IFAD 2013

1. Choice of Fluids in the
Perioperative Setting
Dileep N Lobo, MS, DM, FRCS, FACS, FRCPE
Professor of Gastrointestinal Surgery
University of Nottingham
Antwerp, 30 November 2013

2. Disclosures
 Research funding, speaker’s
honoraria and travel grants from
–Baxter Health Care
–BBraun
–Fresenius Kabi

3. Fluid and electrolyte balance 24 hr post
major surgery
Input Output
Fluid 8000 mL 1000 mL Urine
1000 mL insensible
Sodium 1200 mmol 25 mmol
Nitrogen 600 (catabolism) 400 mmol
Other 500 mmol 75 mmol
mOsmoles 3500 500
6000 mL positive fluid balance
3000 mOsm positive balance
Requires 6 litres of urine to clear sodium + N2
(500 mOsm/L maximum concentration)

4. Dehydration
Overnight fasting Liquids allowed till
2 h before surgery
Urinary
Osmolality
828 (99) mOsm/kg 513 (64) mOsm/kg
Lobo et al, Crit Care Med 2010 + Awad et al, Br J Anaesth 2012

5. Bowel Preparation & Fasting
Sanders et al, Br J Surg 2001
Weight Change -1.6 kg
Change in creatinine +1.8 (μmol/l)

6. Daily Requirements
 Water 25-35 ml/kg
 Sodium 0.9-1.2 mmol/kg
 Potassium 1 mmol/kg
 Calories minimum 400 Calories
(i.e. 100 g dextrose)

7. Chloride and the Kidney
Lobo & Awad, Kidney Int 2014

8. Intestinal Oedema
Marjanovic et al, Ann Surg 2009
Overloaded Restricted

9. Schnuriger et al, J Trauma 2011

10. Lobo & Awad, Kidney Int 2014
0.9% Saline vs. Balanced Crystalloids

11. Liberality, Restriction,
Overload or Balance –
Setting the Record Right

12. A Physiological Experiment
 Standard postoperative management
(Standard) group:
– At least 3 L water and 154 mmol Na/day.
 Salt and water restriction (Restricted)
group:
– No more than 2 L water and 75 mmol Na/day.
Lobo et al, Lancet 2002

13. Lobo et al, Lancet 2002

14. Gastric Emptying Time
1010N =
Restricted GroupStandard Group
LiquidphasegastricemptyingtimeT50(min)
200
150
100
50
0
1010N =
Restricted GroupStandard Group
SolidphasegastricemptyingtimeT50(min)
250
200
150
100
50
0
P=0.028 P=0.017
Lobo et al, Lancet 2002

15. Perioperative Fluid Restriction
 Multicentre RCT
 8 hospitals
 141 patients undergoing colorectal
surgery
 Restricted vs. Standard intraoperative
and postoperative fluids
 GA + Epidural
Brandstrup et al, Ann Surg 2003

16. Study Groups
 Restricted Group:
– Fluids prescribed to maintain constant body weight.
 Standard Group:
– Patients gained 3-7 kg during stay in hospital.
Brandstrup et al, Ann Surg 2003

17. Restricted
Group
n=69
Standard
Group
n=72
P
Overall complications 21 40 0.003
Major complications 8 18 0.040
Minor complications 15 36 <0.001
Tissue- healing
complications
11 22 0.040
Cardiopulmonary
complications
11 22 0.007
Deaths 0 4 0.12
Complications
Brandstrup et al, Ann Surg 2003

18. 0
20
40
60
80
100
<3.5 L 3.5-5.5 L >5.5 L <0.5 kg 0.5-2.5 kg >2.5 kg
Complicationrate(%)
IV fluids on Day 0 Weight gain
N=51 N=48 N=42 N=40 N=52
Weight Gain and Complications
N=45
Brandstrup et al, Ann Surg 2003

19. Restriction or Balance?
 80 patients randomised
 10 ml/kg/h dex saline + 3 X measured
blood loss < 500 ml
 Restricted: < 2 L water and 77 mmol
sodium for 24 h only
 Standard: 3 L water and 154 mmol
sodium for as long as necessary
 Primary end point: hospital stay
McKay et al, Br J Surg 2006

20. McKay et al, Br J Surg 2006

21. McKay et al, Br J Surg 2006

22. McKay et al, Br J Surg 2006

23. Fluid Restriction
 Standard Group
(n=32)
– 2.5 L/day
– 1.5 L 0.9% saline +
1 L 5% dextrose
 Restricted Group
(n=30)
– 1.5 L/day
– 1 L 0.9% saline +
500 ml 5% dextrose
•Daily fluid balance was not used as a
clinical monitoring variable because of
blinding.
•It was not possible to obtain patients
weight on a daily basis.
Vermeulen et al, Trials 2009

24. Outcome
Standard Group
(n=32)
Restricted Group
(n=30)
Unmasking (n) 7 12
Hospital stay (days) 8.3 ± 4.5 12.3 ± 12.7
Total complications (n) 13 23
Major complications (n)
Death
Cardiac
Anastomotic
Readmissions
5
0
0
1
4
12
1
2
6
3
Minor complications (n) 8 11
Vermeulen et al, Trials 2009

25. Lucidity

26. Varadhan & Lobo, Proc Nutr Soc 2010

27. Varadhan & Lobo, Proc Nutr Soc 2010
Complications of Fluid Therapy

28. Varadhan & Lobo, Proc Nutr Soc 2010
Length of Stay

29. How much is too much?
 “It appears that patients need to gain
at least 2.5-3 kg in weight, as a result
of salt and water overload, in the
postoperative period in order to have
a worse outcome than those
maintained in a state of zero fluid
balance.”
Lobo, Ann Surg 2009

30. Intraoperative Goal Directed
Fluid Therapy

31. Causes of delayed discharge
Bennett-Guerrero et al, Anesth Analg 1999

32. Why are GI Complications so
Common?
 Healthy patients tolerate 25-30% loss of blood
volume without change in BP or HR
 Splanchnic perfusion falls with a 10-15%
decrease in blood volume
 Gut hypoperfusion often outlasts
hypovolaemia
 No simple clinical monitoring
Giglio et al, Br J Anaesth 2009

33. Oesophageal Doppler Monitor (ODM)
 Corrected flow time (FTc)
 Stroke volume
 Cardiac index

34. The Evidence

35. Flow-guided Intraoperative Fluid Therapy
Hospital Stay
Overall Complications
Abbas & Hill, Anaesthesia 2008

36. Abbas & Hill, Anaesthesia 2008
ICU Admissions
Return of Bowel Function

37. Oesophageal Doppler Monitor
 No comparison with restrictive fluid management
 Trials not within standardised perioperative care environment
Acta Anaesthesiol Scand, 2011

39. GDT: Which Patients? Which Operations?
 Expected blood loss >500 ml
– Major abdominal
– Orthopaedic and spine
– Major head and neck oncology
– Cardiac, thoracic
 Trauma
 Patients at high risk of complications (poor
LV function)
 Uncertain preop volume status
 ICU: sepsis, burns, etc.

40. Two Questions
Does my patient need
parenteral fluid?
Why does my patient need
parenteral fluid?

41. Why?
 To correct an intravascular or
extracellular volume deficit –
Resuscitation
 To replace ongoing losses –
Replacement
 To supply the daily needs -
Maintenance

42. Summary
Give the right amount of the right
fluid at the right time