelet

Restores circulating platelet

pool

source

of

Crystallo
id fluids
PRC/
WB

Promoting
Cardiacoutput

Colloid fluids

Colloid fluids are much more

effective than crystalloid for
promoting cardiac output

Physiologic
principles of fluid
management

D5W
3L

13L 5L
750 ml
ISF
ISF

27 L

250 ml

2L

IVF

ICF
Hasanul, 2002

31

Physiologic
principles of fluid
management

25% in
the
cascular
space
75% to
interstiti
al space

RL,NaCl

3L

13L 5L

27 L

2250ml 750 ml
ISF
ISF

IVF

ICF
Hasanul, 2002

32

Physiologic
principles of fluid
management

Albumin5%
1L

13L 5L

100%
in the
vascul
ar
space

27 L

1L
ISF
ISF

IVF

ICF
Hasanul, 2002

33

Physiologic
principles of fluid
management

HES-6%
1L

13L 5L

27 L

1000ml
ISF
ISF

IVF

ICF
Hasanul, 2002

34

Physiologic
principles of fluid
management

Albumin25%
100 cc

Volume expander

13L 5L
400
ISF
ISF

27 L

500
IVF

ICF
Hasanul, 2002

35

Physiologic
principles of fluid
management

Haemac
el
1L

13L 5L

27 L

300ml 700ml
ISF
ISF

IVF

ICF
Hasanul, 2002

36

The Preferred Fluid

Despite the superiority of colloid fluids
over crystalloid fluids for increasing
plasma volume and promoting cardiac
output, crystalloid have been the
preferred
resuscitation
fluid
for
hemorrhagic shock for past 50 years.
The principal reasons
Low cost
Lack of documented survival benefit

The favored crystalloid fluid Ringers

lactate

Standard Resuscitation
Regimen
Steps

Methodes

1. Estimate normal blood volume EBV (M):

(EBV)
ml/kg
2. Estimate % loss of blood volume

Class
Class
Class
Class

66 ml/kg ; (F): 60

I: < 15%
II: 15-30%
III: 30-45%
IV: >45%

3. Calculate blood volume defect BVD = EBV x % loss BV

(BVD)
4. Calculate plasma volume deficit PVD = 0,6 x BVD
(PVD)
5. Estimate resuscitation volume RV= PVD x 1 colloid
(RV)
= PVD x 3 crystalloid

Marino The ICU book 4th Ed 2014

Hemostatic
Resuscitation
Fresh frozen plasma
For the resuscitation of massive
blood loss one unit of FFP for
every one or two units PRC
Source of fibrinogen: 2-5 g/L
Aim: maintainning an INR < 1,5
and aPTT < 1,5 times normal

 Cryoprecipitate
Provide fibrnogen: 3,2-4 grams
in 150-200 ml

Platelets
One unit for every 2-5 units PRC
improved survival rates
Goal: maintain a platelet count
> 50.000/mm3 when bleeding is
active

Respons to Initial Fluid

Resuscitation

41

Trauma 7th Ed, 2013

Trauma 7th Ed, 2013

Trauma 7th Ed, 2013

 All patients with suspected serious

injuries require the placement of two
large-bore peripheral IVs.
Higher flow rates are best achieved
with short, large-diameter catheters.
Peripheral IVs are usually placed in the
upper extremities unless there is
significant
injury
to
the
upper
extremities or upper chest with
vascular or soft tissue compromise.

INTRAVENOUS ACCESS
Peripheral
Upper extremities
Lower extremities

Central
Femoral veins
Subclavian vein
Internal jugular vein

INTRAVENOUS ACCESS
A cutdown of the saphenous
vein in the lower extremity or
basilic or cephalic vein in the
upper extremity
Intraosseous cannulation of
the proximal tibia

Theoretical Maximum Flow Rates

Colour

Gauge

Flow

Yellow

24G

13 ml/min

Blue

22G

30 ml/min

Pink

20G

55 ml/min

Green

18G

80-100 ml/min

White

17G

135 ml/min

Grey

16G

180 ml/min

Orange or Brown

14G

270 ml/min

 At the time of placement, blood

should
be
drawn
for
basic
hematologic and chemistry analysis
and type and cross-matching
The treatment for hypovolemic
shock is fluid resuscitation and
hemorrhage control

Remember, STOP
THE
BLEEDING!!!

 Severely
injured
patients
should
receive a 2-L bolus of warm, isotonic
fluid such as Ringers lactate.
Patients
whose
blood
pressure
responds to this initial fluid bolus can
undergo further work-up for potential
injuries and continued crystalloid
resuscitation.
If blood pressure remains low, blood
should be given

 Recent studies administering a

combination of fresh frozen plasma
and packed red blood cells during
massive improved mortality
The optimum ratio of fresh frozen
plasma to packed red blood cells
under investigation
O-negative blood should
be used until type-specific blood
becomes available

Blood
Blood
Transfusion
Transfusion
CaO2 = SaO2 x Hb x 1.34 +
PaO2x0.0031 ml/dl

DO2 = CaO2 x CO x 10 ml/menit

BLOOD REPLACEMENT
Red blood cells (RBCs)
Packed red blood cells (PRBCs) obtained
from whole blood by:
Centrifugation
Apheresis

PRBCs are anticoagulated with citrate mixed

with a preservative solution up to 42 days at
1-6oC
One unite compatible RBCs 250-300 ml
Ht: 55-65% will increase Hb 1g/dL or Ht 3%
Donor RBCs must be either ABO identical or
compatible

 Platelets (PLT)
WB-PLTs (50 ml) prepared by
centrifugation of WB (4-6 WB PLTs)
Single donor platelets (SDPs)
collected from one single donor
Both preparations are stored 20-24oC
maximum of 5 days of storage
Contain an appreciable volume of
plasma
For each SDP or pool of 6 WB-PLT
30.000-60.000/mm3
ABO matching is not stricly necessary

 Fresh Frozen Plasma (FFP)

Plasma is the remaining part of WB after
removal of platelets and cellular
elements
Frozen within 8 hours prevent
inactivation of factors V and VIII
Before transfusion must be thawed in
water bath at 37oC for 30 minutes
The transfusion must occur within 24
hours
ABO-identical
Dose: 10-15 ml/kg (3 to 5 units)

Coagulation Disturbances In Trauma

Coagulation disturbances following
trauma trimodal pattern,
an immediate hypercoagulable state
Followed quickly by a hypocoagulable
state
and ending with a return to a
hypercoagulable state

Coagulopathy in Trauma
Clotting factor depletion (via
both hemorrhage and
consumption)
Dilution (secondary to
massive resuscitation)
Dysfunction (due to both
acidosis and hypothermia)

transfusi
transfusi
Target

7 - 9g%

Rule
of
5
Rule of 5
mL
WB=
5
x
delta
Hbx
mL WB= 5 x delta Hbx
contoh:
BB
BB

BB 60 kg, Hb 4g%, WB yang dibutuhkan = 5 x (9-4)

x 60
=
1500 mL

Penghangatan Cairan dan Darah

Hangatkan cairan s/d 390 C

Tetesan menjadi lebih cepat (guyur)
Jantung lebih kuat untuk pumping
Oxygen Discociation Curve bergeser
kekanan (unloading)
Mencegah hypothermia cegah shivering

Hangatkan Darah

g
n
Ha

D
n
a
k
t
a

h
a
ar

FILT
ER

koagulopati
Transfusi massif :
> volume darah tubuh /24jam
> 4 unit PRC/ 1 jam
> 50% volume darah / 3jam

dilutional thrombocytopenia

Hypothermia : gangguan agregasi

platelet & clotting cascade koagulopati

Kalsium
Pemberian rutin preparat kalsium (Caglukonas atau Ca-chlorida) pada transfusi
darah tidak dianjurkan lagi.
Dugaan hypocalsemia hanya terjadi bila
transfusi massif dengan darah yang diberi
anti coagulant Na-citrate

Transfusi
Transfusi
Target

7 - 9g%

Rule of - 5

ml Whole-Blood = 5 x delta Hb x BB
contoh:
BB 50 kg, Hb 4g%, WB yang dibutuhkan = 5 x 5 x 50
= 1250 ml
= 5 bag [unit]
Hasanul, 2003

Terima Kasih

Pola kerja penanganan shock perdarahan

Hasanul, 2003

Penderita datang
dengan perdarahan
Pasang infus jarum
kaliber besar (16G,
18G), ambil sample
darah

Ukur tekanan darah,

hitung nadi, nilai perfusi,
produksi urine

Tentukan estimasi
jumlah perdarahan,
minta darah
Guyur cepat Ringer Laktat atau
NaCl 0.9% [hangat, 390C] 3x
evaluasi
prakiraan lost-volume [1-2 liter]
8/8/16

67