Update on Fluid Resuscitation

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

2. No Professional or Commercial Interests to Disclose

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 =( 8 η L )/( π r 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

10. 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 . 9 th ed. 2010

11. 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 . 5 th ed. 2013

12. 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 . 5 th ed. 2013

13. 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 . 5 th ed. 2013

14. 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 . 5 th ed. 2013 Myburgh JA, et al. N Engl J Med. 2013;369:1243-51

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

16. 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

17. 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

18. 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

19. 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

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

21. Dextrose Solutions Dextrose added to a crystalloid fluid D 5 , D 10 in NS, 1/2NS, or water 1 gram of dextrose provides 3.4 kcal Benefits Combat protein catabolism by providing calories when NPO D 5 1/2 NS @ 125/ hr x 24 hr = 510 kcal Disadvantages Hyperglycemia, hyponatremia , hypertonicity

22. 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 . 4 th ed. 2013

23. 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

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

25. Resuscitation 201

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

27. 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 F ail. 2010;3:175-177.

28. 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

29. 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. 45 o 45 o

30. 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)

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

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

33. Resuscitation 301

34. 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, ScvO 2 Rady MY. Crit Care . 2005;9(2):170-176 Goodrich C. AACN Adv Crit Care . 2006;17(3):306-316

35. 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

36. 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 2/3 rd 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

37. Endpoints of Resuscitation Central Venous Oxygen Saturation (ScvO 2 ) Proxy of mixed venous oxygen saturation (SvO2) Global indicator of the balance of O 2 delivery and O 2 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 DO 2 = Qx [1.39x( Hgb )(SaO2)+(0.003xPaO 2 )

38. Resuscitation 401

39. 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

40. 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

41. 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, 3x10 11 Use hemostatic adjuncts Transexamic acid, Prothrombin Complex Concentrate Richard Dutton, “Hemostatic Resuscitation”, EM Crit Conference Lecture, 2011

42. 57yo male with AMS, BP-82/50 (MAP-60), HR-114, RR-23, O 2 -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, ScvO 2 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, O 2 -98% ScvO 2 > 70% < 70% SaO 2 < 92% O 2 Intubate > 92% CI < 2.5 > 2.5 Hgb > 8.0 < 8.0 Sedation Transfuse Volume Status SVV < 15% SVV > 15% Pressors Volume Check Perfusion

43. 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

44. Questions, Comments, Concerns, Criticisms Kristopher R. Maday, MS, PA-C, CNSC UAB Physician Assistant Program Pegasus Emergency Group Email: [email protected] Twitter: @PA_Maday