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Principles of intravenous fluid therapy. Jonathan Paddle Consultant in Intensive Care Medicine Royal Cornwall Hospitals NHS Trust 3 rd September 2007.

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Principles of intravenous fluid therapy l.jpg

Principles of intravenous fluid therapy

Jonathan Paddle

Consultant in Intensive Care Medicine

Royal Cornwall Hospitals NHS Trust

3rd September 2007


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"On the floor lay a girl of slender make and juvenile height, but with the face of a superannuated hag... The colour of her countenance was that of lead - a silver blue, ghastly tint; her eyes were sunk deep into sockets, as though they had been driven an inch behind their natural position; her mouth was squared; her features flattened; her eyelids black; her fingers shrunk, bent, and inky in their hue…

In short, Sir, that face and form I can never forget, were I to live beyond the period of man's natural age."


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WILLIAM BROOKE O’SHAUGHNESSY height, but with the face of a superannuated hag... The colour of her countenance was that of lead - a silver blue, ghastly tint; her eyes were sunk deep into sockets, as though they had been driven an inch behind their natural position; her mouth was squared; her features flattened; her eyelids black; her fingers shrunk, bent, and inky in their hue…

Edinburgh graduate, age 22 from Limerick

  • Investigated cholera outbreak in Sunderland:

  • Noted blood “..has lost a large part of its water content.. and.. a great proportion of its neutral saline ingredients..”, leading to venalisation (“blue, thick and cold”); established that the stools contained the missing elements in proportion

  • Therapeutic conclusions:

    “1. To restore the blood to its natural specific gravity;

    2. To restore its deficient saline matters…

    … by the injection of aqueous fluid into the veins.”


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“She had apparently reached the last moment of her earthly existence and now nothing could injure her... Having inserted a tube into the basilic vein, cautiously, anxiously, I watched the effects; ounce after ounce was injected but no visible change was produced.

Still persevering, I thought she began to breathe less laboriously, soon the sharpened features, the sunken eye and fallen jaw, pale and cold, bearing the manifest impress of death’s signet, began to glow with returning animation; the pulse, which had long ceased, returned to the wrist; at first small and quick, by degrees it became more distinct, fuller, slower and firmer, and in the short space of half an hour, when six pints had been injected, she expressed in a firm voice that she was free from all uneasiness, actually became jocular, and fancied all she needed was a little sleep; her extremities were warm and every feature bore the aspect of comfort and health.

This being my first case, I fancied my patient secure, and from my great need of a little repose, left her in charge of the Hospital surgeon”

Thomas A Latta, Leith Physician. Lancet June 18th 1832


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“.. But I had not been long gone, ere the vomiting and purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

…I have no doubt, the case would have issued in complete reaction, had the remedy, which had already produced such effect, been repeated.”


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Dr Latta’s Saline solution purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Two to three drachms of muriate of soda (NaCl), two scruples of the bicarbonate of soda in six pints of water and injected it at temperature 112 Fah

  • ( approx 58mmol/l Na, 49 mmol/l Cl, 9 mmol/l bicarbonate)

  • Ten of the first fifteen patients died


The present day l.jpg
The present day… purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


Current controversies in fluid therapy l.jpg
Current controversies in fluid therapy purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • How much fluid to give

  • Which fluid to use


Assessment of volume status l.jpg
Assessment of volume status purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Look at the patient:

  • Pulse

  • Blood pressure

  • Capillary refill

  • Mucous membranes

  • Peripheral circulation

  • Thirst


Assessment of volume status10 l.jpg
Assessment of volume status purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Try a more invasive approach:

  • Urine output

  • Arterial line

  • Central venous line

  • PA catheter

  • Oesophageal doppler


Assessment of volume status11 l.jpg
Assessment of volume status purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

How about blood tests?

  • U&Es

  • Haematocrit

  • Plasma/urine osmolality

  • Arterial blood gases

  • Lactate


Assessment of volume status12 l.jpg
Assessment of volume status purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

OK, so the patient needs fluid…

How much should we give?


Trauma l.jpg

P=0.04 purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Trauma

  • 598 adults with penetrating torso injuries

  • Randomised to standard care or no fluids until time of operation

Bickell WH et al. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. NEJM 1994; 331: 1105-9


Trauma14 l.jpg
Trauma purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Cochrane Database of Systematic reviews

  • Six randomised controlled studies

  • No evidence in support or against early aggressive fluid resuscitation

  • 52 animal trials hypotensive resuscitation reduced risk of death


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Peri-operative purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • 138 patients undergoing major elective abdominal surgery

  • Randomised to one of three groups (one control and two goal directed therapy groups

Wilson J et al. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 1999; 318: 1099-103


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Peri-operative purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Goal-directed therapy was aimed at optimising oxygen delivery to tissues with:

    • Fluids

    • Inotropes

  • Guided by invasive PA catheter monitoring

Extra 1500 ml fluids pre-op

Wilson J et al. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 1999; 318: 1099-103


Peri operative17 l.jpg
Peri-operative purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Wilson J et al. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 1999; 318: 1099-103


However l.jpg
However… purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • RCT 172 patients undergoing elective colorectal resection

  • Restrictive fluid regime (to maintain neutral body weight) vs. standard post-op fluids

Complications: 33% versus 51% (P = 0.013)

Brandstrup B et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003; 238(5): 641-8.


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Sepsis and the critically ill purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic ShockEmanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., Michael Tomlanovich, M.D., for the Early Goal-Directed Therapy Collaborative Group

Volume 345: 1368-1377 November 8, 2001


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Sepsis and the critically ill purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Rivers E et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. NEJM 2001; 345: 1368-77

  • 263 patients presenting with severe sepsis

  • Single-centre: large American Emergency department

  • Randomised to standard therapy or goal-directed therapy


Protocol group l.jpg
Protocol group purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


Treatment given l.jpg
Treatment given purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


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The take-home message! purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Resuscitate with fluids early and aggressively

    • They won’t get overloaded

    • They won’t get pulmonary oedema

    • They will be less likely to need ICU

  • Be guided by markers of tissue perfusion

    • Urine output

    • Lactate

    • Consider central venous oxygen saturations


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FACTT Study purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Comparison of two fluid management strategies in acute lung injury

  • Randomised controlled trial

  • 1001 patients with ARDS or ALI

  • Conservative v liberal fluid therapy

  • Also compared PAC or CVC

  • Mortality at 60 days, vent free days, organ failure free days

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564-2575


Factt l.jpg
FACTT purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Fluid restriction 43 hrs post admission

  • 24 hours post ALI/ARDS

  • Renal failure pts excluded

  • Volume replete patients

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564-2575


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FACTT purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • No significant difference in mortality

  • Restrictive fluid group had:

    • Better oxygenation indexes

    • More ventilator free days

    • Less renal failure in conservative group

  • Recommendations: Conservative fluid approach without PAC

  • But…………..

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564-2575


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FACTT purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Increase in cardiovascular failure days in patients in conservative group

  • Caution in fluid depleted patients.

  • Relative young age of patients

  • ? Realistic study population

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564-2575


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Now for which fluid… purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


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What is the choice? purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

  • Crystalloids Colloids

    • Saline Albumin

    • Dextrose Gelatins

    • Hartmann’s Starches


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Cell membrane purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Capillary wall

Fluid distribution


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Practical differences purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…

Roberts I, Alderson P, Bunn F, P Chinnock, K Ker and Schierhout G.

Colloids versus crystalloids for fluid resuscitation in critically ill patients (Cochrane Review).

The Cochrane Library, Issue 4, August 24th, 2004


Albumin vs crystalloid l.jpg
Albumin vs. crystalloid purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


Hes vs crystalloid l.jpg
HES vs. crystalloid purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


Gelatin vs crystalloid l.jpg
Gelatin vs. crystalloid purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


Dextran vs crystalloid l.jpg
Dextran vs. crystalloid purging recurring, soon reduced her to her former state of disability … and she sunk in five and a half hours after I had left her…


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“There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death compared to crystalloids in patients with trauma, burns and following surgery.

As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patient types can be justified outside the context of randomised controlled trials”


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A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit

The SAFE Study Investigators

2004; 350: 2247-2256


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Study design in the Intensive Care Unit

  • 16 centres in Australia and New Zealand

  • Randomised, double-blind, trial of 4% albumin compared to 0.9% Saline for fluid resuscitation in the ICU

  • Study fluid given until death, discharge or 28 days


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Study design in the Intensive Care Unit

  • 6997 Patients enrolled

  • 90% power to detect 3% difference in mortality from baseline of 15% mortality

  • A priori sub-groups identified:

    • Trauma

    • Severe Sepsis

    • ARDS


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Fluids administered and effect in the Intensive Care Unit


Outcome l.jpg
Outcome in the Intensive Care Unit


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Outcome in the Intensive Care Unit


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Subgroup Outcome: 28 day mortality in the Intensive Care Unit


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What about starches? in the Intensive Care Unit

  • Starches are polymers of glucose

  • α1,6 linkages produce branched chains called amylopectins

  • Hydroxyethyl radicals can be substituted on glucose units, hence

HYDROXYETHYL STARCH


Why might they be useful l.jpg
Why might they be useful? in the Intensive Care Unit

  • Large molecules, so retained in the plasma

  • Stable molecules, so have a sustained effect

  • Some evidence of specific anti-inflammatory properties that may be therapeutic


Endothelial properties l.jpg
Endothelial properties in the Intensive Care Unit

  • Prospective RCT, single centre

  • 66 patients >65 years old

  • Major abdominal surgery

    • Ringer’s lactate (n=22)

    • Normal saline (n=22)

    • HES 130/0.4 (n=22)

  • From induction of anaesthesia until 1st post-op day to keep CVP 8-12mmHg

Boldt J. Int Care Med 2004; 30: 416-22


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Endothelial properties in the Intensive Care Unit

Boldt J. Int Care Med 2004; 30: 416-22


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Why might they be bad? in the Intensive Care Unit

  • Potential risk of anaphylaxis

  • Some starch solutions cause coagulation disorders

  • Risk of renal impairment

  • Known incidence of pruritis


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Incidence of anaphylaxis in the Intensive Care Unit

  • French multicentre study

  • 49 hospitals

  • 19593 patients

  • Overall 1 in 456 had an anaphylactoid reaction

Laxenaire MC. Ann Fr Anesth Reanim 1994; 13: 301-10


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* in the Intensive Care Unit

*

*

*

Coagulation disorders

  • Small RCT, 21 patients per group

  • Major abdominal surgery for malignancy

  • Compared blood transfusion requirements according to fluid given

Boldt J et al. Br J Anaesth 2002; 89: 722-8


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Renal Impairment in the Intensive Care Unit

Schortgen F, Lacherade J-C, Bruneel F et al. Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet 2001; 357: 911-6

  • 129 patients in three centres

  • Severe sepsis / septic shock

  • 6%HES 200/0.6 vs. 3% Gelatin

  • Prospective RCT


Renal impairment53 l.jpg
Renal Impairment in the Intensive Care Unit

OR 2.57 (1.13 – 5.83) P=0.026

Schortgen F et al. Lancet 2001; 357: 911-6


Renal impairment54 l.jpg
Renal Impairment in the Intensive Care Unit

Boldt J, Brenner T, Lehmann A et al. Influence of two different volume replacement regimens on renal function in elderly patients undergoing cardiac surgery: comparison of a new starch preparation with gelatin. Int Care Med 2003; 29: 763-9

  • 40 patients, single centre

  • HES 130/0.4 vs. Gelatin

  • Prospective RCT


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Renal Impairment in the Intensive Care Unit

No significant differences

Boldt J et al. Int Care Med 2003; 29: 763-9


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Pruritis in the Intensive Care Unit

Morgan PW and Berridge JC. Giving long-persistent starch as volume replacement can cause pruritis after cardiac surgery.Br J Anaesth 2000; 85: 696-9.

  • 85 consecutive cardiac patients

  • Structured interview

  • 58 received EloHAES

  • 27 received no HES


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Pruritis in the Intensive Care Unit

Morgan PW and Berridge JC. Giving long-persistent starch as volume replacement can cause pruritis after cardiac surgery.Br J Anaesth 2000; 85: 696-9.

  • Pruritis experienced in:

    • 13 (22%) of EloHAES patients

    • 0 (0%) of non-HES patients (P=0.007)

  • Median onset (range) 4 (1-12) weeks

  • Greatest duration >9 months


Time to put it all together l.jpg
Time to put it all together! in the Intensive Care Unit


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How much fluid in the Intensive Care Unit

  • Trauma

    • Restrictive fluid strategy until bleeding controlled

  • Peri-operative

    • Fluids early (?pre-op), then cut back

  • Sepsis

    • Early aggressive fluids to restore perfusion

    • Restrict fluids late to avoid oedema


Which fluid l.jpg
Which fluid in the Intensive Care Unit

  • It probably doesn’t matter!

  • Avoid dextrose (water) as large volumes will be required, worsening tissue oedema

  • If using crystalloid, the patient will require 1.4 times the volume compared to colloid

  • Crystalloid may be better in trauma

  • Colloid (or possibly starches) may be better in critically ill / sepsis


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