HEMODYNAMIC MANAGEMENT

Understanding the physiologic and metabolic changes during

this period is the key to successful management. The major
decisions relate to fluid therapy and the ongoing assessment
of the adequacy of perfusion. Principles of Critical Care,3rd,Josse B. Hall,McGraw Hill,2005

Selection of appropriate fluid therapy

It is di fficul t not to support the use of col loid fluids in hypo-oncotic patients. In patients wi th
renal fai lure the
repeated use of col loid fluid may lead to a hyperoncotic state. This is associated with tissue
dehydration and fai lure
of glomerular fi l tration (thus prolonging the renal fai lure). Measurement of a high COP in
patients who have been
treated with arti ficial col loids should direct the use of crystalloid fluids. It is important to note
that excessive
diuresis may also lead to a hyper-oncotic state for which crystal loid replacement may be
necessary.

Fluids
Crystalloids
Types
Sal ine: e.g. 0.9% sal ine, Ringer's lactate, Hartmann's solution, 0.18% sal ine in 4% glucose
Glucose: e.g. 5%, 10%, 20%, 50%
Sodium bicarbonate: e.g. 1.26%, 8.4%
Uses
Crystal loid fluids to provide the dai ly requirements of water and electrolytes. They should be
given to critically
i l l patients as a continuous background infusion to supplement fluids given during feeding, or to
carry drugs.
Higher concentration glucose infusions to prevent hypoglycaemia.
Potassium chloride to supplement crystal loid fluids.
Sodium bicarbonate for correction of metabol ic acidosis, urinary alkalinisation, etc
Routes
IV
Notes
A significant plasma volume deficit should be replaced with col loid solutions since crystalloids
are rapidly lost from
the plasma, particularly during periods of increased capil lary leak, e.g. sepsis. As most plasma
substi tutes are
carried in sal ine solutions, any additional 0.9% sal ine crystal loid infusion is only needed to
replace excess sodium
losses.
The sodium content of 0.9% sal ine is equivalent to that of extracel lular fluid. A daily
requirement of 7080mmol
sodium is normal although there may be excess loss in sweat and from the gastrointestinal tract.
Ringer's lactate or Hartmann's solution have no practical advantage over 0.9% sal ine for fluid
maintenance. They
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may, however, be useful if large volumes of crystal loid are used to avoid hyperchloraemic
acidosis. Hyperchloraemic
acidosis may adversly affect coagulation and renal function.
5% glucose is used to supply intravenous water requirements. The 50g/l glucose content ensures
an isotonic solution
but only provides 200Cal/l. Normal requirement is approximately 1.52l/day. Water loss in
excess of electrolytes is
uncommon but occurs in excess sweating, fever, hyperthyroidism, diabetes insipidus and
hypercalcaemia.
Potassium chloride must be given slowly since rapid injection may cause fatal arrhythmias. No
more than 40mmol/h
should be given al though 20mmol/h is more usual. The frequency of infusion is dictated by
plasma potassium
measurements.

ion content of crystalloids (mmol/l)

Na+ K+ HCO3- Cl- Ca2+
0.9% saline 150 150
Hartmann's 131 5 29 111 2
0.18% saline in 4% glucose 30 30
Ion content of gastrointestinal fluids (mmol/l)
H+ Na+ K+ HCO3- Cl-
Gastric 4060 2080 520 150 100150
Biliary 120140 515 3050 80120
Pancreatic 120140 515 70110 4080
Small bowel 120140 515 2040 90130
Large bowel 100120 515 2040 90130
See also:
Nutri tionuse and indications, p78; Urea and creatinine, p144; Electrolytes
, p146; Sodium bicarbonate, p178; Col loids, p180; Hypernatraemia, p416; Hyponatraemia,
p418; Hyperkalaemia,
p420; Hypokalaemia, p422; Metabol ic acidosis, p434; Diabetic ketoacidosis, p442;
Hyperosmolar diabetic
emergencies, p444; Multiple trauma (1), p500; Mul tiple trauma (2), p502; Burnsfluid
management, p510;
Post-operative intensive care, p534
Sodium bicarbonate
Types
Isotonic sodium bicarbonate 1.26%
Hypertonic sodium bicarbonate (1mmol/ml) 8.4%
Uses
Correction of metabol ic acidosis.
Alkal inisation of urine.
Alkal inisation of blood, e.g. for treatment of tricycl ic antidepressant overdose.
Routes
IV
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Notes
Isotonic (1.26%) sodium bicarbonate may be used to correct acidosis associated wi th renal fai
lure or to induce a
forced alkal ine diuresis. The hypertonic (8.4%) solution is rarely required in intensive care
practice to raise blood pH
in severe metabol ic acidosis. Bicarbonate therapy is inappropriate when tissue hypoperfusion or
necrosis is present.
Administration may be indicated as either speci fic therapy (e.g. alkal ine diuresis for sal icylate
overdose) or if the
patient is symptomatic (usual ly dyspnoeic) in the absence of tissue hypoperfusion (e.g. renal fai
lure).
The PaCO2 may rise if minute volume is not increased. Bicarbonate cannot cross the cel l
membrane wi thout
dissociation so the increase in PaCO2 may result in intracel lular acidosis and depression of
myocardial cel l function.
The decrease in plasma ionised calcium may also cause a decrease in myocardial contracti l ity.
Significantly worse
haemodynamic effects have been reported with bicarbonate compared to equimolar sal ine in
patients wi th severe
heart fai lure.
Convincing human evidence that bicarbonate improves myocardial contracti l ity or increases
responsiveness to
ci rculating catecholamines in severe acidosis is lacking, though anecdotal success has been
reported. Acidosis
relating to myocardial depression is related to intracel lular changes that are not accurately
reflected by arterial blood
chemistry.
Excessive administration may cause hyperosmolal i ty, hypernatraemia, hypokalaemia and
sodium overload.
Bicarbonate may decrease tissue oxygen availabi l ity by a left shift of the oxyhaemoglobin
dissociation curve.
Sodium bicarbonate does have a place in the management of acid retention or alkal i loss, e.g.
chronic renal fai lure,
renal tubular acidosis, fistulae, diarrhoea. Fluid and/or potassium deficits should be corrected
first.
Ion content of sodium bicarbonate (mmol/l)
Na+ K+ HCO3- Cl- Ca2+
1.26% sodium bicarbonate 150 150
8.4% sodium bicarbonate 1000 1000
See also:
Blood gas analysis, p100; Electrolytes
), p146; Crystal loids, p176; Cardiac arrest, p272; Metabol ic acidosis, p434; Sal icylate
poisoning, p454
Colloids
Types
Albumin: e.g. 4.55%, 2025% human albumin solution
Dextran: e.g. 6% Dextran 70
Gelatin: e.g. 3.5% polygel ine, 4% succinylated gelatin
Hydroxyethyl starch: e.g. 6% hetastarch, 6% hexastarch, 6 and 10% pentastarch, 6%
tetrastarch
Uses
Replacement of plasma volume defici t/percentage
Short term volume expansion (gelatin, dextran)
Medium term volume expansion (albumin, pentastarch)
Longer term volume expansion (hetastarch)
Routes
IV
Side-effects
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Di lution coagulopathy
Anaphylaxis
Interference wi th blood cross-matching (Dextran 70)
Notes
Smaller volumes of col loid are required for resuscitation with less contribution to oedema.
Maintenance of plasma
col loid osmotic pressure (COP) is a useful effect not seen wi th crystal loids, but col loids contain
no clotting factors or
other plasma enzyme systems.
Albumin is the main provider of COP and has several other roles. There is no evidence that
maintaining plasma
albumin levels, as opposed to plasma COP wi th artificial plasma substitutes, is better.
Albumin 2025% and Pentaspan 10% are hyperoncotic and used to provide col loid where salt
restriction is necessary.
This is rarely necessary in intensive care as plasma volume expansion is related to the weight of
col loid infused
rather than the concentration. Arti ficial col loids used wi th ul trafi l tration or diuresis are just as
effective in oedema
states.
Polygel ine is a 3.5% solution containing calcium (6.25mmol/l). This prevents use of the same
giving set for blood
transfusions. Succinylated gelatin is a 4% solution with a larger molecular size than polygel ine
giving a sl ightly
longer effect. This, and the lack of calcium in solution, make it more useful than polygel ine for
short term plasma
volume expansion.
In patients with capi l lary leak albumin and smaller molecular weight col loids leak to the
interstitium. In these cases
it is perhaps better to use larger molecular weight col loids such as hydroxyethyl starch, though
conclusive evidence
is lacking.
Hetastarch and hexastarch are usual ly 6% solutions with a high degree of protection from
metabol ism due to a high
degree of substitution (proportion of glucose units substituted with hydroxyethyl groupsDS) or
a high ratio of C2 to
C6 carbon atoms substituted (C2:C6 ratio). The molecular weight ranges vary but molecular
sizes are large enough to
ensure a prolonged effect. These are the most useful col loids in capi llary leak. Prolonged itching
related to
intradermal deposition and interference with coagulation are complications if excessive doses are
used.
Pentastarch and tetrastarch provide only a short term effect simi lar to succinylated gelatin.
Unique features of albumin
Transport of various molecules.
Free radical scavenging.
Binding of toxins.
Inhibi tion of platelet aggregation.
Relative persistence of colloid effect
Albumin +++
Dextran 70 ++
Succinylated gelatin ++
Polygeline +
Hetastarch (high MW, high DS, low C2:C6 ratio) ++++
Hexastarch (medium MW, high DS, high C2:C6 ratio) ++++
Pentastarch (medium MW, low DS, low C2:C6 ratio) ++
Tetrastarch (low MW, low DS, high C2:C6 ratio) ++
Persistence is dependent on molecular size and protection from metabol ism.
High DS and high C2:C6 ratio protect hydroxyethyl starch from metabol ism.
Al l arti ficial col loids are polydisperse (i .e. there is a range of molecular sizes).

Oxford Handbook of Critical Care,2nd,Mervyn Singer,Oxford University Press,2005