1. Peri-operative fluid therapy– trends Work Group Meeting on Fast-track surgery , Vigo, 2009 Dr. med. Aarne Feldheiser Department of Anesthesiology and Intensive Care Campus Mitte and Clinic of Virchow Charité – University Medicine Berlin Director: Prof. Dr. med. Claudia Spies U N I V E R S I T Ä T S M E D I Z I N B E R L I N

3. Example of liberal fluid management Brandstrup, B. et al., Ann Surg, 2003

4. Little Michelin man greets you Fluid overload

5. Example of restrictive fluid management Brandstrup, B. et al., Ann Surg, 2003

6. Restrictive Fluid Management Brandstrup, B. et al., Ann Surg, 2003 Perioperative fluid Administration difference: ~2,5 l

7. Restrictive Fluid Management Brandstrup, B. et al., Ann Surg, 2003 Periopertive Body Weight Changes difference: ~1,8 kg weight difference: ~2,5 kg weight

8. Restrictive Fluid Management Brandstrup, B. et al., Ann Surg, 2003 Number of patients with complications Number of complications

9. Restrictive Fluid Management Brandstrup, B. et al., Ann Surg, 2003 Complication frequency [%] Intravenous fluids Postoperative body weight change

10. Liberal protocol vs. restrictive fluid administration Liberal protocolo: Bolus: 10 ml/kg initially Continuous: 12 ml/kg/h Restrictive protocol : Bolus: keiner Continuous: 4 ml/kg/h Nisanevich, V. et al., Anesthesiology, 2005 Duration of hospital stay: Liberal group: 9 days Restrictive group: 8 days p < 0.01 tachycardia hypotonia Urine for 2 hrs. < 0.5 cc/kg*h Algorithm fluid administration: 250 cc RL, up to 1500 cc Places PVC line: think colloidal fluids, inotropic etc.

11. Liberal protocol vs. restrictive fluid administration Nisanevich, V. et al., Anesthesiology, 2005 Total volume of administered fluids: Perioperative Complications : RestrictiveProtocol RestrictiveProtocol Liberal Protocol Liberal Protocol n = 77 n = 75

12. Studies with advantages of restrictive fluid management Author Perioperative time „ Fast track“ Volume Advantages for ... Lobo 2002 postoperative no 2.000 cc/d vs. 3.000 cc/d &quot; restrictive“ group Brandstrup 2003 intraoperative no estándar vs. guiado por peso group guided by weight Basse 2004 intraoperative yes 2.000 cc vs. 3.000 cc &quot; restrictive“ group Nisanevich 2005 intraoperative no 4 cc/kg/h vs. 12 cc/kg/h &quot; restrictive“ group

13. Advantages for liberal fluid management Holte, K. et al., Ann Surg, 2004 Operation: Laparoscopic cholecystectomy Restrictive: 15 ml / kg weight, Liberal: 40 ml / kg weight Data from the ward and discharge

14. Advantages for liberal fluid management Within a “ Fast-Track“ program Holte, K. et al., Br J Anaesth, 2007 Operation: Colorectal Surgery Restrictive Group Liberal Group Preload of epidural anastesia Fluid protocol during surgery Bowl preparation Before the operation After surgery (ICU)

15. Advantages for liberal fluid management Holte, K. et al., Br J Anaesth, 2007 Postoperative data, Clinic length of stay Restrictive Protocol Liberal Protocol

16. Studies with advantages of liberal fluid management Author Perioperative time „ Fast track“ Volume Advantages for ... Holte 2004 intraoperative yes 15 cc/kg vs. 40 cc/kg “ liberal“ group Moretti 2003 intraoperative no adapted colloidal and cristalloid vs. only cristalloid fluid therapy “ liberal“ group von Heymann 2006 Intraoperative and ICU yes 36 cc/kg vs. 53 cc/kg no difference MacKay 2006 postoperative no <2.000 cc/24h (77mmol Na + /d) vs. 3.000 cc/24h (154 mmol Na + /d) no difference Holte 2007 perioperative yes 7 cc/kg during 1 hour, after 5 cc/kg vs. 18 cc/kg + precharge “ restrictive“ group: pulmonary function improved “ liberal“ group: Hospital stay reduced

17. How much volume we give the patient? You'll see, something will happen today day ...

19. Goal-directed algorithm Heartbeat Volume precharge volume Increase 2 Increase 1 Wakeling, H.G. et al., Br J Anaesth, 2005. p. 634-42.

21. Non-cardíac Doppler Studies 22% reduction in compl.with risk of death and LOS Abdominal 108 Noblett 2006 13% reduction in LOS 37% reduction in compl.with risk of death Abdominal 134 ASA I - III Wakeling 2005 29% reduction in LOS Urology / Gynacology 100 ASA I/II/III Gan 2002 33% reduction in LOS Urology / Gynacology 44 Gan 1999 23% recuction in LOS 44% reduction in total number of Post Op.complications Hip Fracture 90 ASA III/IV Venn 2002 39% reduction in LOS Hip Fracture 40 ASA II/III Sinclair 1997 Result for the patient Surgery n Study

26. Thank you very much for your atention! Dr. med. Aarne Feldheiser, Charité – Medicina universitaria Berlin, [email_address]