UPDATE of FLUID

THERAPY in
TRAUMA and
CRITICALLY ILL
Vanessy Silalahi

INTRODUCTION

The administration of intravenous fluids is one of

the most common intervention for hemodynamic
stabilisation in trauma, perioperative and critical
care setting
The application of fluid during hypovolemic shock
leads to circulatory stabilization and can therefore
be life-saving, but fluid overload is associated with
oedema development and worse outcomes

 Oh noooooooo.

Many new phrases and

understanding :

FLUID OVERLOAD ?
DE-RESUSCITATION ?
HIT CONCEPTS ?
MORE or LESS FLUIDS ?

Lets find out whats interesting.!!!

FLUID OVERLOAD

BACKGROUND
Sepsis is associated with generalised endothelial
injury and capillary leak and has traditionally
been treated with large volume fluid
resuscitation
Some patients with sepsis will accumulate
bodily fluids

Special Articles

Surviving Sepsis Campaign: International

Guidelines for Management of Severe Sepsis
and Septic Shock: 2012
R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach,
Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman
Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart,
Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado, Gordon
D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and
the Surviving Sepsis Campaign Guidelines Committee including the Pediatric
Subgroup* Critical Care Medicine 2013; 41(2):580-637

Crystalloid vs Colloid in the resuscitation of severe sepsis and septic shock

Surviving Sepsis Campaign: International Guidelines for

Management of Severe Sepsis and Septic Shock: 2012
R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky,

Special ArticlesCharles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart,

Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado, Gordon D. Rubenfeld, Steven A. Webb, Richard J.
Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric
Subgroup* Critical Care Medicine 2013; 41(2):580-637

WE FOUND THAT ..
A restrictive fluid management was associated
with a lower mortality compared to patients
treated with a more liberal fluid management
strategy (24.7% vs 33.2%; OR, 0.42; 95% CI
0.320.55; P < 0.0001)
A positive cumulative fluid balance is associated
with IAH and worse outcomes. Interventions to
limit the development of a positive cumulative
fluid balance are associated with improved
outcomes
Manu,et al, Anesthesiologi Intensive Therapy, 2014

Liberal or restricted fluid administration:

intraoperative fluid approach

Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperativeapproach? Della Rocca et al. BMC Anesthesiology 2014, 14:62

The SSC Guidelines focus on the initial

resuscitation but fail to provide information on
the assessment of volume overload or when and
how to perform de-resuscitation
CVP -> little useful data to the pts overall vol
status
Less invasive hemodynamic monitoring are
helpful devices when faced with theraputic
conflict, especially in high-risk patients.
Manu,et al, Anesthesiologi Intensive Therapy, 2014
Christiane S hartog et al, IntensiveCareMed, 2010

Liberal or restricted fluid

administration

Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperativeapproach? Della Rocca et al. BMC Anesthesiology 2014, 14:62

Colloids vs crystalloids in critically

illness
No

Study

Fluids

Methodes

Subjects

Mortality

AKI/RRT

SAFE Study

Albumin 4% vs
Saline

RCT

6933

NS

NS

VISEP Study

6%HES 200/0.5 vs
Ringer Lactate

RCT

537

HES > Ringer

lactate

HES > Ringer

lactate

6S Trial

6%HES 130/0.4 vs
Ringer Acetate

RCT

804

HES > Ringer

acetate

HES > Ringer

acetate

CHEST Trial

6%HES 130/0.4 vs
RCT
Saline

7000

NS

HES > saline

CRYSTAL Trial

Albumin 4% vs Gelatines
vs HES vs Crystalloids

RCT

2857

NS

NS

Cochrane 2013

Colloids vs
Crystalloids

Metaanalysis

trials

HES >

HES >

Fluid Balance=
1. Daily fluid balance is the daily sum of all
intakes and outputs
2. Cumulative fluid balance is the sum total of
fluid accumulation over a set period of time
Fluid Overload = the percentage of: (
Cumulative fluid balance in L / baseline kgbw )
x 100%
-> FO= fluid accumulation > 10% = worse
outcome

Electrolyte Overload, Chloride Overload,

Hyperchloremic metabolic acidosis

Electrolyte Overload, Chloride Overload,

Hyperchloremic metabolic acidosis

increased renal
interstitial pressure may collapse intrarenal c
lymphatics which compromise lymph flow

Late Conservative Fluid Management (LCFM)= two

days of negative fluid balance within the first week of
ICU stay, is a strong and independent predictor of
survival
Late Goal Directed Fluid Removal (LGFR) =
In some patients, more aggressive and active
fluid removal by diuretics and RRTwith net UF
is needed. so called DE-RESUSCITATION

The adverse effects of FO and interstitial oedema are

numerous and have an impact on all end organ
functions
Manu,et al, Anesthesiologi Intensive Therapy, 2014

When to de-resuscitate?
a negative fluid balance increases survival in
patients with septic shock
De-resuscitation should be considered when
fluid overload and fluid accumulation negatively
impact end-organ function, so de-resuscitation is
mandatory in a case of a positive cumulative
fluid balance in combination with poor
oxygenation (P/F ratio < 200), increased
capillary leak (high PVPI > 2.5 and EVLWI >
12 mL kg-1 PBW), increased IAP (> 15 mm Hg)
and low APP (< 50 mm Hg ), high CLI, etc.

How to de-resuscitate ?
fluid management aimed at EVLWI reduction
results in a more negative fluid balance and
improved outcomes

PAL-treatment combines high levels of

positive end-expiratory pressure (PEEP), small
volume resuscitation with hyperoncotic albumin and fluid removal with diuretics (Lasix) or
ultrafiltration during continuous renal
replacement therapy (CRRT)

Goal-Directed Fluid Resuscitation in Critically Ill

and Trauma Patients
Goal-Directed Fluid Resuscitation :
When to start or stop giving fluid
When to start
giving fluid
Minutes
1.Clinical sign of
hypovolemic::
Hypotensive (MAP<65),
tachycardia,
oliguria, CRT> 3 sec
2.Preload
responsiveness:
Low CVP, Low CO/SV,
SVV/PPV>10%,
PLR>10%, IVC
collapsibility

When to restrict-stop
giving fluid
Hours

1.Clinical sign of
normovolemic::
Normotensive (MAP>65),
Normal heart rate
urine output
>0,5cc/kg/min, CRT<3 sec
2.Preload
iresponsiveness:
Increased CVP, increased
CO/SV,
SVV/PPV<10%,,PLR<10%,
IVC normal

When to start remove

fluid
Hours/Days

1.Fluid accumulation/
balance positive:
tachycardia, oliguria
2.Preload iresponsiveness,
fluid overload:
Sign of peripheral edema,
lung edema (rales, CXR),
High CVP, Normal/high
CO/SV, SVV/PPV<10%,
PLR<10%, IVC distensibility
High ELWI

When to stop
fluid removal
Minutes
1.Balance zero/negative
2.Preload
responsiveness:
Low CVP, Low CO/SV,
SVV/PPV>10%,
PLR>10%, but with
improved clinical sign of
organ edema (normal
CXR, ELWI)

MALBRAIN et all. Anesthesiology Intensive Therapy 2014

CLASSIFICATION OF FLUID DYNAMICS :

Combining early adequate (EA) or early conservative (EC)

and late conservative (LC) or late liberal (LL) fluid
management, four distinct groups can be identified with
regard to the dynamics of fluid management: EALC,
EALL, ECLC, and ECLL

4 HIT MODEL of SHOCK : Resuscitation,

Optimisation, Stabilisation, Evacuation (ROSE),
followed by potensial Hypoperfusion.
Manu,et al, Anesthesiologi Intensive Therapy, 2014

The Dynamic Phases of fluid resuscitation in

critically ill or injured patients
THE ROSE CONCEPT
RESUSCITATION

OPTIMIZATION

STABILIZATION

EVACUATION

HIT

1ST HIT: WHEN DO I

2ND HIT: WHEN DO I
START TO GIVE FLUIDS? STOP TO GIVE FLUIDS?

2ND HIT: WHEN DO I

STOP TO GIVE FLUIDS?

3RD / 4TH HIT: WHEN DO I

START / STOP
UNLOADING FLUIDS?

TIME FRAME

MINUTES

HOURS

DAYS

DAYS-WEEKS

GOALS

Correct shock

Maintaining tissue
perfusion

FLUID THERAPY Rapid bolus (4 mL kg-1

1015 min)

MONITORING
TOOLS

A-line, CV-line, PPV

or SVV (manual or via
monitor), uncalibrated
CO, TTE, TEE

Aim for zero or negative Mobilise fluid

Fluid Balance
accumulation (LGFR) =
emptying or DEresuscitation
Titrate maintenance
Minimal maintenance if Oral intake if possible
fluids, conservative use oral intake inadequate, Avoid unnecessary IV
of fluid bolus
provide replacement
fluids
fluids

Calibrated CO (TPTD,
PAC)

Calibrated CO (TPTD,
PAC)

Calibrated CO (TPTD);
Balance; BIA; DEescalation

MALBRAIN et all. Anesthesiology Intensive Therapy 2014

IN TRAUMA ???

Worldwide, traumatic injury is the leading cause

of mortality in patients under the age of 44, and
accounts for more than 6 million deaths each
year.
up to 20% of deaths after trauma might be
preventable
the majority of these are due to uncontrolled
haemorrhage.
Veena Chatrath et al, Journal of Anesthesiology,2012
Amy T Makley et al,Jornal of Surgical Reasearch,2011
Col R Datta, MJAFI, 2010

The standard approach to the trauma victim, who

is hypotensive from presumed hemorrhage ->
transfuse large volumes of fluid as early and
as rapidly as possible

Twenty five percent of all patients admitted to

hospital after trauma develop a coagulopathy
that further increases their risk of significant
haemorrhage

Mortality in patients with a coagulopathy, even

after adjustment for their injury severity, is 34
times higher than patients without coagulopathy

The correction and prevention of traumatic

coagulopathy has become a central goal of
EARLY RESUSCITATION
MANAGEMENT OF HAEMORRHAGIC
SHOCK FOLLOWING INJURY
Veena Chatrath et al, Journal of Anesthesiology,2012
Amy T Makley et al,Jornal of Surgical Reasearch,2011
Col R Datta, MJAFI, 2010

The concept of balanced resuscitation

is further emphasized, and the term
aggressive resuscitation has been
eliminated

The standard use of 2 liters

of crystalloid resuscitation as the
starting point for all resuscitation has
been modified to initiation of 1 liter of
crystalloid.

Fluid Resuscitation based on Classes

of shock by ATLS

Crystalloids
Colloids
Blood transfusions

Four Phases of Fluid Resuscitation in

Critically Ill and Trauma Patients :
SOSD

Salvage

Optimization

Stabilization

De-escalation

Obtain a minimal
acceptable blood
pressure

Provide adequate oxygen Provide organ support

availability

Wean from vasoactive

agents

PERFORM LIFESAVING
MEASURES

Optimize cardiac output, Minimize complications

ScvO2, lactate

ACHIEVE A NEGATIVE
FLUID BALANCE

Vincent JL. De Baker. NEJM 2013

SOSD

Salvage

Optimization

Stabilization

Deescalation

Principles

Life saving

Organ rescue

Organ support

Organ recovery

Goals

Correct shock

Maintain tissue
perfusion

Zero/negative
fluid blance

Mobilize fluid
accumulation

Phase

Obtain
Adequate oxygen
acceptable blood
Organ support
availability
pressure

Focus

Life saving
monitoring

Optimizing
cardiac output,
Scvo2, lactate

Minimizing
complications

Achieving a
negative fluid
balance

Time

Minutes

Hours

Days

Days to weeks

Phenotype

Severe shock

Unstable

Stable

Recovering

Rapid boluses

Fluid titration,
conservative of
fluid
accumulation

Minimal fluid
maintenance if
oral intake
inadequate

Oral intake

Fluid therapy

Weaning
vasoactive agents

Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013

Colloids vs crystalloids in trauma patients

Colloids are more expensive and

one type of colloids (starches)
might increase the risk of death

Cochrane Systematic Review concludes that there

is no evidence that colloids reduce the mortality risk
compared with crystalloids in patients with trauma,
burns or following surgery.

Shock Classification in Trauma

Education of ATLS 2012

EBL Based on Patients Initial

Presentation

Shock Classification in Trauma

Education of ATLS 2012

Responses to initial fluid resuscitation

Traumatic Coagulopathy

Trauma induced coagulopathy describes the

hypocoagulable state that occurs after injury and
exacerbates bleeding.
It is an independent predictor of the need for
massive transfusion and death, and patients who
develop a coagulopathy have an increased
likelihood of protracted intensive care stay,
multi-organ failure (MOF), and specifically renal
failure and acute lung injury

What happens in Traumatic

coagulopathy ??

Hypothermia
Acidosis
Haemodilution
> 40% of trauma patients develop coagulopathy
after >2L crystalloid and colloid administration
Rising up to >70% after 4L
Veena Chatrath et al, Journal of Anesthesiology,2012
Amy T Makley et al,Jornal of Surgical Reasearch,2011
Col R Datta, MJAFI, 2010

What is DCR ..??

1. PERMISSIVE HYPOTENSION
2. HAEMOSTATIC RESUSCITATION and
TRANSFUSION STRATEGIES
- Massive haemorrhage protocols
- Fresh whole blood

3. DAMAGE CONROL SURGERY

Permissive Hypotension for Uncontrolled

Hemorrhagethe early phase of trauma
resuscitation, bloodpressure
Strong clinical arguments but less clinical
evidences, Indirect arguments, SBP : 70-90 mmhg

(1) SBP 6070mmHg for penetrating

trauma
(2)SBP 8090mmHg for blunt trauma
without head trauma/ TBI
(3) SBP 100110mmHg for blunt trauma
with head trauma/TBI.
Tisherman SA, Barie P, Bokhari F, et al. Clinical practice guideline: endpoints of resuscitation. J Trauma 2004; 57:898912.
Gattinoni L, Carlesso E. Supporting hemodynamics: what should we target?What treatments should we use? Crit Care 2013; 17 (Suppl 1):S4.

Consept of low volume fluid resuscitation

either by delaying the time of administration or

minimising the volume given

reduce fluid administration , minimising

dilutional coagulopathy and hypothermia effects

also to reduce theoretical risks of clot

displacement by maintaining a lower systolic
blood pressure
Veena Chatrath et al, Journal of Anesthesiology,2012
Amy T Makley et al,Jornal of Surgical Reasearch,2011

Permissive Hypotension CONTRA

INDICATED in :
1. TBI
And carefully considered in :
1. Elderly
2. Chronic Arterial hypertension
3. Carotid stenosis
4. Angina pectoris
5. Compromised renal function

Veena Chatrath et al, Journal of Anesthesiology,2012

Amy T Makley et al,Jornal of Surgical Reasearch,2011

New concept of fluid resuscitationderesuscitation

GOAL
STRATEGY
FLUID BALANCE

Correct Shock

Maintain tissue
perfusion

Fluid Evacuation

Fluid Bolus

Maintenance

Diuretic - Ultrafiltration

Positive

Neutral/Negative

Negative

HIPOVOLEMIC /
HEMORAGIC

DISTRIBUTIVE /
SEPTIC

OBSTRUKTIF

(FLUID) RESUSCITATION /
SALVAGE

CARDIOGENIC

(FLUID) REMOVAL/
DE-RESUSCITATION

OPTIMIZATIONSTABILIZATION
START

MINUTES
HOURS
DAYS

Murphy et al. The importance of fluid management in acute lung injury secondary to septic shock; CHEST 2009; 136-102-109
Fluid therapy in septic shock, Emanuel P. Riversa b, Anja Kathrin Jaehnea, Laura Eichhorn-Wharry, Samantha Browna and David Amponsah. Curr Opin Crit Care, 2010
Cordemans et al. Fluid management in critically ill patients: the role of extravascular lung water, adbominal hypertension, capillary leak, and fluid balance. Annal of Intensive Care 2012
Vincent JL, De Backer. Circulatory Shock.N Engl J Med 2013
Malbrain et al; Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestion for clinical practice. Anesthesiology Intensive Therapy 2014

CONCLUSION

Capillary leak is an inflammatory condition

Plasma volume expansion to correct

hypoperfusion predictably results in
extravascular movement of water, electrolytes
and proteins

Regardless of the resuscitation strategy, clinician

must maintain a high awareness of the dynamic
relationship between capillary leak, fluid loading,
peripheral oedema, IAH,and the ACS

CONCLUSION

LCFM and de-resuscitation may in the long run

be more important than the initial resuscitation
efforts in patients with shock

No single parameter can change outcome, this

can only be achieved by a good protocol

CONCLUSION
Clinicians MUST KNOW :

When to start giving fluids

When to stop giving fluids

When to start removing fluids

When to stop fluid removal

CONCLUSION

Mortality in patients with trauma haemorrhage is

high
Large volume of crystalloid resuscitation need to
be avoided
Monitoring is essential , as any measurement in
the ICU will only be of value as long as it is
accurate and reproducible, and no measurement
has ever improved survival, only a good
protocol can do this

CONCLUSION

Fluid Overload is detrimental to patients and is

associated with increased morbidity and
mortality

If the patient does not need fluids, dont give

them, and remember that the best fluid may be
the one that has not been given to the patient!

It is essential to give the right fluid at the right

time in the right fashion, and to use the correct
monitor correctly.

THANK YOU
FOR YOUR
KIND
ATTENTION
..