Fluid Therapy in Cardiac Surgery Patients
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Transcript of Fluid Therapy in Cardiac Surgery Patients
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Done by Dr. Ayman RawehAugust 26, 2009
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Goal of Fluid Resuscitation
to restore tissue perfusion cellular oxygenation
maintain end organ function
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The body of a healthy 70 kg male contains about 42 liters of water, which is distributed into the following:
Extracellular Fluid
Intracellular Fluid
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Extracellular Fluid (1/3 of Total Body Water)Volume % of body weight
Interstitial fluid 11.2 liters (16%)Plasma 2.8 liters (4%)Total 14.0 liters (20%)
Intracellular Fluid (2/3 of Total Body Water)Volume % of body weight
Red Cells 2.2 liters (3%)Intracellular Fluid 25.8 liters (37%)Total 28.0 liters (40%)
Intravascular volume (plasma + red cells) is about 5 liters, with a hematocrit of 44%
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Types of Resuscitation Fluid
Crystalloid solutions
Colloid solutions
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Types of Crystalloid SolutionsHypotonic
5% Dextrose ½ Normal Saline
Isotonic Ringer’s Lactate Normal Saline
Hypertonic 3% Normal Saline 6% Normal Saline 7.5% Normal Saline
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Types of Colloid SolutionsProtein Solutions
Human Serum Albumin (5%, 25%) Gelatin Solutions
Non-Protein Solutions Starches
6% hetastarch (HES= hydroxyethyl starch)10% pentastarch
Dextransdextran-40 in normal salinedextran-70 in 5% dextrose in water
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Types of Crystalloid SolutionsHypotonic
5% Dextrose ½ Normal Saline
Isotonic Ringer’s Lactate Normal Saline
Hypertonic 3% Normal Saline 6% Normal Saline 7.5% Normal Saline
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Dextrose Solution 5%
Hypotonic solution
consists of 5g Dextrose in every 100 mL water
does not contain any electrolytes
distributes rapidly and evenly throughout the entire body fluid compartments
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Dextrose Solution 5% (continued)
One liter of intravenous dextrose solution expands intravascular compartment by only 70 ml and the interstitial fluid by 260 mL
has no use in fluid resuscitation to expand the intravascular volume
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Dextrose Solution 5% (continued)
More concentrated dextrose solutions (10%, 20%, and 50%) are available
their use is limited to management of diabetic patients or patients with hypoglycaemia
These solutions are irritant to veins.
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Types of Crystalloid SolutionsHypotonic
5% Dextrose ½ Normal Saline
Isotonic Ringer’s Lactate Normal Saline
Hypertonic 3% Normal Saline 6% Normal Saline 7.5% Normal Saline
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Ringer’s Lactate and Sodium Chloride 0.9% (‘normal saline’)
Isotonic solutionsrapidly redistribute within the extracellular
space (intravascular space and interstitium)One liter of intravenous normal saline or
Ringer’s lactate expands the intravascular volume by 220 mL after equilibration.
Redistribution is complete within 30-60 minutes
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Ringer’s Lactate and Sodium Chloride 0.9% (continued)
a four-fold amount of fluids is needed in comparison to whole blood or colloid plasma substitution in order to achieve the same intravasal volume effect
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Ringer’s Lactate and Sodium Chloride 0.9% (continued)
a risk of interstitial fluid overload
may lead to a decrease in arteriolar PaO2 in case of increasing extravasal lung water
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Types of Colloid SolutionsProtein Solutions
Human Serum Albumin (5%, 25%) Gelatin Solutions
Non-Protein Solutions Starches
6% hetastarch (HES= hydroxyethyl starch)10% pentastarch
Dextransdextran-40 in normal salinedextran-70 in 5% dextrose in water
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Colloid Solutionssufficiently large molecules that normally do
not cross capillary membranes in significant numbers
exert an oncotic pressure
remains intravascular for about 6-25 hours unless an altered permeability condition is present
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Colloid Solutions (continued)
good resuscitation fluids because all the volume administered stays in the circulation
One liter of intravenous hydroxyethyl starch, for example, expands the intravascular volume by 1200-1300 mL after 30-60 minutes
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Types of Colloid SolutionsProtein Solutions
Human Serum Albumin (5%, 25%) Gelatin Solutions
Non-Protein Solutions Starches
6% hetastarch (HES= hydroxyethyl starch)10% pentastarch
Dextransdextran-40 in normal salinedextran-70 in 5% dextrose in water
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Human Serum Albumin
Natural protein
Stays within the intravascular space unless the capillary permeability is abnormal
cause anaphylaxis in rare circumstances.
5% solution – isooncotic, 10% and 25% solutions – hyperoncotic
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Human Serum Albumin (continued)
Expands volume 5x its own volume in 30 minutes (when 25% Albumin Solution is used for example)
65 times more expensive than crystalloids
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Types of Colloid SolutionsProtein Solutions
Human Serum Albumin (5%, 25%) Gelatin Solutions
Non-Protein Solutions Starches
6% hetastarch (HES= hydroxyethyl starch)10% pentastarch
Dextransdextran-40 in normal salinedextran-70 in 5% dextrose in water
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Gelatin SolutionsBovine collagen is the basis for gelatin solutions
up to 50% leaves intravasal space within 1-2 hours
completely metabolized and can be eliminated by the kidneys
do not impact kidney function suitable for use in patients suffering from impaired
kidney function
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Types of Colloid SolutionsProtein Solutions
Human Serum Albumin (5%, 25%) Gelatin Solutions
Non-Protein Solutions Starches
6% hetastarch (HES= hydroxyethyl starch)10% pentastarch
Dextransdextran-40 in normal salinedextran-70 in 5% dextrose in water
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Hetastarch (HES= hydroxyethyl starch) A synthetic highly branched glucose polymer
Cheaper alternative to Albumin
Available as 6% and 10% solution in normal saline solution
Excreted in the urine (smaller particles), metabolised by blood amylase, then excreted into the bile and faeces (medium sized molecules), or undergoes phagocytosis by the reticulo-endothelial system (RES) (larger molecules).
Dose: limit the amount to 20 ml/kg/day
13 times more expensive than crystalloids
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Hetastarch (HES= hydroxyethyl starch) (continued)
Excretion Excreted in the urine (smaller particles)
metabolised by blood amylase, then excreted into the bile and faeces (medium sized molecules)
undergoes phagocytosis by the reticulo-endothelial system (RES) (larger molecules)
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Hetastarch (HES= hydroxyethyl starch) (continued)
Impact on blood coagulation There are reports that HES caused
significant prolongation of prothrombin time and prolonged thromboplastin time
reduced the levels of fibrinogen, factor VIII, factor C, and factor V
but the changes remained within the normal range
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Hetastarch (HES= hydroxyethyl starch) (continued)
Impact on blood coagulation In another report, patients who received large
doses of HES (about 1L) for trauma and surgery
had a prolonged partial thromboplastin time
up to a 50% decrease in factor VIII and factor C
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Hetastarch (HES= hydroxyethyl starch) (continued)
Impact on blood coagulation
HES seems to cause changes in fibrin clot formation and fibrinogenolysis
This characteristic may be related to the incorporation of the HES molecules into the clot, with subsequent prevention of solid clot formation.
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Types of Colloid SolutionsProtein Solutions
Human Serum Albumin (5%, 25%) Gelatin Solutions
Non-Protein Solutions Starches
6% hetastarch (HES= hydroxyethyl starch)10% pentastarch
Dextransdextran-40 in normal salinedextran-70 in 5% dextrose in water
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Pentastarch (Pentaspan)
Lower MW analogue of hydroxyethyl starch (HES)
10% solution in 500 ml normal saline solution vials
eliminated from the circulation at a faster rate than HES because of its smaller molecular weight
is mostly excreted in the urine, so it should be avoided \ in patients with renal disease complicated by oliguria or anuria unless it is related to hypovolemia
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Types of Colloid SolutionsProtein Solutions
Human Serum Albumin (5%, 25%) Gelatin Solutions
Non-Protein Solutions Starches
6% hetastarch (HES= hydroxyethyl starch)10% pentastarch
Dextransdextran-40 in normal salinedextran-70 in 5% dextrose in water
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DextransHigh MW polysaccharide
Dextran 40 - MW 40,000
Dextran 70 - MW 70,000
10% solution in NS or D5W
Excretion is through the urine, faeces and reticulo-endothelial system (RES) (according to molecular size)
Dose: limit to 20 Dose: limit to 20 ml/kg/day
occasional anaphylaxis
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Dextrans (continued)Impact on Coagulation
causes defects in platelet interaction and an antifibrinolytic effects
seems to be incorporated into the polymerising fibrin clot so that it alters clot structure and enhances fibrinogenolysis
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Crystalloids Vs. Colloidsstill a matter of debate and needs to be
determinedColloids and crystalloids have the same
(SAFE Study, 2004) mortality rate ICU or hospital days days of mechanical ventilation days of renal-replacement therapy
Colloids are much more expensive than crystalloids
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Crystalloids Vs. Colloids (continued)Crystalloids can cause interstitial and lung edema
more crystalloids are needed compared to colloids
Colloids have a dose-related coagulopathy (greatest with hetastarch), and occasional anaphylaxis
starch molecules may adversely affect renal function by causing tubular injury
Non-protein colloids can also interfere with antigen detection during cross matching of blood products
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Simulation of Fluid Management
http://pie.med.utoronto.ca/CA/CA_content/CA_fluidManagement.html