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FLUID THERAPY: LOGIC &EVIDENCE- Dr.Padma Puppala MD., FRCA.,Anesthesiology & Critical care
 What does the body do to the fluid? What does the fluid do to the body? What are the effects of surgery on fluid dynam...
WHAT HAPPENS IF YOU GIVE 1LITER OF IV FLUID TO A HEALTHYADULT?Let us try’n find answersquestion by question!
IN HEALTHY VOLUNTEERSAFTER 22ML/KG OF FLUID• 93% of 5% dextrose, 68% of NS, 16-20%% of colloids• leaked out of the Intrava...
STARLINGS FORCES
Acute change in extracellular fluids associated with major surgical proceduresAnnals of Surgery, 1961: Shires et alTHIRD S...
THIRD SPACE-FACT OR FICTION?
The classic “third space” has neverbeen localized• Original methodology supporting the concept of thirdspace were fundamen...
SHIRES & SHOEMAKEREFFECT•Liberal fluid administration becamestandard practice in 80’s & early 90’s•7–10 kg weight gain not...
EFFECTS OF FLUID OVERLOADInterstitial oedemaEffusionsProlonged ventilator therapyOedema of the gutDelayed enteral fee...
EFFECT OF SURGERY ON FLUIDDYNAMICSSalt & water retentionInterstetial oedema
RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYXType 1:Physiologic shiftof protein free fluidType II:Pathological shiftof protein ri...
RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYX
RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYX• Mechanical stress• Endotoxin exposure,• Ischemia–reperfusion injury• Inflammation•...
British Consensus Guidelineson Intravenous Fluid Therapy forAdult Surgical Patients - 2007
PREOPERATIVEFLUID MANAGEMENT• Clear fluids not to be withheld for > 2 hrs (Cochrane)• Carbohydrate rich drink 2-3 hrs befo...
INTRAOPERATIVEFLUID THERAPY• Pre/ co-loading• Maintenance• Replacement• Preoperative deficit• Compensation• Blood loss• In...
GOALS OFINTRAOPERATIVE FLUIDADMINISTRATION• O2 delivery / blood flow - perfusion• Maintain electrolyte composition,• Normo...
HOW MUCH TO GIVE &WHEN TO GIVE ITDepends on• Type of patient• Type of surgery• Acute injury vs. elective• Type of Anesthet...
DEFICITSConventional teaching• Preoperative bowel preparation (1-1.5L)• Preoperative blood loss (trauma) or fluid loss (bu...
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 ...
REPLACEMENT• Insensible losses: (Evaporative)• 0.5 – 1 ml/kg/hr• Third space• 2-5 ml /kg / hr?• NG/ Urine losses• Blood lo...
WHICH CRYSTALLOID
NS VS RLNormal saline Ringer’s Lactateisotonic isotonicExcess of chloride ions More physiologicalno buffer lactate or acet...
INTRAOPERATIVE FLUIDMANAGEMENT: MAJOR SURGERYOptimal stroke volume mayreduce postoperativecomplication rates andduration o...
GDT & STROKE VOLUME
IDEAL PRELOADMONITOR?• CVP?• PCWP?• IVC?• LVEDV?• SPV• PPV/ SVV?• sVO2
SPECIFIC SCENARIOS• Minor surgery• Pulmonary surgery• Hepatic surgery• Vascular surgery• Hip surgery• Trauma• Neurotrauma
HEALTHY OUTPATIENTS –MINOR PROCEDURE
HEALTHY OUTPATIENTS – MINORPROCEDURE• 1 - 2 liters of fluid• Decrease thirst, dizziness, drowsiness, pain and nausea• Redu...
FLUIDS IN MAJORABDOMINAL SURGERY
LIBERAL VS RESTRICTIVE
LIBERAL VS RESTRICTIVE
PULMONARYSURGERYMiller et al: Annals Thoracic Surg 2002• 115 completion pneumonectomies• PPE occurred in 15% with Mortalit...
HEPATIC RESECTIONLOW CVP TECHNIQUE• Low CVP technique: 496 resections• IVF 1 cc/kg/hr and boluses as needed• NTG, dopamine...
HIP REPLACEMENTSharrock: Br J Anaesth; Reg Anesth• 987 surgeries• Spinal/Epidural hypotension (mBP 50-55mmHg)• Fluid restr...
CASE - 1• Fit 38 year old woman, weight 50kgs• Laparoscopic oesophagectomy• Preoperative Hb: 12g/dl• Has been NBM for 8 ho...
1sthour 2ndhour 3rdhour 4thhourPreoperative deficit: 1.5×50×8= 600 ml 300 150 150 0Maintenance: 1.5 × 50 = 75 ml 75 75 75 ...
• Tachycardia• Urine output 20 ml/ hr4 HOURS INTOSURGERYVenous blood gasFio2: 0.4pH 7.39pO2 158pCO2 33BE - 7.1Lactates 2.1...
POSTOPERATIVE FLUID THERAPY• Resume oral intake as soon as possible• When oral intake is adequate, IV fluids should bedisc...
Calculate daily requirementsbefore prescription of fluids & Nutrition
POSTOPERATIVEMAINENANCE FLUIDSNormal saline -1lt5%dextrose 1.5 ltPotassium– 60mmolNormal saline 100ml/hrPotassium- 60mmolH...
ADDITIONALFLUID BOLUSES
• Hypotension• Oliguria• AcidosisTHREE COMMON TRIGGERSFOR FLUID BOLUSES
IDEAL PRELOADMONITOR?• CVP?• PCWP?• IVC?• LVEDV?• PLR• SPVPPV/SVV?
ASSESSMENT OFFLUID NEEDSChanges in stroke volume, radial pulse pressure, induced bypassive leg raising are accurate and in...
• Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
OLIGURIA
RIFLE classification for AKI after modifications by the Acute Kidney Injury Network.Hoste E A , Kellum J A Nephrol. Dial. ...
FLUID THERAPY:PREVENTION OF AKIPOSTOP• Avoid of peri-operative hypovolaemia• Intra & immediate postoperative oliguria is p...
• Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
Hyperchloremic acidosisACIDOSIS
• Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
• Healthy patients; minor surgery• Be generous• Sicker patients; major surgery• Be stingy• Use goal directed therapy when ...
Perioperative fluid therapy logic & evidence
Perioperative fluid therapy logic & evidence
Perioperative fluid therapy logic & evidence
Perioperative fluid therapy logic & evidence
Perioperative fluid therapy logic & evidence
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Perioperative fluid therapy logic & evidence

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Perioperative fluid therapy logic & evidence

  1. 1. FLUID THERAPY: LOGIC &EVIDENCE- Dr.Padma Puppala MD., FRCA.,Anesthesiology & Critical care
  2. 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. 3. WHAT HAPPENS IF YOU GIVE 1LITER OF IV FLUID TO A HEALTHYADULT?Let us try’n find answersquestion by question!
  4. 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. 5. STARLINGS FORCES
  6. 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. 7. THIRD SPACE-FACT OR FICTION?
  8. 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. 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. 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. 11. EFFECT OF SURGERY ON FLUIDDYNAMICSSalt & water retentionInterstetial oedema
  12. 12. RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYXType 1:Physiologic shiftof protein free fluidType II:Pathological shiftof protein rich fluid
  13. 13. RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYX
  14. 14. RECENT EVIDENCE:ENDOTHELIAL GLYCOCALYX• Mechanical stress• Endotoxin exposure,• Ischemia–reperfusion injury• Inflammation• Fluid loading• Acute hypervolemia• Release ANP
  15. 15. British Consensus Guidelineson Intravenous Fluid Therapy forAdult Surgical Patients - 2007
  16. 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. 17. INTRAOPERATIVEFLUID THERAPY• Pre/ co-loading• Maintenance• Replacement• Preoperative deficit• Compensation• Blood loss• Insensible losses• Third space loss
  18. 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. 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. 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. 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. 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. 23. WHICH CRYSTALLOID
  24. 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. 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. 26. GDT & STROKE VOLUME
  27. 27. IDEAL PRELOADMONITOR?• CVP?• PCWP?• IVC?• LVEDV?• SPV• PPV/ SVV?• sVO2
  28. 28. SPECIFIC SCENARIOS• Minor surgery• Pulmonary surgery• Hepatic surgery• Vascular surgery• Hip surgery• Trauma• Neurotrauma
  29. 29. HEALTHY OUTPATIENTS –MINOR PROCEDURE
  30. 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. 31. FLUIDS IN MAJORABDOMINAL SURGERY
  32. 32. LIBERAL VS RESTRICTIVE
  33. 33. LIBERAL VS RESTRICTIVE
  34. 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. 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. 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. 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. 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. 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. 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. 41. Calculate daily requirementsbefore prescription of fluids & Nutrition
  42. 42. POSTOPERATIVEMAINENANCE FLUIDSNormal saline -1lt5%dextrose 1.5 ltPotassium– 60mmolNormal saline 100ml/hrPotassium- 60mmolHartman’s100ml/hr
  43. 43. ADDITIONALFLUID BOLUSES
  44. 44. • Hypotension• Oliguria• AcidosisTHREE COMMON TRIGGERSFOR FLUID BOLUSES
  45. 45. IDEAL PRELOADMONITOR?• CVP?• PCWP?• IVC?• LVEDV?• PLR• SPVPPV/SVV?
  46. 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. 47. • Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
  48. 48. OLIGURIA
  49. 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. 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. 51. • Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
  52. 52. Hyperchloremic acidosisACIDOSIS
  53. 53. • Oliguria• Acidosis• HypotensionTHREE COMMON TRIGGERSFOR FLUID BOLUSES
  54. 54. • Healthy patients; minor surgery• Be generous• Sicker patients; major surgery• Be stingy• Use goal directed therapy when indicatedCONCLUSION

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