4 Phases of IV Fluid

Therapy
DR CHARLIE
Introduction
 IV fluid therapy plays a fundamental role in management of
hospitalised patients.
 Correct usage can be life saving, but with risks.
 Inappropriate usage of fluids occur in up to 20% of patient receiving
fluid therapy
 Too little? (inadequate resuscitation, tissue hypoperfusion)
 Too much? (tissue edema and severe electrolyte derangements)
 Coagulation Abnormalities
 Fluid therapy should be regarded as drug therapy with dose-effect
relationship and side effects, individualised to each patient.
 6S Study
 Higher mortality and incidence of AKI in patients receiving HES
compared with carrier solution of Ringer’s acetate.
 SAFE study
 Higher mortality in patients with traumatic brain injury treated with
albumin solution

 Workgroup tasked by 12th ADQI conference to consider WHEN and

HOW to administer fluid in critically ill patients by addressing 3
questions:
 1) Define goals of IV therapy
 2) Identify monitors of fluid need and effect
 3) Identify fluid therapy in different context (eg, pre-hospital
setting/OT/ICU)
Physiology of Fluid Resuscitation
 Previously, fluid therapy was based on Classic
Compartment Model
 Intracellular, Interstitial, Intravascular
 Hydrostatic and oncotic pressure gradients across
semipermeable membrane responsible for transvascular
exchange.
 However, recent descriptions questioned these models,
identifying a web of glycoproteins and proteoglycans on
luminal side of endothelial cells.
 “ Endothelial Glycocalyx Layer”
 Subglycocalyx space produces colloid oncotic pressure,
determines the transcapillary flow.
 Absorption of fluid from interstitial space occurs through small
number of large pores and returned to circulation as lymph.
 Structure and function of glycocalyx layer determines
membrane permeability.
 Therefore, “leakiness” of this layer causes the development of
interstitial edema.
 Loss of this integrity of the layer can be due to inflammatory
conditions such as sepsis, surgery, trauma, or when
resuscitation fluids are commonly used.
FLUID RESUSCITATION
 Fluid resuscitation includes
 Time- dependent, phase of illness
 Rate and volume of fluid administration
 Groups of patients not included:
 children (,16 yr), pregnant women, burns patients, and patients
with acute shock who have chronic conditions (chronic renal
failure, hepatic failure, diabetic ketoacidosis, and hyperosmolar
states).
Terminology
 Fluid bolus: a rapid infusion to correct hypotensive
shock. It typically includes the infusion of at least 500
ml over a maximum of 15 min
 Fluid challenge: 100–200 ml over 5–10 min with
reassessment to optimize tissue perfusion
 Fluid infusion: continuous delivery of i.v. fluids to
maintain homeostasis, replace losses, or prevent
organ injury (e.g. prehydration before operation or
for contrast nephropathy)
 Maintenance: fluid administration for the provision of
fluids for patients who cannot meet their needs by oral
route. This should be titrated to patient need and
context and should include replacement of ongoing
losses. In a patient without ongoing losses, this should
probably be no more than 1 –2 ml kg-1 h-1
 Daily fluid balance: daily sum of all intakes and outputs
 Cumulative fluid balance: sum total of fluid
accumulation over a set period of time
 Fluid overload: cumulative fluid balance expressed as a
proportion of baseline body weight. A value of 10% is
associated with adverse outcomes
4 Phases of Fluid Therapy

R
escue
O ptimisation
S tabilisation
D eescalation

 Occuring over a time course

when the severity of illness
decreases.
Rescue
 Immediate escalation of therapy
 Resuscitation of life threatening shock
 Characterised by low arterial pressure and signs of impaired perfusion
 Fluid BOLUS

Optimisation
 In COMPENSATED shock
 Fluid therapy to be given cautiously
 Aim: Optimise cardiac function to improve tissue perfusion.
 Mitigate organ dysfunction.
 Fluid CHALLENGE
Stabilisation
 ABSENCE of Shock
 Steady stat: maintenance or ongoing loss of
fluid.

De-escalation
• Fluid REMOVED from patient
• Promote NEGATIVE balance
Monitoring and reassessment
 Individualised to each patient.
 In Rescue phase,
 combine clinical and haemodynamic parameters with
near patient diagnostics.
 No need for sophisticated assessment like ECHO.
 Reassessment and re-challenge without leaving the
bedside and continuous observation.
 ECHO/Doppler, CVP, SCVO2 can be used to determine
appropriate time to transition to Optimisation phase.
 In Optimisation phase,
 Ensuring adequate blood and O2 delivery to at-risk organs.
 Aim to prevent subsequent organ dysfunction and failure
caused by hypoperfusion and tissue oedema.

 In Stabilisation and De-escalation phase,

 Patients need to be seen every few hours and prescribed
either IV Fluids/diuretics accordingly on the basis of
physical examination, blood chemistry and likely clinical
course.
Relevance to clinical trials
 FIRST trial
 Patients severely injured with high injury severity scores and
significantly elevated plasma lactate level post trauma.
 Given in excess of 5L of IV fluids within 24 hours
 CRISTAL trial
 severely hypotensive septic patients requiring very large volumes
of fluid.

 FIRST Trial and CRISTAL trial  Rescue Trial

 SAFE and CHEST studies, including ~7000 ICU patients.
 Noted that most patients was in the optimisation phase
evidenced by significantly lower volumes of fluid administered.
Fluid Resuscitation in perioperative
period
 Using minimally invasive monitors of fluid responsivesness to guide
goal directed fluid therapy to optimise tissue oxygen delivery.
 Employ lung protective ventilation strategies
 LOW TIDAL VOLUME:
 reduction in changes in intrathoracic pressure during respiratory
cycle
 Decrease in variation in venous return and resulting stroke
volume/systolic pressure
 Less pulmonary and extra pulmonary complications within first week
of surgery.
Fluid Therapy for prevention of
organ damage in specific cohorts
 Fluid administration before contrast administration
 Consensus guidelines: 1-1.5ml/kg/hour 12hour before and after
procedure
 When 12 hours pre-hydration regime not possible, 3ml/kg/hour
recommended for 1 hour before and 6 hours before procedure.
 Carefully titrated towards comorbidities (eg decreased renal
function & heart failure)
 Appropriate de-escalation of fluids- prevent cumulative effect.
Conclusions

 “Fit for purpose fluid therapy’

 Tailored to specific indications, time, phase dependent variables,
and the patient.
 Difference between fluid bolus and fluid challenge
 4 phases
 Rescue, Optimize, Stabilise, De-escalation
 Fluid Resuscitation perioperative period
 Considering lung protective ventilation strategy
References

 E.A.Hoste1,2,K.Maitland3,4,C.S.Brudney5 et al; Four phases of

intravenous fluid therapy : a conceptual model, BritishJournal of
Anaesthesia113(5): 740–7(2014) AdvanceAccesspublication9
September2014 . doi:10.1093/bja/aeu300
 John A. Myburgh, M.B., B.Ch., Ph.D., and Michael G. Mythen, M.D.,
M.B., B.S; Resuscitation Fluids, N Engl J Med 2013;369:1243-51. DOI:
10.1056/NEJMra1208627
 Manu L.N.G. Malbrain1 , Paul E. Marik2 , Ine Witters1 et al; Fluid
overload, de-resuscitation, and outcomes in critically ill or injured
patients: a systematic review with suggestions for clinical practice,
Anaesthesiology Intensive Therapy 2014, vol. 46, no 5, 361–380 ISSN
1642–5758 DOI: 10.5603/AIT.2014.0060
Thank you