fluid resuscitation and organ perfusion evaluation

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Fluid Resuscitation and Organ

Perfusion Evaluation

Departemen Anestesiologi dan Terapi IntensifFakultas 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 6-7% of

body weight

– Male : 66 ml/kg

– Female : 60 ml/kg

• The volumes of blood 11-12% of total body

fluid



Body Fluid

Body fluidMen 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 5 L 60 3,6 L

Red Cell 26 2 L 24 1,4 L

Plasma 40 3 L 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



ISF IVF ICF

Physiologic principles of fluid

management

Perdarahan



Acute Blood loss

earliestMovement of

interstitial fluid into the bloodstream

lateActivation of RAA

system

Restoring

volumedeficits

Compensatory Responses

Fully compensate for the

loss of 15-20% BV



10Trauma 7th Ed, 2013



Clinical Evaluation



Clinical Evaluation

ClinicalEvaluation

Pulse rate

Bloodpressure

Pulsepressure

Respiratoryrate

Urineoutput

CNS/mentalstatus



Postural Changes

•Moving from the supine to the standingposition causes a shift of 7 to 8 mL/kg of blood

to the lower extremities

•

In healthy subjects, this change in bodyposition 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, ordizziness on standing.

The only tests with a sensitivity high enough to be of anyvalue 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 inblood) to determine the extent of acute blood lossis 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 ofthe plasma volume ↓the hematocrit.

• This process begins 8 to 12 hours after acute bloodloss



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 impairedtissue oxygenation.



glucose oksigen

38 Mol ATP



glucose oksigen

2 Mol ATP

+

36 Mol Lactate



Serum Lactate

• > 2 mM/L abnormal.

•> 4mM/L more predictive of

increased mortality life-

threatening 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 37°Cand 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



Promote cardiac output

1. CI > L/min/m2

2. MABP > 65 mmHg or < 65 mmHg, iftolerated, untill bleeding is controlled

3. UOP > 0,5 ml/kg/hr

Promote oxygen delivery1. DO2 > 500 ml/min/m2

2. Hb > 7-9 g/dl

3. SaO2 > 90%

Promote aerobic

metabolisme

1. VO2 > 100 ml/min/m2

2. SvO2 > 70%

3. Serum lactate < 2 mM/L within 24 hr

Promote Hemostasis1. INR < 1,5

2. aPTT < 1,5 x control

3. Platelet count > 50 x 109/L

GOAL END-POINTS



Promoting Cardiac Output

• The consequences of a low cardiac

output are far more threatening than

the consequences of anemia, so thefirst 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

solutions

• Distribute throughout the

extracellular space

• Expand the extracellular

volume

• Sodium-rich electrolyte

solutions

• Contain large molecules

do not pass readily out of the

bloodstream

• Retained molecule hold

water in the intravascular

compartment• Expand the 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

Ringer’s lactateNormosol

Expands the extracellular volume

RBC concentrate Packed RBC’s Increases O2 content of blood

Stored plasma FFP Provide coagulation factorsProcoagulant

mixture

Cryoprecipitate Low-volume source of fibrinogen

Platelet concentrate Pooled platelet

Apharesis platelet

Restores circulating platelet pool



Colloid fluids

Crystalloidfluids

PRC/WB P r o m o t i n g C a r d i a c o u t p u t



Colloid fluids are much more effective

than crystalloid for promoting cardiacoutput



31

ISF

13L

ISF IVF ICF

5L 27 L750 ml 250 ml 2 L

D5W

3L

Physiologic principles of

fluid management

Hasanul, 2002



32

ISF

13L

ISF IVF ICF

5L 27 L2250ml 750 ml

RL,NaCl

3L


fluid management

Hasanul, 2002

• 25% in the

cascular

space

• 75% to

interstitial

space



33

ISF

13L

ISF IVF ICF

5L 27 L1L

Albumin-5%

1 L


fluid management

Hasanul, 2002

• 100% in

thevascular

space



34

ISFISF IVF ICF

5L 27 L1000ml

HES-6%1L


fluid management

Hasanul, 2002

13L



35

ISF

13L

ISF IVF ICF

5L 27 L500

Albumin-25%

100 cc


fluid management

Hasanul, 2002

400

Volume expander



36

ISFISF IVF ICF

5L 27 L700ml

Haemacel1L


fluid management

Hasanul, 2002

13L300ml



The Preferred Fluid

•

Despite the superiority of colloid fluids overcrystalloid 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 Ringer’s lactate



Hemostatic Resuscitation

• Fresh frozen plasma

–For the resuscitation of massive blood

loss one unit of FFP for every one ortwo 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

41Trauma 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 withvascular 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 Ringer’s lactate.

• Patients whose blood pressure responds to

this initial fluid bolus can undergo furtherwork-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 andpacked red blood cells during massive

improved mortality

•

The optimum ratio of fresh frozen plasma topacked red blood cells under investigation

O-negative blood shouldbe used until type-specific blood becomes

available



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

DO2 = CaO2 x CO x 10 ml/menit

Blood Transfusion



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 waterbath 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 acidosisand hypothermia)



Target 7 - 9g%

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

= 1500 mL

Bila PRC 750 mL

transfusi

Rule of 5mL WB= 5 x delta Hbx BB



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



FILTER



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



ransfusi

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



Pola kerja penanganan shock perdarahan

Penderita datang dengan

perdarahan

Pasang infus jarum kaliber

besar (16G, 18G), ambilsample darah

Ukur tekanan darah, hitung

nadi, nilai perfusi, produksiurine

Tentukan estimasi jumlah

perdarahan, minta darah

Guyur cepat Ringer Laktat atau NaCl

0.9% [hangat, 390C] 3x prakiraan lost-

volume [1-2 liter] evaluasi

Hasanul, 2003

fluid resuscitation and organ perfusion evaluation

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