Fluid management Dr. Timothy Miller Assistant Professor of Anesthesiology Duke University Medical Center
Disclosure Consultant and research funding Edwards Lifesciences
Goals of fluid therapy 1. Maintain central euvolemia 2. Avoid salt and water excess
The Challenge Hypoperfusion Organ Dysfunction Adverse outcome Edema Organ Dysfunction Adverse outcome Complications OPTIMAL Hypovolemic Adapted from: Bellamy, BJA 2006 Volume Load Overloaded
The Challenge Hypoperfusion Organ Dysfunction Adverse outcome Edema Organ Dysfunction Adverse outcome Complications BOWEL ISCHEMIA OPTIMAL BOWEL WALL EDEMA Hypovolemic Overloaded Volume Load Adapted from: Bellamy, BJA 2006
Brandstrup Restriction Study Multicenter RCT Elective Colorectal Surgery ASA I/II, no bowel prep 172 patients Standard of Care Group Fluid Restricted Group (to maintain pre-op body weight) Brandstrup. Ann Surg. 2003;238:241-8
Brandstrup Study Complications 60 % 45 30 * * * p < 0.05 Restricted Standard 15 0 Overall Minor Major Brandstrup, Ann Sur2g0.032;023083:2;2431-8:241-8
Avoidance of fluid excess 60 Complication rate (%) 45 30 15 0 < 3,5 3,5-5,5 > 5,5 < 0,5 0,5-2,5 > 2,5 IV fluids (Liters) Increased body weight (Kg) Brandstrup. Ann Surg. 2003;238:241-8
Third space evidence. No convincing evidence for a 3 rd Space Never measured Never localized Bottom Most tracer line studies the 3 rd contradict Space DOES its existence NOT EXIST So, don t try to fill it!!! Chappell et al Anesthesiology 2008;109:723-40
Healthy vs. Injured Glycocalyx 5-7 days to regenerate Hypervolemia drives up hydrostatic pressure and damages the glycocalyx Myburgh 2013. N Engl J Med 2013;369:1243-51 Becker et al, Basic Res Cardiol 2010;105:687-701
Crystalloids and weight gain Perioperative Weight gain (g) Chappell et al Anesthesiology 2008;109:723-40
A rational approach to fluid therapy 1 Crystalloids Preoperative deficits Insensible perspiration Third space Urine Output Amount The deficit after usual fasting is low The basal fluid loss via insensible perspiration is approximately 1ml/kg/h during major abdominal A primarily fluid-consuming third space does not exist Should be replaced 1. Chappell D, Jacob M, Hofmann-Kiefer K, et al. A Rational Approach to Perioperative Fluid Management. Anesthesiology. 2008; 109:723-40.
A rational approach to fluid therapy 1 Crystalloids Preoperative deficits Insensible perspiration Third space Urine Output Amount The deficit after usual fasting is low The basal fluid loss via insensible perspiration is approximately 1ml/kg/h during major abdominal A primarily fluid-consuming third space does not exist Should be replaced Colloids Amount Plasma losses from the circulation due to fluid shifting of Timely replacement with an iso-oncotic colloid via a goal-directed approach 1. Chappell D, Jacob M, Hofmann-Kiefer K, et al. A Rational Approach to Perioperative Fluid Management. Anesthesiology. 2008; 109:723-40.
Goal no. 1: Avoidance of fluid excess, especially crystalloid
Goal Directed Fluid Therapy Stroke Volume Intra-vascular volume
Two questions 1. How can I measure the response to a fluid challenge? 2. Can I predict if the patient is going to be fluid responsive and benefit from a fluid challenge?
Two questions 1. How can I measure the response to a fluid challenge? 2. Can I predict if the patient is going to be fluid responsive and benefit from a fluid challenge?
Frank-Starling Fluid Challenge SV Stroke Volume SV Intra-vascular volume Modified from: Grocott. Anesth Analg 2005
Frank-Starling Fluid Challenge OPTIMAL ZONE SV Stroke Volume SV Intra-vascular volume Modified from: Grocott. Anesth Analg 2005
100 ASA I, II and III patients Surgery with expected blood loss > 500 ml Intraoperative EDM-guided GDT vs. Control Background crystalloid infusion & colloid bolus Primary outcome: LOS
Monitor FTc & SV
Goal Directed Fluid Therapy Control Protocol P value Colloid (ml/kg/hr) Crystalloid (ml/ Kg/hr) Hospital stay (days) Tolerate food (days) 0.9 2.5 15 13 7 5 0.03 5 3 0.01 Gan Anesthesiology 2002; 97:820-6
Goal Directed Fluid Therapy Control Protocol P value Colloid (ml/kg/hr) Crystalloid (ml/ Kg/hr) Hospital stay (days) Tolerate food (days) 0.9 2.5 15 13 7 5 0.03 5 3 0.01 Gan Anesthesiology 2002; 97:820-6
Two questions 1. How can I measure the response to a fluid challenge? 2. Can I predict if the patient is going to be fluid responsive and benefit from a fluid challenge?
Two questions 1. How can I measure the response to a fluid challenge? 2. Can I predict if the patient is going to be fluid responsive and benefit from a fluid challenge? SVV - stroke volume variation PPV - pulse pressure variation PVI - pleth variability index FTc - corrected flow time PLR - passive leg raise
CVP and volume responsiveness Retrospective study 150 volume challenges in 96 patients Volume challenge 500 ml of 6% HES over 20 minutes. Cardiac index Increase 15% = responders (R) Increase < 15% = non-responders (NR) Osman. Crit Care Med 2007; 35: 64-68
Pulse Pressure Variation Parry-Jones. Int J of Intens Care. 2003
Pulse Pressure Variation Fluid challenge if PPV >10-13% Parry-Jones. Int J of Intens Care. 2003
Physiology of SVV/PPV Parry-Jones. Int J of Intens Care. 2003
60,,, # # # ASP,,...., 0 -d, o----d PAOP,.. - 1 - - - - - I - - - -, - 1 0 20 40 60 80 100 Specificity(%) 100
Example - cystectomy
Example - cystectomy SVV 5%, SV 80, BP 120/80 - baseline
Example - cystectomy SVV 5%, SV 80, BP 120/80 - baseline After some blood loss SVV 10-12%, SV 70, BP 120/80
Example - cystectomy SVV 5%, SV 80, BP 120/80 - baseline After some blood loss SVV 10-12%, SV 70, BP 120/80 Give 250 ml colloid SVV 5%, SV 80, BP 120/80
Example - cystectomy SVV 5%, SV 80, BP 120/80 - baseline After some blood loss SVV 10-12%, SV 70, BP 120/80 Give 250 ml colloid SVV 5%, SV 80, BP 120/80 Repeat fluid bolus whenever SVV 10-12%
Example - cystectomy SVV 5%, SV 80, BP 120/80 - baseline After some blood loss SVV 10-12%, SV 70, BP 120/80 Give 250 ml colloid SVV 5%, SV 80, BP 120/80 Repeat fluid bolus whenever SVV 10-12% Start epidural SVV 5%, SV 80-90, BP 85/60 Phenylephrine infusion
120 patients Major abdominal surgery Estimated blood loss greater than 1000ml GDT vs. control 3ml/Kg colloid bolus when SVV > 10% Benes Crit Care 2010, 14:R118
SVV and Fluids 3,000 Control Intervention 2,250 1,500 750 00 Crystalloids HES Benes Crit Care 2010, 14:R118
SVV and serum lactate Group Control Study Benes Crit Care 2010, 14:R118
SVV and complications PARAMETERS STUDY GROUP CONTROL GROUP p VALUE Benes Crit Care 2010, 14:R118
GDT reduces complications Anesth Analg 2011;112:1392 402 OR 0.44 [0.35-0.55] p<0.00001
GDT reduces complications Odds Ratio ED 0.41 [0.30,0.57]* PAC 0.54 [0.33,0.88]* Other 0.32 [0.19,0.54]* Anesth Analg 2011;112:1392 402 OR 0.44 [0.35-0.55] p<0.00001
GDT reduces complications Odds Ratio Background crystalloid infusions with targeted colloid boluses ED 0.41 [0.30,0.57]* PAC 0.54 [0.33,0.88]* Other 0.32 [0.19,0.54]* OR 0.44 [0.35-0.55] p<0.00001 Anesth Analg 2011;112:1392 402
Long-term effects of complications 69% decrease in median survival if 1 30-day complication 105, 951 patients Khuri. Ann Surg 2005;242: 326 343
Long-term effects of complications The occurrence of a 30-day postoperative complication is more important than preoperative patient risk in determining survival after major surgery 69% decrease in median survival if 1 30-day complication 105, 951 patients Khuri. Ann Surg 2005;242: 326 343
Why does GDT work? 27 pigs GA + laparotomy Three groups R-RL GD-RL GD-C RL 3ml/Kg/hr RL 3ml/Kg/hr + boluses 250ml RL RL 3ml/Kg/hr + boluses 250ml colloid Laser Doppler Flowmetry Intestinal tissue oxygen tension Kimberger. Crit Care 2009; 13: R40.
Microcirculatory blood flow in the jejunum mucosa..._ ".,. :. GD-RL R-RL baseline 60 120 180 240min mmhg 80 70 60 50 40 Jejunum wall tissue oxygen tension -- T.r----.r..---r:.--J...I. - --- ----I GD-RL ---r-- r-1-t- - -- -- 1 1 -_ 1 R-RL baseline 60 120 180 240min
Goal no. 2: Optimize stroke volume and/or stroke volume variation using a minimally invasive cardiac output monitor
Which surgery? Major surgery with a mortality rate of > 1% Major surgery with and anticipated blood loss of greater than 500mls Major intra-abdominal surgery Intermediate surgery in high risk patients (including patients aged > 80 years) NHS Enhanced Recovery guidelines
Summary Peri-operative fluid management generally poorly executed. Wide variability in practice Too little fluid Too much fluid, esp. crystalloid
Summary Peri-operative fluid management generally poorly executed. Wide variability in practice Too little fluid Too much fluid, esp. crystalloid Restrictive studies teach us caution Crystalloid excess discouraged Only administer sufficient crystalloid to meet specific crystalloid requirement
Summary Goal - Directed Fluid Therapy Physiologically sound Right Fluid, Right Amount, Right Time Evidence based to reduce morbidity, length of stay, and healthcare costs.
Summary Goal - Directed Fluid Therapy Physiologically sound Right Fluid, Right Amount, Right Time Evidence based to reduce morbidity, length of stay, and healthcare costs. Correct fluid choice important Background crystalloids Targeted colloid boluses