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B|BRAUN

A
,

B|BRAUN

B|BRAUN



100% = 600 / = 60%


~ 1/3

~15%


~ 2/3

~5%

B|BRAUN

+
.
~1-3%

Mo

0.1 nm

1 nm

10 nm

: 25-50
nm

100 nm 1 m

10 m

100 m 1 mm

: 3 nm

B|BRAUN

(posm)


, ,
(
)


,

.

B|BRAUN


(posm)

posm

B|BRAUN

(pcop)

:
( )


,
,
.

B|BRAUN

(pcop)

pcop

B|BRAUN

=
=

B|BRAUN

-( )
(mm Hg)
300

200
()

100

RV
~ 60 ml

SV
~ 70 ml

50

SV
~ 90 ml

RV
~ 90 ml
0

100

150

200 (ml)

B|BRAUN

B|BRAUN

Co

(mmol/l)

(mmol/l)

(mmol/l)
Ma
(mmol/l)

(mmol/l)

(mmol/l)
(mmol/l)
pH
(mOsm/l)
O (mm Hg)
COP

e
141
4
2.5
1
103
1
25
7.4
280
25

143
4
1.3
0.7
115
1
28
7.4
280
4

B|BRAUN

10
155
<0.001
15
8
65
10
7.2
280
?

: -

: -

B|BRAUN

To

Na+ actual - Na+ normal < 0

Na+ actual - Na+ normal = 0

Na+ actual - Na+ normal > 0

B|BRAUN

,
,
280 mOsm/l

B|BRAUN

Na


( Na )


( )

( Na )

B|BRAUN

Na

( Na )

B|BRAUN

B|BRAUN

5%,10%,20%

(,
,

,
-

(,
,
)

(
,

,
,

,
,

(,

,
)

VIII
,

(,

(,

(,
)

(,
)

B|BRAUN


G
()

B|BRAUN

B|BRAUN

~ 130-155 mmol/l

~ 20%

~ 30 min

B|BRAUN


30%, 5


30%,

.

12
10
8
6
4
10

20

30

40

50

60

70 (%)

A. L. Cervera et al., J. Trauma 14 (1974) 506520

B|BRAUN

B|BRAUN

(ICS 2/3, ECS 1/3)

B|BRAUN

> 15%


B|BRAUN

~ 130-155 mmol/l

B|BRAUN


, ,
, ,

(. )

(.
)
-

B|BRAUN



69 000 Dalton

: 14.1 x 4.2 nm


~ 50 g/l (~ 60% of plasma protein) but
~ 22 mm Hg (~ 80% of COP)
,
(. ,
)

B|BRAUN


0.2 /

2.0 /

0.2 /

1.5 /

1.5 /

B|BRAUN

4-5% , , > 95%

20% , , > 95%




(. )

B|BRAUN

B|BRAUN

.
:


,

(:
)
- (:)
( )

B|BRAUN




"leuconostoc mesenteroides"

40 000 70 000 Dalton
1000

B|BRAUN

()

C2, C3, C6


a-

B|BRAUN

R1 =
-CH2- CH2-OH

6
CH2-O-R1
H

4
R2-O

R2 =

O-CH2- CH2-OH H

2
H

O-R2

O-CH2- CH2-OH

B|BRAUN

(M)
()

M = 6/10 = 0.6

-CH2- CH2-OH

B|BRAUN

= 5/10 = 0.5

Composition and physicochemical characteristics of gelatin solutions


Name
Gelofusin Gelafundi
e Braun n
Company
B.
B. Braun
Deriv.
MF
MF
G40
G30
Conc (g/l)
.Mw (Dalton)
30 000
35 000
Mn (Dalton)
23 200
22 600
Mw/Mn
1.29
1.55
Na+ (mmol/l)
154
142
+
K
(mmol/l)
0
0
Mg2+ (mmol/l)
O
O
Ca2+ (mmol/l)
< 0.4
1.4
Cl(mmol/l)
120
80
Lac- (mmol/l)
0
0
Bic- (mmol/l)
0
0
pH
7.4 + 0.3 6.8 + 0.4
Osm. (mOsm/l)
274
250
Rel. visc.
COP (mm Hg)
Gel p.(C)

1.9
33.3
0

Plasmagel = Geloplasma in some


countries

2.0
28.5
<5

Plasmion Plasmage Haemacc Gelifundo


l
el
l
Freseniu Freseniu
Hoechst
Biotest
s MF
s MF
PG
OP
G30
G30
G55
35
35 000
35 000
35 000
30 000
22 600
25 000
24 500
23 300
1.55
1.40
1.43
1.29
150
120
145
145
5
0
5.1
0
1.5
O
O
O
0
13.6
6.25
0.5
100
147
145
100
30
0
0
0
0
0
0
30
6.0 + 0.5 6.0 + 0.5
7.3 + 0.3 7.4 + 0.3
320
350
301
330
2.0
29.0
2-3

2.0
29.0
0

B|BRAUN

1.7 1.8 27.5


28.5 4

2.1
45.6
0

Composition and physicochemical characteristics of dextran


solutions
Name

Rheomacrodex

Macrodex

Company

Pharmacia & Upjohn

Pharmacia & Upjohn

Concentratio (g/l)
n
(Dalton)
Mw

40 000

70 000

(Dalton)

27 000

35 000

1.5

2.0

Mn
Mw/Mn

100

60

Na+

(mmol/l)

154

154

Cl-

(mmol/l)

154

154

5.0 + 0.5

5.0 + 0.5

300

315

4.4

2.7

90

55

pH
Osmolarity

(mOsm/l)

Relative viscosity
CO
P

(mm Hg)

B|BRAUN

Composition and physicochemical characteristics of HES solutions


Name
Company
Concentratio
n
Mw
Mn

Rheohes
B. Braun
(g/l)
(Dalton)
(Dalton)

Mw/Mn

60/100

Elohes
Freseniu
s 60

70 000
40 000

200 000

1.75

60

Hemohes
B. Braun

100

60

200 000

250 000

450 000

80 000

60 000

63 000

71 000

2.50

3.33

3.97

6.34

0.45

0.70 0.80
0.54

0.53 - 0.63 0.45 - 0.55 0.60 - 0.66

MS
DS

0.5

0.5

3.2 : 1

4.5 : 1

9.0 : 1

0.5

C2/C6 ratio

Pentaspa Hespan
n Pont
Du
Du Pont

Na+

(mmol/l)

154

154

154

154

154

Cl-

(mmol/l)

154

154

154

154

154

pH
Osmolarity

6.0 + 1.0
(mOsm/l)

5.5 + 1.5

6.0 + 1.0

5.5+ 1.5

7.3 + 0.3

320

310

308

310

310

Relative viscosity

1.5

1.9/3.7

2.0

COP

24

25 - 30 (6%)
60 - 80 (10%)

25 - 30

70 - 80

25

(mm Hg)

B|BRAUN

3.5 %

~70%

3-4% .
6% 200/0.5

~ 100%

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

~ 145%

10% 40

~ 170%

(%)
0

50

100

150

B|BRAUN

200

3.5 %

~ 1-2 h

3-4% .
6% and 10% 200/0.45 and 0.5
10% 40

~ 3-4 h

6% 70

~ 5-6 h

6% 200/0.62 and 450/0.7

~ 6-8 h

(h)
0

B|BRAUN


( )

,



,
450/0.7

B|BRAUN


(~ 95%)
(~5%),



2/3
,
1/3



( 40)
(70)

B|BRAUN



, ,
.

,


,
, .
.
These effects are stronger with dextrans than with HES
Interference with blood typing and crossmatching is
possible with dextrans and with HES 450/0.7

B|BRAUN

Effects of synthetic colloidal volume replacement


fluids on haemostasis and coagulation
HES 200/0.45 HES 200/0.62
Parameter

Gelatins

HES 200/0.5

HES 450/0.7

Dextran 40

Dextran 70

Factor VIII activity


Platelet adhesion
Platelet
aggregation
Bleeding time
APTT (= PTT)
TT

B|BRAUN

German dosage limits for synthetic colloidal


volume replacement fluids in order to avoid
bleedings

Synthetic
Dose of colloid
colloidal volume on 1st day of
replace-ment fluid therapy
Dextran 40
Dextran 70

HES 200/0.5
HES 450/0.7

Gelatins

1.2 g/kg bw and


day
1.2 g/kg bw and
day
2.0 g/kg bw and
day
1.2 g/kg bw and
day
no limit

Dose of colloid
on consecutive
days of therapy
0.6 g/kg bw and
day
0.6 g/kg bw and
day
2.0 g/kg bw and
day
1.2 g/kg bw and
day
no limit

B|BRAUN

General remarks on colloidal volume replacement


fluids and kidney function
Prolonged use of hypercolloidosmotic solutions without
sufficient administration of crystalloid solutions may
induce acute renal failure
Colloidally dissolved substances can only be dialysed after
hydrolytical breakdown to molecules of MW < 10 000
Dalton
While gelatins and dextrans can be oxidatively metabolised,
HES cannot and may accumulate substantially in tissues in
patients with kidney failure
(References : H. P. Dienes et al., J. Hepatol. 3 (1986) 223-227 and
U. Pfeiffer et al., Klin. Woschenschr. 62 (1984) 862-866)

B|BRAUN

Distribution of infused colloid-free solutions according


to sodium concentration and size of the fluid spaces

ECS (1/3 = 33%)

ICS (2/3 = 66%)

ISS (75%) IVS (25%)

Na+ ~ 140 mmol/l

75 + 25
= 100%
1/3 = 33%

Na+ ~ 0 mmol/l

25 +
2/3 = 66% = 33%

66%

B|BRAUN

Blood components and plasma composition

(%)
100

Plasma

50

Buffy coat

Red blood cells


(41-48%)
0

Per litre : 0.9 l water,


10 g electrolytes,
60-80 g proteins , mainly
albumin (30-50 g),
globulins (20-30 g) and
fibrinogen (~3 g)
Proteins, leucocytes (white blood
cells, e.g. neutrophils, monocytes,
lympho-cytes) and thrombocytes
(platelets)
Serum = Plasma without coagulation
factors and fibrinogen

B|BRAUN

Main functions of blood

Transport of oxygen and carbon dioxide (red blood


cells)
Transport of nutrients, metabolic end products and
drugs (plasma water, sometimes with participation of
albumin)
Immune response (white blood cells and proteins)
Acute closure of wounds (thrombocytes and
coagulation proteins)
Dissolution of blood clots (fibrinolysis)
Maintenance of volaemia (proteins, specially albumin)

B|BRAUN

Factors influencing the oxygen supply to tissues

Blood flow
Depends on heart function, blood pressure, volaemia, and
blood viscosity. Its is specially important that blood flow is
maintained in the capillaries (microcirculation)

Oxygen contents of arterial blood


Depends on lung function, haematocrit, haemoglobin and
arterial oxygen saturation

Oxygen extraction ratio


Depends mainly on pH

B|BRAUN

Normal oxygen delivery at rest

O2

O2

O2

SvO2 = 75%

D02 ~ SV x HR x caO2
SaO2 = 100%
O2

O2

O2

O2

B|BRAUN

Body tissue
OER = 25%

Increased oxygen delivery with physical activity

O2

O2

O2

O2

O2

O2

SvO2 = 75%

D02

~ SV x HR

Body tissue
OER = 25%

x c a O2

SaO2 = 100%
O2

O2

O2

O2

O2

O2

O2

O2

B|BRAUN

Oxygen delivery as a function of haematocrit in


normovolaemic haemodilution
(%)

Oxygen delivery (DO2)

120
100
80
60
40
20
0
0

10

20

30

40

50

60

70

80
(%)

Sunder-Plassmann et al., Anaesthesist 20 (1971)


172

B|BRAUN

Haematocrit

Response to normovolaemic haemodilution in patients at rest

(%)

Change

CO ( = SV x HR )

150

HR
100

SvO
2

50

(g/dl)

7.5

Haemoglobin

15

R. Zander in "Eigenblut", pp.23-33


(1995)

B|BRAUN

Influence of haematocrit on blood viscosity

Relative viscosity
10
9
8

Normal blood

7
6
5
4

Plasma

3
2
1

Water

0
10

20

30

40

50

60

70 (%) Haematocrit

B|BRAUN

Influence of shear stress on blood viscosity

Relative
viscosity
103

Haematocri
t
25%

102

40%
101

60%

100
0.01

0.1

10

100 x 10-5
(N/cm2)

B|BRAUN

Shear stress

Details of the mechanism of the response to


normovolaemic haemodilution

Haemodilution

Haematocrit

Stroke
volume

DO2

Blood
viscosity

Cardiac
output

SV

Cardiac
preload

Oxygen
delivery

HR

B|BRAUN

c a O2

Increased oxygen delivery with normovolaemic


haemodilution

O2

O2

O2

SvO2 = 75%

D02

~ SV

x HR

x c a O2

SaO2 = 100%
O2

O2

O2

O2

B|BRAUN

Body tissue
OER = 25%

Hypovolaemia and shock

B|BRAUN

Definition and types of hypovolaemia

Hypovolaemia
Condition of lack of fluid in the vascular system

Absolute hypovolaemia

Relative hypovolaemia

Reduction of the intravascular


fluid volume due to a loss
of fluid from the intravascular
space

Reduction of the intravascular


fluid volume due to an
increased capacity of the
intravascular space

B|BRAUN

Definition and types of shock

Shock
Condition of profound haemodynamic and metabolic disturbance characterised
by failure of the circulatory system to maintain adequate perfusion of vital
organs

Cardiogenic
shock

Hypovolaemic shock with


absolute hypovolaemia

Hypovolaemic shock with


relative hypovolaemia

Acute ventricular
insufficiency

Loss of volume from


vascular system

Increased capacity
of vascular system

B|BRAUN

Hypovolaemic shock
with absolute
hypovolaemia
Haemorrhagic
shock

Traumatic
shock

Visible blood
losses through
wounds

Invisible internal
blood losses after
trauma

Shock after
burns
Plasma losses into
burn blisters

B|BRAUN

Shock from
dehydration
Losses of water
and electrolytes
with diarrhoea,
vomiting or fistulae

Hypovolaemic shock
with relative
hypovolaemia
Septic
shock

Anaphylactic
shock

Vasodilation as a
consequence of
sepsis

Vasodilation as a
consequence of
anaphylaxis

Neurogenic
shock
Vasodilation due to irreversible interruption of the regulation of intravascular
tone by the central nervous system after
cerebral or spinal trauma

B|BRAUN

Cardiovascular and hormonal response to hypovolaemia

Hypovolaemia

Blood
pressure

Venous
return

Cardiac
output

Sympathetic
activity

Vasoconstriction

Decreased perfusion
in stomach,
intestine, liver,
kidneys, muscle and
skin

Maintained perfusion
in brain, heart and
lung

B|BRAUN

Activation of
renin-angiotensin-aldosterone-system

Pathological aspects of uncompensated hypovolaemia

Reduced blood
flow with rouleau
formation in the
capillaries

Uncompensated
hypovolaemia

Hypoxia, specially
in areas with
reduced perfusion

Acidosis and
endothelial
damage

Activation of
blood coagulation

Further
deterioration of
microcirculation

Multiple organ
failure and death

B|BRAUN


( Committee on Trauma American College of
Surgerions W B Saunders 1982)

15

II

20 - 25

III

-

,
(<400/)

30 -40

IV

40

B|BRAUN

Classification of haemorrhagic or traumatic


hypovolaemia and related changes in
quantifiable parameters

Clas
s
I
II
III

IV

Blood
loss
< 15%

BP
HR
sys dia (per min)
n

0.75-1.5 l
30-40%
1.5-2.0 l
> 40%
> 2.0 l

Cap
. ref.

Respiration

Urine prod.
(ml/min)

80-100

~ 0.8

> 30

100-120

~ 1.0

> 2s

30-20

120

~ 1.1

> 2s

> 20/min

20-10

< 0.75 l

15-30%

SI

> 120

~ 1.5

undetecta- > 20/min


ble

SI : Shock Index = HR/BP(sys) , normal value : 0.5

B|BRAUN

10-0

Classification of haemorrhagic or traumatic


hypovolaemia and related changes in
unquantifiable parameters

Clas
s

Blood
loss
< 15%
< 0.75 l

Extremitie
s

Complexion

Mental
status

normal colour

normal colour

alert

II

1530%
0.75-1.5
l

pale

pale

III

3040% l
1.5-2.0

pale

pale

pale and cold

ashen

IV

> 40%
> 2.0 l

anxious and
aggressive
anxious and aggressive
or sleepy
sleepy, confused or
unconscious

B|BRAUN

Critical values of parameters in connection with blood


losses
Blood loss (%)

Critical value

up to
15%

I
up to
30%
up to
40%

up to
60%

None. Compensation
normally possible
Volaemia
< 90% of normal

II

Haematocrit < 25%

III

Colloidosmotic
pressure
< 20 mm Hg

Consequen
ce
None or transient
hypotension
Reduced cardiac
output
Insufficient oxygen
transport capacity

Risk of pulmonary
oedema

Coagulation factors

IV < 30% of normal

up to
80%

Disturbances of blood
coagulation
more
than

Platelets
< 50.000/mm3

80%

B|BRAUN

Tailored volume replacement and haemotherapy

Blood loss (%)

Problem
I

up to
30%

Measure

Correction of interstitial fluid


Blood volume deficiencies with crystalloids.
100 % of normal Volume replacement with
colloids.

up to
40%

up to
60%

II

Haematocrit < 25%


(Hb < 7.5 g/dl)

I + packed red blood cells

III

Total protein
< 50 g/l

I I + improve colloidosmotic
pressure with colloids
(human albumin ?)

Coagulation factors

I I + coagulation factors
(fresh frozen plasma)

IV < 35% of normal

up to
80%
more
than
80%

Platelets
< 50.000/mm3

I I + coagulation factors
(fresh frozen plasma) +
platelets or fresh blood ( 48
h old)

B|BRAUN

Uses of volume replacement fluids

B|BRAUN

Definition and aims of volume replacement

Definition :
Intravenous administration of liquid suitable for the
replacement of intravascular fluid

Aims :
To prevent or treat hypovolaemia in order to avoid its clinical
consequences

B|BRAUN

Uses of volume replacement fluids

Hypovolaemia outside hospitals

B|BRAUN

Principles for the treatment of hypovolaemia in


acute situations outside a hospital (e. g. traffic
accident)

Establish adequate pulmonary oxygenation


Stop haemorrhage
Insert catheters and administer volume replacement
fluids
Maintain cardiac contractility
Mitigate pain
Rush as quickly as possible to hospital

B|BRAUN

Example for volume replacement protocol in acute


hypovolaemia outside a hospital (e. g. traffic
accident)

Volume replacement a)

Blood losses
Class

% of total blood

approx. in l

e. g. with Gelofusine

< 15 %

< 0.75 l

0.5 - 1.0 l

II

15 % - 30 %

0.8 - 1.5 l

1.0 - 2.0 l

III

30 % - 40 %

1.5 - 2.0 l

2.0 - 2.5 l

IV

> 40 %

> 2.0 l

> 2.5 l

a) Amount of fluid to be monitored by pulse and systolic blood pressure

B|BRAUN

Possible responses of systolic blood pressure and


heart rate to volume replacement in hypovolaemia

(mm Hg) or
(beats x min1)
140

The normalisation of
systolic blood pressure
and heart rate, as shown
here, is found normally
when blood losses are
less than 20% of total
blood volume, and the
patient is no longer
actively bleeding

BPsys and HR

120
100
80
60
40
20

Systolic BP

0
0

60 min

B|BRAUN

Heart rate

Possible responses of systolic blood pressure and


heart rate to volume replacement in hypovolaemia

(mm Hg) or
(beats x min1)
140

Typical behaviour of
systolic blood pressure
and heart rate after
volume replacement in
patients with blood
losses of more than
20% of blood volume
and still actively
bleeding

BPsys and HR

120
100
80
60
40
20

Systolic BP

0
0

60 min

B|BRAUN

Heart rate

Possible responses of systolic blood pressure and


heart rate to volume replacement in hypovolaemia

(mm Hg) or
(beats x min1)
140

Typical behaviour of
systolic blood pressure
and heart rate after
insufficient volume
replacement, our in
patients bleeding more
quickly than volume
replacement fluids can
be administered

BPsys and HR

120
100
80
60
40
20

Systolic BP

0
0

60 min

B|BRAUN

Heart rate

Uses of volume replacement fluids

2a

Blood-saving techniques
Intentional normovolaemic haemodilution

B|BRAUN

Problems with transfusion of homologous blood or


its components ( specially PRBC, FFP, PP)

Possible transmission of infectious diseases


Induction of immunosuppression
Haemolysis with transfusion of blood from wrong blood
group
Allergic, febrile and anaphylactic reactions
Limited availability
Storage time and temperature

B|BRAUN

Trends in the controlled treatment of blood losses


Implementation of blood-saving techniques, e. g.
autologous blood donation
intentional normovolaemic haemodilution
use of a cell saver

Use of synthetic colloids instead of albumin whenever


possible
Use of blood components rather than of whole blood

B|BRAUN

Definition and types of haemodilution

Haemodilution
Reduction of haematocrit with increase of the
liquid phase of blood

Hypovolaemic
haemodilution

Normovolaemic
haemodilution

Hypervolaemic
haemodilution

Reduced volaemia

Maintained volaemia

Increased volaemia

B|BRAUN

Intentional normovolaemic haemodilution


Intentional withdrawal of blood immediately prior to an operation
aiming at a haematocrit of ~ 25% (Hb ~ 7.5 g/dl) and maintaining
normovolaemia by infusion of colloids
The blood volume to be withdrawn (Vdraw) can be estimated as
follows :

Vdraw =

Hct initial - Hct final


x blood volume
Hct initial

blood volume = 7-8% of body weight in adults

B|BRAUN

Exclusion criteria for intentional normovolaemic


haemodilution

Insufficient pulmonary ventilation


Left ventricular failure
Overt coronary insufficiency
Treatment with b-adrenoreceptor blocking drugs
Increased oxygen demands (e. g. fever,
hyperventilation)
Haematocrit < 35% before haemodilution
PT < 70% and APTT > 40 s
Platelet counts < 100 000/mm
K. F. W. Messmer, World J. Surgery 11 (1987) 41-46

B|BRAUN

Example of preoperative normovolaemic haemodilution

preoperative haemodilution
500
ml
blood

Out

operation

500
ml
blood

Monitor.
0
In

10

20
500
ml
coll.

30

40

50

500
ml
coll.

60

70

(min)

Coll. if
required

Crystalloid at 1.5 ml/kg body weight and hour

Y. J. Mortelmans et al., Anesth. Analg. 81 (1995) 1235-1242

B|BRAUN

Colloids and
PRBC as
required

Monitoring of operations using intentional


normovolaemic haemodilution
HR, CI, BPsys , MAP, CVP, PAOP, SaO2 , SvO2 , PaO2 ,
PvO2 , SVR, PVR
Coagulation parameters (PT, APTT, platelet counts)
Haematocrit, total protein or albumin in serum
( better : colloidosmotic pressure)

Fluid balance
Y. J. Mortelmans et al., Anesth. Analg. 81 (1995) 1235-1242

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Uses of volume replacement fluids

2b

Blood-saving techniques
Tailored haemotherapy

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Tailored volume replacement and haemotherapy

Blood loss (%)

Problem
I

up to
30%

Measure

Correction of interstitial fluid


Blood volume deficiencies with crystalloids.
100 % of normal Volume replacement with
colloids.

up to
40%

up to
60%

II

Haematocrit < 25%


(Hb < 7.5 g/dl)

I + packed red blood cells

III

Total protein
< 50 g/l

I I + improve colloidosmotic
pressure with colloids
(human albumin ?)

Coagulation factors

I I + coagulation factors
(fresh frozen plasma)

IV < 35% of normal

up to
80%
more
than
80%

Platelets
< 50.000/mm3

I I + coagulation factors
(fresh frozen plasma) +
platelets or fresh blood ( 48
h old)

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Example for tailored volume replacement and


haemotherapy
% blood loss

LR GEL PRBC ALB

<15

(0.75l)

FFP

PP

Ia 1-2 l
15-30
( 0.75
-1.5 l)

30-40
(1.5
-2.0 l)

Ib

1-2 l

1-2 l

II

1-2 l

1-2 l

1u

III

1-2 l

1-2 l

1-3 u

IV

1-2 l

1-2 l

3-6 u

1u

1-2 l

1-2 l

7-X u

2-X u

40-60
(2.0
-3.0 l)

(1 u)

60-80
(3.0
-4.0 l)
> 80
(> 4.0 l)

Control : Hc = 25-30%,
Hb = 7.5-10g/dl,

Coagulation factors > 30 % of normal value,


Platelets > 50 000/mm

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As
required

1 u = 250 ml

Serum albumin concentrations (ALB) and


colloidosmotic pressure (COP) in intesive care patients
A. F. Grootendorst et al., Intensive Care Med. 14 (1988) 554557
Trial
on the correlation of ALB and COP in intensive care
patients
on the safety of COP as parameter for the control of ALB
administration in order to avoid the development of
pulmonary oedema
on the reduced consumption of albumin and the
corresponding saving of money with such a protocol

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Serum albumin concentrations (ALB) and colloidosmotic


pressure (COP) in intesive care patients
A. F. Grootendorst et al., Intensive Care Med. 14 (1988) 554557
Conclusions
there is a poor correlation between ALB and COP in these
patients ( r = 0.56, p < 0.001)
COP, not ALB is the parameter that should be measured
ALB administration should not be based on fixed values for
hypoalbuminaemia (e. g. 25 g/l)
To maintain COP at ~ 15 mm Hg with ALB administration is
sufficient to avoid development of pulmonary oedema
To use COP instead of ALB as parameters for ALB
administration leads to savings of 1000,- US $ per month

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Uses of volume replacement fluids

Volume replacement in septic shock

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Origin and characteristics of septic shock

Origin
Periodical or continuous invasion of pathogenic bacteria or
their toxins, coming from a septic focus, into blood stream
Characteristics
Increased CI and VO2 , except in the final stage
Reduced vascular resistance
Disturbance of the regulation of microcirculation
Disturbance of oxygen extraction

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Characteristics of septic shock at different


stages
Parameter

Grade
II
III

HR
MAP
PAP
PAOP
SVR
CI
Oxygen extraction
Lactate in serum

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IV

Principles for the treatment of sepsis and septic


shock
Surgical removal of septic focus and antibiotic
treatment
Use of volume replacement, blood components,
inotropes, vasodilators, vasopressors and diuretics to
maintain optimal goals for CI, DO2 , and VO2 , as
defined by Shoemaker, using Hct, PAOP, and MAP for
the monitoring :
CI > 4.5 l/min . m2
Hct > 33%
DO2 > 800 ml/min . m2
PAOP : 15-20 mmHg
VO2 > 170 ml/min . m2
MAP : 70-100 mmHg
Treatment of coagulation disorders
Compensation of organ failures

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Haemodynamic management of high-risk surgical patients and of septic shock

yes

Opt. goals

Re-evaluate
and recycle

no
2 PAOP > 20
no
4

no

yes
Lasix, PEEP, stop fluids

PAOP > 20

Blood or PRBC

5
CI, DO2

yes

Hct < 33

yes

Cardiac
consult

yes
Titrate fluids (15 < PAOP < 20)

no

Fluids

6
no

no
7
70 < MAP < 100

yes
Inotrope

8
CI , DO2

yes
no

no
10

MAP > 100

yes

Vasodilator

no
13

MAP < 70
no

yes

W. C. Shoemaker et al., New Horizons 1 (1993) 145159

Vasopressor

yes

yes
Opt. goals
9
yes
Opt. goals
no

11 MAP < 100 yes 12


yes
Opt. goals
C I , DO2
no
14 MAP > 70 yes 15
yes
Opt. goals
CI , DO2
Protocol
no
no
failure

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Correlation between DO2 and survival in high-risk


surgical patients
(%)
40

168 patients in the control and 101 in the


study group.

29%

In control group CI = 2.8-3.5 l x min-1 x m-2


and DO2 = 400-550 ml x min-1 x m-2
20

16%

In study group CI > 4.5 l x min-1 x m-2 and


DO2 > 600 ml x min-1 x m-2
Deaths in control group
Deaths in study group

0
p < 0.05

W. C. Shoemaker et al., Chest 94 (1988) 11761186

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Uses of volume replacement fluids

Volume replacement in burns

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Immediate measures in patients with severe burns


Remove burnt or burning clothes, cool with water, and
cover the burnt area with sterile material
Administer analgesics intravenously, e. g. opiates

Maintain respiration and oxygenation


Calculate the size of the burn with the rule of nine

Administer crystalloids and colloids according to the body


surface area (BSA) burnt

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Volume replacement in severe burns


The amount of fluid needed in the acute treatment can be
calculated
as follows
Required fluid (ml) = Burnt BSA (%) x bw/2
Administer calculated amount of fluid by giving the first 500 ml as
crystalloid and what remains as colloid (if only crystalloids are
used the amount of fluid is caculated as shown above but without
dividing by 2)
Burn patients may require packed red blood cells additionally to
fluid therapy

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Uses of volume replacement fluids

Volume replacement in crush syndrome


(acute rhabdomyolysis)

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Characteristics of crush syndrome

Large crushes, specially of the extremities, lead to


muscular ischaemia, followed by necrosis
loss of intravascular fluid into the interstitial space
With the onset of reperfusion
intracellular material lost to the extracellular space is now
washed out of the injured areas and leads to hyperkalaemia,
hyperphosphataemia, hyperuricaemia, hypercreatininaemia,
and myoglobinaemia

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Volume replacement in crush syndrome


There is need for aggressive volume replacement (up to
10 l of fluid) with a combination of crystalloids and
colloids in order
to treat the hypovolaemia
to enhance diuresis and eliminate potassium, phosphate,
uric acid, creatinine and myoglobin through kidneys
to avoid kidney failure related to clogging by myoglobin
Volume replacement liquids used should not contain
potassium, as there is already hyperkalaemia
Reference : J. D. Edwards, Internat. J. Intens. Care (1995) 6-7

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