Done by Dr.

Ayman Raweh
August 26, 2009
Goal of Fluid
Resuscitation

to restore
 tissue perfusion
 cellular oxygenation

maintain end organ function

The body of a healthy 70 kg male contains
about 42 liters of water, which is distributed
into the following:

Extracellular Fluid

Intracellular Fluid
Extracellular Fluid (1/3 of Total Body Water)
Volume % of body weight
Interstitial fluid 11.2 liters (16%)
Plasma 2.8 liters (4%)
Total 14.0 liters (20%)

Intracellular Fluid (2/3 of Total Body Water)

Volume % of body weight
Red Cells 2.2 liters (3%)
Intracellular Fluid 25.8 liters (37%)
Total 28.0 liters (40%)

Intravascular volume (plasma + red cells) is about 5 liters, with a hematocrit of 44%
Types of Resuscitation
Fluid

Crystalloid solutions

Colloid solutions
Types of Crystalloid
Solutions
Hypotonic
 5% Dextrose
 ½ Normal Saline

Isotonic
 Ringer’s Lactate
 Normal Saline

Hypertonic
 3% Normal Saline
 6% Normal Saline

 7.5% Normal Saline

Types of Colloid Solutions
Protein Solutions
 Human Serum Albumin (5%, 25%)
 Gelatin Solutions

Non-Protein Solutions
 Starches
 6% hetastarch (HES= hydroxyethyl starch)
 10% pentastarch

 Dextrans
 dextran-40 in normal saline
 dextran-70 in 5% dextrose in water
Types of Crystalloid
Solutions
Hypotonic
 5% Dextrose
 ½ Normal Saline

Isotonic
 Ringer’s Lactate
 Normal Saline

Hypertonic
 3% Normal Saline
 6% Normal Saline

 7.5% Normal Saline

Dextrose Solution 5%
Hypotonic solution

consists of 5g Dextrose in every 100 mL water

does not contain any electrolytes

distributes rapidly and evenly throughout the

entire body fluid compartments
Dextrose Solution 5%
(continued)
One liter of intravenous dextrose solution
expands intravascular compartment by only
70 ml and the interstitial fluid by 260 mL

has no use in fluid resuscitation to expand the

intravascular volume
Dextrose Solution 5%
(continued)

More concentrated dextrose solutions (10%,

20%, and 50%) are available

 their use is limited to management of diabetic

patients or patients with hypoglycaemia

 These solutions are irritant to veins.

Types of Crystalloid
Solutions
Hypotonic
 5% Dextrose
 ½ Normal Saline

Isotonic
 Ringer’s Lactate
 Normal Saline

Hypertonic
 3% Normal Saline
 6% Normal Saline

 7.5% Normal Saline

Ringer’s Lactate and
Sodium Chloride 0.9%
(‘normal saline’)
Isotonic solutions
rapidly redistribute within the extracellular space
(intravascular space and interstitium)
One liter of intravenous normal saline or Ringer’s
lactate expands the intravascular volume by 220
mL after equilibration.
Redistribution is complete within 30-60 minutes
Ringer’s Lactate and
Sodium Chloride 0.9%
(continued)

a four-fold amount of fluids is needed in

comparison to whole blood or colloid plasma
substitution in order to achieve the same intravasal
volume effect
Ringer’s Lactate and
Sodium Chloride 0.9%
(continued)

a risk of interstitial fluid overload

 may lead to a decrease in arteriolar PaO2 in case of

increasing extravasal lung water
Types of Colloid Solutions
Protein Solutions
 Human Serum Albumin (5%, 25%)
 Gelatin Solutions

Non-Protein Solutions
 Starches
 6% hetastarch (HES= hydroxyethyl starch)
 10% pentastarch

 Dextrans
 dextran-40 in normal saline
 dextran-70 in 5% dextrose in water
Colloid Solutions
sufficiently large molecules that normally do
not cross capillary membranes in significant
numbers

exert an oncotic pressure

remains intravascular for about 6-25 hours

unless an altered permeability condition is
present
Colloid Solutions
(continued)
good resuscitation fluids because all the
volume administered stays in the circulation

One liter of intravenous hydroxyethyl starch,

for example, expands the intravascular
volume by 1200-1300 mL after 30-60
minutes
Types of Colloid Solutions
Protein Solutions
 Human Serum Albumin (5%, 25%)
 Gelatin Solutions

Non-Protein Solutions
 Starches
 6% hetastarch (HES= hydroxyethyl starch)
 10% pentastarch

 Dextrans
 dextran-40 in normal saline
 dextran-70 in 5% dextrose in water
Human Serum Albumin
Natural protein

Stays within the intravascular space unless the

capillary permeability is abnormal

cause anaphylaxis in rare circumstances.

5% solution – isooncotic, 10% and 25% solutions

– hyperoncotic
Human Serum Albumin
(continued)

Expands volume 5x its own volume in 30

minutes (when 25% Albumin Solution is used
for example)

65 times more expensive than crystalloids

Types of Colloid Solutions
Protein Solutions
 Human Serum Albumin (5%, 25%)
 Gelatin Solutions

Non-Protein Solutions
 Starches
 6% hetastarch (HES= hydroxyethyl starch)
 10% pentastarch

 Dextrans
 dextran-40 in normal saline
 dextran-70 in 5% dextrose in water
Gelatin Solutions
Bovine collagen is the basis for gelatin solutions

up to 50% leaves intravasal space within 1-2 hours

completely metabolized and can be eliminated by

the kidneys

do not impact kidney function

 suitable for use in patients suffering from impaired kidney
function
Types of Colloid Solutions
Protein Solutions
 Human Serum Albumin (5%, 25%)
 Gelatin Solutions

Non-Protein Solutions
 Starches
 6% hetastarch (HES= hydroxyethyl starch)
 10% pentastarch

 Dextrans
 dextran-40 in normal saline
 dextran-70 in 5% dextrose in water
Hetastarch (HES=
hydroxyethyl starch)
 A synthetic highly branched glucose polymer

 Cheaper alternative to Albumin

 Available as 6% and 10% solution in normal saline solution

 Excreted in the urine (smaller particles), metabolised by blood amylase, then

excreted into the bile and faeces (medium sized molecules), or undergoes
phagocytosis by the reticulo-endothelial system (RES) (larger molecules).

 Dose: limit the amount to 20 ml/kg/day

 13 times more expensive than crystalloids

Hetastarch (HES=
hydroxyethyl starch)
(continued)
Excretion
 Excreted in the urine (smaller particles)

 metabolised by blood amylase, then excreted into

the bile and faeces (medium sized molecules)

 undergoes phagocytosis by the reticulo-endothelial

system (RES) (larger molecules)
Hetastarch (HES=
hydroxyethyl starch)
(continued)
Impact on blood coagulation
 There are reports that HES caused

 significant
prolongation of prothrombin time and
prolonged thromboplastin time

 reducedthe levels of fibrinogen, factor VIII, factor C,

and factor V

 but the changes remained within the normal range

Hetastarch (HES=
hydroxyethyl starch)
(continued)
Impact on blood coagulation
 In another report, patients who received large doses
of HES (about 1L) for trauma and surgery

 had a prolonged partial thromboplastin time

 up to a 50% decrease in factor VIII and factor C

Hetastarch (HES=
hydroxyethyl starch)
(continued)
Impact on blood coagulation

 HES seems to cause changes in fibrin clot formation

and fibrinogenolysis

 This characteristic may be related to the

incorporation of the HES molecules into the clot,
with subsequent prevention of solid clot formation.
Types of Colloid Solutions
Protein Solutions
 Human Serum Albumin (5%, 25%)
 Gelatin Solutions

Non-Protein Solutions
 Starches
 6% hetastarch (HES= hydroxyethyl starch)
 10% pentastarch

 Dextrans
 dextran-40 in normal saline
 dextran-70 in 5% dextrose in water
Pentastarch (Pentaspan)
Lower MW analogue of hydroxyethyl starch (HES)

10% solution in 500 ml normal saline solution vials

eliminated from the circulation at a faster rate than

HES because of its smaller molecular weight

is mostly excreted in the urine, so it should be avoided

\ in patients with renal disease complicated by oliguria
or anuria unless it is related to hypovolemia
Types of Colloid Solutions
Protein Solutions
 Human Serum Albumin (5%, 25%)
 Gelatin Solutions

Non-Protein Solutions
 Starches
 6% hetastarch (HES= hydroxyethyl starch)
 10% pentastarch

 Dextrans
 dextran-40 in normal saline
 dextran-70 in 5% dextrose in water
Dextrans
 High MW polysaccharide

 Dextran 40 - MW 40,000

 Dextran 70 - MW 70,000

 10% solution in NS or D5W

 Excretion is through the urine, faeces and reticulo-endothelial system

(RES) (according to molecular size)

 Dose: limit to 20 Dose: limit to 20 ml/kg/day

 occasional anaphylaxis
Dextrans (continued)
Impact on Coagulation

 causes defects in platelet interaction and an

antifibrinolytic effects

 seems to be incorporated into the polymerising

fibrin clot so that it alters clot structure and
enhances fibrinogenolysis
Crystalloids Vs. Colloids
still a matter of debate and needs to be
determined
Colloids and crystalloids have the same (SAFE
Study, 2004)
 mortality rate
 ICU or hospital days

 days of mechanical ventilation

 days of renal-replacement therapy

Colloids are much more expensive than

crystalloids
Crystalloids Vs. Colloids
(continued)
 Crystalloids can cause interstitial and lung edema

 more crystalloids are needed compared to colloids

 Colloids have a dose-related coagulopathy (greatest with

hetastarch), and occasional anaphylaxis

 starch molecules may adversely affect renal function by

causing tubular injury

 Non-protein colloids can also interfere with antigen

detection during cross matching of blood products
Simulation of Fluid
Management

http://pie.med.utoronto.ca/CA/CA_content/CA_
fluidManagement.html