Sparing the Beans! Postoperative Fluid Management!
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1 Sparing the Beans! Postoperative Fluid Management! ASER 2016 Annual Congress! Washington DC, April 2016!! Mattias Soop MD PhD! Colorectal Surgeon, Salford Royal NHS Foundation Trust! Honorary Reader, University of Manchester! Honorary Associate Professor of Surgery, The University of Auckland!
2 Disclosures! Travel support from Baxter Healthcare 2013! Travel support from NPS Pharma 2014! Travel support from Fresenius Kabi 2015! Unrestricted research grant Shire Pharmaceuticals !
3 Fluid overloading is an avoidable, iatrogenic and major cause of morbidity! l/day! Varadhan, Proc Nutr Soc 2010;1.!
4 Fluid overloading is an avoidable, iatrogenic and major cause of morbidity! Adjusted odds of increased/decreased (% and 95% CI)! Thacker. Ann Surg 2016;263:502!
5 How much fluid sparing is needed?! Lobo! 2002! Brandstrup 2003! Nisanevich 2005! McArdle! 2009! IV fluids during and! first 48 h after surgery! 30-day incidence of overall complications! Balanced! Overload! Delta! Balanced! Overload! 5 l! 8.5 l! 3.5 l! 10%! 70%! 4 l! 7.8 l! 3.8 l! 33%! 51%! 5.6 l! 7.9 l! 2.3 l! 17%! 31%! 9.5 l! 13 l! 3.5 l! 10%! 64%! Lobo, Lancet 2002;359:1812. Brandstrup, Ann Surg 2003;238:641.! Nisanevich, Anesthes 2005;103:25. McArdle, Ann Surg 2009;250:28!
6 Fluid overloading is still common in contemporary daily practice! 6000! 65 pts, colorectal surgery! 71 pts, colorectal surgery, ERAS! Volume (ml)! 4500! 3000! 1500! 46%! 54%! 0! Fluid overload (net balance >1l)! Normovolaemia (net balance 1l)! Warrillow, Anaesth Intensive Care 2010;38:259. Boersema, Surg Today 2014; in print.!
7 Postoperative fluids less complex than intraoperative! Intraop!! Loss of vascular tone! Myocardial suppression! Positional changes! Blood loss! Insensible losses! Postop!! (Loss of vascular tone)!! Meet maintenance needs!
8 Fluid and electrolyte maintenance! NICE guidelines 2013, UK:! ml/kg/day! GIFTASUP guidelines 2011, UK:! Sodium mmol/day, potassium mmol/day, litres of water! guidance.nice.org.uk/cg GIFTASUP 2011.!
9 Fluid and electrolyte maintenance! Required! Saline! Plasma-Lyte 148! Dex saline 20 KCl! Water (ml)! 2000! 2000! 2000! 2000! Na (mmol)! 80! 308! 280! 60! Cl (mmol)! 80! 308! 196! 100! K (mmol)! 40! 0! 10! 40! GIFTASUP 2011.!
10 Fluid and electrolyte replacement! Gastric losses! Bile, Ileostomy! Plasma-Lyte 148! Na (mmol/l)! 40! 140! 140! Cl (mmol/l)! 140! 125! 98! K (mmol/l)! 14! 5! 5! GIFTASUP 2011.!
11 In practice! Maintenance (stop 8am day 1)! Can the patient drink?! Yes! Oral fluids! Replacement! Can the patient drink?! Check U&Es daily! No! Yes! No! Dex saline + 20 KCl/l! 1 ml/kg/h (infusion pump)! Oral fluids (incl ORS)! Replace losses >500 ml 1:1! with Plasma-Lyte 148!
12 What is oliguria?! Renal medicine! definition! <400 ml/day! <0.2 ml/kg/h! 500 mosm solutes/day! 1200 mosm/kg water! Klahr, NEJM 1998;338:671.!
13 What is oliguria?! Renal medicine! definition! Perioperative medicine definition! <400 ml/day! <900 ml/day! <0.2 ml/kg/h! <0.5 ml/kg/h! 500 mosm solutes/day! 1200 mosm/kg water! Empirical observations during Korean War! Klahr, NEJM 1998;338:671.!
14 Low perioperative urine output observed since 1905! TABLE I.-Amount of Urine, shwwing Rate of Secretion in c.cm. per Half-hour. Case. e e e X0 e e 'd L4 4 0 N A 2I 20 15Z _ 9.30 a8.8 B II C ) _ -1)tlo IO.60 D) Lost co CO E o G CO O H o I Lost O 4 2o.6o General Average the nervous condition of the patient preceding operation.! surgery! Pringle, BMJ 1905;2(2332):542!
15 Water and sodium retention!! Adrenergic activity!! ADH!! Reninangiotensin II axis! Sweny, Br J Anaesth 1991;67:137.!
16 Why 0.5 ml/kg/h?! Korean War! ! Evacuation helicopters, MASH units, Dextran, Renal Care Centre! If a casualty excretes urine at the rate of 30 to 40 cc. per hour, adequate replacement can be assumed.! - Major Curtis P Artz, Director, Army Surgical Research Team, 1954! history.amedd.army.mil/booksdocs/korea/ recad1/ch2-3.html!
17 Association low perioperative urine output and postoperative kidney dysfunction! 15,102 patients undergoing general surgery! Dependent variable: AKI within 7 days! No association between intraop UO (ml/kg/h) and AKI! Kheterpal, Anesthesiology 2007;107:892.!
18 Perioperative urine output target RCT! 0.2 ml/kg/h vs 0.5 ml/kg/h! Within ERAS protocol with standardised maintenance fluid protocol! Hypothesis: Lower target is non-inferior (kidney perfusion, function and tubular damage) and fluid sparing! Puckett, Royal Australasian College of Surgeons 2014!
19 Postoperative fluid therapy less complex than intraoperative! Maintenance and replacement requirements for water and electrolytes well defined! Dextrose-saline with 20 KCl/l! Plasma-Lyte 148!
20 Re-defining perioperative urine output target as 0.2 ml/kg/h instead of 0.5 ml/kg/h results in:! No change in kidney perfusion, function or tubular damage! Fluid sparing of 2.4 litres over 48 h! Needs confirmation in larger studies!
21 Thank you Your husband s doing well, but we re going to need to keep him overnight because he s funny and I m lonely. mattias.soop@manchester.ac.uk!
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