Fluid Therapy in Fast-Track Surgery. What is the evidence? ...relatively inconclusive findings in the literature on the choice

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1 Symposium on Fast-Track Surgery Luzern, June 26, 2008 Fluid Therapy A Key to Success in Fast-Track Surgery? Fluid Therapy in Fast-Track Surgery What is the evidence? Remind me of the basics Body Fluid Compartments Thomas Lücke Klinik für Anästhesiologie und Operative Intensivmedizin (Prof. Dr. med. Dr. h.c. K. van Ackern) Universitätsklinikum Mannheim...relatively inconclusive findings in the literature on the choice of type and amount of fluid administered in elective surgery Capillary membrane Cell membrane Page 0.data suggest that the amount of fluid might influence surgical outcomes improvements seen with fluid restriction intraoperative goal-directed therapy might improve outcomes Page 1 IVFV: intravascular fluid volume (blood volume) ECFV: extracellular fluid volume (PV = ECFV/5) ICFV: intracellular fluid volume Page 2 Zander R: Flüssigkeitstherapie, Bibliomed 2006 Remind me of the basics Body Fluid Compartments Volume replacement: When and how much? Volume replacement: When and how much? Preoperative deficits The composition and use of intravenous fluids should only be dictated by the targeted fluid space Goals of therapy: Clinical example: ASA I, 70 kg NPO ab 22:00h Fluid compartment Typical IV solution maintaining organ function by ensuring perspiratio insensibilis (0,5 ml/kg/h): 350 ml Volume replacement IVFV Colloid (6% hydroxyethyl starch) sufficient oxygen transport and tissue oxygenation maintaining normal circulatory volume without urinary losses: 450 ml total extracellular deficit: 800 ml Fluid therapy ECFV Cristalloid (balanced electrolyte solution) hypovolemia with consecutive malperfusion hypervolemia with interstitial edema (damage to the endothelial glycokalyx) total ECF volume: 14 l, PV = 2,8 l (EZR/5) Electrolyte- or ICFV osmotherapy Page 3 Zander R: Flüssigkeitstherapie, Bibliomed 2006 Dextrose 5% replacement of preoperative deficits compensation for perioperative interstitial losses Page 4 intravascular deficit due to preop fasting: 160 ml Page 5 Jacob M: AAS 2008; 52:

2 Volume replacement: When and how much? Compensation for perioperative interstitial losses Volume replacement: When and how much? The active role of the vascular system: endothelial glycokalyx Changing nature of Starling s principle for fluid exchange across non-fenestrated endothelium semipermeable membrane (selective pores) exerted by the glycocalyx Page 6 Jacob M: Anaesthesist 2007; 56:747 hydrated gel-like surface matrix with bound macromolecules glycokalyx plus plasma proteins (albumin) forms the ESL Page 7 Jacob M: Anaesthesist 2007; 56:747 subglycocalyx fluid of lower protein concentration than intersitial fluid interstitial protein concentration 30-60% of plasma concentration (large pores) glycocalyx as the primary moelcular sieve for plasma proteins Page 8 Levick JR, J Physiol 2004; 557.3:704 The active role of the vascular system: context-sensitive volume effects Fluid therapy in Fast Track Surgery: Status quo in Germany 2007 I) What and how much (hypothetic case: 70y, sigmoid resection) Fluid therapy in Fast Track Surgery: Status quo in Germany 2007 II) How Normovolemia Hypervolemia (ANP ) Damage to glycocalyx: vascular barrier Page 9 Jacob M: Anaesthesist 2007; 56:747 PLT/GLC adhesion Page 10 Hasenberg T: Anaesthesist 2007; 12:1223 Page 11 Hasenberg T: Anaesthesist 2007; 12:1223 2

3 Fluid therapy in Fast Track Surgery: When, what and how much? Rational (advanced) strategies and endpoints: fluid restriction preload optimization Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 3

4 Critical appraisal of the study: Study summary: 0.9% NaCl instead of balanced cristalloid solution 152 patients ASA I-III HAES 6% vs NaCl to treat intravascular volume deficits major abdominal surgery (colorectal, pancreatic..) postop: G5% vs NaCl duration of surgery (mean): 260 min intra- and postop differences in therapy blood loss (mean ): 400 ml comparison of adequate and inadequate fluid therapy liberal protocol group (LPG): bolus 10 ml/kg RL, followed by 12 ml/kg/h Page 18 restrictive protocol group (RPG): no fluid bolus, 4 ml/kg/h use of HES: LPG: 0, RPG: 3 Page 19 Nisanevich V et al.: Anesthesiology 2005; 103:25-32 Page 20 Nisanevich V et al.: Anesthesiology 2005; 103:25-32 Results: Study summary: Results: intraop fluid: / vs /- 946 ml 32 patients ASA I-III intraop fluid (RL): 5050 vs 1640 ml number of postoperative complications: 32 vs 17 elective colorectal surgery, established fast-track-concept pulmonary function improved in the restrictive group number of patients with complications: 23 vs 13 (p <0.05) duration of surgery (mean): 120 min reduced stress response in the liberal group blood loss (mean ): 250 ml number of postoperative complications : 1 vs 18 (L vs R, p < 0,01) liberal protocol group (LPG): bolus 10 ml/kg RL, followed by 18 ml/kg/h number of patients with complications : 1 vs 6 ( L vs R, p = 0,08) Page 21 Nisanevich V et al.: Anesthesiology 2005; 103:25-32 restrictive protocol group (RPG): no fluid bolus, 7 ml/kg/h RL HES: 7 ml/kg (500 ml) in each group Page 22 Holte K: BJA 2007; 99:500-8 Since morbidity tended to be increased with the restrictive fluid regimen, future studies should focus on the effect of individualized goal-directed fluid administration strategies... Page 23 Holte K: BJA 2007; 99:

5 Goal: avoidance of hypovolemia and fluid overload maximization of tissue oxygenation by optimized cardiac preload Actual data: 9 studies on GDT (7 intra-, 2 postop) monitoring: esophageal doppler, LiDCO Strategy: fluid: colloid-boli for an increase in SV > 10% monitoring of flow-related variables (SV, corrected flow time) application of colloid-boli to maximize SV Outcome: shortening of HLS: 7 studies Study endpoints: hospital length of stay (HLS) gastrointestinal problems Page 24 reduction of postop intensive care treatment: 2 studies reduction of PONV and ileus: 3 Studien Page 25 Bundgaard-Nielsen M, et al. AAS 2007; 51: Page 26 Noblett SE, et al. Brit J Surg 2006; 97:820-6 Page 27 Noblett SE, et al. Brit J Surg 2006; 97:820-6 major complications: 15 vs 2 % (p = 0.043) Page 28 Noblett SE, et al. Brit J Surg 2006; 97:820-6 Page 29 Noblett SE, et al. Brit J Surg 2006; 97:

6 CVP-guided preload optimization (Goal-directed) CVP-guided preload optimization (Goal-directed) Using heart-lung interactions to assess fluid responsiveness during MV Control (n = 29) CVP (n = 31) ED (n = 30) Age 84, ASA III III III Letality (pred)% duration of surgery (min) Control (n = 29) CVP (n = 31) ED (n = 30) intraop cristalloid (ml) intraop colloid (ml) fluid balance (Vol - BL) Control (n = 29) CVP (n = 31) ED (n = 30) days until "medically fit" 13,9 10 7,7 HLOS (days) 17,5 13,3 13,5 Page 30 Venn R, et al. BJA 2002; 88:65-71 Page 31 Venn R, et al. BJA 2002; 88:65-71 Page 32 Luecke T: Anaesthesist 2007; 56: Using heart-lung interactions to assess fluid responsiveness during MV Conclusion: Individualized, protocol-driven preload optimization (Goaldirected) as the strategy of choice Conclusion: Individualized, protocol-driven preload optimization (Goaldirected) as the strategy of choice Open questions and problems: four colorectal studies on perioperative stroke volume optimization surrogate parameters instead of hard endpoints (tissue oxygenation) Individually tailored fluid therapy is therefore a main component of modern fasttrack colorectal surgery optimal endpoint? increase of SV by volume loading: feasible or necessary? esophageal doppler limited to the intraoperative period PiCCO too invasive Analysis confined to patients on controlled MV without spontaneous breathing activity and with stable sinus rythm Page 33 Page 34 Kehlet H: Lancet 2008; 371:791-3 costs role of new monitoring strategies to measure tissue oxygenation Page 35 6

7 Fluid Therapy in Fast-Track Surgery Backup Slides Individualisierte, protokollgesteuerte Vorlastoptimierung (Goal-directed) We are still confused, but on a much higher level (W. Churchill) Page 36 Page 37 Page 38 Gan T, et al. Anesthesiology 2002; 97:820-6 Individualisierte, protokollgesteuerte Vorlastoptimierung (Goal-directed) Individualisierte, PiCCO-gesteuerte Vorlastoptimierung (Goal-directed) Remind me of the basics: Lessons learned from shock resuscitation Schock: inadäquate Gewebeoxygenierung (gemessen am jew. Sauerstoffbedarf) Shock resuscitation strategies (ATLS): Wiederherstellung normaler Werte für RR, HF, Urinausscheidung HLOS: 6 vs 7 Tage (p = 0.03) Werte abnormal: unkompensierter Schock Werte normal: Page 39 Gan T, et al. Anesthesiology 2002; 97:820-6 Page 40 Page 41 Adäquate Gewebeoxygenierung Inadäquate Gewebeoxygenierung = kompensierter Schock 7

8 Säure-Base Status (BE, Laktat) Säure-Base Status (BE, Laktat) : Balancierte vs. Kochsalzbasierte Konzepte Supranormal DO 2 and CO: Supply and demand: DO 2 VO 2 Grundlage: Inadäquates Gewebssauerstoffangebot resultiert in anaerobem Stoffwechsel Ausmass des anaeroben Stoffwechsels proportional zur Schockschwere Messbar im Basendefizit und Laktat Daten: Enge Korrelation für BE/Laktat zum Schweregrad des Schocks Korreliert zu Bluttransfusion, MODS, Mortalität Grossteil der Daten von Patienten mit Trauma und Sepsis Entscheidend ist der Verlauf der Parameter über die Zeit Keine Daten mit BE oder Laktat als Endpunkt Page 42 Tisherman SA et al.: J Trauma 2004; 57: Page 43 Boldt J et al.: Eur J Anaesthesiol 2007; 3: Page 44 Huang Y.C., Chest 2005 Supranormal DO 2 and CO: Parameters Supranormal DO 2 and CO: Clinical Trials Supranormal DO 2 and CO: Metaanalysis DO 2 (ml/min) = CO (l/min) x CaO 2 CaO 2 = 1,34 x Hb x SaO 2 + 0,003 x PaO 2 Targets: CI > 4.5 l/min/m 2 PAOP > 18 mmhg DO 2 > 600 ml/min/m 2 VO 2 > 170 ml/min/m 2 Strategy: volume plus inotropes Page 45 Huang Y.C., Chest 2005 Page 46 Kern JW, Shoemaker WC. Crit Care Med 2002; 30: Page 47 Kern JW, Shoemaker WC. Crit Care Med 2002; 30:

9 Supply and demand: DO 2 VO 2 relationships Target variable: svo 2 / scvo 2 Supply and demand: DO 2 VO 2 relationships Target variable: scvo 2 Supply and demand: DO 2 VO 2 relationships Target variable: scvo 2 Page 48 Levy M., Chest 2005 Page 49 Collaborative Group on perioperative scvo 2 monitoring. Crit Care 2006; 10:R158 Page 50 Collaborative Group on perioperative scvo 2 monitoring. Crit Care 2006; 10:R158 Supply and demand: DO 2 VO 2 relationships Target variable: scvo 2 Page 51 Collaborative Group on perioperative scvo 2 monitoring. Crit Care 2006; 10:R158 9