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No fluids ?

You have to be joking ……..

Basic principles of care

We may disagree about the type of fluids ….

But limit them …… hypoperfused, blue edges,

high lactate …. Sorry

Give the fluids !

How much fluid should we give?

- ‘A target PAOP of 14-18 has often been used because this pressure is commonly thought to yield an optimal CO while minimising the risk of hydrostatic pulmonary oedema.’ Crit Care Med 2000;28:3314-31
- The clinical trial - ‘…ensure adequate filling…’
- The ICU resident - ‘...I think he’s well filled now…’

It’s too vague!

Yet fluid resuscitation has a very powerful effect upon outcome

Numerous monitoring options PiCCO LiDCo Oesophageal doppler

- Clinical
- Pulmonary artery catheter
- Cardiac output, PAOP, RVEF, SvO2

- Surrogate volume measurements (ITBVI, GEDV), EVLW
- Stroke volume variation

These monitors do alter fluid & vasopressor management

Mimoz O et al, Crit Care Med 1994

What is the outcome of fluid resuscitation?

- MAP & urine output
- Warm peripheries
- Cardiac output
- PAOP
- ITBVI/GEDVI
- SvO2
- Stroke volume variation?

What is the outcome of fluid resuscitation?

- MAP & urine output
- Warm peripheries
- Cardiac output
- PAOP
- ITBVI/GEDVI
- SvO2
- Stroke volume variation?

- Tissue oxygenation
- pH
- Base Deficit
- Lactate
- Lactate/pyruvate ratio
- PrCO2
- IAP

- Intra-abdominal haemorrhage
- Animal studies
- No fluids or dextran+hypertonic saline or large volume Ringers
- No fluids resulted in a low flow state
- No difference in blood loss
- Bruscagu J Trauma 2002 52(6):1147
- Varicoda J Trauma 2003 55(1):112

- Delayed recuss, hypotensive recuss (MAP 60), aggressive recuss (MAP 75)
- Delayed recuss decreased blood loss but did not restore perfusion, blood loss and fluids similar for aggressive and hypotensive grps (47± 7 and 45±10 ml/kg) and total fluids (118±73 and 171±85)
- Hypotensive grp had improved tissue perfusion
- Esteban-Varela 20(5):476 2003

- Rivers data - early adequate fluids

So fluids ?

- Diebel et al J Trauma 1992 ;33 Caldwell J Surg Res 1987, Bangard J Trauma 1995
- Decreased THBF and mesenteric perfusion
- But the effects are worsened by hyovolaemia
- Intra-abdominal hypertension
- Decreased CI ……53% if volume deplete ….17% of replete
- So sorry …. Isn’t this debate done and dusted
- Masey Paediatr Res 1985 19:1244
- Kashton J Surg Res 1981 30 :249

Fluids and IAP

- Predictors McNelis Arch Surg 2002 ;137;133
- 24 hour fluid balance and peak airway pressures on multivariate analysis
- Retrospective study
- Matched for age, sex, diagnosis, procedure BUT not severity
- ACS defined as IAP >25, oliguria and increased airway pressure
- The IAH were sicker ! APACHE II 38 vs 16
- Higher number emergencies 72 vs 14%
- Intra-op data the same
- 24 hour fluid balance 16 vs 7 L
- What do the authors suggest …..
- ACS reflects ongoing physiological derrangement
- 8L fluid balance 0.7% risk , 15 L 70% risk, 18 L 90% risk
- Clinical judgment is more important than predictive equations

Malbrain - prevalance study IAH ICM 2004

- 1 day point prevalence study
- 97 patients - incidence of IAP>12 50% : IAP>20 8%
- Univariate analysis
- SOFA
- Fluid recuss > 3.5 L
- > 6 u blood
- BMI

- Multivariate analysis
- BMI p=0.013
- Fluids p=0.07
- Tf p=0.11
- Coagulopathy p=0.054

the paper looks at supranormal vs normal goals …

Nothing to with fluids per se ! Balogh Arch Surg 2003 138:637

ISS > 15 trauma patients well matched ISS 28±3 27 ± 2

Lactate 4.2±1 vs 3.9 ±1 Pre ITU fluids (blood and crystalloid similar)

2 treatment protocols : D02 > 600 or 500

In D02 > 600 ml.min/m2 compared to > 500 ml/min/m2

Higher C02 gap 16±2 vs 7± 1*

IAH 42 vs 20% * ACS 16 vs 8%*

Mortality 27 vs 11%*

Supra normal goals or otherwise ?

More Ringers lactate given in > 600 grp

13.2 ± 2 vs 7± 1 L*

No difference in blood Tf - trend only

Protocol to Hb > 10 , Ringers to achieve PAOP 15

Inotropes

Pressors MAP > 65 mmHg

Lactate, BD , CI - all normalised at the same rates

So was this fluid needed ± is there an effect of the type of fluid

Should we be measuring COP in this group of patinets

- IAP n=18
- IAP>15mmHg n= 12 given fluid bolus 500 ml gelofusin

Correlation between IAP and markers of preload

CVP

r = 0.66

p = 0.003**

- IAP n=18
- IAP>15mmHg n= 12

PCWP

r = 0.59

p = 0.02

Predictors of fluid responsivenessLinear regression Analysis (SPSS)

So , a case

- 55 years , 10 days post Whipples - collapse … intra-abdominal bleed
- Recussitation at local hospital Tf - ongoing bleeding Hb 4, BP 90/40, CVP 22, Noradrenaline 0.2 , IAP 28
- Embolized - Hb up to 8 IAP 26 8 L +ive since presentation, still on noradr, Pa02 8 on 60% PC ventilation, lactate 8
- ITBVI 700 EVLWI 5 SVV 19 %
- So fluids or not ?
- We did - 12 L positive balance in next 24 hours
- Lactate fell to 2 ITBVI 800 EVLWI 6 SVV 10%

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