Given at the 2014 Tennessee Association for Physician Assistants Spring Fling

1. Fluid Resuscitation
From The Basics To Being A Resuscitationist
Kristopher R. Maday, MS, PA-C, CNSC
University of Alabama at Birmingham
Physician Assistant Program
Pegasus Emergency Group

3. Objectives
• IV Access and types of IVF
• Fluid dynamics and physiology
• Criteria for assessing volume status and fluid
responsiveness
• How to become a Resuscitationist

4. Resuscitation 101

5. Intravenous Access
• Peripheral IV
– Standard access
• 14-25 gauge
– Pros
• Quick, inexpensive
• Lower infection risk
– Cons
• Short term
– Need to rotate every 72-96 hr
• Blow out
Cheung E, et all. Canadian Family Physician. 2009;55:494-496.

6. Intravenous Access
• Central Venous Line
– Terminate within the thorax
– Indications
• Long term access
• High osmolar fluids, vasopressors
• Inaccessible peripheral access
– Cons
• More technically challenging
• Increased infection risk
• Iatrogenic complications
Cheung E, et all. Canadian Family Physician. 2009;55:494-496.

7. Intraosseous Access
• Inserted into tibia, sternum, or humerus
• Indications
– Unable to perform traditional peripheral IV
– Bridge to traditional line
• Cons
– Unable to infuse rapid volume
– Risk of compartment syndrome
– Fractures
Day MW. Critical Care Nurse. 2011;31(2):76-89.

8. Let’s Take You WAAAAAAY Back…….
• Poiseuille’s Law
– Resistance to flow is dependent on radius
and length of tube and viscosity of fluid
– R=(8ηL)/(πr
4
)
• A 2x increase in diameter will yield a 16x increase in flow

9. Standard Triple lumen CVL
7 fr - 3 lines
18g proximal
18g middle
16g distal
16cm
R=146.7
TraumaCath/VasCath
8fr - 2 lines
14g
14g
15cm
R=54.38
14g peripheral IV
3.83cm
R=15.26

11. Normal Body Fluid Composition
• Total body water
– Gender differences
• Males - 60% of body weight
• Females – 50% of body weight
– Components
• Intracellular – 2/3 of total body water - 40% of body weight
• Extracellular – 1/3 of total body water - 20% of body weight
– Intravascular
» 20-25% of extracellular volume
» 5% of body weight
– Interstitial
» 75-80% of extracellular volume
» 15% of body weight
– Obese/elderly – decrease by 10%
• Total blood volume - 7% of body weight
Ch. 3. In: Schwartz’s Principles of Surgery. 9th ed. 2010

12. Fluid Movement
• Fluid movement is constant and is influenced by:
– Hydrostatic pressure
– Colloid osmotic pressure
– Membrane permeability
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013

13. Fluid Movement
• Hydrostatic pressure
– The mechanical force of water pushing against a
membrane. In the intravascular space, it is the pumping
action of the heart that generates this force.
– At the arterial end of the capillary, hydrostatic pressure
forces water, sodium and glucose across the membrane
into the interstitial space
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013

14. Fluid Movement
• Osmotic Pressure
– Movement of fluid between the ICF and ECF is primarily
a function of osmotic forces
• Plasma proteins pull water back into the vascular space at the
venous end of the capillary bed
– Measurement of solute concentration in serum is termed
osmolarity
• Serum osmolarity – 2(Na+) + glucose/18 + BUN/2.8
– Normal – 270-290 mOsmo/L
– Dehydrated - >290 mOsmo/L
– Fluid Overload - <270 mOsmo/L
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013

15. Fluid Movement
• Membrane permeability
– Transport of substances across the
cell membrane depends on the
substance to be transported
– Passive
• Transport does not require energy and
is accomplished by osmosis, diffusion,
or the force of hydrostatic pressure
– Active
• Transport requires the expenditure of
metabolic energy by the cell
– Larger and electrically charged particles
Ch. 49. In: Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. 2013
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51

16. Types of IV Fluids
• Crystalloids
– Hypertonic
– Isotonic
– Hypotonic
• Dextrose solutions
• Colloids
– Albumin
– Dextran
– Hetastarch
– Gelatins

17. Crystalloids
• Electrolyte solutions with small molecules that can
diffuse freely throughout the extracellular space
• Principle component is NaCl
– Most abundant solute in extracellular fluid
 Predominant effect of volume resuscitation with
crystalloids in to expand interstitial volume, rather
than intravascular volume
 3 types
– Hypertonic
– Isotonic
– Hypotonic

18. Crystalloids
• Isotonic
– 0.9% NaCl (normal saline, NS)
– Closer to physiologic norms
• Can produce metabolic acidosis
– Allows for larger volume to be infused for resuscitation
– Lactated Ringers (Ringer’s lactate, LR)
• Contains less sodium and chloride, more potassium, more
calcium
• Higher pH than NS
• Contains lactate which is converted to HCO3- by liver
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51

19. Crystalloids
• Hypertonic
– 1.5%, 3%, 7%, 23.5% NaCl
– Solute concentration higher than the solute concentration
of the serum
• Infusion causes an increase in the solute concentration of the
serum, pulling fluid from the interstitial space to the vascular space
through osmosis
– Can be used to treat increasing ICP
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51

20. Crystalloids
• Hypotonic
– 0.45% NaCl (1/2 NS), 0.225% NaCl (1/4 NS)
– Considerably lower osmolarity than serum
– Good for fluid maintenance and replacing free water
deficit
Myburgh JA, et al. N Engl J Med. 2013;369:1243-51

21. Crystalloid Solute Concentration and Effects on pH
Ch. 12. In: The ICU Book. 4th ed. 2013

22. Dextrose Solutions
• Dextrose added to a crystalloid fluid
– D5, D10 in NS, 1/2NS, or water
• 1 gram of dextrose provides 3.4 kcal
• Benefits
– Combat protein catabolism by providing calories when
NPO
• D51/2 NS @ 125/hr x 24 hr = 510 kcal
• Disadvantages
– Hyperglycemia, hyponatremia, hypertonicity

23. Colloids
• More effective at increasing intravascular volume
because they contain large, poorly diffusible, solutes
that create an osmotic pressure to keep water in the
vascular space
– ***3 times more effective than crystalloids***
• Good for fluid resuscitation in patients with full
interstitial reserves
• 4 main types
– Albumin
– Hetastarch
– Dextran
– Gelatins
Mitra S, et al. Indian J Anaesth. 2009;53(5):592-607
Ch. 12. In: The ICU Book. 4th ed. 2013

24. Colloids
• Albumin solutions
– 5%, 25%, given in 250mL aliquots
– Blood product, so slight risk of
transfusion reaction
• Hydroxyethyl starches (HES)
– 6%, 500-1000mL, do not exceed
20mL/kg
– Chemically manufactured starch
polymer
– Inhibits factor VII and vWF and
impairs platelet aggregation
Mitra S, et al. Indian J Anaesth. 2009;53(5):592-607
• Dextrans
– 10% dextran-40, 6% dextran-70
– Glucose polymer
– Inhibits factor VII and vWF,
impairs platelet aggregation, and
increases fibrinolysis
– Can cause ARF (unknown)
• Gelatins
– 4% Succinylated, 3.5% Urea-
crosslinked, Oxypolygelatins
– Less reactions, uncommon in
US

25. Volume Changes with Colloids
Ch. 12. In: The ICU Book. 4th ed. 2013

26. Resuscitation 201

27. Who Needs Resuscitation?
Initial Assessment and Resuscitation. In: Current Therapy of Trauma and Surgical Critical Care. 1st ed. 2008
• Labs
– Lactate
• Normal - < 2 mg/dL
– Base Deficit
• Normal – > -2

28. Predicting Fluid Responsiveness (Old and Busted)
• Central Venous Pressure
– No association between CVP and
circulating blood volume
– CVP does not predict fluid
responsiveness
• Pulmonary Capillary Wedge Pressure
– Risk > Benefit
• Jugular Venous Distension
– More accurate modalities
Marik PE. CHEST. 2008;134(1):172-178. Leier CV. Circ Heart Fail. 2010;3:175-177.

29. • Orthostatic Measurements
– Supine and Standing measurement of BP and HR
• Positive test
– Decrease in 1) systolic > 20mmHg or diastolic > 10mmHg and 2) increase
in pulse rate 10-25 bpm within 3 min
– > 1L blood loss needed for 97%
sensitivity and 98% specificity
Carlson JE. Southern Medical Journal. 1999;92(2):167-173.
Predicting Fluid Responsiveness (Old and Busted)
McGee S et al. JAMA. 1999;280(11):1022-1029

30. Predicting Fluid Responsiveness (New Hotness)
• Passive Leg Raise
– Increases venous return in patients who are preload
responsive
• Identifies patients on ascending portion of Starling Curve
Marik PE. Annals of Intensive Care. 2011. 1:1.
45o 45o

31. • IVC Distensibility
– Change in diameter of IVC between end-inspiration
(dMax) and end-expiration (dMin)
• dIVC Index – (dMax-dMin)/dMin
– > 18% change predicts fluid responsiveness with > 90% sensitivity and
specificity
Barbier C et al. Intensive Care Med. 2004;30:1740-1746
Predicting Fluid Responsiveness (New Hotness)

32. Barbier C et al. Intensive Care Med. 2004;30:1740-1746

33. • Stroke Volume Variation (SVV)
– Changes in SV during inspiration/expiration
– Normal <15%
Michard F. Anesthesiology. 2005;103:419-428
Predicting Fluid Responsiveness (New Hotness)

34. Resuscitation 301

35. Endpoints of Resuscitation
• 3 main goals to achieve
– Restoration of adequate oxygen delivery
– Resolution of existing oxygen debt
– Elimination of anaerobic metabolites
• Traditional endpoints
– HR, BP, mental status, urine output
• Global endpoints
– Lactate, base deficit, ScvO2
Rady MY. Crit Care. 2005;9(2):170-176 Goodrich C. AACN Adv Crit Care. 2006;17(3):306-316

36. Endpoints of Resuscitation
• Lactate
– Metabolic byproduct of anaerobic metabolism
• Most sensitive marker of tissue perfusion
– Lactate clearance and mortality
• < 24 hours – 0%
• 24-48 hours – 25%
• > 48 hours – 86%
– Higher lactate and duration of hyperlactatemia
correlated with increased rates of MODS
Abramson D et al. J Trauma. 1993;35:584-589 Manikis P et al. Am J Emerg Med. 1995;13:619-622

37. Endpoints of Resuscitation
• Base Deficit
– Used as a lactate proxy
– Grades
• Mild (2-5 mmol/L)
• Moderate (6-14 mmol/L)
• Severe (> 14 mmol/L)
– Studies have shown:
• Elevated initial BD was associated with lower initial BP and
increased fluid requirement
• 2/3rd of patients with increasing BD had ongoing blood loss
• Increase in BD between ED and ICU had increased risk of
hemodynamic collapse, increased transfusion requirements,
coagulopathy, and mortality
Tisherman SA et al. J Trauma. 2004;57:898-912 Davis JW et al. J Trauma. 1988;44:1464-1467 Rixen D et al. Shock. 2001;15:83-89

38. Endpoints of Resuscitation
• Central Venous Oxygen Saturation (ScvO2)
– Proxy of mixed venous oxygen saturation (SvO2)
• Global indicator of the balance of O2 delivery and O2
consumption
– < 70% suggests tissue hypoperfusion
– Need CVL or PA catheter
Rivers E et al.N Eng J Med. 2001;345(19):1368-1377
Oxygen Delivery
DO2=Qx[1.39x(Hgb)(SaO2)+(0.003xPaO2)

39. Resuscitation 401

40. Hemostatic Resuscitation
• Used in the acutely bleeding trauma patient
• Benefits
– Maintains circulating volume
– Limits IVF administration
• Uses blood products instead of crystalloids
– Limits ongoing hemorrhage
• Revolves around 2 principles
– Permissive hypotension
– Aggressive blood product use

41. Permissive Hypotension
• Balance of maintaining adequate perfusion, but
preventing exsanguination until surgical bleeding
can be controlled
– Target = MAP of 65 mmHg
• If MAP < 65, then resuscitate with IVF or products
• If MAP > 65, then check perfusion
– Good perfusion  Masterful inactivity
– Poor perfusion  Fentanyl
• Special considerations
– Non-hemorrhagic causes of hypotension, TBI
“Injection of a fluid that will increase blood pressure has dangers in itself…If the pressure is raised before the surgeon is ready to check any
bleeding that might take place, blood that is sorely needed may be lost” Cannon W. JAMA 1918;70:618-621
Dutton RP et al. J Trauma. 2002;52(6):1141-1146 Wiles MD. Anaesthesia. 2013;68(5):445-449

42. Massive Transfusion
• Roots in the military and started gaining civilian traction
in mid 2000s
• 2 principles
– Replace what is lost
– Prevent coagulopathy before it develops
• Multiple definitions of triggers
• Shoot for a 1:1:1 of blood products
– 1 unit PRBC – 335ml, Hct 55%
– 1 unit FFP – 275ml, 80% coagulation activity
– 1 unit Plt – 50ml, 3x1011
• Use hemostatic adjuncts
– Transexamic acid, Prothrombin Complex Concentrate
Richard Dutton, “Hemostatic Resuscitation”, EM Crit Conference Lecture, 2011

43. 57yo male with AMS, BP-82/50 (MAP-60), HR-114, RR-23, O2-89% on RA
IVC U/S shows dIVC 73%, Intubate, NGT placed
A-line and 18g PIV x 2 placed, FloTrac shows SVV 31% and CI 3.4, ABG shows BD -11, Lactate 4.2
2L LR bolus, Labs sent, Foley placed (~50cc)
SVV 16%, BD -10, BP-81/54 (MAP-62), HR-111, Lactate 4.0
R IJ CVL placed, ScvO2 59%, Hgb 7.4, INR 2.8, EtOH 321, BUN 63
4U PRBC, 4U FFP, 25mcg Fentanyl
SVV 11%, CI 3.2, BD -6, Lactate 2.8, Hgb 9.1, INR 2.4
BP-102/72 (MAP 81), HR-94, O2-98%
ScvO2
> 70%
< 70% SaO2
< 92%
O2
Intubate
> 92% CI
< 2.5
> 2.5
Hgb
> 8.0 < 8.0
Sedation Transfuse
Volume
Status
SVV < 15%
SVV > 15%
Pressors
Volume
Check
Perfusion

44. How to be a Resuscitationist
• Critically evaluate patients who may need volume
• Identify the need and type of access
• Select appropriate fluid and know the expected
physiologic changes
• Interpret endpoints of resuscitation
• Assess special populations for more aggressive
management

45. Questions, Comments, Concerns, Criticisms
Kristopher R. Maday, MS, PA-C, CNSC
UAB Physician Assistant Program
Pegasus Emergency Group
Email: maday@uab.edu
Twitter: @PA_Maday