Fluid Resuscitation


Article Author:
Heather Wallace


Article Editor:
Hariharan Regunath


Editors In Chief:
Myron Bodman
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
12/13/2018 1:53:51 PM

Introduction

The primary role of fluid resuscitation is to maintain organ perfusion (hemodynamics) and substrate (oxygen, electrolytes, among others) delivery through the administration of fluid and electrolytes. An enteral route can be used; however, when oral intake is not possible, clinicians can replace fluid losses by intravenous (IV) administration.[1]

Anatomy

Body fluids are distributed into intracellular and extracellular compartments. Intracellular compartment contributes to most total body water. Extracellular fluids are within the interstitial, intravascular, and trans-cellular spaces.[2] Predominant electrolytes in body fluids are sodium and potassium, where sodium is the dominant cation in the extracellular fluid and potassium is the dominant cation in the intracellular fluid. Sodium and magnesium are the other minor cations in the intracellular fluids and are electrochemically balanced by phosphate, sulfate, and bicarbonate anions. Calcium and magnesium are the other cations found in minor concentrations in the extracellular fluid, and they are balanced by chloride, bicarbonate, phosphate, and sulfate anions.[2]

Indications

Trauma

Trauma is the number one cause of death in the United States for individuals between 1 and 44 years of age. Among them, hemorrhagic shock is the primary cause of death for 30% to 40% in the first 24 hours following injury. Loss of blood triggers a compensatory hemodynamic response to restore volume. The compensatory mechanisms click in when there is acute blood loss of more than 5% to 10%. Blood losses of greater than 20% will require fluid resuscitation to support the continued delivery of oxygen to vital organs.[0]

Trauma and acute blood loss trigger compensatory mechanisms aimed at restoring volume deficits to maintain adequate perfusion of vital organs. Trans-capillary refill occurs first and involves the shift of fluid from the interstitial space into the intravascular space secondary to increased capillary permeability and decreased plasma colloid osmotic pressure. The resultant effect is the sequestration of about 1 liter of fluid into intravascular spaces. Activation of the renin-angiotensin-aldosterone system occurs next, activated by the reduction in renal perfusion and causing sodium and water retention by the kidneys.

The overall goal is to replace the fluid lost from the interstitial compartment to the intravascular spaces. But one must exercise caution, because an aggressive large volume fluid resuscitation may lead to hypothermia, acidosis, and coagulopathy.[0][0] Typical indications for resuscitation are a systolic blood pressure of less than 80 to 85 mm Hg or one that is rapidly decreasing and/or a decline in mental status without evidence of head trauma.[0]

Two major types of fluids used for resuscitation are colloids which specifically expand the intravascular volume and crystalloids, which briefly expand the intravascular volume and quickly re-distribute into the interstitial compartment. For resuscitation, crystalloids are given as 1- to 2-liter bolus in patients with hemorrhagic shock. However, recent studies using colloids favor permissive hypotension. For example, in patients with penetrating trauma, aggressive fluid resuscitation may exacerbate bleeding, so the emphasis is on administering small boluses of fluid (250mL) allowing a low systolic blood pressure equal to  90 mm Hg or mean blood pressure equal to 50 mm Hg until one achieves sustained hemorrhagic control. This strategy has been shown to improve survival and reduce the amount of fluid replaced.

It is important to remember that it is only safe to allow low blood pressures when there is good clinical evidence of adequate organ perfusion indicated through adequate urine output and mental status.[0] Crystalloids should ideally serve as a bridge to maintain perfusion until blood products are available in hemorrhagic shock. Hence, one should consider limited 500-ml bolus doses in patients without or impending shock until blood products become available.[5]

Sepsis

Sepsis is a leading cause of morbidity and mortality in critically ill patients with mortality ranging between 20% to 45%. Uncontrolled inflammation, tissue hypoperfusion, microvascular and micro-cellular level abnormalities, and dysfunction are critical determinants in the progression toward multiple organ failure, which predict poor outcomes. Septic shock is defined as refractory hypotension that results from a systemic inflammatory response syndrome (SIRS) caused by or suspected to be from an infection.[6]

The key characteristic of septic shock is systemic vasodilation which results in hypovolemia, decreased tissue perfusion and decreased oxygen delivery. The main aim of fluid resuscitation is to restore hemodynamics to optimize tissue perfusion and ultimately the tissue oxygen delivery.[6]

For resuscitation, one should give crystalloids at a dose of 30 mL/kg of ideal body weight as early as possible, typically within the first 3 hours. Central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygen saturation (ScvO2) can guide fluid resuscitation if shock (mean arterial blood pressure - MAP less than 65 mm Hg or lactate level greater than 4.0 mmol/L) persist. Within the first 6 hours of initial resuscitation, one should aim for a CVP target between 8 to 12 mm Hg in spontaneously breathing patients and CVP between 12 to 15mm Hg in mechanically-ventilated patients; a MAP greater than 65 mm Hg and ScvO2 greater than 70% have been shown to improve mortality. Lactate level should be monitored during resuscitation since increases may reflect a decrease in tissue perfusion.[6]

Contraindications

0.9% saline should be used with caution in patients with subarachnoid hemorrhage or postoperative acute kidney injury (AKI) as these conditions can themselves cause alterations in serum sodium concentration (hypo or hypernatremia).[7][8]

Colloids such as hydroxyethyl starch (HES) should be avoided in septic shock because of their adverse effects on coagulation and renal function. A blinded, randomized, controlled trial of 800 severely septic intensive care unit (ICU) patients in Scandinavia found that 6% HES is associated with an increase in death at 90 days compared to Ringer’s acetate.[7][9][8]

Intravenous albumin is contraindicated in patients with traumatic brain injury.[10]

Complications

Large amounts of intravenous fluids can cause hypervolemia and potentially electrolyte imbalance. In septic shock, overzealous use of intravenous fluids for a prolonged period can cumulatively increase the total body water, especially in patients with compromised renal, cardiac or hepatic function. This excess free water often accumulates in the extravascular lung (pulmonary edema) and subcutaneous tissues (pedal or sacral edema) and poses problems during recovery, for example, failure to wean from the ventilator and muscle weakness, both of which will cause prolongation of hospital stay and increase the associated risk of nosocomial complications. A 0.9% saline causes hyperchloremic acidosis following excess use and is associated with nephrotoxicity.

Clinical Significance

The goal of fluid resuscitation is to maintain homeostasis. This goal requires not only administering enough fluid volume to optimize hemodynamics and perfusion but also to maintain electrolyte balances. Maintenance fluids are given for select indications such as prolonged fasting for planned surgical procedures and conditions limiting oral fluid intake (severe nausea, vomiting, diarrhea). Maintenance fluid volume requirements in children is based on body weight with 100 ml/kg per day for the first 0 to 10 kg, an additional 50 ml/kg per day for the next 10 to 20 kg, and 20 ml/kg/day for weight greater than 20 kg. In adults, maintenance fluid is typically 35 ml/kg per day. One must also consider electrolyte replacement besides maintaining the required fluid volumes. Sodium is required at a concentration of 1 to 2 mEq/kg per day and potassium is replaced at a rate of 0.5 to 1 mEq/kg per day.[2][1]

Enhancing Healthcare Team Outcomes

Additional components for consideration in trauma resuscitation are to minimize the use of crystalloid fluid due to the potential for increasing the inflammatory response. Studies have also shown early use of blood products improve outcomes in trauma patients.[0] The PROPPR (Pragmatic Randomized Optimal Platelet and Plasma Ratios, 2016) study assessed 1:1:1 versus 1:1:2 ratios of plasma to platelets to red blood cells in severely injured patients and found that there were earlier hemorrhage control and decreased deaths secondary to exsanguination in the first 24 hours in the 1:1:1 group.[0] In pediatric patients, fluid resuscitation is indicated in the presence of hemorrhagic shock. An initial bolus of 20 mL/kg of either warmed 0.9% saline or lactated ringers is given. A repeat bolus of 20 mL/kg can be given if there is a transient or no response to initial bolus and then switch to resuscitation with blood products (10 mL/kg). There is no evidence to support permissive hypotension or damage control resuscitation in pediatric patients.[0][2]

Choices of fluid for septic shock resuscitation vary. Crystalloids are the fluids of choice in septic shock resuscitation, but no crystalloid solution is specifically favorable over the other due to a lack of evidence of direct comparisons in septic shock patients.[2][1][7] The Crystalloid versus Hydroxyethyl Starch Trial (CHEST) which was a blinded, randomized, controlled trial of 7000 ICU patients found that 6% HES was not associated with a significant increase in death at 90 days but was associated with an increase in the renal-replacement therapy rate. The Saline versus Albumin Fluid Evaluation (SAFE) Trial in Australia and New Zealand found a correlation between albumin resuscitation and a decrease in the adjusted risk of death at 28 days in septic patients.[8][11]


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Fluid Resuscitation - Questions

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In the Advanced Trauma Life Support protocol for patients with hypotension, what is the fluid of choice for resuscitation?

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Attributed To: Contributed by Tammy J. Toney-Butler, RN, CEN, TCRN, CPEN



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A 3-year-old boy comes to the emergency room after falling off the back of a motorcycle. What is the recommended fluid of choice for resuscitation in this age group?



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A patient is admitted to the emergency department after a motor vehicle accident. He has a blood pressure of 120/78 mm Hg, respiration rate of 22 breaths per minute, a pulse of 123 beats per minute, and he is afebrile. He is immediately started on 125 ml/hr of normal saline. Over the next 3 hours, he has a urine output of 10 cc/hr, 13 ml/her, and 18 ml/hr. His central venous pressure is 3 cm H2O and his blood pressure remains the same. The Foley catheter appears to be draining well. What is the next step in his management?



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What initial volume of fluid is appropriate for a 4-year-old child in shock?



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What is the standard pediatric dose for fluid resuscitation?



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A 75-year-old lady is admitted for planned elective knee replacement surgery the next day. She has long-standing hypertension for which she takes amlodipine. She has no other medical problems. Laboratory parameters are all within normal limits. She is to be placed on intravenous fluids, and her weight at admission was 68 kg. Which one of the following is the correct choice and rate per hour?



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An 85-year-old gentleman is brought to the emergency department with altered mental status. His heart rate is 120/min, regular in rhythm, blood pressure 85/40 mmHg, respiratory rate 35/min, temperature 101 F, weight 75 kg, and oxygen saturation 88% on room air. Lung exam revealed coarse breath sounds right lower base, and chest x-ray confirmed a right lower lobe infiltrate. He also has meningeal signs on the exam. He was emergently intubated and placed on mechanical ventilation. Which of the following is the correct choice and rate for intravenous fluids?



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A 55-year-old female is admitted with decompensated cirrhosis and refractory ascites with abdominal pain and distension. She usually gets therapeutic paracentesis of 4 to 6 liters as an outpatient every 1 to 2 weeks. The last one was five days prior. On exam, she had scleral icterus, temperature 38.4 C, heart rate 80/min, blood pressure 88/40 mmHg, respiratory rate 26/min and pulse oximetry 96% on room air. The abdomen was tense with diffuse mild tenderness and a fluid thrill. She had 3+ bilateral pitting lower extremity edema and asterixis. Serum creatinine 2.4 mg/dL and WBC 16 x 10^3/microL with a left shift. Diagnostic and therapeutic paracentesis is performed. Which of the following should be considered as a treatment regimen?



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Fluid Resuscitation - References

References

Cantle PM,Cotton BA, Balanced Resuscitation in Trauma Management. The Surgical clinics of North America. 2017 Oct     [PubMed]
Wise R,Faurie M,Malbrain MLNG,Hodgson E, Strategies for Intravenous Fluid Resuscitation in Trauma Patients. World journal of surgery. 2017 May     [PubMed]
Brown JB,Cohen MJ,Minei JP,Maier RV,West MA,Billiar TR,Peitzman AB,Moore EE,Cuschieri J,Sperry JL, Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. The journal of trauma and acute care surgery. 2013 May     [PubMed]
Rhodes A,Evans LE,Alhazzani W,Levy MM,Antonelli M,Ferrer R,Kumar A,Sevransky JE,Sprung CL,Nunnally ME,Rochwerg B,Rubenfeld GD,Angus DC,Annane D,Beale RJ,Bellinghan GJ,Bernard GR,Chiche JD,Coopersmith C,De Backer DP,French CJ,Fujishima S,Gerlach H,Hidalgo JL,Hollenberg SM,Jones AE,Karnad DR,Kleinpell RM,Koh Y,Lisboa TC,Machado FR,Marini JJ,Marshall JC,Mazuski JE,McIntyre LA,McLean AS,Mehta S,Moreno RP,Myburgh J,Navalesi P,Nishida O,Osborn TM,Perner A,Plunkett CM,Ranieri M,Schorr CA,Seckel MA,Seymour CW,Shieh L,Shukri KA,Simpson SQ,Singer M,Thompson BT,Townsend SR,Van der Poll T,Vincent JL,Wiersinga WJ,Zimmerman JL,Dellinger RP, Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive care medicine. 2017 Mar     [PubMed]
Boer C,Bossers SM,Koning NJ, Choice of fluid type: physiological concepts and perioperative indications. British journal of anaesthesia. 2018 Feb     [PubMed]
Anthon CT,Müller RB,Haase N,Hjortrup PB,Møller K,Lange T,Wetterslev J,Perner A, Effects of hydroxyethyl starch 130/0.42 vs. Ringer's acetate on cytokine levels in severe sepsis. Acta anaesthesiologica Scandinavica. 2017 Sep     [PubMed]
Malbrain MLNG,Van Regenmortel N,Saugel B,De Tavernier B,Van Gaal PJ,Joannes-Boyau O,Teboul JL,Rice TW,Mythen M,Monnet X, Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Annals of intensive care. 2018 May 22     [PubMed]
Myburgh J,Cooper DJ,Finfer S,Bellomo R,Norton R,Bishop N,Kai Lo S,Vallance S, Saline or albumin for fluid resuscitation in patients with traumatic brain injury. The New England journal of medicine. 2007 Aug 30     [PubMed]
The Crystalloid versus Hydroxyethyl Starch Trial: protocol for a multi-centre randomised controlled trial of fluid resuscitation with 6% hydroxyethyl starch (130/0.4) compared to 0.9% sodium chloride (saline) in intensive care patients on mortality. Intensive care medicine. 2011 May     [PubMed]

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