Fluid Resuscitation for Shock

First off… we need to guess roughly how much blood had the patient lost.

Just by looking at few simple things would give you a guide.

  • Blood pressure
  • Pulse rate
  • Mental status

There are other parameters such as respiratory rate and urinary output but the 3 mentioned above are the easiest to assess. They take less time. I like short cuts.

Blood pressure

If blood pressure is within the normal range, estimated blood loss would be about 1.5L or less.

If it is lower than normal, then it is above 1.5L.

Pulse rate

If it is between <100 – 120 beats/min, it is less than 1.5L.

If it is above 120 beats/min, it is above 1.5L.

Mental status

If the patient looks normal with anxiety, it is less than 1.5L.

If the patient is confused and he/she starts scolding your father, mother, girlfriend or boyfriend, it is above 1.5L.

If estimated blood loss is above 1.5L, the patient may need blood transfusion. Get ready packed red blood cells.

Always keep in mind that the patient needs oxygen and glucose to be alive. So make sure the patient is breathing and his circulation is intact.

Make sure at least one large bore cannula is inserted.

Okay. Now you need to decide. Crystalloids or colloids? Make a decision and quick.

I’ll go with 0.9% saline since it’s the safest. Run it as fast as you can. Use your hands to pump the solution bag if it’s not fast enough.

How much to give? It depends. It’s between 1 – 2 litres. In young and healthy adults, 2 litres would be appropriate. In elderly patients, try not to overload their poor poor heart. Try 1 litre first.

Keep an eye on the patient’s blood pressure and pulse rate.

Once the patient’s status is stabilized, treat the cause.

Fluid Therapy for the Needy

Crystalloids or Colloids?

In an emergency setting, which one would be the better choice?

Seriously, I can’t be bothered with all the statistics that researchers produce in their papers about which is superior than the other.

Every individual is different and their needs should be tailored. Decision is not made based on some research papers who knows nuts about your patient more than you do.

I’ll list down the advantages and disadvantages of both the solution.

Cystalloids

Advantanges:

  • It’s cheap.
  • Easily available.
  • No anaphylactic effects.

Disadvantages:

  • Stays for a short period of time in the intravascular compartment.
  • More is needed to achieve euvolaemic status. 3 times more as compared to colloids.

Colloids

Advantages:

  • Stays longer in the intravascular compartment.
  • Less amount is needed.

Disadvantages:

  • More expensive.
  • Produce anaphylatic effects in certain individuals.
  • Interferes with blood grouping and cross-matching.

Points to take note…

  1. If someone has sepsis or burns… do not resuscitate with colloids. Both sepsis and burns produce leaky capillaries. The colloid molecules would just leak into the interstitial space. It does not play its role as an intravascular volume expander. It produces an osmotic effect in the interstitial space instead and causes oedema.
  2. If blood has not been taken for grouping and cross-matching, don’t bother using colloids.
  3. If patient is severely in shock, giving crystalloid may not be fast enough. Use colloids instead. It’ll buy you some time.

Fluid Therapy for the Needy

Bladder Cancer

Someone presents with painless haematuria. Suspect bladder cancer until proven otherwise.

The following steps to be taken:

To Diagnose.

Determine the presence of the tumour. Do an intravenous urethrogram first to confirm any mass in the bladder as well as any that’s located along the urinary tract.

Followed by cystourethroscope under general anaesthesia. You get a better view by sticking in the scope.

Locate the site of tumour, the numbers present and appearance.

To Stage.

During the scope, do a biopsy. Then followed by transurethral resection of bladder tumour (TURT) if needed.

CT scan to determine affected lymph nodes and local invasion of the tumour.

To Treat.

Few choices available.

If bladder tumour is superficial (Ta, T1), then just by endoscopic diathermy.

If larger (T1, T2), then proceed to TURT.

If it is invasive (T2, T3), just remove the bladder by doing a cystectomy.

Complications of TURT.

Blood clots forming in the bladder after the procedure.

Bladder perforation.

Aftermath.

Those with bladders, of course you follow up with them with regular cystourethroscopy to detect any recurrence.

Those without bladders, there will be 2 choices:

To make a new bladder, or so called neobladder. Continence is retained. Uses colon or small bowel. Or… an internal reservoir is made to contain the urine, and is connected to the body surface. Urine is drained at regular intervals by catheter.

To create a passage for urine output without any storeroom. Incontinence. Ureters are implanted on the ileum. Ileum opens on to the abdominal wall. A urine stoma is created.

Chemotherapy?

Intravesical epirubicin or mitomycin C reduces recurrent rates.

Cisplastin and methotrexate are useful as well.

Waseh… I tired liao. That’s pretty much it la.. got anything I add later la…

Composition of Colloid Solutions

The less frequent road travelled. Not many use colloid solution as a primary form of fluid resuscitation. However, it’s good to know what are they, and when are they need.

Natural colloid, albumin, has very limited usage these days. I won’t be talking about it. And besides, I’m lazy.

I’ll be mentioning these 3 synthetic colloids:

  • Dextrans
  • Gelatin
  • Hetastarch

Dextrans

There are 2 types available. The 40 and 70. Each represents the molecular weight (MW) of the polysaccharides present. 40000 and 70000 respectively.

They are actually sugar water… so to say. The dextrans are polysacs in solution with either 0.9% saline or 5% dextrose solution.

Dextran 40 lasts about 6 hours. Dextran 70 last 4 times more, 24 hours.

Gelatin

Also present in 2 types. The Haemaccel and Gelofusine.

Molecular weight for Haemaccel is 35000. As for Gelofusine, it’s 30000.

Lasts about 2 hours in the circulation.

They are made from pigs. So be careful when you’re giving them in certain cultures.

Contents of Haemaccel:

  • 145 mmol/L of Na
  • 145 mmol/L of Cl
  • 5 mmol/L of K
  • 6.25 mmol/L of Ca
  • pH 7.4

Contents of Gelofusine:

  • 154 mmol/L of Na
  • 125 mmol/L of Cl
  • 0.4 mmol/L of K
  • 0.4 mmol/L of Ca
  • pH 7.4

Hetastarch

Also also known as hydroxyethyl starches.

Again, 2 types available. Elohes 6% (MW of 200000) and Hespan (MW of 450000).

Very good but very expensive. So don’t bother using them unless it’s really necessary.

Fluid Therapy for the Needy

Body Fluid Compartments

I always find this very confusing… can’t they just say it in normal language? Bleh. Knowing it is one thing, but being able to apply it is another. Fuyo… talking like a pro. Of course I’m not la… that’s what most lecturers like to say… It’s like a cliche or something.

So here, me, a dungu fella, will try to explain it in my own words.

Total Body Water (TBW) = 0.6 x Body Weight

Almost everywhere I get to see that 70kg is the most popular weight being used. So much so that after multiplying, you get 42L. As a result, everyone starts to think that we all have 42L of water in us.

Wrong concept la I tell you.. take me for example la. I’m just like 55kg. I’m lighter than most girls out there… heh. Please ah… this is not sexist. All I know is that I’m sexy.

So, 0.6 x 55kg = 33L of water. See? Difference of 9 litres. Is that significant?

Now, before we proceed, just to clarify these 2 terms first.

Intracellular fluid (ICF)

  • In dungu terms, it means water inside cells la. As long as it’s liquid within anything that’s covered with a membrane it’s ICF la. ICF ICF… isn’t it easier just to say water inside cell? So easy to understand.

Extracellular fluid (ECF)

  • “Extra” means outside ma… so it means water outside cells la..

Now, to sum things up. We all have 2/3 of water inside our cells and 1/3 of water outside our cells. Understooded ma? Don’t use litres yet coz’ it’s misleading, like I mentioned earlier.

Okay, there are now water outside cells. So where do they go? Lepak in your si fatt loong? They like to be in 2 places la… hence comes these 2 terms:

Interstitial fluid

  • It means water between cells la. All cells are sustained in some form of medium right… they don’t just float in thin air in our body.

Plasma

  • Water inside the blood vessels la.

So… the 4 stuff you need to know is:

  • water inside cells (ICF)
  • water outside cells (ECF) which consists of:
    • water in between cells (ISF)
    • water in blood vessels (plasma)

Finally, in the ECF, 3/4 of water goes in between cells and 1/4 goes into the blood vessels.

Okay… I know you couldn’t be bothered will all this crap. You just want to save lives and be the good doctor you’ve always dreamt to be.

Fine. Then just keep this in mind.

A 70 kg patient who comes in with an estimated blood loss of 2L is way different from a 55kg patient who has the same exact amount of blood loss. Why?

If you are to calculate, the 70kg fella has 3.5L of plasma and the poor 55kg fella only has 2.75L of plasma. Both lost 2L of blood. Who’s in a more severe state? Duh. So treat smartly and don’t treat everyone equally. Don’t be so kayu la…

Reorganize your priority and resuscitate immediately.

Fluid Therapy for the Needy

Composition of Crystalloid Solutions

These are some useful information on crystalloids and their contents. At least you know what you’re giving instead of giving them blindly.

Normal saline (0.9% saline)

  • 154 mmol/L of Na
  • 154 mmol/L of Cl
  • Osmolalilty: 308 mosm/L
  • pH 5.0
  • Potential problems: hypernatraemia, hyperchloraemic acidosis

Half normal saline (0.45% saline)

  • 77mmol/L of Na
  • 77mmol/L of Cl
  • pH 5.0

D5W (5% dextrose)

  • 278 mmol/L of glucose
  • pH 4.0

Hartmann’s solution (Sodium lactate)

  • 131 mmol/L of Na
  • 111 mmol/L of Cl
  • 29 mmol/L of lactate (later converted to bicarbonate in liver…)
  • 5 mmol/L of K
  • 2 mmol/L of Ca
  • Osmolality: 279 mosm/L
  • pH 6.5
  • Potential problem: hyperkalaemia

Ringer’s lactate (pretty similar to Hartmann’s)

  • 130 mmol/L of Na
  • 109 mmol/L of Cl
  • 28 mmol/L of lactate
  • 4 mmol/L of K
  • 3 mmol/L of Ca

Fluid Therapy for the Needy