Correos Electrónicos 1. Optimizacion Cardiovascular, Fluidos

Tips Para la Prescripción de Fluidos y
Optimización Cardiovascular en el
Paciente
TITULO con
DE TU Trauma
PLATICA
Leo Londoño, DVM, DACVECC

Tu nombreUnit Director
Hemodialysis
ClinicalMédico Veterinario,
Professor, Tu Universidad.
Emergency and Critical care
Líneas donde
University of puedes
Florida,colocar tu resumen
College curricular Medicine
of Veterinary
Aquí van tus redes sociales.
londonol@ufl.edu
#leo.londono.7
How do we Prescribe Fluids?
4 Phases of Fluid Therapy
FLUID RESUSCITATION
Polytrauma
• Neutered male
• 8 year old
• Vehicular Trauma
• Previously healthy
• Tachycardia (HR 168 bpm)
• Weak peripheral pulses
• Hypotension (SBP 64 bpm)
• Shock Index : 2.62
• Obtunded, non-ambulatory
• Tachypnea (RR 56 bpm)
• A-FAST: Free abdominal fluid
• T-FAST: Ventricular kissing
Oxygen Delivery
DO2
Cardiac Output Oxygenation

Hemoglobin
💩
Heart Stroke PaO2

Rate Volume
FiO2
Ventilation
Preload Afterload Contractility
# 🆘
Shock Pathophysiology
OER: VO2/DO2
Anaerobic
Threshold
---OER: 50%--- ---OER: 30%---
VO2 (ml/min)
Critical DO2
DO2 (ml/min)
ØBlood flow redistribution
Anaerobic
Threshold ØCapillary recruitment
ØIschemic changes:
VO2 (ml/min)
1.GI
2.Kidneys
Critical DO2
3.Lungs
DO2 (ml/min)
Dysoxia:
Lactate = late marker!!!! ØLactate production
ØMetabolic acidosis
VO2 (ml/min)
ØNa-K-ATPase pump
dysfunction
Critical DO2
ØCytotoxic edema
ØIncreased Ca++
ØCell death
DO2 (ml/min)
• Causes a transient osmotic shift
• Should be followed by isotonic
crystalloids
• Hemorrhagic shock and traumatic
brain injury (TBI)
• 2-5 ml/kg over 5-10 min
• Smaller volume of resuscitation
• Improves hemodynamic status
• Improved cardiac contractility
• Decreases endothelial swelling
• Possible immunomodulatory effect
• Will exacerbate hypernatremia
pertonic Saline in TBI
HELP
• Hypertonic
• Elevate
• Low-temperature
• PLR’s (Pupillary light reflexes)
Osmotherapy
• Control of intracranial
hypertension
• No clear-cut evidence
• Comparative effects on cerebral
physiology are begining to be
elucidated
• Interstitial pressure of Oxygen
in brain tissue (PbtO2) as a new
therapeutic target
Head elevation: 15-30 degrees
6
Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in
pediatric traumatic brain injury. Khanna, Sandeep; Davis, Daniel; Peterson, Bradley; Fisher, Brock; et al.
Critical Care Medicine. 28(4):1144-1151, April 2000.
TBI is not Equal to Head Trauma
• Liberal resuscitation fluid strategies may

cause more harm than good.
• Addressing patient’s pain is one of the most

important contribution that ER veterinarians
can make
Polytrauma
• Tachycardia (HR 144 bpm)
• Improved peripheral pulses
• Hypotension (SBP 86 bpm)
• Shock Index : 1.67
• Obtunded, non-ambulatory
• Tachypnea (RR 44 bpm)
• A-FAST: Free abdominal fluid
• T-FAST: Improved SV
Oxygen Delivery
DO2
Cardiac Output Hemoglobin Oxygenation
Heart Stroke PaO2

Rate Volume
FiO2
Ventilation
Preload Afterload Contractility
⤵ 🆘
Resuscitation Fluids –
Choosing the Right Gun
Chloride-rich solutions
(e.g. NaCl 0.9% - 154 mEq/L)
•Might be associated with an elevation in mean serum creatinine

•Increase in the incidence of AKI
•Increase in the need for dialysis
Yunos, N. M. et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid

administration strategy and kidney injury in critically ill adults. JAMA 308, 1566–1572 (2012).
0.9% NaCl Vs Plasmalyte
• N= 31,000
• Mortality: 5.6% vs. 2.9 %
• Major Complications: 33% vs. 23.7 %
ØPost-surgical infections
ØAKI and need for dialysis
ØTransfusion requirement
Isotonic (Replacement) Fluids
Fluid Type Osmolal Na + K+ Cl- Mg2+ Ca2+ Buffer
mOsm/L mEq/L mEq/L mEq/L mEq/L mEq/L mEq/L
0.9% NaCl 308 154 0 154 0 0 0
LRS 273 130 4 109 0 3 Lactate- 28
Plasmalyte 295 140 5 98 3 0 Acetate-27

- 148 Gluconate-23
Normosol- 295 140 5 98 3 0 Acetate-27

R Gluconate-23
0.9% Saline contributes to perpetuaJon
of acidosis:
1. Ampliﬁes myoglobin-induced AKI
2. Worsens adrenergic receptor
response
3. Pulmonary funcjon?
emic Shock
• Balanced crystalloids
• Judicious fluid administration
Ø10-20 ml/kg IV bolus dogs
Ø5-10 ml/kg IV bolus cats
• Cardiovascular Reassessment
Resuscitation Fluids –
Choosing the Right Gun
Synthetic colloids
(e.g. 6% hydroxyethyl starch HES 130/0.4)
•Associated with increased in-hospital mortality

•Increased need for renal replacement therapy
Perner, A. et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in

severe sepsis. N. Engl. J. Med. 367, 124–134 (2012).
Hydroxyethyl Starch Solutions-
FDA Boxed Warning
ØDo not use HES solutions in critically ill adult patients, including
those with sepsis.
ØAvoid use in patients with pre-existing renal dysfunction.
ØDiscontinue use of HES at the first sign of renal injury.
ØNeed for renal replacement therapy has been reported up to 90
days after HES administration.
ØMonitor the coagulation status of patients as excess bleeding has
been reported with HES solutions in this population.
• For every 1 mL/kg increase in 6% HES
(670/0.75) dose that a dog received,
there was 1.6% increased chance of
having more severe RTV (OR 1.016;
95% CI 1.004–1.029).

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Tips Para la Prescripción de Fluidos y

Leo Londoño, DVM, DACVECC

Cardiac Output Oxygenation

Heart Stroke PaO2

• Liberal resuscitation fluid strategies may

• Addressing patient’s pain is one of the most

Cardiac Output Hemoglobin Oxygenation

Heart Stroke PaO2

•Might be associated with an elevation in mean serum creatinine

Yunos, N. M. et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid

0.9% NaCl 308 154 0 154 0 0 0

LRS 273 130 4 109 0 3 Lactate- 28

Plasmalyte 295 140 5 98 3 0 Acetate-27

Normosol- 295 140 5 98 3 0 Acetate-27

•Associated with increased in-hospital mortality

Perner, A. et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in

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