Journal Reading: Resuscitation Fluids

JOURNAL READING
Resuscitation Fluids
John A. Myburgh, M.B., B.Ch., Ph.D., and Michael G. Mythen, M.D.,

M.B., B.S.
Disusun Oleh:
Imada Khoironi
Kharisma Fatwasari
Kepaniteraan Klinik Bagian Anestesi
Fakultas Kedokteran Unissula
Semarang
RSI Sultan Agung Semarang
Introduction
Fluid
resuscitation with colloid and crystalloid

solutions is a ubiquitous intervention in acute
medicine.
The selection and use of resuscitation fluids is based
on physiological principles, but clinical practice is
determined largely by clinician preference, with
marked regional variation.
Albumin is regarded as the reference colloid solution,
but its cost is a limitation to its use.
The use of hydroxyethyl starch (HES) solutions is
associated with increased rates of renal-replacement
therapy and adverse events among patients in the
intensive care unit (ICU).
All resuscitation f luids can contribute to
the formation of interstitial edema,

particularly under inf lammatory conditions
in which resuscitation f luids are used
excessively
The selection of the specific f luid should be
based on indications, contraindications, and
potential toxic effects in order to maximize
efficacy and minimize toxicity
History of Fluid Resuscitation

1832, Robert Lewins
the quantity necessary to be injected will

probably be found to depend upon on the
quantity of serum lost; the object being to
place the patient in nearly his ordinary
state as to the quantity of blood circulating
in the vessels.
1885, Alexis Hartmann
Asanguinous fluid resuscitation

(who modified a physiologic salt solution
developed in 1885 by Sidney Ringer for
rehydration
of
children
with
gastroenteritis.)
1941
Human albumin was used for the first time

in large quantities for resuscitation of
patients who were burned during the
attack on Pearl Harbor in the same year.
The Physiology of Fluid

Resuscitation
Clinicians have based their selection of
resuscitation fluids on the classic
compartment model;
The interstitial of the intracellular fluid
compartment
Intravascular of the extracellular fluid
compartment
The factors that dictate fluid distribution
across these compartments
1896, Ernest Starling
Capillaries and postcapillary venules acted

as a semipermeable membrane absorbing
fluid from the interstitial space. This
principle was adapted to identify the
hydrostatic and oncotic pressure gradients
across the semipermeable membrane as
the
principal
determinants
of
transvascular exchange.
Recent descriptions have

questioned these
classic models
The Ideal Resuscitation Fluid

Produces a predictable and sustained increase in intravascular
volume
Has a chemical composition as close as possible to that of

extracellular fluid
Metabolized and completely excreted without accumulation in

tissues
Does not produce adverse metabolic or systemic effects
Cost-effective in terms of improving patient outcomes
Category of Fluid Resuscitation
Colloid
solutions
Suspensions of molecules within a carrier solution that are relatively

incapable of crossing the healthy semipermeable capillary membrane
owing to the molecular weight of the molecules
Colloids are more effective in expanding intravascular volume because
they are retained within the intravascular space and maintain colloid
oncotic pressure
The volume-sparing effect of colloids, as compared with crystalloids, is
considered to be an advantage, which is conventionally described in a 1:3
ratio of colloids to crystalloids to maintain intravascular volume
Semisynthetic colloids have a shorter duration of effect than human
albumin solutions but are actively metabolized and excreted
Solutions of ions that are freely permeable but contain concentrations of

sodium and chloride that determine the tonicity of the fluid
Crystalloids are inexpensive and widely available and have an established,
Crystalloid although unproven, role as first-line resuscitation fluids
solutions
Types of Resuscitation Fluid
Albumin
Human albumin (4 to 5%) in saline is
considered to be the reference colloidal

solution
It is produced by the fractionation of blood
and is heattreated to prevent transmission
of pathogenic viruses
It is an expensive solution
It is availability is limited
Investigators in Australia and New Zealand
conducted the Saline versus Albumin Fluid

Evaluation
(SAFE)
study,
a
blinded,
randomized, Controlled trial, To Examine The
Safety Of albumin in 6997 adults in the ICU;
The
study
assessed
the
effect
of
resuscitation with 4% albumin, as compared
with saline, on the rate of death at 28 days.
The study showed no significant difference
between albumin and saline with respect to
the rate of death
Resuscitation with albumin was associated
with a significant increase in the rate of

death at 2 years among patients with
traumatic brain injury.
Resuscitation with albumin was associated
with a decrease in the adjusted risk of
death at 28 days in patients with severe
sepsis.
No significant difference in hemodynamic
resuscitation end points, such as mean

arterial pressure or heart rate, was
observed between the albumin and saline
groups, although the use of albumin was
associated with a significant. The Ratio Of
The Volumes Of Albumin To The volumes of
saline administered to achieve these end
points was observed to be 1:1.4.
Semisynthetic Colloids
Semisynthetic Colloids Include HES, succinylated
gelatin,
Urealinked
gelatinpolygeline
preparations, And Dextran solutions.
HES
solutions are produced by hydroxyethyl

substitution of amylopectin obtained from
sorghum, maize, Or potatoes.
A high degree of substitution on glucose molecules
protects against hydrolysis by nonspecific
amylases in the blood, thereby prolonging
intravascular expansion, but this action increases
the potential for HES to accumulate in
reticuloendothelial tissues, such as skin (resulting
in pruritus), liver, and kidney.
The potential that such solutions may
accumulate In tissues
The Recommended Maximal Daily Dose
Of HES Is 33 To 50 Ml Per Kilogram Of
Body Weight Per day.
HES vs Ringers Acetat

In a blinded, randomized, controlled trial
involving 800 patients with severe sepsis in

the ICU. Scandinavian investigators reported
that the use of 6% HES, as compared with
Ringers acetate, was associated with a
significant increase in the rate of death at 90
days and a significant 35% relative increase
in the rate of renal-replacement therapy
These results are consistent with previous
trials of 10% HES in similar patient
populations
HES vs Saline
The use of 6% HES, as compared with
saline, was not associated with a significant

difference in the rate of death at 90 days.
The use of HES was associated with a
significant 21% relative increase in the rate
of renalreplacement therapy
Crystalloids
Sodium
chloride (saline) is the most commonly used

crystalloid solution on a global basis.
Normal (0.9%) Saline Contains Sodium And Chloride In Equal
concentrations, Which Makes It Isotonic As Compared With
Extracellular fluid.
Given the concern regarding an excess of sodium and
chloride associated with normal saline, balanced salt
solutions are increasingly recommended as first-line
resuscitation fluids in patients undergoing surgery, patients
with trauma, and patients with diabetic ketoacidosis.
Resuscitation with balanced salt solutions is a key element in
the initial treatment of patients with burns, although there is
increasing concern about the adverse effects of f luid
overload, And A Strategy Of permissive hypovolemia In
Such Patients Has Been advocated.
Dose and Volumes
No currently available resuscitation fluid
can be considered to be ideal. The

selection, timing, and doses of intravenous
f luids should be evaluated as carefully as
they are in the case of any other
intravenous drug, with the aim of
maximizing
efficacy
and
minimizing
iatrogenic toxicity.
Thank You

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JOURNAL READING

John A. Myburgh, M.B., B.Ch., Ph.D., and Michael G. Mythen, M.D.,

resuscitation with colloid and crystalloid

All resuscitation f luids can contribute to

the formation of interstitial edema,

History of Fluid Resuscitation

the quantity necessary to be injected will

1885, Alexis Hartmann

Asanguinous fluid resuscitation

Human albumin was used for the first time

The Physiology of Fluid

1896, Ernest Starling

Capillaries and postcapillary venules acted

Recent descriptions have

The Ideal Resuscitation Fluid

Has a chemical composition as close as possible to that of

Metabolized and completely excreted without accumulation in

Does not produce adverse metabolic or systemic effects

Cost-effective in terms of improving patient outcomes

Category of Fluid Resuscitation

Suspensions of molecules within a carrier solution that are relatively

Solutions of ions that are freely permeable but contain concentrations of

Types of Resuscitation Fluid

considered to be the reference colloidal

Investigators in Australia and New Zealand

conducted the Saline versus Albumin Fluid

Resuscitation with albumin was associated

with a significant increase in the rate of

No significant difference in hemodynamic

resuscitation end points, such as mean

solutions are produced by hydroxyethyl

The potential that such solutions may

HES vs Ringers Acetat

involving 800 patients with severe sepsis in

saline, was not associated with a significant

chloride (saline) is the most commonly used

Dose and Volumes

No currently available resuscitation fluid

can be considered to be ideal. The

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