Fluid for resuscitation of Traumatic Brain Injury

Osmolaritas cairan intravena

Cairan Solute yang berperan dalam osmolaritas Osmolaritas
RL Na+,Cl- 273
D5-RL Glu, Na+,Cl- 525
NaCl 0,9% Na+,Cl- 308
D5-0,45% NaCl Glu, Na+,Cl- 406
NaCl 0,45% Na+,Cl- 154
Mannitol 20% Mannitol 1098
HES 6% Na+,Cl- 310
Dextran 40 Na+,Cl- 300
Dextran 70 Na+,Cl- 300
Albumin (5%) Na+,Cl- 290
Plasma Na+,Cl- 295

Neurosurgical patients often receive diuretics to treat cerebral edema and/or reduce intracranial hypertension.

Conversely, they may also require large amounts of intravenous fluid or blood as a part of resuscitation, therapy of
vasospasm, correction preoperative dehydration, maintenance of intraoperative and postoperative hemodynamic
stability.

Movement of Body Fluid

Starling's Forces
this equation predicts the net flux of fluids across a membrane,
Jv = Kf.[(Pc-Pi) - s(pc-pi)]
where,
Jv = net water flux
Kf = the filtration coefficient
Pci = hydrostatic pressures
pci = oncotic pressures
s = Staverman reflection coefficient
the Staverman reflection coefficient is a measure of capillary permeability to protein, s =
1 completely impermeable.

Cerebral capillary BBB disrupted

2 main factor cause poor outcome in brain injury:
- Hypoxia (PaO2 < 60 mmHg)
- Hypovolemi / shock (Systolic < 90
mmHg)
Sperry RJ et al : The Neuroanaesthesia Hand Book, 1996

Mortality :
Brain injury with :
Hypoxia : 56%
Hypovolemia : 64%
Hypoxia + Hypovolemia : 76%
Without hypoxia+Hypovolemia : 27%

Relation of ICP and mortality in traumatic brain injury

ICP mean (mm Hg) Mortality (%)
0 - 20 19
21 - 40 28
41 - 80 79

Miller JD : Head injury and brain ischemia implication for therapy, Br. J Anaesth. 57 : 120 - 129 , 1985

Cause of secondary brain injury

Systemic Intracranial
Hypotension epidural hematoma
hypovolemia subdural hematoma
hypoxemia intracerebral hematom
anemia increase ICP
hypoglycemia cerebral edema
hyponatremia infarct intracranial
hyperthermia hyperemia cerebral
hypertensionsepsis epilepsy post trauma
coagulopathy

Cotrell JE,Smith DS: Anaesthesia and Neurosurgery,1994

Methods intracranial hypertension control
Head up 10-15 o, (-) venous obstruction.
Adequate Ventilation : PaO2 > 100 mmHg, SpO2 > 97%, PaCO2 35 mmHg.
Osmotic diuretic (Mannitol, furosemide)
Optimal hemodynamic, CPP > 70, CVP 6-10, SJO2 > 55%

Menon DK, Matta BF, 2000;Bendo AA, Luba K : 2000

Methods.(continue)
 Seizure : Phenytoin 10-15 mg/kg, Diazepam 0,2 mg/kg, pentothal 1-3 mg/kg.
Corticosteroid ?
Avoid over hydration (target normovolemia)
Cerebral vasoconstrictor : barbiturate
Temperature control

Neurosurgical patients often receive diuretics (mannitol, furosemide) to treat cerebral edema and/or to reduce
intracranial hypertension.

Conversely, they may also require large amounts if intravenous fluid or blood as part of resuscitation, therapy for
vasospasm, correction preoperative dehydration, or maintenance hemodynamic stability.

If diuretics are good for patients, is it reasonable that fluids and volume expansion might be bad?

The general principles of fluid management often do not take into account the effect of fluids on cerebral
edema,cerebral perfusion, ischemic insult, and water and electrolyte homeostasis.

Proper fluids and electrolyte management neurosurgical patient requires knowledge of the patients underlying
pathophysiologic condition.

Effect of fluids differences between patients wit intact and disrupted Blood-Brain barrier.

Starlings Hypothesis
fluid movement due to filtration
across the wall of a capillary is
dependent on the balance between
the hydrostatic pressure gradient
and the oncotic pressure gradient
across the capillary.

Lam JMK et al, J. Neurosurg, 1997

auto regulation + 5/10 Good outcome

auto regulation + 4/10 Good outcome
auto regulation severe disability 2
death 9

Mild HI : 9/29 auto regulation

Physical properties of solution

One of the key physical properties is osmolality.
Osmolality (number of particles per kg solvent) or osmolarity (per liter solution) for most dilute solution are
approximately equivalent.
Hypotonic sol if osmolarity < 290 mOsm/L, and hypertonic > 290 mOsm/L

Which one and how much fluid should be given?

TBI : intact BBB, Disrupted BBB, trauma + shock.
Which one:
- Crystaloid hypoosmoler?
- Crystaloid hyperosmoler?
- Colloid? (albumin, dextran, gelatin,
starch?)
general rule : avoid hypoosmoler solution and dextrose (keep glucose level 100-150 mg/dl)

Osmolarity of commonly used intravenous fluid

Fluid Osmolarity (mOsm/L) Solute primarily responsible
Lactated Ringers 273 Na, Cl
D5 lactated Ringers 525 Glu, Na, Cl
0.9% saline 308 Na, Cl
D5 0.45% saline 406 Glu, Na, Cl
0.45% saline 154 Na, Cl
20% mannitol 1098 Mannitol
Hetastarch 6% 310 Na,Cl
Dextran 40 (10%0 300 Na,Cl
Dextran 70 (6%) 300 Na,Cl
Albumin 5% 290 Na,Cl
Plasma 295 Na,Cl

Cottrell. Anesthesia and Neurosurgery, 2001 Cottrell. Anesthesia and Neurosurgery, 2001

TBI and Multiple Trauma

Volume effect infuse 1 L fluids (70 kg)

Fluids Plasma vol Interstitial vol Intracel vol
5% albumin 1000 - -
Haemacel 700 300 -
Gelafundin 1000 - -
Plasmafusin 1000 - -
Dextran 40 1600 -260 -340
Dextran 70 1300 -130 -170
Expafusin 1000 - -
Haes steril 6% 1000 - -
Haes steril 10% 1450 -450 -

Effect blood volume

Fluids Times (hours)
6%/10% HES 200/0.5 1.5-2
6% HES 200/0.6 8-12
6% HES 450/0.7 8-12
6% dextran 70 6-8
10% dextran 40 3.5-4.5
4% Plasmafusin 4-6
5% albumin (500 ml) 3.5-4.5
25% albumin (100 ml) 3.5-4.5
Gelatin 4-8

Table : Fluid and Electrolyte Effects

Hypokalemia
Stress and trauma (B-adrenergic stimulation)
Stress-induced aldosterone secretion
Hyperventilation to lower PaCO2 and raise pH
Renal losses due to diuretics or steroids
Hyponatremia
Diminished volume
(e.g., diuretics, adrenal insufficiency, CNS natriuresis)
Normal volume
(e.g., congestive heart failure, renal failure)
Hyperglycemia
Hypernatremia: Diabetes insipidus.
Lam A.M. : Anaesthetic management of acute head injury, 1995

The differences of SIADH, DI, and CSW

Criteria SIADH DI CSW
Intravascular volum Increased Decreased Decreased
Na serum Decreased Increased Decreased
Urine Increase Na urine Polyuria, low urine Polyuria, high Na urine
(> 20 meq/L) osmolarity (>50 meq/L)
Therapy Fluids restriction, Add volume with NaCl Add volume with NaCl
NaCl hypertonic + 0.0225% or NaCl 0.45% 0.9%
furosemid

Management of DI
Hourly monitoring of urinary output.
Maintenance fluids + 75% of previous hours urinary output or maintenance fluids + the previous hours
urinary output minus 50 ml
If urinary output > 300 ml/h : vasopressin or desmopressin.
Conclusion:
General suggestion of fluid management
Use no dextrose containing solution and hypoosmoler solution.
Limit the volume of lactated Ringers sol and use colloid and normal saline-lactate Ringer solution for volume
resuscitation
Limit hetastarch to 1-1.5 L (20 mL/kg) to avoid coagulopathy
No ideal fluid for resuscitation
Depend on serum electrolyte
Maintain hematocrit at 30 to 35%
Keep patient normovolemia, normotension, avoid hypoosmoler and hyperglycemia.

Anesth Analg 2003;96:1453-9

Severe cranio-cerebral trauma ( GCS < 5, 24 hour, stable hemodynamic)

HES 130/0.4 - 6% repetitive dose max 70cc/kgBW/day vs HES 200/0.5-6%
max 33cc/kgBW/day + albumin up to total dose 70 cc/kgBW/day up to 28 days

Result :
HES 130/0.4 HES 200/0.5
Hospital LOS ( days) 20.1 ( 15.4) 22.6 ( 11.8)
Mortality 4/16 3/15
Ventilation days 9.6 ( 7.8 ) 15.6 ( 6.2)
ICU days 12.7( 11.3) 19.5 ( 9.1)