Update Fluid Resuscitation

Management
in
Emergency Cases

Prof. dr. Achsanuddin Hanafie, SpAn, KIC, KAO

Departemen/SMF-Anestesiologi dan Terapi Intensif
FK-USU/RSUP Haji Adam Malik Medan
 Physiology
TOTAL BODY FLUID 60% BW (50 L)

INTRACELLULAR EXTRACELLULAR
20% BW (15L)
FLUID (ICF) FLUID (ECF)
40 % BW (35 L)

INTRAVASCULAR INTERSTITIAL
FLUID (PLASMA) FLUID
5 % BW (3,5 L) 15 % BW (11,5 L)
 Composition of the body compartments

Perioperative fluid shifting towards the interstitial space is fact, whereas the classical
third space is fiction
EFFECTS OF RAPID
LOSS OF 2 LITERS
OF ISOTONIC FLUID.

FOR EXAMPLE,
HEMORRHAGE THAT
OCCURS IN 15 OR 30
MINUTES.

SHOCK
EFFECTS OF SLOW LOSS OF 2
LITERS OF ISOTONIC FLUID.

FOR EXAMPLE, DIARRHEA

THAT OCCURS OVER A 6 - 12
HPI PERIOD. THE LOSS IS NOW
SHARED BY THE ENTIRE
EXTRACELLULAR SPACE.

MILD
DEHYDRATION
EFFECTS OF SLOW LOSS
OF 4 LITERS OF ISOTONIC
FLUID.
DIARRHEA OR VOMITING
WOULD STILL BE GOOD
EXAMPLES, BUT NOW THE
SLOW LOSS IS OF GREATER
MAGNITUDE.
HEMODYNAMICS WOULD
STILL BE PRESERVED, BUT
THE INTERSTITIAL
RESERVOIR IS SEVERELY
DEPLETED.

SEVERE DEHYDRATION
EFFECTS OF SLOW LOSS
OF SIX LITERS OF
ISOTONIC FLUID.
ASSUMING NO REPLACEMENT
HAS BEEN GIVEN, A LOSS OF
THAT MAGNITUDE OVER SIX OR
EIGHT HOURS WOULD SEVERELY
COMPROMISE BOTH
INTERSTITIAL PLUS
INTRAVASCULAR SPACES.

SEVERE DEHYDRATION
PLUS SHOCK
 Reasons IV Fluids are Given

Resuscitation

Adequate replacement,
no ongoing losses

Replacement Maintenance
Inadequate maintenance,
ongoing losses
 Unbalanced
Treatment Choices for Fluid Management
Fluid Management

Crystalloid Colloid

Natural Synthetic Synthetic

Unbalanced Balanced balanced unbalanced
Sodium Ringer’s Lactate Human HES HES
Chloride Ringer’s Acetate Albumin Gelatin Dextran
0.9% Hartmann’s
FFP Gelatin

Different fluids with different modes of action,

and different side effects
PENYEBAB HYPOVOLEMIA

 HEMORRHAGIC

 NON - HEMORRHAGIC
 HEMORRHAGIC
 Trauma
 Vascular
 Gastrointestinal
 Retro peritoneal
 Obstetric and Gynecology
 PERKIRAAN KEHILANGAN DARAH
KELAS 1 KELAS 2 KELAS 3 KELAS 4

Kehilangan darah (ml) Sampai 750 750 - 1500 1500 - 2000 > 2000

Kehilangan darah
Sampai 15 % 15 – 30 % 30 – 40 % > 40 %
(% volume darah)
Denyut Nadi ( x / menit ) < 100 > 100 > 120 > 140

Tekanan Darah Normal Normal Menurun Menurun

Tekanan Nadi Normal atau Naik Menurun Menurun Menurun

Frekwensi Pernafasan
14 - 20 20 - 30 30 - 40 > 35
( x / menit )
Produksi urine (ml/jam) > 30 20 - 30 5 – 15 Tidak berarti

CNS (Status Mental) Sedikit Cemas Agak Cemas Cemas, Bingung Bingung, Lesu

Penggantian Cairan Kristaloid dan Kristaloid dan

Kristaloid Kristaloid
(Hukum 3 : 1) Darah Darah
 NON-HEMORRHAGIC

1. External Fluid Loss 2. Interstitial Fluid

 Dehydration Redistribution
 Vomiting  Thermal injury
 Diarrhea  Trauma
 Polyuria  Anaphylaxis

3. Increased Vascular Capacitance

 Sepsis
 Anaphylaxis
 Toxins / Drugs
 Tanda-tanda defisit cairan ekstraselular
RINGAN SEDANG BERAT
• CNS
• Respon baik • Mengantuk • Refleks tendon
• Apatis • Anestesi pada akral
• Respon lambat • Stupor
• Anoreksia • Koma
• Aktifitas turun
• Sianosis
•KARDIOVASKULAR
• Takikardia • Takikardia • Hipotensi
• Hipotensi • Akral dingin
• Nadi lemah • Nadi tak-teraba
• Vena kolaps • Detak jantung jauh
• JARINGAN • Mukosa lidah
• Lidah kecil, • Atonia
kering
• Turgor lunak, keriput • Mata cowong
• Turgor • Turgor

•URINE • Pekat, turun

• Pekat • Oliguria
• DEFISIT • 3 – 5 % BB •6 – 8 % BB • 10 % BB
PRE – HOSPITAL and EMERGENCY ROOM
Early evacuation
Temporary hemostatic control
Early hemostatic resuscitation
Permissive hypotension

OPERATING ROOM
Abbreviated surgical procedure

INTENSIVE CARE UNIT

Correction of physiology

OPERATING ROOM
Defenitive Surgical
 The Management of Hypotension Shock in the Trauma Patient

If definitive care is not available in your facility make early contract with retrieval services
Primary Survey
Includes organising the trauma team, calling the surgeon and notifying the blood bank
Also consider early call to Retrieval Services (AMRS “Formally MRU”)

Exposure/
Airway/C-spine Breathing Circulation Disability
Environment
Adjuncts

• Protect airway secure • Definitive • Secure venous • Assess • Undress • X-ray

if unstable control of access x 2 large neurological status patient • Chest
• Airway adjunct as airway • Blood • AVPU • Maintain • Pelvis
needed • Oxygen • X match • Alert temperature • Lateral
• Control of C-spine • FBC • Resounds to C-Spine
• Creatine vocal stimuli
• ABG’s • Responds to
• Blood painful stimuli
ETOH • unresponsive
• Control
external
bleeding
 Remember – BP and HR will not identify all trauma patients who are in shock
Assess – History and perfusion Indices – ABG’s, Base deficit, lactate, HB and HCT

Perform secondary survey NO SIGNS OF SHOCK?

YES
Identify the source of haemorrhage
External Long bones Chest X-ray Abdomen Retroperitonium
Careful visual Careful visual Chest X-ray DPA and/or Fast Pelvic X-ray
inspection inspection
* Diagnostic Peritoneal Aspiration (DPA)
> 10 ml of frank blood = positive DPA
** Focused abdominal Sonography in Trauma (FAST).
Free Fluid = Positive Fast
Interventions
External Long bones Chest X-ray Abdomen Retroperitonium
Careful visual Splint +/- reduce#t Chest tube Emergency laparotomy Externally stabilise
inspection pelvis
Emergency angiogram
 CRYSTALLOID COLLOID

RL Albumin
RA Plasma
RSol Dextran
NaCl 0.9 % Gelatin
HES
Crystalloid
 Crystalloid adalah terminology yang
digunakan untuk cairan yang tidak
mengandung molekul molekul besar,
sehingga tidak memiliki kekuatan (tekanan)
onkotik (tekanan onkotik = 0)
Colloid
 Colloid adalah terminology yang digunakan
untuk cairan yang mengandung molekul
molekul besar (≥ 30.000 D) sehingga
memiliki tekanan onkotik  menjaga air
tetap dalam kompartemen intravaskular.
ADVANTAGES
Balanced electrolyte composition
Buffering capacity (lactate/acetate)
No risk of adverse reaction
Minimal effect on haemostasis
Promoting diuretics
Inexpensive
DISADVANTAGES / RISK

Poor plasma volume support

Large volume needed
Overhydration / edema formation
Reduced plasma COP (Colloid Oncotic Pressure)
Hypothermia
 COLLOID
ADVANTAGES
Good intravascular persistence
Moderate volume required
Plasma COP moderately altered
Minor risk of tissue oedema
Enhanced microvascular blood flow
Moderation of SIRS
DISADVANTAGES / RISK
Volume overload
Disturbed haemostasis
Tissue accumulation
Adverse effects on renal function
Anaphylactoid reaction
More expensive
 Physiologic principles of
fluid management
hypotonic

Not for
D5W= H2O
resuscitation !!!
3L
EDEMA

3L 24 L
9L 2L
750 ml 250 ml
ISF
ISF IVF ICF
Physiologic principles
of fluid management Isotonic fluid
Membutuhkan volume
yang lebih besar, CRYSTALLOID
Lebih murah, RL, RA, RSol
3L
Side effek lebih kecil
NaCl 0.9%
edema intersitiel

9L 3L 24 L
2250ml 750 ml
ISF
ISF IVF ICF

Edema perifer pada pasien trauma atau post operatip , tidak

merupakan tanda adekuatnya volume intravaskular
Physiologic
principles of fluid
management

Albumin-5%
expensive 1L

9L 3L 24 L
1L
ISF
ISF IVF ICF
Physiologic principles
of fluid management

Albumin-25%
expensive 100 ml

VOLUME
EXPANDERS

9L 3L 24 L
400 500 ml
ISF
ISF IVF ICF
Physiologic principles
of fluid management
•Lebih cepat mengkoreksi
volume intra vaskular HES-6%, 200/0.5
•Mempertahankan tekanan HES-6%, 130/0,4
onkotik intravaskular 1L
•Lebih mahal dari
kristalloid

9L 3L 24 L
1L
ISF
ISF IVF ICF
 Physiologic principles of
fluid management
•Lebih cepat mengkoreksi
volume intra vaskular
POLYGELINE
•Mempertahankan tekanan (HAEMACCEL)
onkotik intravaskular 1 Liter
•Lebih mahal dari
kristalloid
• sebagian shift ke ISC

9L 3L
24 L
300 700 ml

ISF
ISF IVF ICF
Physiologic principles
of fluid management
•Lebih cepat mengkoreksi
volume intra vaskular GELATIN
(GELOFUSINE)
•Mempertahankan tekanan
1 Liter
onkotik intravaskular
•Lebih mahal dari
kristalloid

3L
9L 24 L
1000
ml
ISF
ISF IVF ICF
Physiologic principles
of fluid management
•Lebih cepat mengkoreksi Dextran - 40
volume intra vaskular
Dextran - 70
•Mempertahankan tekanan
1L
onkotik intravaskular
• volume expand
•Coagulopathy

9L 3L 24 L
260 1600 340

ISF
ISF IVF ICF
 Unbalanced
Treatment Choices for Fluid Management
Fluid Management

Crystalloid Colloid

Natural Synthetic Synthetic

Unbalanced Balanced balanced unbalanced
Sodium Ringer’s Lactate Human HES HES
Chloride Ringer’s Acetate Albumin Gelatin Dextran
0.9% Hartmann’s
FFP Gelatin

Different fluids with different modes of action,

and different side effects
PENYEBAB HYPOVOLEMIA

 HEMORRHAGIC

 NON - HEMORRHAGIC
 HEMORRHAGIC
 Trauma
 Vascular
 Gastrointestinal
 Retro peritoneal
 Obstetric and Gynecology
 PERKIRAAN KEHILANGAN DARAH
KELAS 1 KELAS 2 KELAS 3 KELAS 4

Kehilangan darah (ml) Sampai 750 750 - 1500 1500 - 2000 > 2000

Kehilangan darah
Sampai 15 % 15 – 30 % 30 – 40 % > 40 %
(% volume darah)
Denyut Nadi ( x / menit ) < 100 > 100 > 120 > 140

Tekanan Darah Normal Normal Menurun Menurun

Tekanan Nadi Normal atau Naik Menurun Menurun Menurun

Frekwensi Pernafasan
14 - 20 20 - 30 30 - 40 > 35
( x / menit )
Produksi urine (ml/jam) > 30 20 - 30 5 – 15 Tidak berarti

CNS (Status Mental) Sedikit Cemas Agak Cemas Cemas, Bingung Bingung, Lesu

Penggantian Cairan Kristaloid dan Kristaloid dan

Kristaloid Kristaloid
(Hukum 3 : 1) Darah Darah
 NON-HEMORRHAGIC

1. External Fluid Loss 2. Interstitial Fluid

 Dehydration Redistribution
 Vomiting  Thermal injury
 Diarrhea  Trauma
 Polyuria  Anaphylaxis

3. Increased Vascular Capacitance

 Sepsis
 Anaphylaxis
 Toxins / Drugs
 Tanda-tanda defisit cairan ekstraselular
RINGAN SEDANG BERAT
• CNS
• Respon baik • Mengantuk • Refleks tendon
• Apatis • Anestesi pada akral
• Respon lambat • Stupor
• Anoreksia • Koma
• Aktifitas turun
• Sianosis
•KARDIOVASKULAR
• Takikardia • Takikardia • Hipotensi
• Hipotensi • Akral dingin
• Nadi lemah • Nadi tak-teraba
• Vena kolaps • Detak jantung jauh
• JARINGAN • Mukosa lidah
• Lidah kecil, • Atonia
kering
• Turgor lunak, keriput • Mata cowong
• Turgor • Turgor

•URINE • Pekat, turun

• Pekat • Oliguria
• DEFISIT • 3 – 5 % BB •6 – 8 % BB • 10 % BB
 CHANGES OF THE DIFFERENT FLUID COMPARTMENTS
WHEN USING DIFFERENT FLUID-REPLACEMENT
STRATEGIES

Compartment Glucose 5% Crystalloid Colloids

Intravascular ↑ ↑ ↑↑↑

Interstitial ↑↑ ↑↑ -

Intracellular ↑↑↑ - -
 Goals for fluid resucitation
Achievement of normovolemia and hemodynamic stability
Correction of major acid-base disturbances
Compensation of fluxes from the interstitial/intracellular
compartments
Improvement of microvascular blood flow
Prevention cascade system activation
Normalisation of oxygen delivery to tissue cells and cell
metabolism
Prevention of reperfusion injury
 Basic Considerations
• Fluid therapy should be individualized
• Understand the purpose and goals of giving IV
fluid to your specific patient

• Prescribe IV Fluids like drugs

• Specific dose
• Specific indication

• Reassess routinely
• Changes in patient status may require a change
in fluid prescription
 3Rs
Right amount of the
Right fluid at the
Right time
Aspects of Fluid Management

• Targets • Managements
 Aspects of Fluid Management
• Targets :

• Intravascular fluid volume or

• Extracellular fluid volume or

• Both extracellular and intracellular fluid volumes

 Aspects of Fluid Management

• Managements :

• Volume replacement

• Fluid replacement

• Electrolyte replacement or osmotherapy

 Aspects of Fluid Management
• Targets :
• Intravascular fluid volume or
• Extracellular fluid volume or
• Both extracellular and intracellular fluid volumes

• Managements :
• Volume replacement
• Fluid replacement
• Electrolyte replacement or osmotherapy
 Aim Definition Composition Type of fluid
Volume Replace IVFV loss, Isooncotic Colloids
correct hypovolemia to Isotonic Crystalloids
Replacement maintain hemodynamic
and perfusion
Fluid Compensate or replace Isotonic Crystalloids
ECFV loss due to
Replacement cutaneous, enteral or
renal fluid loss
Electrolyte Restore electrolyte Hypertonic NaCl 3%
imbalance and a Isotonic Crystalloids
Replacement physiological total body H2O base D5W
and fluid volume (ECFV and
Osmotherapy ICFV)
 How much is enough fluids?
Increasing evidences of the perioperative fluid
management influence the postoperative
outcome.
The concept of ‘third space’ fluid loss that
doesn't really exist.
A restrictive vs liberal vs individualized goal-
directed fluid management.
 THE VOUME KINETIC OF CRYSTALLOID
RESUSCITATION
CRYSTALLOID RESUSCITATION
Hahn GR, Anesthesiology 2010 INTACT GLYCOCALIX

ARDS Hydrostatic

20-30 min
after
Osmotic

Peripheral
edema 75-80%

Burst LYMPH

INTRACELLULAR INTERSTITIAL INTRAVASCULAR Urine

Endothelial Surface layer (Glycocalix)

Endothelial Capillary Junction
WHAT ABOUT COLLOID ?
 THE INTRAVASCULAR VOLUME COLLOID
HYPERVOLEMIA
COLLOID
GOAL-DIRECTED
EFFECT OF COLLOIDS – THE ROLE OF
GLYCOCALIX
ACUTE HYPERVOLEMIA
Not only crystalloids are shifted out SHEDDING GLYCOCALIX
of the vasculature, but also colloids in LEAKAGE
setting of acute hypervolemia

ARDS

85-98%
LEAKAGE

Peripheral
edema 55-60%

Burst LYMPH

INTRACELLULAR INTERSTITIAL INTRAVASCULAR Urine <<

Endothelial Surface layer (Glycocalix)

6% HES 130/0.4 Jacob 2003, 5% Albumin Rehm 2000, 6% HES
Endothelial Capillary Junction 200/0.5 Rehm 2000, 5% Alb Rehm 2001, 6% HES 200/0.5 Rehm 2001
Tissue Normal
edema distance

Cellular
hypoxia

The Importance Of Local Capillary Oxygen Tension And Diffusion

Distance In Determining The Rate Of Oxygen Delivery And The
IntracellularPO2
Leach RM. Thorax2002;57:170–177
FLUID RESUSCITATION-INDUCED TISSUE HYPOXIA
A VICIOUS CIRCLE

Hypoperfusion/
Tissue hypoxia
Fluid-induced
Tissue hypoxia
Capillary Leakage
Syndrome
Interstitial/
Tissue edema
Aggressive
Fluid
resuscitation
 DILEMMA OF FLUID RESUSCITATION
IN CAPILLARY LEAK SYNDROME

Septic shock Severe Dengue and Trauma/

Preeclampsia High risk surgery
 FLUID RESUSCITATION, PROBLEM
SOLVING OR NEW PROBLEM

ARDS in preeclampsia, peripheral edema in DSS, Burst Abdomen

FLUID RESUSCITATION, PROBLEM
SOLVING OR NEW PROBLEM
 FLUID ACCUMULATION AND MULTI ORGAN DYSFUNCTION
Aggressive Fluid Strategies
Adversely Affect Every
System and Organ

Tissue Edema

Diffusion Distance

Cellular Damage
Prowle JR et al. Nat Rev Nephrol 2010;6:107
 Respiratory
• Pulmonary ↑
• Pleural effusion ↑
• Altered pulmonary and
• chest wall elastance (cfr IAP ↑)
• paO2 ↓ paCO2 ↑ PaO2/FiO2 ↓
• Extra vascular lung water ↗
• Lung volumes ↓ (cfr IAP ↑)
• Prolonged ventilation ↑
• Difficult weaning ↑
• Work of breathing ↑
Hepatic
• Hepatic congestion ↑
• Impaired synthetic function
• Cholestatis ↑
• Cytochrome p 450 activity ↓
• Hepatic compartment syndrome
Abdominal Wall
• Tissue edema ↑
• Poor wound Healing ↑
• Wound Infection ↑
• Pressure ulcers ↑
• Abdominal compliance ↓
Fluid
Overload
Gastrointestinal/visceral
• Ascites formation ↑ Gut edema 
• Malabsorption ↑ ileus ↑
• Bowel contractility ↓
• IAP ↑ and APP (=MAP-IAP) ↓
• Success enteral feeding ↓
• Intestinal permeability ↑
• Bacterial translocation ↑
• Splanchnic microcirculatory flow ↓
• ICG-PDR ↓, pHi ↓
Central nervous system
• Cerebral edema, impaired
• Cognition, delirium
• ICP ↑ CPP ↓ IOP ↑
• ICH, ICS, OCS
Cardiovascular
• Myocardial edema ↑
• Conduction disturbance
• Impaired contractility
• Diastolic dysfunction
• CVP ↑ and PAOP ↑
• Venous return ↓
• SV ↓ and CO ↓
• Myocardial depression
• Pericardial effusion ↑
• GEF ↓ GEDVI ↑ CARS ↑
Renal
• Renal interstitial edema
• Renal venous pressure 
• Renal blood flow 
• Interstitial pressure 
• Salt + Water retention 
• Uremia  GFR  RVR 
Fluid overload, de-resuscitation, and outcomes in critically ill or
injured patients: a systematic review with suggestion for
clinical practice. Anesthesiology Intensive Therapy 2014
 Hypoperfusion Edema
Organ Organ
dysfunction dysfunction
Adverse outcome Adverse outcome
Complications

Hypovolemic Overloaded

Bellamy MC. Br J Anaesth. 2006;97:755-757.

 Fluid optimization
A
B


Perioperative morbidity risk

Cardiac /
pulmonary events
 Ileus
 Poor tissue
 Wound dehiscence
perfusion
 Wound infection
 Organ failure
 Tissue hypoxia
 Nausea, vomiting
 Prolong ICU stay

Hypovolemia Overloaded
Bellamy MC. Br J Anaesth. 2006;97:755-757.
How much is enough fluids?

too wet..

too dry..
 Harmonious Balance
No-hypovolemia No-hypervolemia
 Five major aspects are of importance when
volume replacement is considered

1. The type of fluid must be decided,

2. The amount of fluid must be defined,
3. The criteria for guiding volume therapy must
be defined,
4. Possible side effects should be considered,
5. Costs are of importance.
 Pengetahuan fisiologi dari kesimbangan
cairan dan elektrolit mutlak diperlukan

 Pengenalan terhadap pilihan jenis cairan terhadap

pendekatan klinis sangat di butuhkan

 Pemilihan cairan ditentukan berdasarkan keadaan

klinis pasien

 Pemahaman tentang proses perpindahan cairan

antar kompartemen di tubuh sangat diperlukan
dalam hal pemilihan cairan
A. Hanafie ‘18