Fluid management of Neurosurgical patient, Recent update
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1 Fluid management of Neurosurgical patient, Recent update Catholic University of Daegu Department of anesthesiology and pain medicine Taeha. Ryu.
2 Fluid management of Neurosurgical patient The major aims. minimize the risk for inadequate CPP maintain good neurosurgical conditions Volume status Hypervolemia cerebral edema Hypovolemia hypotension CPP, cerebral edema
3 Overview of the two main barriers in the CNS Particle and Fibre Toxicology 2010, 7:3
4 Schematic diagram of capillary membrane
5 Recent debates in fluid management Normal Saline vs Balanced Solutions Colloids vs Crystalloids Restricted vs Conventional Goal directed vs Conventional Monitoring for fluid status
6 To be discussed 1. Choice of fluids A. Contents of crystalloids; balanced vs normal saline B. Colloids vs crystalloids 2. Amounts of fluids A. Goal directed vs conventional, restrictive vs conventional 3. The means to monitor the effect of fluid therapy A. monitors for fluid status; cost, risk
7 Balanced sloution vs Normal saline CONTENTS OF FLUIDS
8 General Principles of Fluid Management for Neurosurgical Patients 1. Maintain Normovolemia 2. Avoid reduction of serum osmolarity Miller s anesthesia 7th
9 Electrolyte Concentraions 0.9% Saline Lactated Ringer s Plasmalyte 148 or A Normosol- R Plasma Sodium Potassium Chloride Calcium Bicarbonate (acetate) 23 (gluconate) Lactate Magnesium Osmolarity
10 Osmolarity and cerebral edema Anesthesiology :6
11 Recommendation 1 Because of the risk of inducing hyperchloraemic acidosis in routine practice, when crystalloid resuscitation or replacement is indicated, balanced salt solutions e.g. Ringer s lactate/acetate or Hartmann s solution should replace 0.9% saline, except in cases of hypochloraemia e.g. from vomiting or gastric drainage. Evidence level 1b
12 Normal Saline Non-glucose containg Non-Calcium containg Reconstituting packed RBC Is normal saline normal? Slightly hyperoncotic Hyprechloremic normal-anion gap acidosis
13 Perioperative buffered versus non-buffered fluid administration for surgery in adults (Review) Burdett, Dushianthan et al. 2012
14 Hyperchloremia After Noncardiac Surgery Is Independently Associated with Increased Morbidity and Mortality: A Propensity-Matched Cohort Study McCluskey, Karkouti et al. 2013
15 Balanced vs chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study Single-center, two-arm, randomised, double-blind, pilot controlled trial Patients with severe TBI(GCS 8) or SAH (WFNS<III) who were mechanically ventilated. isotonic balanced solutions or isotonic sodium chloride solutions for 48 hours. Roquilly et al. Critical Care 2013, 17:R77
16 Balanced vs chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study Roquilly et al. Critical Care 2013, 17:R77
17 Balanced vs chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study Roquilly et al. Critical Care 2013, 17:R77
18 Balanced vs chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study Roquilly et al. Critical Care 2013, 17:R77
19 Balanced vs chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study Roquilly et al. Critical Care 2013, 17:R77
20 COLLOIDS VS CRYSTALLOIDS
21 Human albumin solution for resuscitation and volume expansion in critically ill patients. Outcome; Deaths Subgroup; hypovolemia Roberts, Blackhall et al. Cochrane Database Syst Rev. 2011
22 Human albumin solution for resuscitation and volume expansion in critically ill patients. Outcome; Deaths Subgroup; Burn Outcome; Deaths Subgroup; Hypoalbuminemia Roberts, Blackhall et al. Cochrane Database Syst Rev. 2011
23 Outcome; Deaths Colloids vs crystalloids for fluid resuscitation in critically ill patients Colloids compared to crystalloids Perel, Roberts et al. 2013
24 Colloid solutions for fluid resuscitation Albumin or PPF vs HES, Outcome Death. Albumin or PPF vs gelatin, Outcome Death. Bunn and Trivedi 2012
25 Colloid solutions for fluid resuscitation Albumin or PPF vs dextran, Outcome Death. Modified gelatin vs HES, Outcome Death. Modified gelatin vs dextran, Outcome Death Bunn and Trivedi 2012
26 The NEW ENGLAND JOURNAL of MEDICINE HES 130/0.42 vs Ringer s Acetate in Severe Sepsis The 6S trial The 6S trial, Perner, Haase et al. 2012
27 The NEW ENGLAND JOURNAL of MEDICINE HES 103/0/4 or Saline for Fluid Resuscitation in ICU CHEST trial CHEST trial, Myburgh, Finfer et al. 2012
28 INTENSIVE CARE MEDICINE Gattas, Dan et al Fluid resuscitation with 6 % HES (130/0.4 and 130/0.42) in acutely ill patients: systematic review Forest plot for mortality
29 INTENSIVE CARE MEDICINE Gattas, Dan et al Fluid resuscitation with 6 % HES (130/0.4 and 130/0.42) in acutely ill patients: systematic review Forest plot need for RRT
30 Assessment of hemodynamic efficacy and safety of 6% HES 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: The CRYSTMAS study Efficacy outcome HES 130/0.4 (n=88) NaCl 0.9% (n=86) P Mean volume of study drug used, ml (SD) 1,379 (886) 1,709 (1,164) Mean time to initial HDS, hours (SD) 11.8 (11.1) 14.3 (11.1) NS Number of patients prescribed IV catecholamines (%) 88 (88.0) 87 (90.6) NS Guidet, Martinet et al. 2012
31 Assessment of hemodynamic efficacy and safety of 6% HES 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: The CRYSTMAS study Outcomes HES 130/0.4 NaCl 0.9% P LOS in the ICU (days) 15.4 ± ± 22.2 NS LOS in the hospital (days) 37.7 ± ± 31.6 NS The AUC of the SOFA Score 6.9 ± ± 3.1 NS Mortality rate until day 28 31/100 (31.0 %) 24/95 (25.3%) 0.37 Mortality rate until day 90 40/99 (40.0%) 32/95 (34%) 0.33 Guidet, Martinet et al. 2012
32 Assessment of hemodynamic efficacy and safety of 6% HES 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: The CRYSTMAS study ARF occurred in 24 (24.5%) and 19 (20%) patients for HES and NaCl, respectively (P = 0.454). Number of patients by the AKIN and RIFLE classifications Guidet, Martinet et al. 2012
33 JAMA Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock CRISTAL study Cumulative Incidence of Death Within First 28 Days After Randomization Annane, Siami et al. 2013
34 JAMA Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock CRISTAL study Annane, Siami et al. 2013
35 JAMA Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock CRISTAL study Annane, Siami et al. 2013
36 Drugs in R&D Bioequivalence Comparison between Hydroxyethyl Starch 130/0.42/6 : 1 and Hydroxyethyl Starch 130/0.4/9 : 1 Lehmann, Marx et al. 2007
37 Drugs in R&D Bioequivalence Comparison between Hydroxyethyl Starch 130/0.42/6 : 1 and Hydroxyethyl Starch 130/0.4/9 : 1 Lehmann, Marx et al. 2007
38 EJA Effects of balanced HES solutions on gut mucosal microcirculation and exhaled nitric oxide in septic rats Total capillary perfusion. Intercapillary area (ICA) between all perfused capillaries (ICAtotal) (*P<0.05 vs crystalloid). Langanke, Hinkelmann et al. 2013
39 EJA Effects of balanced HES solutions on gut mucosal microcirculation and exhaled nitric oxide in septic rats Exhaled nitric oxide Exhaled nitric oxide was used used as a surrogate marker for pulmonary inflammation. The lowest exhaled nitric oxide concentrations were recorded after waxy maize bolus resuscitation only (*P<0.05 vs crystalloid). Langanke, Hinkelmann et al. 2013
40 INTENSIVE CARE MEDICINE Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients Reinhart, Perner et al. 2012
41 Performance of Bedside Transpulmonary Thermodilution Monitoring for Goal-Directed Hemodynamic Management After Subarachnoid Hemorrhage Early goal-directed therapy for the patients c vasospasm after SAH 116 patients / after surgical clipping PAC vs PiCCO Validation study; 16 patients Clinical Assessment study; 100 patients Mutoh, Kazumata et al. 2009
42 Performance of Bedside Transpulmonary Thermodilution Monitoring for Goal-Directed Hemodynamic Management After Subarachnoid Hemorrhage Mutoh, Kazumata et al. 2009
43 Performance of Bedside Transpulmonary Thermodilution Monitoring for Goal-Directed Hemodynamic Management After Subarachnoid Hemorrhage Mutoh, Kazumata et al. 2009
44 Performance of Bedside Transpulmonary Thermodilution Monitoring for Goal-Directed Hemodynamic Management After Subarachnoid Hemorrhage PiCCO Conventional P Vasospasm 50% 66% 0.03 DIND 32% 48% 0.03 Vasospasm related cbr infarction Modified Rankin Scale Score at 3Mos 0 to 3 Medical therapy-related cardiopulmonary complications 6% 14% % 44% % 12% 0.01 DIND: delayed ischemic neurological deficit Mutoh, Kazumata et al. 2009
45 Effect of human albumin administration on clinical outcome and hospital cost in patients with subarachnoid hemorrhage Suarez, Shannon et al. 2004
46 The NEW ENGLAND JOURNAL of MEDICINE A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit - The SAFE Study Investigators - Status at 28 days Albumin Saline RR (95% CI) P value No.Death/No.Total (%) Trauma Overall TBI No BI 81/596 (13.6%) 59/241 (24.5%) 22/355 (6.2%) 59/590 (10.0%) 38/251 (15.1%) 21/339 (6.2%) No Trauma 641/ / ( ) 0.62 ( ) 1.00 ( ) 0.96 ( ) Finfer, Bellomo et al. 2004
47 The NEW ENGLAND JOURNAL of MEDICINE Saline or Albumin for Fluid Resuscitation in Patients with Traumatic Brain Injury - The SAFE Study Investigators - Kaplan Meier Estimates of the Probability of Survival P = for each by the log-rank test Myburgh, Cooper et al. 2007
48 The NEW ENGLAND JOURNAL of MEDICINE Saline or Albumin for Fluid Resuscitation in Patients with Traumatic Brain Injury - The SAFE Study Investigators - Myburgh, Cooper et al. 2007
49 Albumin Resuscitation for TBI: Is Intracranial Hypertension the Cause of Increased Mortality? Cooper, Myburgh et al. 2013
50 Fluid resuscitation in patients with traumatic brain injury: what is a SAFE approach? Van Aken, Kampmeier et al. 2012
51 The ALIAS Pilot Trial A Dose-Escalation and Safety Study of Albumin Therapy for Acute Ischemic Stroke II: Neurologic Outcome and Efficacy Analysis Palesch, Hill et al. 2006
52 High-dose albumin treatment for acute ischaemic stroke (ALIAS) part 2: a randomised, double-blind, phase 3, placebo-controlled trial Ginsberg, Palesch et al. 2013
53 The Albumin in Subarachnoid Hemorrhage (ALISAH) Multicenter Pilot Clinical Trial: Safety and Neurologic Outcomes Suarez, Martin et al. 2012
54 Goal directed fluid managements AMOUNTS OF FLUIDS
55 Liberal vs. restrictive perioperative fluid therapy a critical assessment of the evidence Liberal vs. restrictive fixed-volume regimens are not well defined in the literature regarding the definition, methodology and results, and lack the use of or information on evidence-based standardized perioperative care-principles (fast-track surgery), thereby precluding evidence-based guidelines for procedure-specific perioperative fixed-volume regimens. Bundgaard-Nielsen, Secher et al. 2009
56 INTENSIVE CARE MEDICINE Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study Independent factors affecting the long term survival Age ; HR 1.04, p< Randomization to the GDT ; HR 0.61, p=0.02 Postop Cardiac Cx ; HR 3.78, p=0.007 Rhodes, Cecconi et al. 2010
57 Maintaining Tissue Perfusion in High-Risk Surgical Patients: A Systematic Review of RCTs
58 Optimising stroke volume and oxygen delivery in abdominal aortic surgery: a randomised controlled trial Bisgaard, Gilsaa et al. 2013
59 Hamilton, Cecconi et al. 2011
60 Length of Stay Corcoran, Rhodes et al. 2012
61 Pneumonia Corcoran, Rhodes et al. 2012
62 Renal Complications Corcoran, Rhodes et al. 2012
63 Corcoran, Rhodes et al time to first bowel movement (days) time to resumption of normal diet (days)
64 Stroke Volume Variation as a Predictor of Fluid Responsiveness in Patients Undergoing Brain Surgery Berkenstadt, Margalit et al. 2001
65 Delta down compared with delta pulse pressure as an indicator of volaemia during intracranial surgery Deflandre, Bonhomme et al. 2008
66 Evaluation of SVV Obtained by the FloTrac /Vigileo System to Guide Preoperative Fluid Therapy in Patients Undergoing Brain Surgery Li, Ji et al. 2012
67 Performance of Third-generation FloTrac/Vigileo system during hyperdynamic therapy for delayed cerebral ischemia after SAH Mutoh, Ishikawa et al. 2012
68 HYPERTONIC SALINE MANNITOL
69 A comparison of the cerebral and hemodynamic effects of mannitol and hypertonic saline in a rabbit model of acute cryogenic brain injury Scheller, Zornow et al. 1991
70 Comparison of mannitol and hypertonic saline in the treatment of severe brain injuries Sakellaridis, Pavlou et al. 2011
71 Critical Care Medicine Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: A meta-analysis of randomized clinical trials relative risk (RR) of successful control of elevated intracranial pressure difference in mean quantitative reduction of intracranial pressure Kamel, Navi et al. 2011
72 Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis Mortazavi, Romeo et al. 2012
73 Thank you.
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