Fluid therapy and colorectal surgery
           Use or abuse?

          José Vicente Roig Vila, MD, PhD, EB S Q-C


   X ...
Factors related to the contribution of
Intra Operative Fluids
• Quantitative                        • Quantitative
 Prior ...
Circulatory disturbances during laparotomy
• Causes of hypovolaemia
      Fasting
      Bowl preparation
      Blood Loss
...
Pathophysiology of fluids excess
                                   Impairment of
                                 pulmona...
Duration of postoperative hospital stay
 in colorectal surgery
• Postoperative ileus
• Mobilization
• Stress response
• Co...
Perioperative Fluid Therapy
 Traditional health care
   3.5 - 6 liters of fluids on the day of surgery
   2 - 5 litres / ...
Brandstrup y cols, Ann Surg 2003

                                   U.
                                        C.
       ...
Problems with fluid theraphy management

   • Few
           Reduced circulating effective volume
           Subtraction o...
How to avoid problems?
• Use   of prefixed dosage
         ¿2ml/kg/hour?           ¿20ml/Kg/hour?
         ¿400 ml/hour?  ...
Postoperative fluid theraphy administration


“… We must keep in mind that the capacity of the patient
to excrete salt in ...
How to prevent overload ?
• Using targeted intraoperative colloids
• Take the opportunity of an early oral intake
• Admini...
Perioperative fluid administration

                     “Liberal“               “Restrictive“ (~2,5 )ts.
Weight gain Day ...
Optimization
of fluid therapy


Transesophageal
    Doppler




              U.
                   C.
                   ...
Postoperative Fluid Therapy

                         58%
                                                                ...
Fluid
                                                          restriction

Utility (%)
Very useful                      ...
Objetives
 To present the results of a cohort of patients
 with traditional perioperative management in
 terms of what flu...
Material and methods
 N= 121 patients: 80 H (66%), 41 M (34%)
 Age: 68.4 years (17-90).
 Scheduled colorectal surgery with...
Results

• Anastomosis
      Colic N= 65 (53.7%)
      Rectal N= 56 (46,3%)
• Hospital stay post-surgery 10,3 (5.6) days
•...
Results

 I.V. Fluids day 0:
    Mean: 5782 (1244) ml     (2700 – 9200)


       Distributed equally between the surgical...
Relation of i.v. fluids perioperative and mortality
       ml

       4000
                 *
                            ...
Contribution of Na perioperative i.v. &
mortality
  gr




       Operating
       room
                                  ...
Perioperative albumin i.v. and mortality
        ml




                                             U.
P ostoperative tim...
Perioperative fluid i.v. & cardiac complications

    ml   4500
                  *
         4000
                        ...
Perioperative sodium & heart failure

gr




     Operating
     room
                 P ostoperative time (days)
        ...
Perioperative albumin i.v., concentrated
transfusion red blood cells and cardiac
complications



                        ...
Results
 No differences exists between the total volume i.v. or the
  amount of sodium perfused in relation to total
  co...
Results
 We divided the study into 2 phases:
  January – October 2005
    vs
  November 2005 – September 2006


 During ...
Intravenous Fluid Theraphy on Perioperative
ml




                                      *

                              ...
Intravenous sodium on perioperative


                             *
  gr
                    *         **        **
     ...
Results
              Oral intake   FlatusExpulsion   Stool Expulsion
              tolerance



1 st Period   2.82       ...
Conclusions
 The total volume of i.v. fluids and sodium administered
  during the postoperative period appears to be rela...
Post-surgery alterations
 Decreased oncotic pressure
    Increased capillary permeability:
             Leakage of fluids...
Post-surgery alterations

 Cardiac function
        Fluid excess
    

        Increase cardiac energy demand
        In...
Post-surgery alterations

 Pulmonary function
    Excess liquid      Pulmonary edema       cardio-respiratory
      failu...
Post-surgery alterations
 Gastro-intestinal function
   An excess in I.V. fluids provokes:
       Nutritional intolerance...
Post-surgery alterations
 Scare tissue
    Accumulation of fluids in the interstitial space:
        Lowering of the O2 t...
Fluid therapy and colorectal surgery  Use or abuse?
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  • Fluid therapy and colorectal surgery Use or abuse?

    1. 1. Fluid therapy and colorectal surgery Use or abuse? José Vicente Roig Vila, MD, PhD, EB S Q-C X V II X V II M eeting of Coloproctology F ebruary 2008. B aiona, Pontevedra U. C. P.
    2. 2. Factors related to the contribution of Intra Operative Fluids • Quantitative • Quantitative Prior intravascular volume Ability to transport oxygen Prior cardiovascular function Coagulation Anesthetic technique Fluid and electrolyte balance Position of the patient Acid-base balance Thermoregulation Glucose metabolism Duration of surgery Surgical technique Colloids or crystalloids? Intraoperative bleeding Splanchnic ischemia Intraoperative cardiac function Capillary permeability U. Rosenthal MH, Chest 1999 C. P.
    3. 3. Circulatory disturbances during laparotomy • Causes of hypovolaemia Fasting Bowl preparation Blood Loss Open Abdomen Vasodilatation Epidural analgesia • Initial reduction of the splanchnic circulation • Changes in regional circulation during laparotomy quot;The human body compensates well a decrease in the volume of blood plasma derived as splanchnic area increasing the flow resistance. quot; U. Lobo DN et al. Lancet 2002. C. P.
    4. 4. Pathophysiology of fluids excess Impairment of pulmonary function Reduction of cardiac function Increase of intestinal wall edema Paralytic ileus Fluid Excess Decreased tissue oxygenation Hypercoagulation Wound healing alteration U. C. Holte et al, Br J Anaesth 2002 P.
    5. 5. Duration of postoperative hospital stay in colorectal surgery • Postoperative ileus • Mobilization • Stress response • Complications • TRADITION
    6. 6. Perioperative Fluid Therapy  Traditional health care 3.5 - 6 liters of fluids on the day of surgery 2 - 5 litres / day after 3 - 6 Kg weight gain Correlation with postoperative complications Pulmonary 7% vs. 24% Healing 16% vs. 31% (Brandstrup y cols, Ann Surg 2003) • Maintain a balance between perfusion and overload U. C. P.
    7. 7. Brandstrup y cols, Ann Surg 2003 U. C. P.
    8. 8. Problems with fluid theraphy management • Few Reduced circulating effective volume Subtraction of the flow in the intestine, kidney ... • Many Loss towards the extracellular space Peripheral and pulmonary edema Edema of the intestinal wall U. C. P.
    9. 9. How to avoid problems? • Use of prefixed dosage ¿2ml/kg/hour? ¿20ml/Kg/hour? ¿400 ml/hour? ¿1000 ml/hour? There is wide variation in the requirements Variability increases with surgery complexity •Measurement of the Central Venous Pressure (CVP) Not related to blood volume Measurements not valid in operating room • Targeted Fluid Therapy Based on volume, not on individualized pressure U. C. P.
    10. 10. Postoperative fluid theraphy administration “… We must keep in mind that the capacity of the patient to excrete salt in a normal manner is diminished during this period, and the same situation happens with the capacity to excrete water during the first 24 hours. Le Quesne. Lancet, 1953 U. C. P.
    11. 11. How to prevent overload ? • Using targeted intraoperative colloids • Take the opportunity of an early oral intake • Administration of fluids I.V. only to maintain body weight • Wise use of vasopressors with epidural analgesia Fearon Clinical Nutrition, 2005 • Maintain minimum diuresis The ADH is secreted with the reduction of blood volume A functional hypovolaemia is common after abdominal surgery Maintenance of intra operative volume may reduce the secretion of ADH Decrease the secretion of ADH with the optimization of volume. U. C. P.
    12. 12. Perioperative fluid administration “Liberal“ “Restrictive“ (~2,5 )ts. Weight gain Day 2 kg 0,5 kg 1 32% 17% Rate of complications Gastrointestinal ↑ ↑ function ↑ Hospital stay ↑ Nisanevich et al, Anesthesiology 2005 U. C. P.
    13. 13. Optimization of fluid therapy Transesophageal Doppler U. C. P.
    14. 14. Postoperative Fluid Therapy 58% <2000 2500 >3000 6% 36% U. Roig et al. Perioperative care in colorectal surgery C. Current practice patterns and opinions. Colorectal Disease (in press) P.
    15. 15. Fluid restriction Utility (%) Very useful 21 (16.5) Useful 25 (19.7) Useless 33 (26) N.A. (not applicable) 48 (37.8) Has its usage/opinion evolved during the past 10 years? Same 75 (65.8) Used before/ now discontinued 3 (2.6) Much less 3 (2.6) Less 2 (1.8) More 31 (27.2) U. Roig et al. Perioperative care in colorectal surgery C. Current practice patterns and opinions. Colorectal Disease (in press) P.
    16. 16. Objetives To present the results of a cohort of patients with traditional perioperative management in terms of what fluids is concerned, by analyzing its relationship with perioperative complications U. C. P.
    17. 17. Material and methods N= 121 patients: 80 H (66%), 41 M (34%) Age: 68.4 years (17-90). Scheduled colorectal surgery with resection/ anastomosis. Perioperative management to classical way January 2005/September 2006. The clinical pathway included: •Systematic Mechanical Bowel Preparation. •Postoperative fluids >= 2500 ml IV /day. •No routine usage of NGT. •Initial tolerance oral volume after peristaltic movement. •Mobilization at 48 hours post-surgery U. C. P.
    18. 18. Results • Anastomosis Colic N= 65 (53.7%) Rectal N= 56 (46,3%) • Hospital stay post-surgery 10,3 (5.6) days • Mortality N= 6 (5%) • Morbility N= 58 (47.9%) patient • Avdg. complications = 0.8 (1.1) / patient U. C. P.
    19. 19. Results  I.V. Fluids day 0: Mean: 5782 (1244) ml (2700 – 9200) Distributed equally between the surgical and the immediate postoperative period. U. C. P.
    20. 20. Relation of i.v. fluids perioperative and mortality ml 4000 * ** 3500 3000 No 2500 Sí 2000 1500 1000 500 0 0 1 2 3 4 5 6 7 8 9 0 1 Operating room Q o ó n u a r f i U. P ostoperative Time (days) C. P. * P =0.1; * * P = 0.008
    21. 21. Contribution of Na perioperative i.v. & mortality gr Operating room U. P ostoperative time (days) C. P. * P =0.05; * * P = 0.006; * * * P = 0.01
    22. 22. Perioperative albumin i.v. and mortality ml U. P ostoperative time (days) C. P.
    23. 23. Perioperative fluid i.v. & cardiac complications ml 4500 * 4000 ** 3500 3000 No 2500 Sí 2000 1500 1000 500 0 Operating room U. P ostoperative time (days) C. P. * P =0.01; * * P = 0.02
    24. 24. Perioperative sodium & heart failure gr Operating room P ostoperative time (days) * P =0.08; * * P = 0.02 U. C. P.
    25. 25. Perioperative albumin i.v., concentrated transfusion red blood cells and cardiac complications Concentrated Red cells Operating room U. Postoperative (days) C. P. * P=0.03 **P= 0.02
    26. 26. Results  No differences exists between the total volume i.v. or the amount of sodium perfused in relation to total complications, anastomotic dehiscences, reintervention rate, infection, or other cardiorespiratory complications.  POSSUM: It correlates with the volume perfused r= 0,28; p= 0.002, as well as the sodium: r= 0.29; p< 0.001. U. C. P.
    27. 27. Results  We divided the study into 2 phases: January – October 2005 vs November 2005 – September 2006  During the 2nd period we had a special interest in controlling the i.v. fluids administered in the postoperative, giving restrictive pattern by both volume and the amount of sodium. U. C. P.
    28. 28. Intravenous Fluid Theraphy on Perioperative ml * *** * * Operating room 1st Period 2nd Period U. P ostoperative time (days) C. P. * P <0.05 ;* * * P < 0.001
    29. 29. Intravenous sodium on perioperative * gr * ** ** *** *** *** PP ostoperative (days) ostoperatorio (días) U. C. * P <0.05 ;* * P <0.01; * * * P < 0.001 P.
    30. 30. Results Oral intake FlatusExpulsion Stool Expulsion tolerance 1 st Period 2.82 2.56 4.8 2 nd Period 1.97 2.09 3.8 p 0.009 0.049 0.03 U. C. P.
    31. 31. Conclusions  The total volume of i.v. fluids and sodium administered during the postoperative period appears to be related to post-surgery complications and mortality.  Adequate amounts are still unknown  In any case, it seems appropriate a restrictive regime associated with early oral intake U. C. P.
    32. 32. Post-surgery alterations  Decreased oncotic pressure Increased capillary permeability: Leakage of fluids from E.I.Vascular to E. Interstitial Secondary dilution on crystalloid administration  Endocrine response Decrease NA excretion – H2O2 Aldosterone, Increase excretion K corticosteroids, Increased capillary permeability SRA II, inflammatory mediators ... Fluid retention U. C. P.
    33. 33. Post-surgery alterations  Cardiac function Fluid excess  Increase cardiac energy demand Increase cardiovascular morbidity Adequate volume for maximum ventricular contraction  (Frank-Starling curve) (Esophageal Echo Doppler) 2300 cc liquids Better gastro-intestinal mucosal perfusion Diminution in complications U. C. P.
    34. 34. Post-surgery alterations  Pulmonary function Excess liquid Pulmonary edema cardio-respiratory failure  Renal function Post-surgery hemodynamic Relation / renal function: Not clear On healthy: saline overload It takes 2 days to eliminate U. C. P.
    35. 35. Post-surgery alterations  Gastro-intestinal function An excess in I.V. fluids provokes: Nutritional intolerance Prolonged ileus Endotoxine translocation – bacteria Sepsis – MOF Oedema mycosis – Lower O2 tissue perfusion Dehiscence Compartment syndrome : following renal/respiratory failure U. C. P.
    36. 36. Post-surgery alterations  Scare tissue Accumulation of fluids in the interstitial space: Lowering of the O2 tissue perfusion  Coagulation Lower activity of anticoagulation factors Incidence PVT > in patients with higher fluid demand i.v.  Immobilization Lower plasma volume (300 – 500 cc) If prolonged, the interstitial volume increases in comparison to the intra-vascular Its’ effects over the fluid balance has not been studied. U. C. P.

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