Goal-Directed Fluid Therapy: A New Way of Thinking. Ji Su Jenny Kim & Logan D. MacLean SRNA, BSN, CCRN DNP Candidates
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1 Goal-Directed Fluid Therapy: A New Way of Thinking Ji Su Jenny Kim & Logan D. MacLean SRNA, BSN, CCRN DNP Candidates
2 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
3 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
4 Brief History of Fluid Management Srinivasa, S. & Hill, A. G. (2012). Perioperative fluid administration: historical highlights and implications for practice. Surgical Retrospection, 256(6),
5 Why Should I Care?
6 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
7 Hypovolemia Hypervolemia
8 Hypovolemia Complications Low cardiac output Hypovolemia Decreased tissue perfusion Shock/organ failure Chappell, D., Jacob, M., Hofmann-Kiefer, K., Conzen, P., & Rehm, M. (2008). A rational approach to perioperative fluid management. Anesthesiology, 109(4): 723 Brandstrup, B. (2006). Fluid therapy for the surgical patient. Best Practice Research Clinical Anaesthesiology, 20(2), 265.
9 Hypervolemia Complications Respiratory effects GI effects Hypervolemia Coagulation Joshi, G. P. (2018). Intraoperative fluid management. UpToDate. Retrieved February 26, 2018, from Thacker, J. K., Mountford, W. K., Ernst, F. R., Krukas, M. R., & Mythen, M. M. (2016). Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample US surgical populations. Annals of Surgery, 263(3), Wound healing
10 Shin, C. H., Long, D. R., McLean, D., Grabitz, S. D., Ladha, K., Timm, F. P., Eikermann, M. (2017). Effects of intraoperative fluid management on postoperative outcomes: a hospital registry study. Annals of Surgery, doi: /SLA
11 Thacker, J. K., Mountford, W. K., Ernst, F. R., Krukas, M. R., & Mythen, M. M. (2016). Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample US surgical populations. Annals of Surgery, 263(3),
12 Why Should I Care? Surgical Anesthetics Patient-related Surgical procedure Excessive fluid administration Age > 65 yr Vascular Blood transfusion (>4 units) ASA physical status > 2 Thoracic Residual neuromuscular blockade History of respiratory disease Upper abdominal Intraoperative hypothermia OSA Neurosurgery Use of NG tube Preoperative SpO2 < 96% Head and neck Inadequate ventilator settings History of CHF Emergency procedure Reintervention Surgical duration > 2h Open laparotomy > laparoscopy Futier, E., Marret, E., & Jaber, S. (2014). Perioperative positive pressure ventilation: an integrated approach to improved pulmonary care. Anesthesiology, 121(2), Recent respiratory infection (<1 mo) Partial or total functional dependency Active smoking Alcohol abuse Preoperative sepsis Weight loss > 10% in the last 6 months Preoperative anemia (<10g/dl) Obesity
13 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
14 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
15 Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
16 Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
17 Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
18 Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
19 Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
20 ml Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
21 Fluid Compartments
22 Fluid Compartments 30L 12L 3L
23 Fluid Compartments 30L 12L water Na+ Na+ K+ K+ protein protein 3L
24 Fluid Compartments 30L 12L water Na+ Na+ K+ K+ protein protein water Na+ K+ protein protein 3L
25 Endothelial Glycocalyx Brettner, F., Chappell, D., & Jacob, M. (2012). The concept of the glycocalyx Facts that influence perioperative fluid management. Trends in Anaesthesia and Critical Care,2(4), doi: /j.tacc
26 Endothelial Glycocalyx Brettner, F., Chappell, D., & Jacob, M. (2012). The concept of the glycocalyx Facts that influence perioperative fluid management. Trends in Anaesthesia and Critical Care,2(4), doi: /j.tacc
27 Protect Endothelial Glycocalyx Inhalational Agents (sevoflurane) Plasma proteins Hydrocortisone Etanercept (TNF-a receptor) Antithrombin III Antioxidants Ischemia/Reperfusion Sepsis/Inflammation Hypervolemia ANP Hyperglycemia Surgical Stress Destroy Bashandy, G. M. (2014). Implications of recent accumulating knowledge about endothelial glycocalyx on anesthetic management. Journal of Anesthesia,29(2), doi: /s
28 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
29 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
30 Intra-Operative Fluid Replacement 80kg pt undergoing Exploratory Laparotomy; NPO for past 10 hours Hours Fluid Deficit Maintenance Insensible Losses EBL Urine Output Hourly Total Total Hour (300) 150 1,810 1,810 Hour (900) 50 2,010 3,820 Hour (150) 30 1,240 5,060 mls
31 Maintenance Fluids/Insensible Losses Maintenance Requirements for Different Surgeries Surgical Trauma Fluid Volume Example Surgery Superficial 1-2 ml/kg/hr Peripheral surgery Minimal 3-4 ml/kg/hr Head and neck, hernia, knee surgery Moderate 5-6 ml/kg/hr Major surgery without exposed abdominal contents Severe 8-10 ml/kg/hr (or more) Major abdominal, especially with exposed abdominal contents Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., & Ortega, R. (2013). Clinical Anesthesia, 7 th edition. Philadelphia, PA: Lippincott Williams & Wilkins.
32 Intra-Operative Fluid Replacement 80kg pt undergoing Exploratory Laparotomy; NPO for past 10 hours Hours Fluid Deficit Maintenance Insensible Losses EBL Urine Output Hourly Total Total Hour (300) 150 1,810 1,810 Hour (900) 50 2,010 3,820 Hour (150) 30 1,240 5,060 mls
33 Fundamentals 1. Preoperative fasting patients are hypovolemic due to ongoing insensible perspiration and urinary output 2. Insensible perspiration increases dramatically during surgery due to exposure 3. An unpredictable fluid shift towards the third space requires generous substitution 4. Hypervolemia is harmless because the kidneys regulate the overload
34 Intra-Operative Fluid Replacement 80kg pt undergoing Exploratory Laparotomy; NPO for past 10 hours Hours Fluid Deficit Maintenance Insensible Losses EBL Urine Output Hourly Total Total Hour (300) 150 1,810 1,810 Hour (900) 50 2,010 3,820 Hour (150) 30 1,240 5,060 mls
35 Intra-Operative Fluid Replacement 80kg pt undergoing Exploratory Laparotomy; NPO for past 10 hours Hours Fluid Deficit Maintenance Insensible Losses EBL Urine Output Hourly Total Total Pre-op fasting for 10hrs = No differences between theoretical and actual plasma volumes using indocyanine green (2008) Hour (300) 150 1,810 1,810 Hour (900) 50 2,010 3,820 Pre-op fasting for >8hrs = No differences between pre and post fasting plasma volumes using transthoracic echocardiography (2014) Hour (150) 30 1,240 5,060 mls Jacob, M., Chappell, D., Conzen, P., Finsterer, U., Rehm, M. (2008). Blood volume is normal after pre-operative overnight fasting. Acta Anaesthesiologica Scandinavica, 52(4), Muller, L., Briere, M., Bastide, S., Roger, C., Zoric, L., Seni, G., de La Coussaye, J. E. Ripart, J., & Lefrant, J. Y. (2014). Preoperative fasting does not affect haemodynamic status: a prospective, non-inferiority, echocardiography study. British Journal of Anaesthesia, 112(5),
36 Intra-Operative Fluid Replacement 80kg pt undergoing Exploratory Laparotomy; NPO for past 10 hours Hours Fluid Deficit Maintenance Insensible Losses EBL Urine Output Hourly Total Total Hour (300) 150 1,810 1,810 Hour (900) 50 2,010 3,820 Hour (150) 30 1,240 5,060 mls
37 Maintenance Fluids/Insensible Losses Maintenance Requirements for Different Surgeries Surgical Trauma Fluid Volume Example Surgery Superficial 1-2 ml/kg/hr Peripheral surgery Minimal 3-4 ml/kg/hr Head and neck, hernia, knee surgery Moderate 5-6 ml/kg/hr Major surgery without exposed abdominal contents Severe 8-10 ml/kg/hr (or more) Major abdominal, especially with exposed abdominal contents Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., & Ortega, R. (2013). Clinical Anesthesia, 7 th edition. Philadelphia, PA: Lippincott Williams & Wilkins. Navarro, L. H. C., Bloomstone, J. A., Auler Jr, J. O. C., Cannesson, M., Rocca, G. D., Gan, T. J., Kramer, G. C. (2015). Perioperative fluid therapy: a statement from the international fluid optimization group. Perioperative Medicine, 4(3).
38 Maintenance Fluids/Insensible Losses Maintenance Requirements for Different Surgeries Surgical Trauma Fluid Volume Example Surgery Superficial 1-2 ml/kg/hr Peripheral surgery Minimal 3-4 ml/kg/hr Head and neck, hernia, knee surgery Moderate 5-6 ml/kg/hr Major surgery without exposed abdominal ml/kg/hr contents Severe 8-10 ml/kg/hr (or more) Evaporation/fluid loss through exposure: Major abdominal, especially with exposed abdominal contents Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., & Ortega, R. (2013). Clinical Anesthesia, 7 th edition. Philadelphia, PA: Lippincott Williams & Wilkins. Navarro, L. H. C., Bloomstone, J. A., Auler Jr, J. O. C., Cannesson, M., Rocca, G. D., Gan, T. J., Kramer, G. C. (2015). Perioperative fluid therapy: a statement from the international fluid optimization group. Perioperative Medicine, 4(3).
39 Fluid Resuscitation Classical Approach 3:1 ratio Recent Findings 1.3:1 to 2:1 ratio The efficacy and safety of colloid resuscitation in the critically ill (2011) Crystalloids versus colloids: exploring differences in fluid requirements by systematic review and meta-regression (2015) Cortes, D. O., Barros, T. G., Njimi, H., Vincent, J. (2015). Crystalloids versus colloids: exploring differences in fluid requirements by systematic review and meta-regression. Anesthesia & Analgesia, 120(2), Hartog, C. S., Bauer, M., & Reinhart, K. (2011). The efficacy and safety of colloid resuscitation in the critically ill. Anesthesia & Analgesia, 120(1),
40 Intra-Operative Fluid Replacement 80kg pt undergoing Exploratory Laparotomy; NPO for past 10 hours Hours Fluid Deficit Maintenance Insensible Losses EBL Urine Output Hourly Total Total Hour (300) 150 1,810 1,810 Hour (900) 50 2,010 3,820 Hour (150) 30 1,240 5,060 mls
41 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
42 Goal-Directed Fluid Therapy Map History of Fluid Management Significance of Fluid Management Fluid Compartment Physiology Traditional Theories of Fluid Management Fluid Management Indicators & Interventions
43 Indications and Interventions Scientific Method Traditional Indicators Advanced Indicators Pharmacokinetic Indicator: Volume Effect Crystalloid vs. Colloid
44 Scientific Method Target Indication Therapy Outcome Variable Normovolemia Intravascular Hypovolemia Volume Replacement Blood Volume
45 Scientific Method Target Indication Therapy Outcome Variable Normovolemia Intravascular Hypovolemia Volume Replacement Blood Volume
46 Traditional Indicators BP, HR, CVP Urine output Not sensitive or specific 62 ± ± 7 55 ± 8 HR Blood volume: 3959 ± 387 ml 3501 ± 499ml 3934 ± 500 ml (n = 10) Hct: 0.35 ± ± ± 0.04 Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
47 Advanced Flow Measurements Frank Starling Curve Pulse Pressure Variation (PPV) Stroke Volume Variation (SVV) Limitations Doherty, M., & Buggy, D. J. (2013). Intraoperative Fluids. Survey of Anesthesiology,57(1), doi: /01.sa dc
48 Indications and Interventions Scientific Method Traditional Indicators Advanced Indicators Pharmacokinetic Indicator: Volume Effect Crystalloid vs. Colloid
49 Volume Effect Percentage of infused solution that 2) does not cause interstitial edema 1) remains within circulatory compartment and 30L 12L 3L
50 Volume Effect Percentage of infused solution that 2) does not cause interstitial edema 1) remains within circulatory compartment and Calculation Methods Hematocrit Dilution (98% existing data) Acute Normovolemic Hemodilution (ANH) 30L 12L 3L
51 Volume Effect: Hematocrit Dilution - Initial hct - Initial blood volume * initial Hct = Red Cell Volume - Intravenous volume therapy - New Hct - Calculation of increase in blood volume
52 Volume Effect: Hematocrit Dilution - Initial hct Initial blood volume * initial Hct = Red Cell Volume - Intravenous volume therapy - New Hct - Calculation of increase in blood volume
53 Volume Effect: Hematocrit Dilution - Initial hct Initial blood volume * initial Hct = Red Cell Volume 5 L * 0.40 = 2 L RCV 5 L - 2 L = 3 L Plasma - Intravenous volume therapy - New Hct - Calculation of increase in blood volume
54 Volume Effect: Hematocrit Dilution - Initial hct Initial blood volume * initial Hct = Red Cell Volume 5 L * 0.40 = 2 L RCV 5 L - 2 L = 3 L Plasma - Intravenous volume therapy 1 L Colloid - New Hct - Calculation of increase in blood volume
55 Volume Effect: Hematocrit Dilution - Initial hct Initial blood volume * initial Hct = Red Cell Volume 5 L * 0.40 = 2 L RCV 5 L - 2 L = 3 L Plasma - Intravenous volume therapy 1 L Colloid - New Hct Calculation of increase in blood volume
56 Volume Effect: Hematocrit Dilution - Initial hct Initial blood volume * initial Hct = Red Cell Volume 5 L * 0.40 = 2 L RCV 5 L - 2 L = 3 L Plasma - Intravenous volume therapy 1 L Colloid - New Hct Calculation of increase in blood volume 2 L RCV = x L Plasma x = 3.7 L Plasma
57 Volume Effect: Hematocrit Dilution - Initial hct Initial blood volume * initial Hct = Red Cell Volume 5 L * 0.40 = 2 L RCV 5 L - 2 L = 3 L Plasma - Intravenous volume therapy 1 L Colloid - New Hct Calculation of increase in blood volume 2 L RCV = x L Plasma x = 3.7 L Plasma
58 Volume Effect: Hematocrit Dilution - Initial hct Initial blood volume * initial Hct = Red Cell Volume 5 L * 0.40 = 2 L RCV 5 L - 2 L = 3 L Plasma - Intravenous volume therapy 1 L Colloid +700 ml = 1000 ml Volume Effect of 1L Colloid 70% - New Hct Calculation of increase in blood volume 2 L RCV = x L Plasma x = 3.7 L Plasma
59 Protect Endothelial Glycocalyx Inhalational Agents (sevoflurane) Plasma proteins Hydrocortisone Etanercept (TNF-a receptor) Antithrombin III Antioxidants Ischemia/Reperfusion Sepsis/Inflammation Hypervolemia ANP Hyperglycemia Surgical Stress Destroy Brettner, F., Chappell, D., & Jacob, M. (2012). The concept of the glycocalyx Facts that influence perioperative fluid management. Trends in Anaesthesia and Critical Care,2(4), doi: /j.tacc
60 Volume Effect Percentage of infused solution that 2) does not cause interstitial edema 1) remains within circulatory compartment and Calculation Methods Hematocrit Dilution Acute Normovolemic Hemodilution (ANH) 30L 12L 3L
61 Acute Normovolemic Hemodilution (ANH) Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
62 Acute Normovolemic Hemodilution (ANH) BV: 4L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
63 Acute Normovolemic Hemodilution (ANH) BV: Blood Loss: - 1L LR: 4L + 3L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
64 Acute Normovolemic Hemodilution (ANH) BV: Blood Loss: - 1L LR: 4L + 3L BV: 3.5L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
65 Acute Normovolemic Hemodilution (ANH) BV: Blood Loss: - 1L LR: 4L + 3L BV: 3.5L Volume Effect of LR 17% Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
66 Acute Normovolemic Hemodilution (ANH) BV: 4L Blood Loss: - 1L LR: + 3L Volume Effect of LR 17% BV: 3.5L
67 Acute Normovolemic Hemodilution (ANH) BV: 4.1 L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
68 Acute Normovolemic Hemodilution (ANH) BV: 4.1 L Blood Loss: L 6% HES: L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
69 Acute Normovolemic Hemodilution (ANH) BV: 4.1 L Blood Loss: L 6% HES: L BV: 4.3 L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
70 Acute Normovolemic Hemodilution (ANH) BV: 4.1 L Blood Loss: L 6% HES: L BV: 4.3 L Volume Effect of Colloid (ANH) 98% Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
71 Acute Normovolemic Hemodilution (ANH) BV: 4.1 L Blood Loss: L 6% HES: L BV: 4.3 L Volume Effect of Colloid (ANH) 98% Vs. Volume Effect (Hct dilution) 127% Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
72 Acute Normovolemic Hemodilution (ANH) 30L water 12L K+ Na+ protein protein water Na+ Na+ K+ K+ protein protein Volume Effect of Colloid (ANH) 98% 3L Vs. Volume Effect (Hct dilution) 127%
73 Acute Normovolemic Hemodilution (ANH) Volume Effect of LR 17% Volume Effect of Colloid (ANH) 98% Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
74 Scientific Method Target Indication Therapy Outcome Variable Normovolemia Intravascular Hypovolemia Volume Replacement Blood Volume
75 Scientific Method Target Indication Therapy Outcome Variable Normovolemia Intravascular Hypovolemia Volume Replacement Blood Volume
76 Volume Loading (VL) BV: 4.2 L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
77 Volume Loading (VL) BV: 4.2 L Blood Loss: --- Albumin: L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
78 Volume Loading (VL) BV: 4.2 L Blood Loss: --- Albumin: L BV: 4.7 L Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
79 Volume Loading (VL) BV: 4.2 L Blood Loss: --- Albumin: L BV: 4.7 L Volume Effect of Colloid (VL) 38% Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
80 Volume Effect is Context Sensitive Volume Effect of Colloid (ANH) 98% Volume Effect of Colloid (VL) 38% Jacob, M., Chappell, D., Hofmann-Kiefer, K., Helfen, T., Schuelke, A., Jacob, B.,... Rehm, M. (2012). The intravascular volume effect of Ringers lactate is below 20%: A prospective study in humans. Critical Care,16(3). doi: /cc11344
81 Indications and Interventions Scientific Method Traditional Indicators Advanced Indicators Pharmacokinetic Indicator: Volume Effect Crystalloid vs. Colloid Crystalloid Colloid
82 Why Should I Care? - Hypervolemia and hypovolemia are not benign. - Evidence challenges traditional theories of fluid replacement and indicators. - Integrity of the EGL has many implications for perioperative fluid therapy (namely, hypervolemia, surgical stress, ischemia). - Volume effect is context sensitive. Proper indications matter.
83 THANK YOU!
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