CCPEM: Critical Care Perspectives in Emergency Medicine www.ccpem.

com, Copy Editor: Renzo Cardena, MD USC+LAC Emergency Medicine

December 2010: Fluid Resuscitation in critically ill ED patients

Guest Speaker Alan Heffner M.D.

BACKGROUND: Hypoperfusion (defined in many ways; via blood pressure, hyperlactatemia, clinical malperfusion or oliguria) Cardiovascular Support is essential in managing medical illnesses, especially in the critically ill Fluid is the cornerstone of cardiovascular support, with the fundamental Goal of improving Stroke Volume, Cardiac Output and ultimately Oxygen delivery. IDENTIFY AND PROCEED WITH RESUSCITATION Once a patient presents with Clinical Hypoperfusion, begin by asking if the patient is eligible to receive Fluids?
***Key Point: not all patients are fluid responsive (therefore it is essential to identify who is eligible to receive fluids)

Fundamental physiology states: Left Heart Cardiac Output can be no greater than Right Heart Venous Return o Therefore must see Preload as a determinant of Cardiac Output o First step in providing cardiovascular support is to fluid optimize patients as best as possible

TAKE IT TO THE BEDSIDE Total Body Volume Status may not be linked to the potential to improve the cardiovascular system with fluids o For Example patients with CHF, Nephrotic Syndrome or End-Stage Liver disease are generally total volume overloaded (Hypervolemic); however it does not mean that they are intravascularly replete or if they will be fluid responsive. o It is Easiest to identify at the bedside, patients who are Hemorrhaging or clearly volume depleted Aside from identifying who will be fluid responsive, try to delineate which patients will not benefit with volume; o Right Heart Failure (from massive PE) which is a type of shock will worsen with fluids.

FLUID CHOICE (Goal to optimize the amount of fluid that is retained in the vascular space) Isotonic: Lactate Ringers (LR), Normal Saline and new option Isotonic-Bicarbonate o 75% of volume still distributes extravascularly, therefore in hemorrhage or apparent hypovolemia, may require multiple liters of fluid resuscitation to meet their physiological end points. o Large volumes of resuscitation equate to large volumes of Interstitial Fluid & Extravascular Fluid o May be deleterious to certain organs; Acute Lung Injury (from excess interstitial fluid in lungs) o Therefore need the Right Fluid at the Right amount, that is to say Preload Optimize, NOT Preload Maximize Isotonic-Bicarbonate (1L of Sterile H2O with 3 Amps of HCO3) = Isotonic/Physiologic Resuscitation fluid Ultimately initial fluid choice is not as important as subsequent fluid administration, which should depend on Metabolic and Acid Base profile of patients o Example: patient with significant Metabolic Acidosis + Hypovolemia (from Diarrhea, Ostomy output, Severe Sepsis or advanced Acute Renal Injury) o Important to remember that Isotonic Normal Saline is an acidifying solution so OK to use initially but transition to LR or Isotonic-HCO3 in order to not exacerbate the metabolic Acidosis.

FLUID REVIEW:

Isotonic HCO3 would be more effective at reversing existing Acidosis, by replacing HCO3 loss. o Also, patients with the combination of hypovolemia, acute renal failure & hyperkalemia Isotonic HCO3 would be a better choice because no K is added to the body Special Note that none of these solutions have been proven to have any mortality outcome which benefits use of one solution over another. Suggestions made are simply to match the physiologic support parameters during all phases of resuscitation. True Fluid Bolus: a reasonable aliquot of fluid to make a difference such as 10-20 cc/kg of Isotonic Crystalloid fluid over 15min, with an immediate assessment of perfusion status (warmer extremities, BP and urine output). o Immediate assessment is necessary to determine if; 1. Patient is Preload-Optimize, 2 Patient is no longer responsive to fluid or 3. Have met the end point of the resuscitation. o A fluid bolus challenges the Cardiovascular system to determine if the patient is within the ascending limb of LV-Function curve, and by adding fluid, one hopes that Stroke Volume + Cardiac Output is enhanced and therefore O2 delivery is improved. o It has been shown that in severe sepsis up to 50-60cc/Kg of fluid is require within the first few hours. Up to 50% of these patients meet their physiologic end points with fluid alone. The rest dont respond because, 1.Not enough fluid has been given to the patient or 2. The patient is not responsive to fluid. It is essential to identify the Fluid non-responders. This group may have a more complex cardiovascular puzzle producing their hypoperfusion, more so than simple fluid resuscitation can resolve. Also this group may benefit from more invasive measurements of perfusion assessment.

CARDIAC PRELOAD Pressure surrogates of Cardiac Preload: o CVP = reasonable surrogate for volume status and cardiac preload o However, it turns out the CVP is bad at telling us what we really need to know, such as will patient be volume responsive? Better way to determine Preload is from Bedside Ultrasound (from Subcostal view): o By visualizing the junction of the vena cava and right atrium, one can asses respiratory variability or collapse of vena cava with respiration o Hypoperfused patients with a normal Cardiovascular function have a collapsibility index of 50% if they are likely to respond to fluids. This is true for spontaneous breathing patients. o Assessing fluid-responsiveness in ventilated (Positive pressure) patients is done by using an Arterial-Line and seeing 13% variation in Stroke Volume (taking pulse pressure variations over a few cycles) A Pseudo-preload boost is done by having patient lie supine and transiently elevating both legs to 45 while using some device to measure stroke volume. Volume responsiveness is likely if a 15% improvement in Stroke volume is observed over 2 minutes (Caveat is that one needs a device to measure stroke volume). COLLOIDS v CRYSTALLOIDS: Colloids: larger molecular structures have longer retention in intravascular space. Therefore, a smaller volume of colloid can provide the same benefit of a larger amount of crystalloid. o It has been shown that trauma patients with traumatic brain injuries show an increase risk of worse outcomes when resuscitated with albumin. o However, certain few selected patients may benefits from albumin administration such as; Severe Sepsis, end-stage liver disease, hypoalbuminemia (< 2.5) or Malarial patients (based on pediatric trials)

Hyperoncotic Albumin (20-25% albumin) o Best for patients with End-stage Liver disease presenting with SBP o Lasix refractory patients, then combine Lasix + Hyperoncotic Albumin = improved response to lasix o Hypotensive patients undergoing; renal replacement tx, plasmaphoresis or large volume paracentesis Hypertonic Saline (provides transcapillary refill of fluid into vascular space via osmosis) good for; o Intracranial hypertension o Neurological disease is ICU

THOUGHTS ON MAINTENANCE FLUIDS Rarely needed if have done an adequate and thorough resuscitation Recognize that some ICU patients will get an excess of 1.5-2 L of fluids just with IV-Meds, so dont give maintenance fluids unless necessary. However, if patient is getting admitted to hospital and requires maintenance fluids the appropriate fluid is isotonic saline, assuming the resuscitation is complete. Most patients have an appropriately elevated ADH response secondary to their illness. So it would be inappropriate to start hypotonic fluids, since this will complicate initial hospital course with hyponatremia FINAL THOUGHTS When a hypoperfused patient presents to the ED, first determine if they are going to be fluid-responders or non fluid responders. Dont get cornered into using only Isotonic fluids. Recognize that there are other fluid options one can use to match the physiologic needs of patients. Preload is a determinant of Cardiac Output and Cardiac Output provides the driving pressure necessary to deliver oxygen to end organs. An adequate fluid bolus is an adequate amount of fluid, administered over a short amount of time. Finally, remember to Preload Optimize, NOT preload Maximize.