CME FLUID RESUSCITATION MALAYSIA BY TSAQOLAIN RASIP.pptx

fluids resus

1. Fluid Management in Resuscitation Muhammad Tsaqolain Pai 16 May 2024 Bilik Seminar

2. Topics Introduction Indication Phases of Fluid Resuscitation Assessment of Hydration Types of Fluid in Resuscitation

3. Introduction Treat fluid as drug (know 4D) Need to know when to give Take account of patient’s condition Treatment should be individualized Risk and benefit of fluid to patient

4. 4 D’s of Fluid DRUG DOSAGE DURATION

5. Indication For Intravenous Fluid Resuscitation : T o correct an intravascular volume deficit Maintenance: to cover the patient’s daily basal requirements of water, glucose and electrolytes. Replacement Fluid: to correct fluid deficits that cannot be compensated by oral intake Nutrition Fluid

6. Too Low vs Too Much Too low (Restrictive) - Cause underhydration - lead to ischemia, irreversible injury, AKI Too Much - Cause Overhydration - Leads to edema, hypoxia, overload, fluid creep , irreversible injuries

7. Phases of Fluid Therapy (ROSE)

8. R.O.S.E Concept of Fluid Therapy VOLUME STATUS Resuscitation Optimisation Stabilisation Evacuation Duration Minutes Hours Days Days to Week Status Severe shock Unstable Stable Recovering Examples - Septic shock - Hemorrhagic shock - Major burn - Intraop - <15% Burn - GI Losses - Post op Enteral feed Aim/Goal Patient Rescue Organ Rescue (maintenance) + avoid fluid overload/creep Organ support/ homeostasis Focus on organ recovery and resolving of fluid overload Fluid Balance POSITIVE NEUTRAL ZERO- NEGATIVE BALANCE NEGATIVE Fluid Type Balanced Crystalloid Blood Product Fluid replacement Maintenance Remarks 30cc/kg/1 H or 4cc/kg bolus given over 5-10 mins Late conservative fluid management - 2 consecutive negative fluid balance in a week

9. How to Assess Hydration? Traditional (static) vs Advanced (dynamic) Traditional - Clinical assessment (skin, eye, tongue, fontanelle etc ) - BP, HR, CRT - Urine output - CVP, PAC - PAOP, EDV, IVC diameter

10. Advanced ( Goal Directed) - More precise - Evaluate cardiac output response to preload (fluid responsiveness) - Echocardiography - Lactate : for hyperlactinemia , signs of hypoperfusion

11. Types of Fluid in Resuscitation

12. Types of Fluid Crystalloid Non Balanced Crystalloid : Normal Saline Balanced Crystalloid : Hartmann, Ringer’s, Sterofundin Isotonic Sodium Bicarbonate 1.3% Isotonic Sodium Bicarbonate 4.2% Colloid Gelatin Hydroxyethyl Starch (HES) Human Albumin

13. Crystalloid as 1 st line of Fluid in Resuscitation Why? - Low viscosity - Venodilator - Provides high flow rate

14. Explain what is hyperchloremic met acidosis and how it helps in lossess ?

15. *MAKE30 : Major Adverse Kidney Events by 30 days

16. Hartmann Ringer’s Sterofundin

17. NAGMA VS HAGMA Anion Gap = Na + K ]- [ Cl+HCO3 ] Normal Range : 8-16mmol/L HYPERCHLOREMIA (Decreased HCO3 compensated by Chloride) NORMOCHLOREMIA ( Increased organic acids )

18. Take Home Message Treat fluid as a drug ( 4D) Start resuscitation with crystalloid Use balanced crystalloid in anticipation of > 2L: septic shock, DKA, dengue Isotonic NaHCO3 reduces mortality in NAGMA, AKI patients Human albumin reduces mortality in septic patients Avoid gelatin and HES in septic patients Adopt restrictive fluid strategy Administer fluid according to ROSE, different fluid balance at different phase

19. Thank You