FLUIDS FOR SHOCK

NASMAN PUAR
BAGIAN ANESTESIOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS

Introduction
Life-threatening condition
Result from a number of primary causes Be aware of physiologic effects of shock
Be able to detect Report the development or worsening of this

very serious condition

Definitions of shock types:

Hypovolemic shock
Cardiogenic shock

Neurogenic shock

Anaphylactic shock

Septic shock

Definition of Shock
A state of inadequate tissue perfusion

resulting in decreased amount of oxygen to vital tissues and organs leading to reduced removal of waste products of metabolism

Diagnosis of Shock Early Recognition Physiological Diagnosis

Subjective Symptoms and Imprecise Signs:

Objective haemodynamic signs

Weak, thready pulse Cold, clammy skin Altered mental status Unstable vital signs Cyanosis

Hypotension Acidosis Oliguria Collapse Reduced Oxygen Delivery

Classification of Hypovolemic Shock*

Class I Blood loss Blood volume Heart rate
< 750 ml < 15% < 100

Class II
750-1500 ml 15-30% > 100 Normal Decressed

Class III
1500-2000 ml 30-40% > 120 Normal to Decreased 5-15 ml/hr

Class IV
> 2000 ml > 40% > 140 Decreased Decreased nil

Blood pressure Normal Pulse pressure Normal Urine output

> 30 ml/hr 20-30 ml/hr

T. James Gallagher, 1995

Treatment for Hypovolemic Shock

Goals - Increase tissue perfusion and oxygenation status
Maintain airway
Control bleeding Baseline vital signs Level of consciousness

Vascular volume deficit management Goal therapy of shock Restoration of Cardiac Index, DO2, VO2 ( optimized to maintain body metabolic requirement ) Improved tissue perfusion

Delivery O2 = COxHbxSpO2x1,34 +(0,003xPaO2)

Cardiac Output

preload

afterload

contractility

Left ventricular end diastolic volume

intrathoracic pressure

SVR = 80 x ( MAP CVP )

CO CO = Stroke vol xHR

Intravascular Volume

FLUID THERAPY
RESUSCITATION MAINTENANCE

Crystalloid

Colloid

ELECTROLYTES

NUTRITION

1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)

1. Replace normal loss (IWL + urine+ faecal) 2. Nutrition support

colloid or crystalloid ?

Normovolemia
Crystalloids

Colloids Albumin FFP Gelatin HES Dextran

n a t u r a l s y n t h e t i c

Lactated
Ringer's, Normal Saline

Jenis

Composition of Crystalloid & Coloid Solutions

Na Cl K
4 4

Ca

Mg Lact/Acet at

lain2

NaCl0.9%
Ring Lakt

154
138 138

154
112 125

5 3

Lakt/28 Lakt/20

HES/40000

Expafusin
Haes st 6% ,10%
Hemacel Gelafundin Dextran L NaCl 3%

154
145 142 130 500

154

6,25 1,4 2,7

Lakt/28

HES/200000
Polygeline Gelatin/35000 Dextran40

145 5,1 80 108 500

Colloid vs. Crystalloid

Isotonic

Ringer acetate Ringer lactate NaCl 0.9%

ECF

ICF

ISF Plasma

Hypotonic

D5W N4 NaCl 0.45%

ICF > ECF

+ Hyponatremia

ICF

ISF

Plasma

+ hyperglicemia

40

15

colloids

Plasma

ICF

ISF Plasma

hyperoncotic

Colloids
contain large, oncotically active molecules.
natural products (eg, albumin, FFP) Semisynthetic (gelatine, starches or dextrans).

more impermeable to intact capillary membranes than crystalloids.

smaller volumes of colloids than crystalloids are required for fluid resuscitation.

Demands on an ideal Synthetic Colloids: (which does not exist!)

inexpensive and free of infectious agents available in unlimited quantities

stable for long periods of time

colloid osmotic pressure and viscosity like plasma completely degradable and eliminated via kidneys

no longtime storage in the organs

No negative impact on liver- kidney or immune function sufficient volume effect and duration

free of coagulation disorders

free of toxic, allergic and antigenic reactions

1.

HES = Hydroxethylstarch (Not all HES are the same!)

(Based on degree of substitution)

Tetrastarch (0.4)

Pentastarch
(0.5)

Hetastarch
(0.7)
HES 450 /0.7

HES 130 /0.4

HES 200 /0.5

2.
High molecular weight HES HES 450 / 0.7 HES 470 /0.7

(Based on Molecular weight)

Medium Molecular weight HES HES 200 /0.5 HES 200 /0.62

Low molecular weight HES HES 40 /0.5 HES 70 /0,5 HES 110 /0,5 HES 130 /0,4 Hespander, Rheohes, Voluven, Venofundin

Hespan Plasmasteril

Hemohes, Haes-steril Elohes Pentaspan

Gelatin Solutions (Not all Gelatin Solutions are the same!)

4%
Modified Fluid Gelatin (MFG) (succinylated)

Polygeline
diisocyanate)
(urea linked/

3.5%

4% Oxypolygeline (OPG)

Gelofusine, Gelafundin,
Mw= 30 000 dalton

Haemaccel
Mw= 35 000

Gelifundol

Mw= 30 000

Average initial volume effect /average duration of volume effect (in hypovolemic volunteers)
3.5 % Polygeline

~70% ~2-3h
~ 100 % ~3-4h 1oo% 145 % ~ 4h ~ 7-9h ~ 4h

4% Modified Fluid Gelatin 6% HES 200/0.5

6% Dextran 70 6% HES 200/0.62 and HES 450/0.7 10% HES 200/0.45 and 0.5 10% Dextran 40

~ 190 % ~ 3-4h
100 150 200 (%)

50

Effects of solutions on haemostasis and coagulation

Gelatins
Factor VIII, vWF Platelets adhesion aggregation Thrombus formation time Blood typing No effect

HES

Dextrans

No effect No clinical effect

No effect

In emergency situations blood typing prior to infusion

Rivers E.: Early goal-directed therapy in the treatment of severe sepsis and septic shock NEJM 2001; 345:1368-1379

An urban Emergency Department 263 patients Severe sepsis or septic shock Therapy for 6 hours before transfer to ICU Standard therapy (N=133) Therapy guided by ScvO2 catheter (N=130)

Mortality reduced from 46.5% to 30.5%!

Rivers E.: Early Goal-Directed Therapy In The Treatment Of Severe Sepsis And Septic Shock
Algorithm for Study Group NEJM 2001;345:1368

Effects of Synthetic Colloids

Keep the fluid in the IVS Oncotic pressure

Increased IV volume

Hemodilution

Venous flow-back (preload)

Improved rheology

Hematocrit

Cardiac output CO

Flow resistance DO 2

Arterial oxygen concentration c O CaO2

Replacement of blood losses

Blood loss (%)

Step by step

100 90 80 70 60 50 40 30 20 10

Colloids + + crystalloids Cryst.+colloids PRC

+FFP

+platelets

volume - oxygen carriers - plasmatic coagulation - cellular coagulation

Adapted from Adams, H.A. 1996

Conclusion : The decision on what synthetic colloid should be selected has to be made considering the pro and cons of each specific solution and the specific conditions of each individual patient on a case to case basis!