goal-directed fluid therapy: a new way of thinking · perioperative fluid therapy: a statement from...

Goal-Directed Fluid

Therapy: A New Way of

Thinking

Ji Su Jenny Kim & Logan D. MacLean SRNA, BSN, CCRN

DNP Candidates

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

Brief History of Fluid Management

Srinivasa, S. & Hill, A. G. (2012). Perioperative fluid administration: historical highlights and implications for practice. Surgical Retrospection, 256(6), 1113-1118.

Why Should I Care?

Hypovolemia Hypervolemia

Hypovolemia Complications

Low cardiac output

Decreased tissue perfusion

Shock/organ failure

Hypovolemia

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.

Hypervolemia Complications Respiratory

effects

GI effects

Coagulation

Wound healing

Hypervolemia

Joshi, G. P. (2018). Intraoperative fluid management. UpToDate. Retrieved February 26, 2018, from

https://www.uptodate.com/contents/intraoperative-fluid-management

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), 502-510.

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: 10.1097/SLA.0000000000002220

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), 502-510

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 Recent respiratory infection (<1 mo)

Reintervention Partial or total functional dependency

Surgical duration > 2h Active smoking

Open laparotomy > laparoscopy Alcohol abuse

Preoperative sepsis

Weight loss > 10% in the last 6 months

Preoperative anemia (<10g/dl)

Obesity Futier, E., Marret, E., & Jaber, S. (2014). Perioperative positive pressure ventilation: an integrated approach to improved pulmonary care.

Anesthesiology, 121(2), 400-408.

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:10.1186/cc11344

+ 4150 mL


doi:10.1186/cc11344

Fluid Compartments

Fluid Compartments

30L

12L

3L

Fluid Compartments

30L

12L

3L

water Na+ Na+

K+ K+ protein protein

Fluid Compartments

30L

12L

3L

water Na+ Na+


water

Na+ K+

protein

protein

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), 191-198.

doi:10.1016/j.tacc.2012.05.001


Inhalational Agents (sevoflurane)

Plasma proteins

Hydrocortisone

Etanercept (TNF-a receptor)

Antithrombin III

Antioxidants

Ischemia/Reperfusion

Sepsis/Inflammation

Hypervolemia

ANP

Hyperglycemia

Surgical Stress

Pro

tect

Destro

y

Bashandy, G. M. (2014). Implications of recent accumulating knowledge about endothelial glycocalyx on anesthetic management. Journal of Anesthesia,29(2), 269-278. doi:10.1007/s00540-014-

1887-6

Intra-Operative Fluid Replacement

Hours Fluid

Deficit

Maintenance Insensible

Losses

EBL Urine

Output

Hourly

Total

Total

Hour 1 600 120 640 100 (300) 150 1,810 1,810

Hour 2 300 120 640 300 (900) 50 2,010 3,820

Hour 3 300 120 640 50 (150) 30 1,240 5,060 mls

80kg pt undergoing Exploratory Laparotomy; NPO for past 10 hours

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, 7th edition. Philadelphia, PA: Lippincott Williams & Wilkins.



Hours Fluid

Deficit


Losses

EBL Urine

Output

Hourly

Total

Total

Hour 1 600 120 640 100 (300) 150 1,810 1,810

Hour 2 300 120 640 300 (900) 50 2,010 3,820

Hour 3 300 120 640 50 (150) 30 1,240 5,060 mls

“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



Hours Fluid

Deficit


Losses

EBL Urine

Output

Hourly

Total

Total

Hour 1 600 120 640 100 (300) 150 1,810 1,810

Hour 2 300 120 640 300 (900) 50 2,010 3,820

Hour 3 300 120 640 50 (150) 30 1,240 5,060 mls

Hours Fluid

Deficit


Losses

EBL Urine

Output

Hourly

Total

Total

Hour 1 600 120 640 100 (300) 150 1,810 1,810

Hour 2 300 120 640 300 (900) 50 2,010 3,820

Hour 3 300 120 640 50 (150) 30 1,240 5,060 mls



• Pre-op fasting for 10hrs = No differences between

theoretical and actual plasma volumes using indocyanine

green (2008)

• Pre-op fasting for >8hrs = No differences between pre and

post fasting plasma volumes using transthoracic

echocardiography (2014)

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), 522-529.

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), 835-841.



Hours Fluid

Deficit


Losses

EBL Urine

Output

Hourly

Total

Total

Hour 1 600 120 640 100 (300) 150 1,810 1,810

Hour 2 300 120 640 300 (900) 50 2,010 3,820

Hour 3 300 120 640 50 (150) 30 1,240 5,060 mls







abdominal contents


(or more)




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).







abdominal contents


(or more)




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).

Evaporation/fluid loss

through exposure:

0.5-1 ml/kg/hr

Fluid Resuscitation

Classical Approach

● 3:1 ratio

Recent Findings

● 1.3:1 to 2:1 ratio

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), 389-402.

Hartog, C. S., Bauer, M., & Reinhart, K. (2011). The efficacy and safety of colloid resuscitation in the critically ill. Anesthesia & Analgesia, 120(1), 156-164.

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)



Hours Fluid

Deficit


Losses

EBL Urine

Output

Hourly

Total

Total

Hour 1 600 120 640 100 (300) 150 1,810 1,810

Hour 2 300 120 640 300 (900) 50 2,010 3,820

Hour 3 300 120 640 50 (150) 30 1,240 5,060 mls

● Scientific Method

● Traditional Indicators

● Advanced Indicators

● Pharmacokinetic Indicator: Volume Effect

● Crystalloid vs. Colloid

Indications and Interventions

Volume

Replacement

Scientific Method

1

Target

Normovolemia

Indication

Intravascular

Hypovolemia

2

Therapy

3

Outcome

Variable

Blood Volume

4

Traditional Indicators

● BP, HR, CVP

● Urine output

● Not sensitive or specific

62 ± 14 58 ± 7 55 ± 8

HR

Blood volume: 3959 ± 387 ml 3501 ± 499ml 3934 ± 500 ml

(n = 10) Hct: 0.35 ± 0.04 0.28 ± 0.04 0.25 ± 0.04


doi:10.1186/cc11344

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), 53-54. doi:10.1097/01.sa.0000424120.94390.dc

✓ Scientific Method

✓ Traditional Indicators

✓ Advanced Indicators

● Pharmacokinetic Indicator: Volume Effect



● Percentage of infused solution that ○ 1) remains within circulatory compartment and

○ 2) does not cause interstitial edema

Volume Effect

30L 12L

3L



● Calculation Methods ○ Hematocrit Dilution (98% existing data)

○ Acute Normovolemic Hemodilution (ANH)

Volume Effect

30L 12L

3L

- Initial hct

- Initial blood volume * initial Hct = Red Cell Volume

- Intravenous volume therapy

- New Hct

- Calculation of increase in blood volume

Volume Effect: Hematocrit Dilution

- Initial hct



- New Hct



0.40

- Initial hct



- New Hct



5 L * 0.40 = 2 L RCV

5 L - 2 L = 3 L Plasma

0.40

- Initial hct



- New Hct



5 L * 0.40 = 2 L RCV


1 L Colloid

0.40

- Initial hct



- New Hct



5 L * 0.40 = 2 L RCV


1 L Colloid

0.35

0.40

- Initial hct



- New Hct



5 L * 0.40 = 2 L RCV


1 L Colloid

0.35

2 L RCV = x L Plasma

0.35 0.65

x = 3.7 L Plasma

0.40


- Initial hct



- New Hct


5 L * 0.40 = 2 L RCV


1 L Colloid

0.35


0.35 0.65

x = 3.7 L Plasma

0.40


Volume Effect of

1L Colloid

70%

- Initial hct



- New Hct


+700 mL =

1000 mL

5 L * 0.40 = 2 L RCV


1 L Colloid

0.35


0.35 0.65

x = 3.7 L Plasma

0.40


Inhalational Agents (sevoflurane)

Plasma proteins

Hydrocortisone

Etanercept (TNF-a receptor)

Antithrombin III

Antioxidants

Ischemia/Reperfusion

Sepsis/Inflammation

Hypervolemia

ANP

Hyperglycemia

Surgical Stress

Pro

tect

Destro

y

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), 191-198.

doi:10.1016/j.tacc.2012.05.001



● Calculation Methods ○ Hematocrit Dilution

○ Acute Normovolemic Hemodilution (ANH)

Volume Effect

30L 12L

3L

Acute Normovolemic Hemodilution (ANH)


doi:10.1186/cc11344


BV: 4L


doi:10.1186/cc11344


doi:10.1186/cc11344


BV: 4L

Blood Loss: - 1L

LR: + 3L


doi:10.1186/cc11344


BV: 4L

Blood Loss: - 1L

LR: + 3L

BV: 3.5L


doi:10.1186/cc11344


BV: 4L

Blood Loss: - 1L

LR: + 3L

BV: 3.5L

Volume

Effect of LR

17%


BV:

4L Blood Loss: - 1L

LR:

+ 3L

BV:

3.5L

Volume

Effect of LR

17%


doi:10.1186/cc11344


BV: 4.1 L


doi:10.1186/cc11344


BV: 4.1 L

Blood Loss: - 1.4 L

6% HES: + 1.7 L


doi:10.1186/cc11344


BV: 4.1 L

Blood Loss: - 1.4 L

6% HES: + 1.7 L

BV: 4.3 L


doi:10.1186/cc11344


BV: 4.1 L

Blood Loss: - 1.4 L

6% HES: + 1.7 L

BV: 4.3 L

Volume

Effect of

Colloid (ANH)

98%


doi:10.1186/cc11344


BV: 4.1 L

Blood Loss: - 1.4 L

6% HES: + 1.7 L

BV: 4.3 L

Volume

Effect of

Colloid (ANH)

98%

Vs.

Volume Effect

(Hct dilution)

127%


Volume

Effect of

Colloid (ANH)

98%

Vs.

Volume Effect

(Hct dilution)

127%

30L

12L

3L

water Na+ Na+


water

Na+ K+

protein

protein


Volume

Effect of LR

17%

Volume

Effect of

Colloid (ANH)

98%


doi:10.1186/cc11344

Volume

Replacement

Scientific Method

1

Target

Normovolemia

Indication

Intravascular

Hypovolemia

2

Therapy

3

Outcome

Variable

Blood Volume

4

Scientific Method

Volume

Replacement

1

Target

Normovolemia

Indication

Intravascular

Hypovolemia

2

Therapy

3

Outcome

Variable

Blood Volume

4


doi:10.1186/cc11344

Volume Loading (VL)

BV: 4.2 L


doi:10.1186/cc11344

Volume Loading (VL)

BV: 4.2 L

Blood Loss: ---

Albumin: + 1.4 L


doi:10.1186/cc11344

Volume Loading (VL)

BV: 4.2 L

Blood Loss: ---

Albumin: + 1.4 L

BV: 4.7 L


doi:10.1186/cc11344

Volume Loading (VL)

BV: 4.2 L

Blood Loss: ---

Albumin: + 1.4 L

BV: 4.7 L

Volume

Effect of

Colloid (VL)

38%

Volume Effect is Context Sensitive

Volume

Effect of

Colloid (VL)

38%

Volume

Effect of

Colloid (ANH)

98%


doi:10.1186/cc11344

✓ Scientific Method

✓ Traditional Indicators

✓ Advanced Indicators

✓ Pharmacokinetic Indicator: Volume Effect



Crystalloid Colloid

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.

THANK YOU!

goal-directed fluid therapy: a new way of thinking · perioperative fluid therapy: a statement from...

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