4. MMyytthhss:: ““tthhiirrdd ssppaaccee””
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
6. Myth: urine output is a good target Myth: urine output is a good target ffoorr rreessuusscciittaattiioonn
Oliguric normovolemic patients do not increase
their urine output in response to fluid bolus.
7. Renal function
“Evidence “Evidence ffoorr hhaarrmm:: nnoorrmmaall ssaalliinnee””
– 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
formation
Observed electrolyte and acid base deficits
which is readily treated with balanced fluids
– Association with negative outcomes
14. 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
21. The effect of ODM optimisation on post-op morbidity and complications
22. REStrictive OR Targeted fluid therapy “RESORT”:
IInntteerrvveennttiioonn PPaarrttiicciippaannttss
Enhanced recovery after surgery protocol
ASA 1 to 3
Restrictive fluid therapy
vs
Doppler targeted fluid therapy
Stratified: No Stoma vs Stoma
Hypothes
Hypothes
is
is
Intra-operative Doppler targeted fluid
therapy improves outcomes in elective major
colorectal surgery within an ERAS program
26. Selected intra operative, post operative and cumulative fluid administered in
restricted and goal directed arms, by volume and type
Intraop
crystalloid
Intraop
colloid
Cumulative
intraop fl
uid
Cummulativ
e 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
41. modern fluid management
11. . N Noo P Prreeloloaadd
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)
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
44. . E Ennccoouurraaggee e eaarrlyly o orraal li ninttaakkee o off f fluluididss
42. modern fluid management
1. Use preload sensitive parameters to guide optimal fluid therapy for high
risk patients
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)
Doppler technique
Respiratory coupled parameters of Pulse Pressure Variation or Stroke Volume Variation
(Systolic Pressure Variation or Plethysmographic Variation Index)
2. Ignore 2. Ignore u urrininee o ouuttppuutt a ass h haaeemmooddyynnaammicic g gooaall
33.. D Deevveelolopp a auudditit f foorr o ouuttccoommeess a anndd p prroocceesssseess
43. modern fluid management
1. What’s wrong with traditional practice?
Understand the limitations of volume resuscitation
Surrogate endpoints
2. Fluid restriction
2. Fluid restriction
Hypervolemia
Salt and water load
Hypervolemia
Salt and water load
3. Fluid optimisation – Goal directed fluid therapy
3. Fluid optimisation – Goal directed fluid therapy
Correction of hypovolemia will always be an important principal of perioperative
resuscitation
Correction of hypovolemia will always be an important principal of perioperative
resuscitation
4. Time to change practice? YES
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
“Lack of evidence should not be misused as justification for continuing current
arbitrary decision making” Jacob et al, Lancet 2007
Hinweis der Redaktion
Single campus, public and private
5 surgeon – teaching hospital
100 patients in ICU – 18 developed oliguria. 11/18 had clinical eupovolemia that did not respond to fluid bolus. Of note 7/18 had hypovolemia and did respond. ADH played a role in oliguria.
Table shows that the response to surgery leads to a number of
The question is not is the patient oliguria = bad. But that oliguria and review the patient if they are euvolemic then don’t worry.
Oliguria &lt;20mls/hr
Younos Bellomo
Cochrane – only signficant diff in metaanalysis 700+ patients
Electrolyte abnormalities – hyperchloremia, acidosis
More platelet transfusion
No diff in mortality, n+V, blood t/f, LOS
Lobo – reduced complications and hospital stay
Brandstrup 172, colorectal fewer cx 33 vs 51 deaths 0 vs 4
Nisanevich 152, elective abdominal patients faster return of gut fun, less cx and shorter los
Kabon 253 colorectal – no difference, holte 32 fastrack – higher cx in restrictive group.
metaanalsis
NHMRC: back to basics
Tries to address the heterogeneity of current mix of trials. By being the definitive: 3000 patients.
Powered for real patient centre end points.
Generalizability will be immense – the results of this study would change practice if it favours a treatment.
What it does NOT do is study a fixed fluid regimen compared with an individualized targetted regimen in a randomized manner.
Forrest plot of LOS RES vs Lib
Total 1000.
Contemporary
While there are controversies, this concept that fluid therapy matters is important.
You can stuff up a patients recovery/complication rate by giving unwanted fluid load or not giving enough. How you give just enough is a matter of contention.
Keys to fluid optimisation:
Frank Starling relationship
Fluid responsive
Non-fluid responsive
Caveats: do we have a reliable monitor to assess this
Does achieving this conceptual haemodynamic target result in improved patient outcomes
Despite the caveats, these monitors offer us a greater understanding of where the patient is at compared to std monitoring and if we allow it too, it could influence our decision making to improve patient outcomes.
ERAS – contemporary practice. Fluid specific CHO load. Early enteral. Avoid bowel prep.
Things that reduce periop morbidity: Education. NG, IDC, drain tubes. Laparascopic, tissue handling.
ASA 1 to 3 – this is what I wanted to study. I wanted to say to patients walking up to have colorectal surgery – we have the best recovery planned for you possilbe, within that anaesthesia will give you the best fluid resuscitation there is.
Restrictive – no clear evidence base but part and parcel with many eras programs.
Doppler – targetted. Not goal directed. No inotropes – inappropriate. Doppler the strongest evidence base. No clear expertise amongst all the department.
Amend slightly the algorithm for my institution.
Reason bolus. Using absolute, FTc. Clinically relevant.
SVO 10%
At least it gave a signal for clinicians to agree not to give fluid therapy. Avoid the problem of Challand
What is the mean values for fluid administration.
Crystalloid – nd
Colloid – statistically significant, clinically irrelevant
Post op d1 – unexplained difference of 500mls, imed, blinded ward protocols.
Boluses are more frequent in Doppler group
Whilst the mean is only 1 bag.
The difference is that that in 20 patients they had extra 0.5L and in 20% extra 1 L
FR persisted longer
Shows that SVO was done to my satisfaction – only a proportion of patients are FR and got &gt;500mls of fluid.
Successful optimisation of haemodynamic parameters
Overall terms
Between the two groups
Any nd
Major nd
30d Readmission nd – hernia repair, vomiting, pain, one wound infection, community acq pneumonia.
Death – male 74, asa 2 asthma, rectal resection stoma, good progress d3 – fluid down, idc out, coffee ground vomiting. Rapid deterioration – hypotension, hypovolemia, mof. No signs of AMI, or adverse finding intraop beyond bowel with poor perfusion. Gut looks like the source – but not clearly ischaemic bowel. Cardiogenic shock for want of a better diagnosis.
Count of complications grade 1 (any deviation from normal postop course without specific treatment or allowed drugs analgesia, antiemetic) to 2 (requiring pharmacological treament, blood tf or tpn). No treatment or ward based treatment. Blood transfusion, ngt, low uo, cr&gt;200 or doubling, clinical with treatment, neurologic – delirium.
Hypotension – nd
PONV – less in gdt, and ileus favour res. Inconclusive benefit for gdt in gi morbidity.
Count of major complications. Of the 4 RES that had cx, 9 major
1 GDT, 1 major
Uncertainty – Small numbers. Not in keeping with the minor complications.
Contemporary ERAS GDT
nd
Some studies I suspect start with hypovolemia and as a result tdargetted therapy may have benefitted the patients
Some studies are hypervolemia.
Compare traditional approach to a new therapeutic idea in a sufficiently high number of patients
If the study group is better than the control then the study group is the future
If not then nothing changes
Problems
No easily defined control – heterogeneity of practice. Btw clinicians and hospitals and countries. Not just of fluid practice but periop practice
What is restrictive in one group is liberal in another
Thinking about the concept and being deliberate will be enough to bring about change.
