Fluid Resuscitation and Organ Perfusion Evaluation
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Fluid Resuscitation and Organ
Perfusion Evaluation
Departemen Anestesiologi dan Terapi IntensifFakultas Kedokteran UMSU
2014
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Body Fluid
• The volume of total body fluid (in liters)
– Male : 60% of lean body weight (kg)
: 600 ml/kg
– Female: 50% of lean body weight (kg)
: 500 ml/kg
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• A healthy adult male who weighs 75 kg will
then have 0.6 × 75 = 45 liters of total body
fluid
• A healthy adult female who weighs 60 kg will
have 0.5 × 60 = 30 liters of total body fluid
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Blood Volume
• The volume of blood accounts for 6-7% of
body weight
– Male : 66 ml/kg
– Female : 60 ml/kg
• The volumes of blood 11-12% of total body
fluid
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Body Fluid
Body fluidMen Women
ml/kg 75 Kg ml/kg 60 kg
Total body fluid 600 45 L 500 30 L
Interstitial fluid 150 11,3 L 125 7,5 L
Blood 66 5 L 60 3,6 L
Red Cell 26 2 L 24 1,4 L
Plasma 40 3 L 36 2,2 L
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Plasma and Interstitial Fluid
• Extracellular fluid accounts for about 40% of
TBF:
– Extravascular (interstitial)
– Intravascular (plasma)
• Plasma volume is about 25% of interstitial
fluid volume
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ISF IVF ICF
Physiologic principles of fluid
management
Perdarahan
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Acute Blood loss
earliestMovement of
interstitial fluid into the bloodstream
lateActivation of RAA
system
Restoring
volumedeficits
Compensatory Responses
Fully compensate for the
loss of 15-20% BV
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10Trauma 7th Ed, 2013
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Clinical Evaluation
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Clinical Evaluation
ClinicalEvaluation
Pulse rate
Bloodpressure
Pulsepressure
Respiratoryrate
Urineoutput
CNS/mentalstatus
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Postural Changes
•Moving from the supine to the standingposition causes a shift of 7 to 8 mL/kg of blood
to the lower extremities
•
In healthy subjects, this change in bodyposition is associated with a small increase in
heart rate (about 10 beats/min) and a small
decrease in systolic blood pressure (about 3 to
4 mm Hg)
These changes can be exaggerated
in the hypovolemic patient
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• A significant postural (orthostatic) change is
defined as any of the following: – an increase in pulse rate of at least 30
beats/minute,
–
a decrease in systolic pressure > 20 mm Hg, ordizziness on standing.
The only tests with a sensitivity high enough to be of anyvalue are postural
dizziness and postural increments in heart rate in severe
blood loss (630 to 1,150 mL of blood).
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Hematocrit
• The hematocrit (and hemoglobin concentration inblood) to determine the extent of acute blood lossis both common and inappropriate.
•Acute blood loss the loss of whole blood ↓the volume of plasma and erythrocytes hematocrit will not change significantly
• Activating RAA system leading to renal
conservation of sodium and water and expansion ofthe plasma volume ↓the hematocrit.
• This process begins 8 to 12 hours after acute bloodloss
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Chemical Markers of Dysoxia
• Two measures of acid-base balance can
provide information about the adequacy
of tissue oxygenation: – serum lactate concentration
– arterial base deficit
• Both are used as markers of impairedtissue oxygenation.
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glucose oksigen
38 Mol ATP
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glucose oksigen
2 Mol ATP
+
36 Mol Lactate
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Serum Lactate
• > 2 mM/L abnormal.
•> 4mM/L more predictive of
increased mortality life-
threatening elevations of serum
lactate
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Arterial Base Deficite
• The base deficit is the amount (in millimoles)
of base needed to titrate one liter of whole
blood to a pH of 7.40 (at temperature of 37°Cand PCO2 = 40 mm Hg).
• The normal range for base deficit is +2 to 22
mmol/L.
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• Abnormal elevations in base deficit are
classified
–
mild
22 to 25 mmol/L – moderate 26 to 214 mmol/L
– severe <215 mmol/L.
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Resuscitation Strategies
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Promote cardiac output
1. CI > L/min/m2
2. MABP > 65 mmHg or < 65 mmHg, iftolerated, untill bleeding is controlled
3. UOP > 0,5 ml/kg/hr
Promote oxygen delivery1. DO2 > 500 ml/min/m2
2. Hb > 7-9 g/dl
3. SaO2 > 90%
Promote aerobic
metabolisme
1. VO2 > 100 ml/min/m2
2. SvO2 > 70%
3. Serum lactate < 2 mM/L within 24 hr
Promote Hemostasis1. INR < 1,5
2. aPTT < 1,5 x control
3. Platelet count > 50 x 109/L
GOAL END-POINTS
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Promoting Cardiac Output
• The consequences of a low cardiac
output are far more threatening than
the consequences of anemia, so thefirst priority in the bleeding patient
is to support cardiac output.
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Resuscitation Fluid
• The fluids used to promote cardiac output:
– Crystalloid fluids
– Colloid fluids
• Plasma provide clotting factors NOT
USED as a volume expander
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Crystalloid >< Colloid
CRYSTALLOID FLUIDS COLLOID FLUIDS
• Sodium-rich electrolyte
solutions
• Distribute throughout the
extracellular space
• Expand the extracellular
volume
• Sodium-rich electrolyte
solutions
• Contain large molecules
do not pass readily out of the
bloodstream
• Retained molecule hold
water in the intravascular
compartment• Expand the intravascular
(plasma) volume.
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Different Type of Resuscitation Fluid
Type of fluid Products Principal use or result
Colloid fluid Albumin (5%, 25%)
Hetastarch (6%)
Dextrans
Expands the plasma volume
Crystalloid fluid Isotonic saline
Ringer’s lactateNormosol
Expands the extracellular volume
RBC concentrate Packed RBC’s Increases O2 content of blood
Stored plasma FFP Provide coagulation factorsProcoagulant
mixture
Cryoprecipitate Low-volume source of fibrinogen
Platelet concentrate Pooled platelet
Apharesis platelet
Restores circulating platelet pool
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Colloid fluids
Crystalloidfluids
PRC/WB P r o m o t i n g C a r d i a c o u t p u t
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Colloid fluids are much more effective
than crystalloid for promoting cardiacoutput
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31
ISF
13L
ISF IVF ICF
5L 27 L750 ml 250 ml 2 L
D5W
3L
Physiologic principles of
fluid management
Hasanul, 2002
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32
ISF
13L
ISF IVF ICF
5L 27 L2250ml 750 ml
RL,NaCl
3L
Physiologic principles of
fluid management
Hasanul, 2002
• 25% in the
cascular
space
• 75% to
interstitial
space
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33
ISF
13L
ISF IVF ICF
5L 27 L1L
Albumin-5%
1 L
Physiologic principles of
fluid management
Hasanul, 2002
• 100% in
thevascular
space
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34
ISFISF IVF ICF
5L 27 L1000ml
HES-6%1L
Physiologic principles of
fluid management
Hasanul, 2002
13L
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35
ISF
13L
ISF IVF ICF
5L 27 L500
Albumin-25%
100 cc
Physiologic principles of
fluid management
Hasanul, 2002
400
Volume expander
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36
ISFISF IVF ICF
5L 27 L700ml
Haemacel1L
Physiologic principles of
fluid management
Hasanul, 2002
13L300ml
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The Preferred Fluid
•
Despite the superiority of colloid fluids overcrystalloid fluids for increasing plasma volume
and promoting cardiac output, crystalloid have
been the preferred resuscitation fluid for
hemorrhagic shock for past 50 years.
• The principal reasons
– Low cost
– Lack of documented survival benefit
• The favored crystalloid fluid Ringer’s lactate
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Hemostatic Resuscitation
• Fresh frozen plasma
–For the resuscitation of massive blood
loss one unit of FFP for every one ortwo units PRC
–Source of fibrinogen: 2-5 g/L
–Aim: maintainning an INR < 1,5 and
aPTT < 1,5 times normal
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• Cryoprecipitate
–
Provide fibrnogen: 3,2-4 grams in 150-200 ml
• Platelets
–One unit for every 2-5 units PRC
improved survival rates
–
Goal: maintain a platelet count >50.000/mm3 when bleeding is active
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Respons to Initial Fluid Resuscitation
41Trauma 7th Ed, 2013
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Trauma 7th Ed, 2013
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Trauma 7th Ed, 2013
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• All patients with suspected serious injuries
require the placement of two large-bore
peripheral IVs.
• Higher flow rates are best achieved with short,
large-diameter catheters.
• Peripheral IVs are usually placed in the upper
extremities unless there is significant injury to
the upper extremities or upper chest withvascular or soft tissue compromise.
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INTRAVENOUS ACCESS
• Peripheral
–Upper extremities
–Lower extremities
• Central
–Femoral veins
–Subclavian vein
–Internal jugular vein
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INTRAVENOUS ACCESS
• A cutdown of the saphenous vein in
the lower extremity or basilic or
cephalic vein in the upper extremity
• Intraosseous cannulation of the
proximal tibia
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Theoretical Maximum Flow Rates
Colour Gauge Flow
Yellow 24G 13 ml/min
Blue 22G 30 ml/min
Pink 20G 55 ml/min
Green 18G 80-100 ml/min
White 17G 135 ml/min
Grey 16G 180 ml/min
Orange or Brown 14G 270 ml/min
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• At the time of placement, blood should be
drawn for basic hematologic and chemistry
analysis and type and cross-matching
• The treatment for hypovolemic shock is fluid
resuscitation and hemorrhage control
Remember, STOP THE
BLEEDING!!!
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• Severely injured patients should receive a 2-L
bolus of warm, isotonic fluid such as Ringer’s lactate.
• Patients whose blood pressure responds to
this initial fluid bolus can undergo furtherwork-up for potential injuries and continued
crystalloid resuscitation.
• If blood pressure remains low, blood should
be given
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• Recent studies administering a
combination of fresh frozen plasma andpacked red blood cells during massive
improved mortality
•
The optimum ratio of fresh frozen plasma topacked red blood cells under investigation
O-negative blood shouldbe used until type-specific blood becomes
available
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CaO2 = SaO2 x Hb x 1.34 + PaO2x0.0031 ml/dl
DO2 = CaO2 x CO x 10 ml/menit
Blood Transfusion
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BLOOD REPLACEMENT
• Red blood cells (RBCs)
– Packed red blood cells (PRBCs) obtained from whole
blood by:
•
Centrifugation• Apheresis
– PRBCs are anticoagulated with citrate mixed with a
preservative solution up to 42 days at 1-6oC
– One unite compatible RBCs 250-300 ml Ht: 55-65% will increase Hb 1g/dL or Ht 3%
– Donor RBCs must be either ABO identical or
compatible
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• Platelets (PLT)
– WB-PLTs (50 ml) prepared by centrifugation of
WB (4-6 WB PLTs)
– Single donor platelets (SDPs) collected from
one single donor
– Both preparations are stored 20-24oC maximum of 5 days of storage
– Contain an appreciable volume of plasma
–For each SDP or pool of 6 WB-PLT 30.000-60.000/mm3
– ABO matching is not stricly necessary
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• Fresh Frozen Plasma (FFP)
– Plasma is the remaining part of WB after removal
of platelets and cellular elements
– Frozen within 8 hours prevent inactivation of
factors V and VIII
– Before transfusion must be thawed in waterbath at 37oC for 30 minutes
– The transfusion must occur within 24 hours
–
ABO-identical – Dose: 10-15 ml/kg (3 to 5 units)
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Coagulation Disturbances In Trauma
• Coagulation disturbances following
trauma trimodal pattern,
– an immediate hypercoagulable state
– Followed quickly by a hypocoagulable state
– and ending with a return to a
hypercoagulable state
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Coagulopathy in Trauma
• Clotting factor depletion (via both
hemorrhage and consumption)• Dilution (secondary to massive
resuscitation)
• Dysfunction (due to both acidosisand hypothermia)
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Target 7 - 9g%
contoh:BB 60 kg, Hb 4g%, WB yang dibutuhkan = 5 x (9-4) x 60
= 1500 mL
Bila PRC 750 mL
transfusi
Rule of 5mL WB= 5 x delta Hbx BB
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Penghangatan Cairan dan Darah
• Hangatkan cairan s/d 390 C
• Tetesan menjadi lebih cepat (guyur)
• Jantung lebih kuat untuk pumping
•Oxygen Discociation Curve bergeser kekanan(unloading)
• Mencegah hypothermia cegah shivering
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Hangatkan Darah
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FILTER
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koagulopati
• Transfusi massif :• > volume darah tubuh /24jam
• > 4 unit PRC/ 1 jam
• > 50% volume darah / 3jam
• dilutional thrombocytopenia
• Hypothermia : gangguan agregasi platelet& clotting cascade koagulopati
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ransfusi
Target 7 - 9g%
Rule of - 5
ml Whole-Blood = 5 x delta Hb x BB
contoh:
BB 50 kg, Hb 4g%, WB yang dibutuhkan = 5 x 5 x 50
= 1250 ml
= 5 bag [unit]
Hasanul, 2003
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Pola kerja penanganan shock perdarahan
Penderita datang dengan
perdarahan
Pasang infus jarum kaliber
besar (16G, 18G), ambilsample darah
Ukur tekanan darah, hitung
nadi, nilai perfusi, produksiurine
Tentukan estimasi jumlah
perdarahan, minta darah
Guyur cepat Ringer Laktat atau NaCl
0.9% [hangat, 390C] 3x prakiraan lost-
volume [1-2 liter] evaluasi
Hasanul, 2003