Dr Nirmal P Shah Fluid Managment

1. ADVANCES IN FLUID
RESUSCITATION
WHAT IS THE CONCEPT OF A STATE OF
ZERO FLUID BALANCE
DR NIRMAL SHAH

2. • Although fluid and electrolytes most frequently prescribed
drug,prescription done badly
• Prescription left to most junior member of surgical team in
> 90% case
Taylor.Recent advances in surgery.2014

3. • Much confusion between fluid maintenance, replacement
and resuscitation
Taylor.Recent advances in surgery.2014

6. BODY WATER

8. HEMORRHAGIC SHOCK
J Obstet Gynaecol Can 2002;24(6):504-11

9. CHOICE OF FLUIDS
• Crystalloids
• Colloids
• Blood products
• Whole blood
• PRBC
• FFP
• Platelets

12. EFFECT OF DIFFERENT SOLUTIONS ON
PLASMA VOLUME EXPANSION
Rizoli: J Trauma, Volume 54(5) Supplement.May 2003.S82-
S88

13. ADVANTAGES
Crystalloids…
• Inexpensive.
• Use for maintenance
fluid and initial
resuscitations
• Intravascular half-life
20-30 minutes.
Colloids…
↑ plasma volume
Less peripheral
oedema
Smaller volumes for
resuscitation
Intravascular half-life
3-6 hours.

14. DISADVANTAGES
Crystalloids…
• Dilute plasma protien
• Peripheral edema.
• Pulmonary edema.
Colloids…
Expensive.
Coagulopathy.
Anaphylactic reaction.

15. BLOOD
SUBSTITUTES

16. COMPARISON OF THE PROPERTIES
Property Blood Blood Volume
expanders
Volume
expansion
Yes Yes Yes
Oxygen carrying
capacity
Yes Yes No
Other therapeutic
proteins
Yes No No
Therapeutic life 1-2 months 1-2 days Hours (varies with
dose and species)
Storage life 1 month 6-24 months 2 years
Changes during
storage
Yes No No
Type specific Yes No No
Viral inactivation No Yes Yes
Size Large Small Small
Viscosity High Low/moderate Low
Deanna J. Nelson Encyclopedia of Pharmaceutical Technology. 2002:236 -
262

17. • HBOC: hemoglobin-based oxygen carrier
• PFC: Perfluorocarbons

18. ADVERSE EFFECTS OF HBOCS
• Vasoactivity: Nitric oxide binds to free Hb,
• vasoconstricition occurs.
• Gastrointestinal side effects: nausea, vomiting, diarrhea,
and bloating.
• binding of nitrous oxide to gastrointestinal tissues is
the proposed cause.
• Interfere with laboratory assays. Crit Care Clin 25 (2009) 279–301

19. BALANCED CRYSTALLOIDS VS 0.9%
NORMAL SALINE
• Hamburger showed that erythrocytes least likely to lyse in
0.9% NS
• Indifferent saline,Normal saline or even physiological
saline
• Content:
Na 154 mmol/l, nearly 10% higher
Cl 154 mmol/l, 50% higher than extra cellular fluid
Taylor I.Recent advances in surgery.2014

20. • 0.9% saline excreted more slowly than 5% dextrose or
balanced crystalloids like Hartmann 's solution,Ringer
lactate or Plasma-lyte 148
• Calculated blood volume expansion very similar
Taylor I.Recent advances in surgery.2014

21. • Saline tend to overload interstitial space causing more
oedema because of
a) Toxic effect on endothelial glycocalyx
b) Detrimental effect on renal hemodynamic and function
Zausig Y.Impact of crystalloidal and colloidal nfusion preparation on coronary vascular
integrity, interstitial edema and cardiac performance in isolated heart.2013

22. 0.9% NS EFFECT ON RENAL HEMODYNAMIC
• Slow and sustained suppression of renin angiotensin
aldosterone axis
• Hyperchloremic acidosis with renal oedema lead to
reduction in renal blood flow and renal perfusion
• Depolarisation of macula densa basement membrane via
chloride channel Taylor I.Recent advances in surgery.2014

23. • Review of literature fail to reveal single study showing
0.9% saline superior to more physiological crystalloids
• Renal transplantation study :
19% patient treated for hyperkalemia
31% patient treated for metabolic acidosis
O’Malley CM.A randomissed double blinded comparision of RL and 0.9% NS.2005

24. • Abdominal aortic aneurysm repair
Received more blood product and bicarbonate therapy
• 0.9% saline because of high chloride content cause harm
to kidney
Waters JH.NS vs RL for intraoperative fluid managment.2001

25. • Recent study support for chloride restrictive fluid strategy
in critically ill patients
• Chloride restricted group has decreased incidence of
acute kidney injury
• No difference in hospital mortality ,icu stay or icu length
of stay
Yunos NM.JAMA.2012

26. • Current indication of 0.9% NS:
Alkalosis
Hypochloremia secondary to vomitimg or high NG tube
aspirate
Neurosurgical patient
Taylor I.Recent advances in surgery.2014

27. COLLOIDS VS CRYSTALLOIDS
• Homogenous non- crystalline large molecule or ultra
microscopic particle dispersed through fluid
• Large enough to be retained within circulation and exert
an oncotic pressure across capillary membrane
Taylor I.Recent advances in surgery.2014

28. • Theoretically 100% efficacy in expanding blood volume
but in practice 60-70% of infused volume stay in
intravascular component

29. • Efficacy of colloid to expand plasma volume greater in
hypovolemic subject
• In critically ill patient , do not offer major advantage over
crystalloids with respect to hemodynamic effect
Myburg JA.N Eng J Med.2013

30. • In study of 800 patient of severe sepsis in ICU
Use of 6% HES cause significant increase in death at 90
days compared with Ringers acetate
35% relative increase in rate of renal replacement therapy
Perner et al. N Engl J Med 2012;367:124-
34.

31. HYDROXYETHYL STARCH 130/0.42 VERSUS
RINGER’S ACETATE IN SEVERE SEPSIS
Perner et al. N Engl J Med 2012;367:124-

32. • In CHEST study, use of 6% HES compared with 0.9% NS
No significant difference in death rate at 90 days
21% relative increase in rate of renal replacement therapy
Mybergh et. N EJ M 2012;367:1901-11

33. HYDROXYETHYL STARCH OR SALINE FOR FLUID RESUSCITATION IN
INTENSIVE CARE
Mybergh et. N EJ M
2012;367:1901-11

34. • Both study showed no significant difference in short term
hemodynamic resuscitation apart from transient increase
in CVP and lower vasopressor requirement
• HES ban in UK
• Gelatin and colloid licensed to use

35. A COMPARISON OF ALBUMIN AND SALINE FOR FLUID
RESUSCITATION IN THE INTENSIVE CARE UNIT
The SAFE Study Investigators, . N Engl J Med 2004;350:2247-2256

36. SALINE OR ALBUMIN FOR FLUID RESUSCITATION
IN PATIENTS WITH TRAUMATIC BRAIN INJURY
The SAFE Study Investigators* NEJM 2007; 357;9

37. ALBUMIN ADMINISTRATION IN PATIENTS WITH SEVERE
SEPSIS DUE TO SECONDARY PERITONITIS
C.D. Chou J Chin Med Assoc 2009;5:243-250
Baseline albumin concentration more than 20
g/l.
Baseline albumin concentration of 20 g/l or
less

38. INTRAOPERATIVE FLOW-DIRECTED
FLUID THERAPY
• Gastrointestinal complication account 51% of all
complication and cause of delayed discharge
• Reduced splanchic circulation and oxygenation due to
intraoperative hypotension or occult hypovolemia
Taylor I.Recent advances in surgery.2014

39. • Healthy patient tolerate 25-30% reduction in blood
volume without change in BP or Heart rate
• Splanchic hypo perfusion occur after 10-15% reduction in
blood volume
Taylor I.Recent advances in surgery.2014

40. MONITOR AND DIRECT FLOW GUIDED THERAPY
• Transoesophageal Doppler – Most common
• Arterial pulse contour analysis
• Lithium dillution
• Thoracic bioelectrical impedance analysis
• Partial non breathing system
• Transpulmonary thermodilutiin technique
Funk DJ.Anaesth analg.2009

41. • Measurement of stroke volume corrected flow time(FTc) in
descending aorta
• 200-250 ml fluid bolus(colloid) over 5-10 min if FTc less
than 0.35 s
Taylor I.Recent advances in surgery.2014

42. • Stroke volume increase of more than 10% or FTc less than
0.35 s- indicative of intravascular hypovolemia and
necessitate further bolus
• Stroke volume not increase after initial bolus or FTC more
than 0.4 s- Further bolus not recommended
Taylor I.Recent advances in surgery.2014

43. • Recent meta analysis demonstrate significant reduction in
Post operative hospital stay
Overall complications
Gastrointestinal complications
Need for ICU stay
Return of bowel function
Taylor I.Recent advances in surgery.2014

44. • Intervention reduce rate of
Renal failure
Respiratory failure
Wound infection
But not rate rate of
Arrhythmia
MI
Venous thrombosis Taylor I.Recent advances in surgery.2014

45. • In double blinded multi centre trial1
No benefit to fluid therapy using zero balance
No significant difference in complication and hospital stay
• Similar result in elective collectomy in established
enhanced recovery protocol ( fluid resuscitation )2
1Brandstrup B.Br J Anaesth.2012. 2Srinivasa S.Br J Surg.2013

46. • No additional benefit in low risk patient and those
managed with ERAS protocol
• Useful in high risk patient with expected blood loss more
than 500 ml and with uncertain preoperative volume
status

47. LIMITED FLUID RESUSCITATION
Bickell WH et al. N Engl J Med. 1994; 331: 1105–1109.
Immediate Delayed
Resuscitation Resuscitation P Value
Survival to discharge 193/309 (62) 203/289 (70) 0.04
Blood Loss (ml) 3127  4937 2555  3546 0.11
LOS (hospital) (days) 14  24 11  19 0.006
LOS (ICU) (days) 8  16 7  11 0.30

48. EFFECTS OF DELAYING FLUID RESUSCITATION ON AN INJURY TO
THE SYSTEMIC ARTERIAL VASCULATURE
JAMES F. HOLMES. Et al. ACADEMIC EMERGENCY
MEDICINE 2002; 9:267–274

49. DELAYING FLUID RESUSCITATION IN HEMORRHAGE SHOCK
INDUCE PRO-INFLAMMATORY CYTOKINE RESPONSE
Delayed fluid resuscitation in hemorrhagic shock induces increased
production of pro-inflammatory cytokines and the release of
cytokine was correlated with the time delayed for resuscitation.
Chieng-Chang Lee. et al. Anal of EMERGENCY
MEDICINE 2007; 49:37-44

50. SAFETY OF RECOMBINANT ACTIVATED FACTOR VII
IN RANDOMIZED CLINICAL TRIALS
N Engl J Med 2010;363:1791-800.

51. ZERO FLUID BALANCE
• Relatively narrow range for safe fluid therapy
• Not unusual to receive 5-10 litre of fluid and 600-1000 mmol Na
in first 24 hr
• Lead to fluid overload,oedema and adverse outcome
Taylor.Recent advances in surgery.2014

52. • Overnight fasting and bowel preparation lead to fluid
deficit
• Current Recommendation:
Allow patient to drink clear fluids up to 2 hr prior to
induction of anaesthesia
Taylor I.Recent advances in surgery.2014

54. • Number of randomised controlled trial published
• Standard,liberal and restricted regimen
• Restricted regimen led to better outcome than standard
regimen1
• No difference2
1Nisanevich V.Anaesthesiology.2005;103:25-32
2Kalyan JP.British Journal of surgery.2013;100:1739-46

57. • Restricted regimen worse than standard regimen3
• Early trial tended to give standard group excess of salt and
water with postoperative weight gain ranging 3-7kg
indicative of 3-7litre fluid retention
• Restricted group right amount of fluid, not gain weight
hence in state of zero fluid balance
3Vermeulen H.Itrials.2009;10:50

59. • Both complication and hospital stay less in restricted
group
• Fluid retention exceeding 2.5 litre indicated by 2.5 kg
postoperative weight gain develop postoperative
complication
• Weight gain not dictated only by amount of fluid
Lobo DN.Fuid overload and surgical outcome.2009

60. • Postoperative oedema lead to
 Prolonged ileus
Anastomotic dehiscence
• Anastomotic dehiscence likely to occur if cumulative fluid
load exceed 10.5 litre in first 72 hr
Schnuriger B.Crystalloid after primar at initial trauma laparotomy colon resection and anastomosis.2011

61. FLUID THERAPY IN ERAS PROTOCOL
• Low intraoperative fluid regimens associated with lower
transfusion and fluid replacement requirements, and
subsequently better clinical outcomes
• Administering too much fluid lead to increased interstitial
lung water, pulmonary edema and pneumonia, which lead
to pulmonary complications Wuethrich PY. Eur Urol 2013

62. • Goal of preoperative fluid management for patient to
arrive in the operating room in a hydrated and euvolemic
state
• Goal of intraoperative fluid management to maintain
central euvolemia and to avoid excess salt and water
Timothy E.CanadianJournalofAnaesthesia·November2014

63. • Postoperatively, intravenous fluid administration
discontinued once oral intake started
Timothy E.CanadianJournalofAnaesthesia·November2014

64. CONCLUSION
• 0.9%% NS recommended in Alkalosis and
Hypochloremia secondary to vomitimg or high NG tube
aspirate
• No additional benefit in low risk patient
• Useful in high risk patient with expected blood loss more
than 500 ml and with uncertain preoperative volume
status
• Allow patient to drink clear fluids up to 2 hr prior to

65. •THANK YOU