Intravenous Fluid Therapy in Critical Illness GINA HURST, MD DIVISION OF EMERGENCY CRITICAL CARE HENRY FORD HOSPITAL DETROIT, MI Objectives Establish goals of IV fluid therapy Review fluid types and availability Understand the concept of balanced solutions Discuss potential effects of hyperchloremia in the critically ill 1
Intravenous Fluids Therapeutic efficacy Predictable response Low side effect profile Safety Suitability Ease of administration Cost Intravenous fluids Indication Type What is my therapeutic goal?? Restore volume Maintain homeostasis Dose 2
Intravenous fluids Indication Type What is my therapeutic goal?? Restore volume Maintain homeostasis Dose Ideal: close chemical composition to circulating plasma Plasma Composition 3
Intravenous fluids Solute Plasma Dextran Gelatin Albumin 5% Normal Saline Ringer s lactate Hartmann solution Plasmalyte Na+ 135-145 154 154 145 154 130 131 140 K+ 4-5 0 0 0 0 4.5 5 5 Ca2+ 2.2-2.6 0 0 0 0 2.7 4 0 Mg2+ 1-2 0 0 0 0 0 0 1.5 Cl- 95-110 154 120 145 154 109 111 98 Acetate 0 0 0 0 0 0 0 27 Lactate 0.8-1.8 0 0 0 0 28 29 0 Gluconate 0 0 0 0 0 0 0 23 Bicarbonate 23-26 0 0 0 0 0 0 0 Osmolarity 291 308 274 ~300 308 280 279 294 Colloid 35-45 100 40 50g 0 0 0 0 Colloid resuscitation: Hetastarch 6S trial HES vs LR increased 90 d mortality, Increased need for RRT Increased rate of blood product transfusion CHEST HES vs NS Increased AKI and need for RRT No difference in mortality 4
Colloid resuscitation: Albumin SAFE Albumin vs NS Albumin better in sepsis No difference in mortality CRISTAL Colloid vs NS No difference in 28 d mortality Possible increase in 90 d mortality with colloid 5
Crystalloid: 0.9 % Normal Saline 154 meq of NaCl/L 287 mosm/kg ph of 5.5-6 0.9% NaCl solution isotonic in vitro Non-physiologic ion content Lack of buffering capacity Crystalloid: Balanced Solutions Organic anions Lactate, acetate, gluconate Buffering capabilities Calcium Magnesium Potassium Ringer s lactate Hartmann solution Plasmalyte 130 131 140 4.5 5 5 2.7 4 0 0 0 1.5 109 111 98 0 0 27 28 29 0 0 0 23 0 0 0 280 279 294 6.5 6.5 7.4 6
Fluid Choice and In-hospital Mortality Raghunathan et al Crit Care Med 2014; 42:1585-1591 Mortality is lowest in group receiving greatest amount of balanced solutions Raghunathan et al Crit Care Med 2014; 42:1585-1591 7
Impact of IV fluid composition on outcomes in patients with SIRS Shaw et. al Critical Care 2015; 19:334 Saline cohort with greater in-hospital mortality (3.27% compared to 1.03%) Balanced vs. 0.9 NS 8
Claims against hyperchloremia Metabolic Acidosis Increased inflammatory cytokines Renal vasoconstriction Decreased renal blood flow/diuresis/natiuresis Increased interstitial edema Possible coagulopathy Metabolic acidosis Inflammatory cytokines Hyperchloremia with acidosis due to change in strong ion difference SID=[(Na+K+Mg+Ca) (Cl+lactate)] Animal studies correlate increasing hyperchloremia with worsening hemodynamic profile and inflammation 9
Metabolic acidosis Inflammatory cytokines Increasing acidemia associated with elevation in: IL-6 IL-10 TNFa Kellum et al CHEST 2006 130;4:962-7 Claims against hyperchloremia Metabolic Acidosis Increased inflammatory cytokines Renal vasoconstriction Decreased renal blood flow/diuresis/natiuresis Increased interstitial edema Possible coagulopathy 10
Effect of hyperchloremia on renal function Effect of hyperchloremia on renal function Rat model of shock (Almac et al Resuscitation 2012; 83:1166-72) Hyperchloremia/acidemia more profound in NS group Normal saline group with lowest creatinine clearance and lowest renal blood flow after resuscitation. 11
Effect of hyperchloremia on renal function Healthy human subjects (Chowdhury Ann Surg 2012;256:18-24) NS vs plasmalyte NS with increased time to micturition NS with decreased UOP. Renal blood flow NS decrease in mean flow by 9% Cortical tissue perfusion NS decrease perfusion by 11.7% Effect of hyperchloremia on renal function Chloride liberal IVF (Yunos et al. JAMA 2012 308;15:1566-72) Increased risk of AKI and use of RRT OR 0.52 12
Normal Saline Preferred Traumatic brain injury LR with decrease in serum osm comp to NS 287 +/-4 vs. 290 +/-5 (Williams Anesth Analg 1999;88:999-1003) Worsening cerebral water content and ICP in animal models Shackford J Neurosurg 1992;72:91-98 Zornow Anesth 1987;67:936-41 13
Summary Balanced IV fluids are preferred for large volume resuscitation Hyperchloremia is increasingly shown to be associated with morbidity and mortality TBI or other risk of ICP should be treated with NS 14
Use your fluids wisely! 15