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Fluids Management

Fluids Management. Jamal A. Alhashemi, MBBS, MSc , FRPC, FCCP, FCCM Professor of Anesthesiology & Critical Care Medicine Faculty of Medicine, King Abdulaziz University. Objectives. By the end of the lecture, students should be able to: Compare crystalloids with colloids

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Fluids Management

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  1. Fluids Management Jamal A. Alhashemi, MBBS, MSc, FRPC, FCCP, FCCM Professor of Anesthesiology & Critical Care Medicine Faculty of Medicine, King Abdulaziz University

  2. Objectives • By the end of the lecture, students should be able to: • Compare crystalloids with colloids • Determine the volume status of patients based on clinical exam & invasive monitors • Institute appropriate fluid therapy for the resuscitation of trauma patients

  3. Case History • A 24 yr old male involved in an MVC 1/2 h ago as an unrestrained driver. His primary survey revealed fractured left femur but no other injuries. In ER, his HR 120/min, BP 70/40, RR 24, SpO2 100% on FiO2 0.5 by facemask.

  4. What are the issues? • Shock • Tachypnea • Fractured femur, ongoing bleeding • Potential C-spine injury • Potential closed head injury

  5. What should you do next? • ABC • Volume resuscitation • Which type of fluid? • How fast? • How much? How do we know? • ? Vasopressors

  6. Crystalloids: 0.9% NaCl (NS) 0.45% NaCl 0.225% NaCl 3% NaCl Lactated Ringer 5% Dextrose (D5W) D5 LR D5 NS D5 1/2NS D5 1/4NS 10% Dextrose (D10) 25% Dextrose (D25) 50% Dextrose (D50) Types of Fluids

  7. Colloids: 6% HES 5% Albumin Plasma Protein Fraction (PPF) Fresh Frozen Plasma (FFP) Whole Blood Gelatins Types of Fluids

  8. Body Fluid Composition ICF (2/3) ECF (1/3) ISF (2/3) IVF (1/3) H2O H2O H2O Na+ Na+ Cl - Cl - HES

  9. Crystalloids Cheap Readily available Large volume Maintenance & resuscitation fluid No allergic potentials No infectious risk Colloids Expensive Not readily available Small volume Resuscitation fluid Not for maintenance Potential for allergy Risk of infection Crystalloids vs. Colloids

  10. Fluid Therapy • Maintenance Therapy • 4 ml/kg/h • 2 ml/kg/h • 1 ml/kg/h • Deficit • Replace as fast as possible • 3:1 rule when giving crystalloids • Ongoing losses including “third spacing” • Fluid therapy = maintenance + deficit + losses

  11. Monitoring of Fluid Therapy • Clinical exam • HR • MAP • ?JVP and “postural drop” • Urine output • Central venous pressure (CVP) • Pulmonary artery catheter (PAOP) • Serum lactate & ScvO2

  12. Goals of Therapy - I • MAP ≥ 65 mmHg • HR < 100/min • Urine output • Adults ≥ 0.5 ml/kg/h • Pediatrics ≥ 1 ml/kg/h • ScvO2 ≥ 70% • Serum lactate ≤ 2 mmol/l

  13. Goals of Therapy - II • CVP • CVP 8-12 mmHg • 5, 7 rule • PA catheter • PAOP 10-12 mmHg • 2, 5 rule • Trends are more important than absolute numbers

  14. Complications of Fluid Therapy • Fluid overload • Generalized edema • Pulmonary edema • Electrolyte disturbances • Na+ • K+ • Ca++ • Hypothermia • Coagulopathy

  15. Case Management - I • ABC • Two large-bore iv cannulae • CBC, coags, urea & electrolytes • X-match 4-6 units of PRBCs • LR for initial resuscitation

  16. Case Management - II • HES may be added subsequently • Blood may be needed later • Early blood administration if there is ongoing uncontrolled hemorrhage • FFPs only for documented coagulopathy

  17. Conclusion - I • Most of the hypotension encountered in the surgical patient is due to hypovolemia • Never use hypotonic solutions for fluid resuscitation • Never use dextrose-containing solutions for fluid resuscitation

  18. Conclusion - II • Never use FFP for fluid resuscitation • Blood may be used for severe hemorrhage or uncontrolled bleeding • Always monitor the adequacy of fluid resuscitation

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