The difference in the resuscitation fluid volume requirement was not due to differences in urine output or insensible loss, but solely to the difference in retained fluid. Edema in burned skin was reduced significantly in the ascorbic acid group, paralleling the decreased fluid retention. Large mammals may need larger doses because of their more complex oxygen free-radical—generating systems. Oxygen radicals are considered to play an important role in increased vascular permeability, 1 lipid peroxidation of the cell membrane, 17 and initiation of local and systemic inflammation 18 after burn injury.
In particular, increased xanthine oxidase concentrations have been well described in an animal model. However, no clinically applicable drug has been reported. The potential clinical benefit of modifying postburn edema formation and lipid peroxidation using systemically administered antioxidants has been explored previously. Thomson et al 20 reported that postburn increases of lipid peroxidation in humans can be reduced by administration of superoxide dismutase, a free-radical scavenger. Recently, Knox and associates 21 have advocated the use of a mixture of antioxidants and anti-inflammatory drug ascorbic acid, vitamin E, L-glutamine, and ibuprofen in the early treatment of patients with severe burns, but the effectiveness of such treatment has not been confirmed.
Ascorbic acid is a potent water-soluble natural antioxidant capable of scavenging oxygen radicals, 22 , 23 terminating lipid peroxidation, 3 regenerating vitamin E, 24 , 25 and exerting various different effects. Antioxidant therapy with adjuvant administration of high-dose ascorbic acid has been previously reported to reduce postburn lipid peroxidation, 3 early postburn microvascular fluid and protein leakage, 4 postburn wound edema, 5 and increased microvascular permeability 30 and to decrease resuscitation fluid volume requirements in a guinea pig model.
Lipid peroxides increase immediately after burn injury, indicating oxygen free-radical injury. Conjugated dienes and the more stable MDA are often used as markers of lipid peroxidation. We confirmed herein that high-dose ascorbic acid reduces postburn serum MDA levels in burned patients. We did not measure cardiac output and cardiac contractility, and so cannot exclude the possibility of a direct cardiotonic action of ascorbic acid.
The Parkland formula is the most popular resuscitation formula in the United States. However, patients with large burns and with inhalation injury need more fluid than those with lesser burns. The clinical benefits of the reduced fluid resuscitation volume with stable hemodynamic values that we observed using ascorbic acid led to a clear reduction in edema and body weight gain and were associated with reduced respiratory impairment and a reduced requirement for mechanical ventilation.
We did not reach a significant reduction of mortality rate in this study, because most deaths in modern burn centers occur during the septic shock phase. However, in our small series, there were numerically fewer deaths in the ascorbic acid group at 7 days after injury and fewer fasciotomies as well, which we find encouraging.
Fluid Balance and Volume Resuscitation for Beginners
We believe that this new therapy is also effective in much more serious cases. Our study involved a small number of patients and therefore must be viewed as preliminary. Questions remaining unanswered at this time include the metabolic and immunologic responses and wound healing in patients subsequent to the initial period described herein.
Our results show, however, that high-dose ascorbic acid therapy as an adjunct to resuscitation in severely burned patients is well tolerated, and that further investigation is clearly warranted. All Rights Reserved. Figure 1. View Large Download. Table 1. Am J Pathol. Role of histamine, complement and xanthine oxidase in thermal injury of skin. The effects of high-dose vitamin C therapy on postburn lipid peroxidation. J Burn Care Rehabil.
Fluid Balance and Volume Resuscitation for Beginners
Effects of high-dose vitamin C administration on postburn microvascular fluid and protein flux. Antioxidant therapy using high-dose vitamin C: reduction of postburn resuscitation fluid volume requirements. World J Surg. How long do we need to give antioxidant therapy during resuscitation when its administration is delayed for two hours? J Chromatogr. Anal Biochem. Multiple organ failure: generalized autodestructive inflammation? High-dose vitamin C therapy for extensive deep dermal burns. Biochem J. Am J Clin Nutr. Study of safety of continuous intravenous infusion of high dose-vitamin C in healthy human volunteers [abstract].
J Trauma. Biochem Biophys Res Commun. Ann N Y Acad Sci. Inhibition of oxidation of methyl linoleate in solution by vitamin E and vitamin C. J Biol Chem. The access should not be established distal to a site of injury e. The principles of goal-directed therapy apply equally well to children as to adults. There is limited information on the efficacy and safety of synthetic colloids e.
The role of all clear fluids is limited in trauma resuscitation due to their adverse effects of dilutional coagulopathy and anemia and generation of edema that hinders tissue perfusion and promotes organ dysfunction including ileus, abdominal compartment syndrome and ARDS. Due to the small volumes required, many pediatricians use human colloids such as plasma or albumin for intravascular volume replacement in preference to synthetic clear fluids [ 92 ].
During the maintenance phase of resuscitation, children appear to be at risk of hyponatremia. Despite advances in trauma care, the elderly, either chronologically or biologically, are at increased risk of morbidity, particularly limitation of mobility and self-care ability, and mortality after trauma [ 96 ]. Cardiovascular changes of aging include stiffening of the arterial circulation and loss of compliance of the left ventricle. The elderly thus tolerate hypo- and hypervolemia poorly. Volume loss reduces preload resulting in ventricular under-filling and a disproportionate drop in cardiac output.
Over-hydration is as dangerous due to the lack of ventricular compliance predisposing to the development of edema, particularly pulmonary edema [ 97 ]. Assessment of fluid requirements in the elderly is best done by echocardiography as noninvasive measurements based on pressure or pulse contour analysis are subject to variation due to the changes in the cardiovascular system from aging [ 98 ].
Careful re-evaluation and vigilant monitoring should to performed to determine if further fluid administration is required; particularly if underlying heart disease is suspected. Appropriate and effective initial resuscitation of victims of burns is vital for survival and reduction of morbidity and mortality [ 99 ]. The deeper and more extensive the burn, the greater the fluid requirements, but excessive fluid administration will also increase morbidity by generation of edema [ ]. The formulas used for calculating volume requirements e.
The use of colloid solutions is controversial. Hyperoncotic colloids worsen outcome, but the role of albumin or synthetic colloids e. Colloid solutions shorten the time to achieve hemodynamic goals, but increase expense without a concomitant improvement in outcome. Placement of a feeding tube should be part of the resuscitation protocol for burns. Maintenance of enteral feeding maintains the gut associated lymphoid tissue that participates in maintenance of immunity at all epithelial surfaces including the skin. Two simple investigations should be used to monitor the effectiveness of resuscitation from burns.
Development of acute renal failure carries a very poor prognosis with extensive burns [ ]. A more detailed review of fluids in burn resuscitation is beyond the scope of this paper; however, further references are provided [ , ].
Crush injury is seen in victims of motor vehicle collisions who are entrapped and have limbs compressed, resulting in direct muscle trauma followed by a reperfusion injury when freed. Similar injury is seen in prolonged immobilization after a fall or drug overdose and entrapment in collapsed buildings after natural disasters [ ]. South Africa has an unfortunate history of interpersonal violence. With the breakdown in the rule of law in many communities, alleged criminals may be assaulted by community members using traditional whips sjamboks. This results in extensive muscle injury; however, muscle perfusion is maintained so reperfusion does not occur [ ].
Muscle injury releases myoglobin that is detrimental to kidneys.
With diffuse injury, such as community sjambok assaults, the surface area of the body injured should be quantified as for burns. Traditionally, 0. Alternatives, to limit the occurrence of hypernatremia and hyperchloremic acidosis, include 0. Should presentation be delayed, creatinine and potassium should be measured while initial fluid loading occurs, as the kidneys may have been damaged beyond immediate recovery. Failure to produce urine after initial fluid loading associated with an elevated urea, creatinine and potassium indicates the need for urgent renal replacement therapy.
Further fluid loading should not be administered, as the absolute volume overload that arises in the absence of urine output will result in pulmonary edema with hypoxia requiring intubation and ventilation. There is no role for loop or osmotic diuretics, and the use of sodium bicarbonate to induce alkaline diuresis is also not supported by evidence [ ]. Trauma, particularly vehicular, or due to intimate partner violence is a common cause for maternal and fetal morbidity and mortality.
In the developing world, neonatal intensive-care facilities are limited so maternal considerations take precedence in resuscitation until fetal viability is likely [ ]. Fluid administration follows accepted principles of resuscitation [ ]. Should delivery occur during resuscitation, significant blood loss may occur due to post-partum hemorrhage. Oxytocin availability may be limited due to expense and requirement for refrigeration. Misoprostol is an accepted alternative, but is only available in an oral form that may need to be administered rectally during resuscitation [ ].
It should be remembered that the physiological compensation for blood loss might be better tolerated in pregnancy due to the physiological changes that predominantly take place in the second and third trimesters and include an increased circulating blood volume and cardiac output. Awareness of this should be maintained to avoid underestimation of blood loss and underlying injuries. Fluids are drugs and should be managed as such.
Appropriate early fluid resuscitation in trauma patients is a challenging task. Care should be taken in selecting both the type and volume to promote appropriate perfusion and oxygen delivery, avoiding the adverse effects seen when giving too little or too much. Ongoing fluid strategies following resuscitation should incorporate dynamic markers of volume status whenever possible.
All aspects of fluid administration should be incorporated into daily fluid plans, including feeding and infusions of medications. A sound knowledge of the differences and physiological consequences of specific trauma groups is essential for all practitioners delivering care for trauma patients [ 7 ]. The costs covering the open access publication USD of this review article were covered by an unrestricted educational grant from the International Fluid Academy IFA. Robert Wise and Michael Faurie declare that they have no competing interests. Eric Hodgson is a paid speaker and advisory board member for Fresenius-Kabi.
National Center for Biotechnology Information , U. World Journal of Surgery. World J Surg. Published online Jan 5. Malbrain , 5 and Eric Hodgson 3, 6. Manu L. Author information Copyright and License information Disclaimer. Robert Wise, Email: az. Corresponding author. Abstract Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. Penetrating versus blunt injury versus head injuries There are three distinct groups of trauma patients, but often there is an overlap.
Open in a separate window. Flow diagram of initial fluid resuscitation of trauma patients. Blood and blood products The goal of resuscitation is to achieve adequate tissue perfusion and oxygenation while correcting any coagulopathy. Hemoglobin solutions Modified hemoglobin solutions are not substitutes for blood as they do not possess the metabolic functions of erythrocytes. Monitoring coagulopathy Trauma-induced coagulopathy [ 37 ] is a relatively new concept, and the pathophysiology is still not completely understood.
Post-resuscitation fluid management Background The consequences of under- or over-resuscitation with intravenous fluids are both detrimental [ 43 , 44 ]. The post-resuscitation period may be considered after: Hemostasis and correction of coagulopathy ongoing blood product replacement no longer required [ 45 ]. Maintenance fluid In providing maintenance fluids, care should be taken to avoid causing tissue edema. Static markers of cardiac preload Considering the Frank—Starling relationship, the response to volume infusion is more likely to occur when the ventricular preload is low, rather than when it is high.
The respiratory variation of hemodynamic signals Observing the respiratory variation of hemodynamic signals has emerged as an alternative for assessing volume responsiveness without administering fluid. Recommendations for current best practices: If ultrasonography is available, then we advise using dynamic changes in IVC together with other clinical parameters. Special groups Pediatrics Infants and children suffer from trauma, particularly vehicular trauma, with an increasing incidence in the developing world [ 86 ]. Burns Appropriate and effective initial resuscitation of victims of burns is vital for survival and reduction of morbidity and mortality [ 99 ].
Pregnancy Trauma, particularly vehicular, or due to intimate partner violence is a common cause for maternal and fetal morbidity and mortality. Conclusion Fluids are drugs and should be managed as such. Acknowledgements The costs covering the open access publication USD of this review article were covered by an unrestricted educational grant from the International Fluid Academy IFA. Compliance with ethical standards Competing interest Robert Wise and Michael Faurie declare that they have no competing interests.
References 1. Perioperative fluid and volume management: physiological basis, tools and strategies. Ann Intensive Care. Marik P. Iatrogenic salt water drowning and the hazards of a high central venous pressure. A rational approach to perioperative fluid management.
Hyrdoxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. Comparison of hydroxyethyl starch colloids with crystalloids for surgical patients: a systematic review and meta-analysis. Eur J Anaesthesiol. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolaemic shock. Chappell D, Jacob M. Hydroxyethyl starch—the importance of being earnest. Twisting and ignoring facts on hydroxyethyl starch is not very helpful. Fluid resuscitation in trauma patients: what should we know? Curr Opin Crit Care.
Early enteral nutrition reduces mortality in trauma patients requiring intensive care: a meta-analysis of randomised controlled trials. Crit Care. Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation. Br J Surg. Ince C, Groeneveld A. The case for 0. Kidney Int.
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Lira A, Pinsky M. Choices in fluid type and volume during resuscitation: impact on patient outcomes. Hafizah M, Liu C, Ooi J Normal saline versus balanced-salt solution as intravenous fluid therapy during neurosurgery: effects on acid-base balance and electrolytes.
J Neurosurg Sci. Galvagno S, Mackenzie C. New and future resuscitation fluids for trauma patients using hemoglobin and hypertonic saline. Anaesthesiol Clin. Use of hypertonic saline injection in trauma. Am J Health Syst Pharm. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. Is albumin use SAFE in patients with traumatic brain injury? The polycompartment syndrome: a concise state-of-the-art review. Anaesthesiol Intensive Ther. Hemodynamic parameters to guide fluid therapy. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries.
J Trauma. Massive transfusion of blood in the surgical patient. Surg Clin N Am. Transfusion of plasma, platelets and red blood cells in a vs a ratio and mortality in patients with severe trauma: the PROPPR randomised controlled trial. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. Intensive Care Med.
Holcomb J. Optimal use of blood products in severely injured trauma patients haematology. Am Soc Hematol Educ Progr. Miller T. New evidence in trauma resuscitation—is the answer? Perioper Med. Levien L. South Africa: clinical experience with hemopure. Are hemoglobin-based oxygen carriers being withheld because of regulatory requirement for equivalence to packed red blood cells?
Am J Ther. Cell-free hemoglobin-based blood substitutes and risk of myocardial infarction and death: a meta-analysis. Africa SS Mid-year population estimates Statistical release P; Pretoria, South Africa. Noninvasive assessment of intra-abdominal pressure by measurement of abdominal wall tension. J Surg Res. The second assessment of volume status is the parasternal short axis view at the mid papillary muscles where collapse of the left ventricular cavity without dilation of the right ventricle is diagnostic of hypovolemia.
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- Initial resuscitation fluid management!
The finding of a full left ventricle does not rule out volume responsiveness [ 41 ]. It is also possible to use cardiac ultrasonography to measure stoke volume and stroke volume variation [ 42 ] but this requires significantly more skill in image acquisition. Two new technologies are also being developed to guide fluid therapy. Endotracheal tube-based cardiac output monitors exploit the relationship between the electrical current generated by the flow of electrolytes through the ascending aorta and stroke volume.
Pulse-wave transit time systems approximate stroke volume by calculating the time between the end of the QRS complex on electrocardiogram and the beginning of the arterial pulse on an arterial line or plethysmogram. Both have been successfully validated against thermodilution cardiac output estimates from pulmonary artery catheters [ 43 , 44 ], but neither has been studied in a way that measures clinical outcomes. Fluid administration is a mainstay of therapy in the ICU. Shock and inadequate volume resuscitation carry a high mortality.
Common conditions such as sepsis and ARDS present challenges and competing priorities with regard to fluid balance and therapy. Little consensus exists regarding optimal resuscitation strategies, and the level of evidence of current literature does not support the superiority of one strategy, technology, or parameter over others.
What are colloids
Still, administration of fluid in a goal-directed manner is associated with improved outcomes. Traditional parameters, such as the MAP and CVP, are not based on strong foundations of evidence, even though they play an important role in recommended therapies. Dynamic respiratory indices, such as the PPV, show promise in the identification of patients whose stroke volume will respond to additional fluid. New monitoring systems have been developed to help tailor goal directed therapy to individual patients.
Beyond the hemodynamic parameters, resuscitating to metabolic goals such as a target ScvO 2 or lactate clearance has been shown to reduce mortality in septic and cardiogenic shock, suggesting such goals may be worth achieving. Skip to main content Skip to sections. Advertisement Hide. Download PDF. Introduction The assessment of intravascular fluid volume or fluid responsiveness is both important and difficult. Hemodynamic Parameters Adequate circulating volume is a necessary condition of adequate stroke volume and oxygen delivery, although assessing this volume is difficult.
Metabolic Parameters Although an adequate perfusion pressure is often a sign of appropriate resuscitation, occult hypoperfusion is possible in the setting of seemingly adequate hemodynamic conditions [ 13 ]. Lactate, the product of anaerobic metabolism, is an indicator of insufficient oxygen delivery to cells. As elevated lactate levels decrease, perfusion is inferred, and the assumption is that organ function should improve.
In the Jones et al. They established non-inferiority of lactate to ScvO 2 monitoring. Fluid totals were not different between the two groups. Jansen et al. Patients in the intervention group had improved outcomes ICU length of stay, time on the ventilator, and mortality in the multivariate analysis and also received significantly more fluid than controls. Jones et al. Less time on ventilator, in ICU. However, each device has significant limitations including the need to purchase proprietary monitors, and the LiDCO and PiCCO systems require the placement of a proprietary arterial catheter brachial, axillary, or femoral placement.
This greatly limits their utility in patients who are not considered high risk. Unlike the Vigileo, these two systems allow for internal calibration of the pulse contour analysis with cardiac output calculation via transpulmonary thermodilution and lithium dilution techniques, respectively. The benefit of the Vigileo system is that the monitor attaches to a standard arterial catheter and can be used at the radial artery. It does not internally validate the pulse contour analysis with a cardiac output calculation. The ease of use of the Vigileo system makes it an attractive monitoring option for goal directed therapy in critically ill patients, but accuracy of all the devices during rapid hemodynamic changes remains a major concern.
Disclosure Jeffrey A. Katz and Christopher G. Choukalas have no conflict of interest. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. CrossRef Google Scholar. ARDS Network. Comparison of two fluid-management strategies in acute lung injury. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. Google Scholar. Takala J. Should we target blood pressure in sepsis?
Crit Care Med. Does central venous pressure predict fluid responsiveness? This meta-analysis describes the poor relationship between CVP and total body volume and, more importantly, volume responsiveness. Critics argue effect size heterogeneity invalidates the results. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Intensive Care Med. Russell JA. Management of Sepsis. New Engl J Med. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality.
This paper essentially outlines that total body hypervolemia is associated with worse patient outcomes. The significance of goal directed fluid therapy is to give intravenous fluid when appropriate and necessary and avoid when not. The importance of fluid management in acute lung injury secondary to septic shock. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery.
Br J Surg. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. Clinical review: volume of fluid resuscitation and the incidence of acute kidney injury- a systematic review. Crit Care. Abuelo JG. Normotensive ischemic acute renal failure. Goal-directed fluid management based on the pulse oximeter—derived pleth variability index reduces lactate levels and improves fluid management. PubMed Google Scholar. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study.
Randomized control trial in abdominal surgery patients using Vigileo showing decreased post op complications and length of stay but no mortality difference. Dynamic changes in arterial waveform-derived variables and fluid responsiveness: A systematic review of the literature.