Fluid therapy
Resuscitation goals adequate of microcirculation Maintenance fluid , electrolyte, acid base balance Nutrition energy metabolism and cell construction to maintan organ function
Colloids or Crystalloids?
There are two main physiologic reasons to believe that colloid could be more efficacious than crystalloid: (1) more rapid plasma volume expansion, since the colloid solution remains in the vascular space (in contrast to saline, two-thirds of which enters the interstitium); (2) a lesser risk of pulmonary edema, since dilutional hypoalbuminemia will not occur .
Colloid
Intravascular space expander Volume expansion varies per-individual colloid chosen Osmotically active with high molecular weight Maintain oncotic pressure Influence coagulation system Variable electrolyte content Intra-vascular half-life varies between 2 8 hour Adverse reaction More expensive than crystalloids
Use the best colloid for the selective patients to achieve the goals of therapy with the least of side effect
Albumin
One of the original plasma expander Accounts for 60 80 % of plasma oncotic pressure Derived from pooled human plasma Available as 5 % and 20% solution Blood albumin level prognostic indicator !, not an absolute value to be maintained by exogenous albumin infusion Blood derived product
Albumin ( cont )
Dextran
Branched chain polysacharide Produced plasma expansion by a colloidal osmotic effect Mostly used in restoring intravascular volume 2 preparation :
Dextran 70 Dextran 40
Both are in saline 0.9% 50- 70% excreted unchanged in the urine, the rest is metabolized in the liver H2O + CO2
Gelatin
Second most commonly used plasma expander after hydroxyethyl-starch 2 different formulations
4% modified 9 succinylated fluid gelatin gelofusin 3.5% polygeline degraded gelatin polypeptides cross linked via urea bridges Haemaccel
Succinylated gelatin result in negative charge so spread out the molecule result in filling of iv volume and sealed endothelial leakage
Gelatin ( cont )
MW 30000-35000 dalton rapi excretion via urine with complete plasma clearance within 3 days, complete excretion from the body in 1 week Up to 50% removed within 1st 4-8 hour No storege in RES Claimed to be no effect on coaulation unless due to dilution No limitation of volume to be given Benefit over HES in renal compromised patients after renal transplant ( Cittanova M, lancet December 1996 ) Derived from animal bovine : theoretical risk of transmission of contagion
Gelatin ( cont)
Rapid migration out of the iv space needs more volume to achieve the same volume expansion effect of HES possibility of overhydration especially in critically ill/ renal/cardiac dysfunction Volume effect 3-4 hours Anaphylactoid reaction >>
Hydroxyethyl- starch
Derived from chemically modified amylopectin ( wax corn starch) Osmolarity 310 mOsm close to normal physiological osmolarity Concentration 6% and 10% Approximate pH 5.5 Available in saline 0,9% and in lactated ringer solution
Capillary Physiology
HES
MW vary 450 130 dalton Differ in degree of substitution substitution ratio Vary greatly in the t1/2 intravascularly, duration of effect and plateau effect and rate of elimination Plateau effect up to 4 hour, volume efficacy 1:1 duration varying 4-8 hour Broken down by amylase in the plasma Removed by renal excretion after degradation ( small molecule 50 ) Low incidence of anaphylactoid reaction More expensive crystalloid
HES ( cont..)
High molecular weight HES have a very narrow therapeutic benefit range Medium to lower MW HES more ideal as volume resuscitation Decrease the increase of vasoactive mediators & beneficially alter membrane stabilization Boldt M, Anest/analg 1996 showed improved systemic HD, splanchnic perfusion in trauma & septic patient Voght N, Anest-analg 1996 demonstrated the safety of HES 200/0.5 in doses larger than the recommended dose not for renal impairment
HES 130/0.4 (6% - Voluven) infusion during CVVH resulted in stable HD accompanied with constant value of diuresis and creatinin clearance and DO2 Histologic PA did not reveal significant increased cellular infiltration of alveolar capillaries compared to other colloids
96h
72h
48h
0-24h
Microcirculatory analysis : Arteriolar & venular diameter Functional Capillary Density Rolling leukocyte fraction in arteriole & venular Adherent leukocyte counts in arteriolar & venular
Arteriolar diameter
HES
Base line
33.7(9.9)
Venular diameter
HES NaCl Control
37.8(7.3) 37.4(5.4) 40.5(8.9) 37.9(4.6)
NaCl
38.8(15.3 ) )
Control
41.6(16.1) 32.9(5.2)
30 min
33.2(7.1) 41.2(17.1
40(18)
35.3(5)
3h
4h 8h 24h
32.7(8.5) 40.5(17.2
)
31.9(9.6) 38.2(15.6
)
31.1(8.9) 39.4(10)
32.8(13.9) 46.2(15.1 )
HES 130/0.4
Functional Capillary Density and macromolecular leakage caused by sepsis attenuated by HES 130/0.4 vs crystalloid and control
All groups decreased arteriolar and venular leukocyte rolling fraction at 30 min
Rolling leukocyte in arteriol Rolling leukocyte in venule
HES
Base line 30 min 3h
HES
23.6(14.3)
NaCl
17.5(7.1)
0.0(0.0)
39.7(33.6)
3.0(6.4)
24.3(26.7)
4h
8h 24 h
13(26.6)
39.4(43.1)
53.7(39.3)
84.5(20.7) 64.8(12.4)
20(21)
58.4(29.8) 72.8(26.1)
63(10.2)
73.8(19.5) 79.2(10)
1.0(2.0)
11.4(27)
Conclusion
How to choose the right colloid : Know the relevant benefit of each colloid give the colloid which achieve the maximal correction for the clinical deficit with the minimal volume given Choose the colloid with the least clinically proven side effect and complications Consider : anaphylactoid reaction, coagulation and renal function accumulation