Your SlideShare is downloading. ×
Perioperative fluid therapy logic & evidence
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Perioperative fluid therapy logic & evidence

1,205
views

Published on

Published in: Health & Medicine, Technology

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,205
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Two groups of patients have been studied. The control group consisted of five patients having general anesthesia and minor surgical procedures involving minimal tissue trauma and minimal blood loss. These patients received no fluids or electrolytes during the surgical procedure and were used to demonstrate the accuracy and reproducibility of the method. The study group consisted of 13 adults undergoing elective major surgical procedures. As in the control group simultaneous measurements of plasma volume, red blood cell mass, and extracellular fluid volume were made at the beginning of operation and were then remeasured after two hours ofthe surgical procedure. During this time no fluids or electrolytes were administered to the patients. The present data demonstrate a marked reduction in the S35O4 space in response to the acute trauma of operation. This could be explained by either: 1) External loss from the body by such routes as whole TAIBLE 4. Con/tro Preop. Patient 3 12 22 4 5 8 9 10 11 12 14 16 17 19 P'ostol). Na K Na K 140 144 139 144 135 136 138 142 142 139 145 136 139 140 4.5 139 5.0 142 4.6 141 Experimiient(al 4.6 140 4.8 139 4.4 136 5.1 139 4.2 142 4.8 139 5.0 140 4.7 143 4.6 138 5.1 136 4.9 140 4.8 5.1 4.6 4.5 5.0 4.5 5.0 4.2 4.9 4.7 4.9 4.9 5.1 4.8 blood loss, plasma oozing, or by drainage of ultrafiltrate in some fashion such as drainage from the operative site; or -2) Internal redistribution or sequestration into an area where S3O4 no longer equilibrates with the extracellular pool.
  • To prevent this type of fluid shifting, it seems crucial to protect the endothelial surface layer. Perioperative alteration of this structure has two main causes: first, the release of inflammatory mediators due to surgical trauma; and second, the release of atrial natriuretic peptide during iatrogenic acute hypervolemia.
  • To prevent this type of fluid shifting, it seems crucial to protect the endothelial surface layer. Perioperative alteration of this structure has two main causes: first, the release of inflammatory mediators due to surgical trauma; and second, the release of atrial natriuretic peptide during iatrogenic acute hypervolemia.
  • To prevent this type of fluid shifting, it seems crucial to protect the endothelial surface layer. Perioperative alteration of this structure has two main causes: first, the release of inflammatory mediators due to surgical trauma; and second, the release of atrial natriuretic peptide during iatrogenic acute hypervolemia.
  • This is based on pediatric studies and therefore may overestimate needs.
  • OUT COME STUDIES SHOWING ILL EFFECTS OF EXCESS FLUID ADMINISTRATION
  • We spoke about general guidelines and about how trauma and 3rd space loss may require extra fluid, but now lets look at more specific pt populations.
  • We spoke about general guidelines and about how trauma and 3rd space loss may require extra fluid, but now lets look at more specific pt populations.
  • These pts had elective bowel or other abdominal organ surgery. There was no difference in mortality.
  • ?is this retrospective data?
  • RIFLE classification for AKI after modifications by the Acute Kidney Injury Network. Patients are classified according to the worst of creatinine or urine output criteria. Patients do not need to fulfil both creatinine and urine output criteria. Diagnosis of AKI on the basis of creatinine criteria is fulfilled when patients experience an increase in serum creatinine ≥0.3 mg/dL or >150% within a 48-h period. Figure adapted from Bellomo et al. [2].
  • Transcript

    • 1. FLUID THERAPY: LOGIC &EVIDENCE- Dr.Padma Puppala MD., FRCA.,Anesthesiology & Critical care
    • 2.  What does the body do to the fluid? What does the fluid do to the body? What are the effects of surgery on fluid dynamics? Does perioperative fluid therapy impact patientoutcomes? Are we getting it right? Should we re-evaluate our practice?
    • 3. WHAT HAPPENS IF YOU GIVE 1LITER OF IV FLUID TO A HEALTHYADULT?Let us try’n find answersquestion by question!
    • 4. IN HEALTHY VOLUNTEERSAFTER 22ML/KG OF FLUID• 93% of 5% dextrose, 68% of NS, 16-20%% of colloids• leaked out of the Intravascular compartment, within an hour• Excretion of salt & water takes 2 days• FRC decreases by 10%• Diffusion capacity by 6%• Reduced tissue oxygenation
    • 5. STARLINGS FORCES
    • 6. Acute change in extracellular fluids associated with major surgical proceduresAnnals of Surgery, 1961: Shires et alTHIRD SPACE• 13 adults, elective major surgical proceduresVs 5 minor procedures• Measured• Plasma volume• Red blood cell mass• Eextracellular fluid volume• Loss of ECV (up to 28%)• ?Sequestration of fluid in a non-functional extracellularspace that is beyond osmotic equilibrium with thevascular space
    • 7. THIRD SPACE-FACT OR FICTION?
    • 8. The classic “third space” has neverbeen localized• Original methodology supporting the concept of thirdspace were fundamentally flawed?• Numerous trials report an unchanged or increased fECVafter surgery
    • 9. SHIRES & SHOEMAKEREFFECT•Liberal fluid administration becamestandard practice in 80’s & early 90’s•7–10 kg weight gain not uncommon•Proportionately increased risk ofmorbidity and mortality
    • 10. EFFECTS OF FLUID OVERLOADInterstitial oedemaEffusionsProlonged ventilator therapyOedema of the gutDelayed enteral feedingTranslocation of bacteriaProlonged ICU & hospital stayReduced tissue oxygen tensionImpaired wound healing
    • 11. EFFECT OF SURGERY ON FLUIDDYNAMICSSalt & water retentionInterstetial oedema
    • 12. RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYXType 1:Physiologic shiftof protein free fluidType II:Pathological shiftof protein rich fluid
    • 13. RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYX
    • 14. RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYX• Mechanical stress• Endotoxin exposure,• Ischemia–reperfusion injury• Inflammation• Fluid loading• Acute hypervolemia• Release ANP
    • 15. British Consensus Guidelineson Intravenous Fluid Therapy forAdult Surgical Patients - 2007
    • 16. PREOPERATIVEFLUID MANAGEMENT• Clear fluids not to be withheld for > 2 hrs (Cochrane)• Carbohydrate rich drink 2-3 hrs before surgery• Reduces postoperative insulin resistance• Facilitates recovery from surgery.• Bowel preparation to be avoided wherever possible• Simultaneous correction with Hartmans if mandatory• Gastric losses to be treated with potassium containingsolutions
    • 17. INTRAOPERATIVEFLUID THERAPY• Pre/ co-loading• Maintenance• Replacement• Preoperative deficit• Compensation• Blood loss• Insensible losses• Third space loss
    • 18. GOALS OFINTRAOPERATIVE FLUIDADMINISTRATION• O2 delivery / blood flow - perfusion• Maintain electrolyte composition,• Normoglycaemia,• Body temperatureThe focus of our efforts should be to avoidcollateral damage due to interstitial oedema
    • 19. HOW MUCH TO GIVE &WHEN TO GIVE ITDepends on• Type of patient• Type of surgery• Acute injury vs. elective• Type of Anesthetic• Positioning• Evidence base / general trends across the world
    • 20. DEFICITSConventional teaching• Preoperative bowel preparation (1-1.5L)• Preoperative blood loss (trauma) or fluid loss (burns)• Preoperative NPO (hourly maintenance x duration)• Typically replaced over first 2-4 hoursEvidence?• Blood volume is normal after pre-operative overnightfasting Acta Anaesthesiol Scand. 2008 Apr;52(4):522-9.
    • 21. MAINTENANCE• (4-2-1 rule)• 4 ml/kg/hr for first 10 kg of body weight• 2 ml/kg/hr for 2nd 10 kg of body weight• 1 ml/kg/hr for each kg of body weight above 20 kg• 1.5 ml/ kg/ hr for adults
    • 22. REPLACEMENT• Insensible losses: (Evaporative)• 0.5 – 1 ml/kg/hr• Third space• 2-5 ml /kg / hr?• NG/ Urine losses• Blood losses:• 1 to 1 for colloid or bloodRoutine replacement of high insensible and thirdspace losses should be abolished in favour ofdemand-related fluid regimensReplace withCrystalliod
    • 23. WHICH CRYSTALLOID
    • 24. NS VS RLNormal saline Ringer’s Lactateisotonic isotonicExcess of chloride ions More physiologicalno buffer lactate or acetate bufferexcreted more slowly Rapid eliminationChoice in Vomiting Choice in Diarrhea• Ringer lactate is preferable for co-loading & maintenance?• Crystalloid boluses are less effective in drug induced hypotension• NS indicated in hyperchloraemic metabolic alkalosis as in vomiting
    • 25. INTRAOPERATIVE FLUIDMANAGEMENT: MAJOR SURGERYOptimal stroke volume mayreduce postoperativecomplication rates andduration of hospital stay“Good” ventricles are preload dependent“Poor” ventricles are afterload dependent
    • 26. GDT & STROKE VOLUME
    • 27. IDEAL PRELOADMONITOR?• CVP?• PCWP?• IVC?• LVEDV?• SPV• PPV/ SVV?• sVO2
    • 28. SPECIFIC SCENARIOS• Minor surgery• Pulmonary surgery• Hepatic surgery• Vascular surgery• Hip surgery• Trauma• Neurotrauma
    • 29. HEALTHY OUTPATIENTS –MINOR PROCEDURE
    • 30. HEALTHY OUTPATIENTS – MINORPROCEDURE• 1 - 2 liters of fluid• Decrease thirst, dizziness, drowsiness, pain and nausea• Reduce time to discharge• May improve respiratory function post operativelyStudy Surgery T vs C Fluid Number ResultGoodarzi et al2006Strabism 30 vs10 mlKH RL 100 Significant+ on PONVChaudary etal2008Openchole 12 vs 2ml/kg/hrRL/ HES 60 Significant+ on PONVRLSignificant+ on PONV
    • 31. FLUIDS IN MAJORABDOMINAL SURGERY
    • 32. LIBERAL VS RESTRICTIVE
    • 33. LIBERAL VS RESTRICTIVE
    • 34. PULMONARYSURGERYMiller et al: Annals Thoracic Surg 2002• 115 completion pneumonectomies• PPE occurred in 15% with Mortality of 43%• Mortality related to Fluid administration12 hours 1800 vs 250024 hours 2300 vs 2800
    • 35. HEPATIC RESECTIONLOW CVP TECHNIQUE• Low CVP technique: 496 resections• IVF 1 cc/kg/hr and boluses as needed• NTG, dopamine, mannitol as needed• Urine output > 25 cc/hr• SBP > 90 mmHg• CVP < 5 mmHg• Results• Reduction in BL and transfusion• Improved visualization of surgical field• Reduces pressure in hepatic tissues• One patient with renal failure due to aminoglycosideMelendez et al J Am Coll Surg 1998
    • 36. HIP REPLACEMENTSharrock: Br J Anaesth; Reg Anesth• 987 surgeries• Spinal/Epidural hypotension (mBP 50-55mmHg)• Fluid restriction to minimize perioperative CHF• Epinephrine as needed to maintain BP and CO• Improved Outcome• Reduction in EBL and transfusions compared tocontrols• 0 renal failures• 3 deaths (0.4%)
    • 37. CASE - 1• Fit 38 year old woman, weight 50kgs• Laparoscopic oesophagectomy• Preoperative Hb: 12g/dl• Has been NBM for 8 hours.• Surgery under GA
    • 38. 1sthour 2ndhour 3rdhour 4thhourPreoperative deficit: 1.5×50×8= 600 ml 300 150 150 0Maintenance: 1.5 × 50 = 75 ml 75 75 75 75Insensible loss: 1 × 50 = 50 ml 50 50 50 50Third space: 4 × 50 = 200 ml 200 200 200 200Additional bolus to compensate ↓BP 200Total crystalloid 825 475 475/ 475Estimated Blood loss 0 100 200 200colloid 0 100 200 200Physiological dataHeart rate 84 90 88 112?Mean arterial pressure 82 84 90 90CVP: Fluctuating & unreliable due to positioning changesUrine output 30ml 25ml 20ml
    • 39. • Tachycardia• Urine output 20 ml/ hr4 HOURS INTOSURGERYVenous blood gasFio2: 0.4pH 7.39pO2 158pCO2 33BE - 7.1Lactates 2.1scVO2 88Hb 8.0 gm/dl
    • 40. POSTOPERATIVE FLUID THERAPY• Resume oral intake as soon as possible• When oral intake is adequate, IV fluids should bediscontinued• Parenteral nutrition reserved for patients who cannot receiveenteral feeds 5 days after surgery• Aim for zero sodium and fluid balance• Fluid volume and content should be those required for dailymaintenance and replacement of any on-going losses• In oedematous patients, aim for gradual persistent negativesodium and water balance
    • 41. Calculate daily requirementsbefore prescription of fluids & Nutrition
    • 42. POSTOPERATIVEMAINENANCE FLUIDSNormal saline -1lt5%dextrose 1.5 ltPotassium– 60mmolNormal saline 100ml/hrPotassium- 60mmolHartman’s100ml/hr
    • 43. ADDITIONALFLUID BOLUSES
    • 44. • Hypotension• Oliguria• AcidosisTHREE COMMON TRIGGERSFOR FLUID BOLUSES
    • 45. IDEAL PRELOADMONITOR?• CVP?• PCWP?• IVC?• LVEDV?• PLR• SPVPPV/SVV?
    • 46. ASSESSMENT OFFLUID NEEDSChanges in stroke volume, radial pulse pressure, induced bypassive leg raising are accurate and interchangeable indicesfor predicting fluid responsiveness in nonintubated patientswith severe sepsis or acute pancreatitis.Crit Care Med. 2010 Sep;38(9):1824-9
    • 47. • Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
    • 48. OLIGURIA
    • 49. RIFLE classification for AKI after modifications by the Acute Kidney Injury Network.Hoste E A , Kellum J A Nephrol. Dial. Transplant.2010;ndt.gfq133© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rightsreserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
    • 50. FLUID THERAPY:PREVENTION OF AKIPOSTOP• Avoid of peri-operative hypovolaemia• Intra & immediate postoperative oliguria is physiological• Fluid boluses are not justified in Isovolaemic patient• Persistent oliguria in isovolaemic patient warrants furtherinvestigation• There is no evidence base to favour the routine prescriptionof crystalloid or colloids to protect kidney function in theperi-operative periodCochrane Database of Systematic Reviews 2005; Issue 3,http://www.renal.org/clinical/guidelinessection/AcuteKidneyInjury.aspx
    • 51. • Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
    • 52. Hyperchloremic acidosisACIDOSIS
    • 53. • Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
    • 54. • Healthy patients; minor surgery• Be generous• Sicker patients; major surgery• Be stingy• Use goal directed therapy when indicatedCONCLUSION