Crystalloids for Shock Resuscitation

Khemmachart Pongsanon, MD.Division of Pulmonology and Critical Care, Department of Pediatrics

Charles Sidney Burwell, MD.Harvard Medical School, Dean

1935-1949

Half of what we have taught you is wrong.

Unfortunately, we don’t know which half !

Evidence-based Evidence based medicine

Crystalloids for shock resuscitationy• Physiology of body fluid Physiology of body fluid

C t ll id • Crystalloids – Types and basic components– Clinical studies

Fluid for shock resuscitation Preload Oxygen content

(CaO )Myocardialcontractility

Stroke volume(SV)

Cardiac output

(CaO2)Oxygen delivery

(DO2)

Afterload

Heart rate

p(CO)

Systemic vascularBlood pressure

(BP)(HR)

Sys e c ascu aResistance (SVR)

•Hypovolemic

VD

•Distributive

•Cardiogenic D•Cardiogenic•Obstructive

Transcapillary filtrationp y

Intravascular fluids Starling’s equation

Interstitial fluids

Intravascular fluids g q

Jv = K [ (Pc-Pi)- σ(¶c - ¶i)]Interstitial fluids [ ( ) (¶ ¶ )]

P : hydrostatic pressure

I t ll l fl id

y p¶ : osmotic pressure

Intracellular fluids c : capillary / intravasculari : interstitium

Transcapillary filtrationp y• Hydrostatic pressure (P) I t l fl idHydrostatic pressure (P)

– Water moves from high P to low P I t titi l fl id

Intravascular fluids

from high P to low P• Osmotic pressure (¶)

Interstitial fluids

– ¶ = 19.3 x osmolality – Plasma osmolality = 2(Na) + glucose + BUNPlasma osmolality = 2(Na) + glucose + BUN

18 2.8W t f l ¶ t hi h ¶– Water moves from low ¶ to high ¶

Crystalloids for shock resuscitationy• Physiology of body fluidPhysiology of body fluid

C t ll id • Crystalloids – Types and basic components– Clinical studies

Crystalloids y• Fluid comprise of water and electrolytesFluid comprise of water and electrolytes• Highly permeable from intravascular

into interstitium Intravascular fluids

Interstitial fluids

• ≤ 25% remains intravascularly• Higher volume must be required to • Higher volume must be required to

replace blood loss

Crystalloids y• High volume resuscitation may causeHigh volume resuscitation may cause

– Increase intravascular hydrostatic pressureDecrease intravascular osmotic pressure– Decrease intravascular osmotic pressure

Intravascular fluidsFluid bolus

Interstitial fluids

Intravascular fluidsFluid bolus

Interstitial fluids

Edema Edema

Crystalloids y• DisadvantagesDisadvantages

– Fluid leakage•Tissue edema

– Short intravascular durationShort intravascular duration•More volume is required

– Dilutional coagulopathy•Trauma patients bleeding •Trauma patients, bleeding

Crystalloids y• AdvantagesAdvantages

– Save, cost-effectiveness– Almost always available– Low risk of complicationsLow risk of complications

•Allergic reactions•Renal toxicity

Crystalloids in septic shock y p

I t i C M d 2013 39(2) 165 228Intensive Care Med 2013;39(2):165-228.

Crystalloids in septic shock y p

I t i C M d 2013 39(2) 165 228Intensive Care Med 2013;39(2):165-228.

Crystalloids in trauma y• Advanced trauma life supportAdvanced trauma life support

– Initial resuscitation with 1-2 L of crystalloids

• Resuscitation with at least 1 L of crystalloid per unit of PRC– Associated with improved mortalityAssociated with improved mortality

Spoerke N. J Trauma 2011;71:380-3.

Crystalloids in trauma y• Crystalloid resuscitation ≥ 1.5 LCrystalloid resuscitation ≥ 1.5 L

– Associated with increased mortality

• Crystalloid resuscitation up to 1 L– Not associated with increased mortality

Ley EJ J Trauma 2011;70:398-400Ley EJ. J Trauma 2011;70:398-400.

Crystalloids y• Isotonic solutionIsotonic solution

– NSS, LRS, ARSH t i l ti• Hypertonic solution– NaCl 3%, 5%, 7.5%

• Hypotonic solution• Hypotonic solution– Dextrose in water: 5%, 10% D/W– 5% D/N/2, 5% D/N/3

Crystalloids yFluids Na K Cl Lactate/

HCO3Ca Osm pH

(mEq/L) (mEq/L) (mEq/L) HCO3(mEq/L)

(mmol/L) (mOsm/L)

ECF 142 4 103 27 5 290ECF 142 4 103 27 5 290

LRS 130 4 109 28 3 273 6 5LRS 130 4 109 28 3 273 6.5

NSS 154 154 308 6

3% NaCl

513 513 1026 6.5NaCl

Normal saline solution• Isotonic solutionIsotonic solution• One of the most common crystalloid

for fluid resuscitation• Slightly hypernatremic than plasmaSlightly hypernatremic than plasma

– 154 vs 142– Preferred in brain injury or

hyponatremiahyponatremia

Normal saline solution• Markedly hyperchloremic than plasmaMarkedly hyperchloremic than plasma

– 154 vs 103– Large volume resuscitation may cause

hyperchloremic metabolic acidosishyperchloremic metabolic acidosis•35 ml/kg in healthy patient•Caution in trauma, operative

patientspatients

Lactated Ringer’s solutiong• Balanced salt solution Balanced salt solution • Slightly hyponatremic than plasma• Provide Cl, K, Ca, HCO3

• HCO3 derived from lactate metabolitesHCO3 derived from lactate metabolites– Acetated Ringer’s solution in liver diseases

L i k f h hl i t b li • Lower risk of hyperchloremic metabolic acidosis, compared to NSSacidosis, compared to NSS

NSS vs LRS• Infants with diarrhea, severe dehydrationInfants with diarrhea, severe dehydration

– Initial resuscitation with NSS or polyelectrolytes fluid polyelectrolytes fluid

– Mean fluid volume 90-92 ml/kg in 2.4 hours– Successful shock recovery in both groups– NSS group had more incidence of NSS group had more incidence of

metabolic acidosis

Juca CA. Annals Trop Paed. 2005;25;253-60.

NSS vs LRS• Hemorrhagic hypovolemic shockHemorrhagic hypovolemic shock

– NSS resuscitation associated withSignificant higher volume required•Significant higher volume required

•Significant higher incidence of– Hyperchloremia, metabolic acidosis

•Significant lower fibrinogen levelSignificant lower fibrinogen level– Dilutional coagulopathy

Todd SR. J Trauma. 2007;62:636-9.

Hypertonic saline solution (HSS)yp ( )• Hypertonic than plasmaHypertonic than plasma• Increase intravascular osmotic pressure• Plasma volume expander

– 4 fold of infused HSS

Intravascular fluidsHSS

I t titi l fl id

HSS

Interstitial fluids

Hypertonic saline solution (HSS)yp ( )• Considered in Considered in

– Refractory hypovolemic shock– High risk of tissue edema

•Intracranial hypertensionIntracranial hypertension•Brain edema•Prolonged GI surgery •Burn•Burn

Hypertonic saline solution (HSS)yp ( )• Short plasma half-lifeShort plasma half life• Plasma expansion lasts quite short • Combined with colloids

– Albumin, HES, dextranAlbumin, HES, dextran– RR death 0.5, 0.25 and 0.91 (p > 0.05)

Perel P. Cochrane Database Syst Rev 2012.CD000567.

HSS: Effects on preload and C.O.p

Increase preloadIncrease preload(Plasma volume expander)

HSS: Effects on contractilityy

Increase m ocardial contractilitIncrease myocardial contractility•Hyperosmolar effect•Decrease myocardial edema•Decrease myocardial edema•Restore transmembrane potential

HSS: Effects on afterload

Improve microcirculationImprove microcirculation•Reduce tissue edema•Reduce endothelial cell edemaReduce endothelial cell edema•Widening of capillary lumen

Crystalloids: conclusion y• Cost-effectiveness, available, safe Cost effectiveness, available, safe • Leakage can cause tissue edema• Initial fluid in hypovolemic & septic shock

– Appropriate volume is the key to successpp p y• NSS : hyperchloremic acidosis, coagulopathy

LRS • LRS : less side effects than NSS• HSS : volume expander, cardiac function, HSS : volume expander, cardiac function,

microcirculation, immunomodulation, edema