Modern perioperative fluid management

Dr Tuong PhanStaff Specialist Anaesthetist, Dept

Anaes and Pain MedicineSt Vincent’s Hospital Melbourne

Disclosures:Grant funding from ANZCA, and St Vincent’s Research FundRELIEF - Site Investigator St Vincent’s Melbourne

“modern fluid management”

1. What’s wrong with traditional practice?1. What’s wrong with traditional practice?

3. Fluid optimisation – Goal directed fluid therapy3. Fluid optimisation – Goal directed fluid therapy

4. Time to change practice?4. Time to change practice?

2. Fluid restriction2. Fluid restriction

Fig 1 ECV changes in human beings during hemorrhagic shock or operative procedures measured with the 35 SO 4 -tracer. Note that the quality of the trials was very disparate and direct comparison of the results cannot be performed (see the text and Tables ...

Birgitte Brandstrup , Christer Svensen , Allan Engquist

Hemorrhage and operation cause a contraction of the extracellular space needing replacement—evidence and implications? A systematic review

Surgery, Volume 139, Issue 3, 2006, 419 - 432

Myths: “third space”Myths: “third space”

Myths: “third space”Myths: “third space”

Oliguric normovolemic patients do not increase their urine output in response to fluid bolus.

Myth: urine output is a good target for resuscitationMyth: urine output is a good target for resuscitation

Renal function– Hyperchloremic renal vasoconstriction

(Animal)– Human studies longer to micturition and

decreased diuresis cf Hartmann’s like solution

Gut– Human volunteers higher incidence of

abdominal discomfort– Dec gastric perfusion

Haemostasis– Possible inc blood product and blood loss– TEG: saline prolongation until clot

formationObserved electrolyte and acid base deficits which is readily treated with balanced fluids

– Association with negative outcomes

“Evidence for harm: normal saline”“Evidence for harm: normal saline”

“Evidence for harm: starch colloids”“Evidence for harm: starch colloids”

“modern fluid management”

1. What’s wrong with traditional practice?1. What’s wrong with traditional practice?

3. Fluid optimisation – Goal directed fluid therapy3. Fluid optimisation – Goal directed fluid therapy

4. Time to change practice?4. Time to change practice?

2. Fluid restriction2. Fluid restriction

Evidence for harm: “HYPERvolemia”Evidence for harm: “HYPERvolemia”

Evidence for harm: “HYPERvolemia”Evidence for harm: “HYPERvolemia”

Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003 Nov;238(5):641–8..

Evidence for harm: “HYPOvolemia”Evidence for harm: “HYPOvolemia”

A trial in perioperative fluid therapy

Inclusion criteria

1. All elective abdominal or pelvic surgery >2hours, LOS >3 days Colectomy, oesophagectomy, gastrectomy,

pancreatectomy, open vascular, open urology

1. At least one “at risk” criteria Age>70, IHD, CCF, DM, Cr >200, BMI>35, albumin

<30, AT <12

1. Or at least 2 or more risk factors ASA 3-4, COAD, BMI 30-35, PVD, Hb<100, Cr 150-

199, AT 12-14

Primary endpoint

Disability free survival up to 1 year (WHODAS)

RELIEF: Conclusive evidence

1500 1500

“modern fluid management”

1. What’s wrong with traditional practice?1. What’s wrong with traditional practice?

3. Fluid optimisation – Goal directed fluid therapy3. Fluid optimisation – Goal directed fluid therapy

4. Time to change practice?4. Time to change practice?

2. Fluid restriction2. Fluid restriction

“Optimal Fluid therapy”

Opt

imum

Incr

easi

ng

Mor

bidi

ty

HypervolemiaHypovolemia

Editorial “Wet, dry or something else?”

Bellamy, BJA 97 (6), Dec2006

Goal directed therapy

The effect of ODM optimisation on post-op morbidity and complications

Part

icip

ants

Part

icip

ants

Inte

rven

tion

Inte

rven

tion

Enhanced recovery after surgery protocolASA 1 to 3

Restrictive fluid therapyvsDoppler targeted fluid therapy

Stratified: No Stoma vs Stoma

Hyp

othe

sis

Hyp

othe

sis

Intra-operative Doppler targeted fluid therapy improves outcomes in elective major colorectal surgery within an ERAS program

REStrictive OR Targeted fluid therapy “RESORT”:

RESORT

Oesoph Doppler

Hypotension ORSVI <35mls ORFTc <360msec

∆SV >10% = fluid responsive

Intraop crystalloid

Intraop colloid

Cumulative intraop fluid

Cummulative to day 2 post op

Restrictive 1570 (909) 171 (272) 1769 (1066) 4679 (2425)

Doppler guided

1545 (686) 556 (530) 2115 (817) 5481 (2151)

ns <0.001 0.008 0.016

Selected intra operative, post operative and cumulative fluid administered in restricted and goal directed arms, by volume and type

Frequency of boluses

start endSVI 43.41 51.6 0.0011

CI 3.1 4.6 0.0553FTc 338 366 0.0038

star

t

end

Length of stay (days)

Medically ready length of stay (days)

p=0.007

RES Doppler RES Doppler RES Doppler

StudynSurgery

ASAStoma rate LOS median 5 6 5 5 6 6.5

No Pt with Cx % 73% 70% 30% 32% 52% 60%Clavien Dindo grade III-V

9 7 9 1

Patients with major Cx

8 (10%) 10 (14%) 4 (8%) 1 (2%)

incl rectal and stoma

1-3 (exclude 4)

excl rectal and

22% 29%

Srinivasa BJS 2012Brandstrup 2012

BJA Phan 201485 150 100

LiDCOrapidTM

Date of download: 7/24/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery:   A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305

Participant Flow

Figure Legend:

Date of download: 7/24/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery:   A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305

Results for Secondary Outcomes

Figure Legend:

Date of download: 7/24/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery:   A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305

Cumulative Incidence of Mortality Up to 180 Days After Surgery Using a Cardiac Output–Guided Hemodynamic Therapy Algorithm Intervention vs Usual Care

Figure Legend:

Date of download: 7/24/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery:   A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305

Meta-analysis of Number of Patients Developing Complications After SurgerySize of data markers corresponds to weighting for each component trial.aNew trials identified in updated literature search.

Figure Legend:

“Optimal Fluid therapy”In

crea

sing

M

orbi

dity

HypervolemiaHypovolemia

Opt

imum

modern fluid management

1. No Preload1. No Preload

3. Replacement of losses with titrated BOLUSES of colloid or crystalloid Treat hypotension and normovolemia with vasopressors

3. Replacement of losses with titrated BOLUSES of colloid or crystalloid Treat hypotension and normovolemia with vasopressors

4. Encourage early oral intake of fluids4. Encourage early oral intake of fluids

2. Intraoperative: 5-8mls/kg/hr of balanced crystalloid maintenance (Hartmann’s or Plasmalyte)

2. Intraoperative: 5-8mls/kg/hr of balanced crystalloid maintenance (Hartmann’s or Plasmalyte)

modern fluid management1. Use preload sensitive parameters to guide optimal fluid therapy for high risk patients

Doppler technique

Respiratory coupled parameters of Pulse Pressure Variation or Stroke Volume Variation (Systolic Pressure Variation or Plethysmographic Variation Index)

1. Use preload sensitive parameters to guide optimal fluid therapy for high risk patients

Doppler technique

Respiratory coupled parameters of Pulse Pressure Variation or Stroke Volume Variation (Systolic Pressure Variation or Plethysmographic Variation Index)

2. Ignore urine output as haemodynamic goal2. Ignore urine output as haemodynamic goal

3. Develop audit for outcomes and processes 3. Develop audit for outcomes and processes

modern fluid management1. What’s wrong with traditional practice?

Understand the limitations of volume resuscitationSurrogate endpoints

1. What’s wrong with traditional practice?Understand the limitations of volume resuscitationSurrogate endpoints

3. Fluid optimisation – Goal directed fluid therapyCorrection of hypovolemia will always be an important principal of perioperative resuscitation

3. Fluid optimisation – Goal directed fluid therapyCorrection of hypovolemia will always be an important principal of perioperative resuscitation

4. Time to change practice? YES“Lack of evidence should not be misused as justification for continuing current arbitrary decision making” Jacob et al, Lancet 2007

4. Time to change practice? YES“Lack of evidence should not be misused as justification for continuing current arbitrary decision making” Jacob et al, Lancet 2007

2. Fluid restrictionHypervolemiaSalt and water load

2. Fluid restrictionHypervolemiaSalt and water load