16. #ifad219 report of fluid day spain (colomina)
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A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects. Many questions remain to be answered indeed: Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost? Does HES still have a place in the OR? Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin? Is it really impossible to avoid fluid overload by using only crystalloids? Is there still a definitive place for human albumin? How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others? How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy? What with the fluids beyond resuscitation? And what do the authors of the big fluid trials do in real life themselves? The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill. Date: October 26th 2019, 8:00 - 18:00
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16. #ifad219 report of fluid day spain (colomina)
- 1. Maria J. Colomina Data September 30th 2019 Anesthesia & Critical Care Department Bellvitge University Hospital – Barcelona - Spain Haemostasis, Transfusion Medicine and Fluid Therapy Section - Spanish Society of Anesthesiology, Resuscitation and Pain Therapy
- 2. M. Basora – C. Cassinello – R. Ferrandis – P. Guilabert – J.L. Jover – J.V. Llau – J. Ripollés Data September 30th 2019 Fluid Day Study_MJ. Colomina et al._ 2019
- 3. Conflict of interest • Travel funding from Vifor and CSL Behring© • Honoraria for lectures from Baxter© and Vifor © Fluid Day Study_MJ. Colomina et al._ 2019
- 4. A more modern approach is to ask which fluid regimen is associated with the best outcome. Surprisingly, only a few such studies were published before this millennium. Fluid Day Study_MJ. Colomina et al._ 2019 What happened in the meantime? Robert G. Hahn
- 5. Intra & postoperative period? Fluid Day Study_MJ. Colomina et al._ 2019 What’s the context?
- 6. It is unclear what type of fluids are the most used It is unclear what volume of fluids are administered during routine surgical procedures It is unclear if the fluid management is is used by specific control (monitoring) And whether significant variability exits What’s the context? Fluid Day Study_MJ. Colomina et al._ 2019
- 7. Maintenance fluid therapy in a tertiary hospital: A prevalence study. Uña Orejón R, Gisbert de la Cuadra L, Garríguez Pérez D, Díez Sebastián J, Ureta Tolsada MP. Rev Esp Anestesiol Reanim. 2017 Jun - Jul;64(6):306-312. doi: 10.1016/j.redar.2016.12.006. Epub 2017 Feb 14. [Pilot study of intravenous fluid therapy management in adult patients at a tertiary care hospital]. Cordero Cruz AM, Moreno Villares JM, Gomis Muñoz P, Valero Zanuy MÁ, Calleja Hernández MÁ. Nutr Hosp. 2012 May-Jun;27(3):943-7. doi: 10.3305/nh.2012.27.3.5744. What are our research questions? Fluid Day Study_MJ. Colomina et al._ 2019 • The purpose of intravenous fluid therapy (IFT) is to maintain or restore internal equilibrium by administering fluids and/or different electrolyte components. Its correct use and the prevention of complications arising from their misuse depend on the knowledge of the medical team on this subject. We analyzed this issue in different clinical areas of a tertiary hospital. • The professionals who prescribe IFT perceive the need to design IFT training programs, together with the production of guides and consensus protocols. • To assess the types of maintenance fluids used in our hospital, comparing their volume and composition to the standards recommended by the guidelines. • Normal Saline Solution is the most frequently used solution. In contrast to excess doses of sodium and chlorine, there is a great deficit of other ions, buffering agents and caloric intake in the fluid therapy regimens that are usually prescribed.
- 8. What are our research questions? Fluid Day Study_MJ. Colomina et al._ 2019 Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis. Lilot M, Ehrenfeld JM, Lee C, Harrington B, Cannesson M, Rinehart J. Br J Anaesth. 2015 May;114(5):767-76. doi: 10.1093/bja/aeu452. Epub 2015 Jan 13. • Variation in clinical practice in the perioperative environment and intensive care unit is a major challenge facing modern medicine. The objective of the present study was to analyse intraoperative crystalloid administration practices at two academic medical centres in the USA. • The average corrected crystalloid infusion rate across all providers at both institutions was 7.1 (sd 4.9) ml kg(-1) h(-1), an overall cCOV of 70%. Individual providers ranged from 2.3 (sd 3.7) to 14 (sd 10) ml kg(-1) h(-1). The final regression model strongly favoured personnel as predictors over other patient predictors. Perioperative Fluid Utilization Variability and Association With Outcomes: Considerations for Enhanced Recovery Efforts in Sample US Surgical Populations. Thacker JK, Mountford WK, Ernst FR, Krukas MR, Mythen MM. Ann Surg. 2016 Mar;263(3):502-10. doi: 10.1097/SLA.0000000000001402. • To study current perioperative fluid administration and associated outcomes in common surgical cohorts in the United States. • The study showed significant associations between high fluid volume given on the day of surgery with both increased LOS (odds ratio 1.10-1.40) and increased total costs (odds ratio 1.10-1.50). High fluid utilization was associated with increased presence of postoperative ileus for both rectal and colon surgery patients. Low fluid utilization was also associated with worse outcomes.
- 9. A correct Fluid optimization would probably lead to decreased variability and improved outcomes
- 10. What are our research questions? What are the types of fluids we use in our daily practice? What is the total amount administered during the intraoperative and postoperative period? Does the amount and type of fluids change with the type of patient or type of surgery? Do we use specific monitoring for fluid therapy? Fluid Day Study_MJ. Colomina et al._ 2019
- 11. Hypothesis: Fluid therapy in the surgical environment is administered in a protocolized manner and in accordance with the recommendations of the different clinical practice guidelines. Objectives: To analyze the management of perioperative fluid therapy in our daily practice for any type of surgery To know the type and quantity of fluids that are administered for any type of surgical setting To determine the existence of factors that may influence the variability of the management of perioperative fluid therapy
- 12. Methods • Fluid Day was a prospective, national, multicentre observational study • Designed by Haemostasis, Transfusion Medicine and Fluid Therapy Section • Funded & Sponsored by Spanish Society of Anaesthesiology • National code: HTF-FLU-2018-01 / AEMPS: SED-HEA-2018-01 • Clinical Trials Network (awarded IJ/BCCB 2018) • Distributed recruitment centralised data collection (HUB) • >130 hospitals, each with a regional co-ordinator (RC) • Each RC aims to get as many centres as possible • Aiming for 3000- 3,500 patients • 2 days observational period (18 and 20 February 2019) Fluid Day Study_MJ. Colomina et al._ 2019
- 13. Methods Inclusion Criteria: • Patients over 18 years of age surgically treated during the 24 hours of the two-day study of both programmed and emergency surgery Exclusion Criteria: • Interventions performed outside the surgical area: complementary examination cabinets. • Interventions that do not require the presence of an anesthesiologist. • Ophthalmologic surgery • Surgery performed with local anesthesia. Fluid Day Study_MJ. Colomina et al._ 2019
- 14. Fluid Day Study_MJ. Colomina et al. _ 2019 Methods Demographic Sex, age, weight and height, ASA Commorbidities Cardiac, pulmonary, Kidney function, … until 23 in total Elixhauser score Surgical procedure Type and duration of intervention. Postoperative follow-up time and destination Crystalloids • SF 0.9% • RL • Isofundin ® • Plasmalyte® • SGA 5%- 10% • SGS ........ ml Colloids • HEA 130 / 0.4 • Gelatins • Albumin Monitoring Use of goal- guided Fluid Therapy protocols Other …
- 15. Methods •Aortic surgery •Cardiac surgery •Intra-thoracic procedures with lung resection •Major transplant surgery (heart, lung, liver) •Intracranial and spine surgery •Gynecologic and urologic surgery •Intra-abdominal surgery without bowel resection •Intra-thoracic surgery without lung resection •Cardiac catheterization procedures including electrophysiology studies, ablations, AICD, pacemaker •Colorectal surgery with bowel resection •Kidney transplant •Major joint replacement (shoulder, knee, and hip) •Open radical prostatectomy, cystectomy •Major oncologic general surgery or gynecologic surgery •Major oncologic head and neck surgery •Hernia repair •ENT procedures without planned flap or neck dissection •Diagnostic cardiac catheterization •Interventional radiology •GI endoscopy with stent placement •Cystoscopy Low Risk Procedures associated with minimal physiologic effect High Risk Procedures with possible significant effect on hemodynamics, blood loss Very High Risk Procedures with major impact on hemodynamics, fluid shifts, possible major blood loss Intermediate Risk Procedures associated with moderate changes in hemodynamics, risk of blood loss Surgery Risk Stratification https://www.uclahealth.org/anes/risk-stratification Fluid Day Study_MJ. Colomina et al._ 2019
- 16. Methods Patient Medical Risk Stratification https://www.uclahealth.org/anes/risk-stratification Low Risk •Hypertension •Hyperlipidemia •Asthma •Other chronic, stable medical condition without significant functional impairment •Age 70 or older •Non-insulin dependent diabetes •History of treated, stable CAD •Morbid obesity (BMI > 30) •Mild renal insufficiency High Risk •Recent coronary stent •Chronic CHF •Insulin-dependent diabetes mellitus •Renal insufficiency: creatinine > 2 •Moderate COPD: FEV1 50% to 70% •Obstructive sleep apnea •History of stroke or TIA •Known diagnosis of dementia •Chronic pain syndrome ASA I – II ASA III – IV Fluid Day Study_MJ. Colomina et al._ 2019
- 17. Preliminary Results Fluid Day Study_MJ. Colomina et al._ 2019
- 18. Fluid Day Study_MJ. Colomina et al._ 2019
- 19. Fluid Day Study_MJ. Colomina et al._ 2019
- 20. Study population [All] n=6314 N Sex, N(%) Men 3091 (49.0%) 6314 Women 3223 (51.0%) Years, average (SD) 57.8 (17.1) 6314 Years, Median [C1;C3] 60.0 [45.0;71.0] 6314 BMI, average (SD) 27.6 (5.56) 6199 IMC, Media [C1;C3] 26.8 [23.9;30.3] 6199 Old pyramid Fluid Day Study_MJ. Colomina et al._ 2019
- 21. HTA 2411 (39.2%) Obesity 1010 (16.4%) Diabetes 913 (14.8)+ COPD 655 (10.6%) Depresion 492 (8%) Hypothyroidism 468 (8%) HTA, with complications 468 (7.6%) Cardiac arrhythmia 425 (7%) Neurological diseases 387 (7%) Tumor witouth metastasis 364 (6%) 0 10 20 30 Comorbidities* % 71% patients with any comorbidities *10 most prevalents comorbidities Fluid Day Study_MJ. Colomina et al. _ 2019
- 22. Type of surgery Other, 57 (1%) Cardiac, 88 (1.5%) Toracic, 99 (1.7%) Maxillofacial, 152 (2.6%) Neurosurgery, 161 (2.8%) Plastic & Reconstructive, 164 (2.8%) Vascular, 242 (4.2%) ORL, 397 (6.9%) Gynecological, 556 (9.7%) Urologycal, 700 (12.2%) Digestive & General Surgery, 1509 (26.2%) Orthopedic & Traumatology, 1631 (28.3%) 0 10 20 % surgeries 92% scheduled 8% emergency Fluid Day Study_MJ. Colomina et al._ 2019
- 23. Surgery Risk Stratification Fluid Day Study_MJ. Colomina et al._ 2019
- 24. Surgical duration & ASA
- 25. Post-surgical care 78% 17% 3% 1% 1% PARU DS Critical Care Anesthesia ICU Intermediate care Warm %surgeries PARU Postanesthesia recovery room Unit DS Day surgery ICU Intensive Care Unit Fluid Day Study_MJ. Colomina et al._ 2019
- 26. All Surgery Low- Intermediate & Patient Low Risk Surgery Low- Intermediate & Patient High Risk Surgery High-Very high & Patient Low Risk Surgery High-Very high & Patient High Risk N N=6314 N=3830 N=943 N=987 N=554 Crystalloids Crystalloids, N (%) 6203 (98.2%) 3758 (98.1%) 924 (98.0%) 975 (98.8%) 546 (98.6%) 6314 Crystalloids number+, Median [Q1;Q3] 2.00 [1.00;2.00] 2.00 [1.00;2.00] 2.00 [1.00;2.00] 2.00 [1.00;2.00] 2.00 [1.00;2.00] 6203 Balanced, N (%) 4912 (79.2%) 2973 (79.1%) 699 (75.6%) 802 (82.3%) 438 (80.2%) 6203 Normal Saline ,N (%) 2883 (46.5%) 1651 (43.9%) 462 (50.0%) 475 (48.7%) 295 (54.0%) 6203 Medical dilution, N (%) 1749 (28.2%) 1019 (27.1%) 269 (29.1%) 297 (30.5%) 164 (30.0%) 6203 Other: Dextrose component, N (%) 396 (6.38%) 195 (5.19%) 87 (9.42%) 57 (5.85%) 57 (10.4%) 6203 Fluid Day Study_MJ. Colomina et al. _ 2019 Type of Fluids Intraoperative period
- 27. All Surgery Low- Intermediate & Patient Low Risk Surgery Low- Intermediate & Patient High Risk Surgery High-Very high & Patient Low Risk Surgery High-Very high & Patient High Risk N N=6314 N=3830 N=943 N=987 N=554 Colloids Colloids, N (%) 466 (7.51%) 153 (4.06%) 104 (11.3%) 120 (12.3%) 89 (16.4%) 6207 Total ml, Median [Q1;Q3] 500 [300;500] 500 [350;500] 500 [250;500] 500 [500;500] 500 [300;500] 465 Total ml/Kg, Median [Q1;Q3] 6.25 [4.31;7.69] 6.25 [4.58;7.69] 6.02 [3.79;8.33] 6.10 [4.93;7.14] 6.37 [4.49;8.48] 460 HEA*, N (%) 274 (58.8%) 93 (60.8%) 60 (57.7%) 79 (65.8%) 42 (47.2%) 466 Gelatin*, N (%) 163 (35.0%) 52 (34.0%) 36 (34.6%) 37 (30.8%) 38 (42.7%) 466 Albumin*, N (%) 37 (7.94%) 9 (5.88%) 12 (11.5%) 5 (4.17%) 11 (12.4%) 466 Type of Fluids Intraoperative period Fluid Day Study_MJ. Colomina et al. _ 2019
- 28. Fluid Day Study_MJ. Colomina et al._ 2019 Type of Fluids Intraoperative period Surgery High Risk & Patient High Risk with intraoperative colloids All N=89 Types of Surgery, N (%): Cardiac Trasplant 1 (1.12%) Cardiac Surgery 23 (25.8%) Vascular Surgery 6 (6.74%) Neurosurgery 6 (6.74%) Thoracic surgery 3 (3.37%) General 13 (14.6%) Orthopedic & Trauma 23 (25.8%) Plastic & Reconstructive 1 (1.12%) O.R.L. 2 (2.25%) Urology 9 (10.1%) Liver transplant 1 (1.12%) Other 1 (1.12%)
- 29. Fluid Day Study_MJ. Colomina et al._ 2019 Dose & Total amount Intraoperative period All Surgery Low- Intermediate & Patient Low Risk Surgery Low- Intermediate & Patient High Risk Surgery High-Very high & Patient Low Risk Surgery High-Very high & Patient High Risk N N=6314 N=3830 N=943 N=987 N=554 Crystalloid administrated = crystalloid + medical dilution Total ml/Kg , Median [Q1;Q3] 8.33 [5.43;13.3] 7.69 [5.00;11.8] 8.33 [5.26;13.3] 11.1 [6.91;17.2] 12.5 [6.86;20.6] 6142 Total ml/Kg / h surgery , Median [Q1;Q3] 6.35 [4.17;9.52] 6.67 [4.23;10.0] 6.00 [4.04;9.08] 6.41 [4.36;9.33] 5.46 [3.83;8.17] 6039 Total ml/Kg with medical dilution, Median [Q1;Q3] 9.04 [6.00;14.3] 8.29 [5.56;12.3] 9.17 [5.81;14.1] 12.0 [7.78;18.3] 13.2 [7.62;21.8] 6158 Corrected crystalloid administrated = crystalloid + medical dilution - estimated blood loss - urine output Total ml/Kg, Median [Q1;Q3] 6.71 [3.97;10.7] 6.49 [4.08;10.0] 6.67 [3.73;10.5] 7.72 [4.29;12.5] 7.44 [3.11;13.0] 6126 Total ml/Kg / h surgery, Median [Q1;Q3] 5.15 [3.00;8.21] 5.64 [3.35;8.82] 4.99 [2.91;7.65] 4.62 [2.61;7.29] 3.66 [1.67;6.14] 6023 Total ml/Kg with medical dilution, Median [Q1;Q3] 7.44 [4.61;11.5] 7.14 [4.67;10.6] 7.40 [4.23;11.3] 8.74 [5.20;13.5] 8.33 [3.70;14.0] 6142
- 30. Fluid Day Study_MJ. Colomina et al._ 2019 Dose & Total amount Postoperative period All Surgery Low- Intermediate & Patient Low Risk Surgery Low- Intermediate & Patient High Risk Surgery High-Very high & Patient Low Risk Surgery High-Very high & Patient High Risk N N=6314 N=3830 N=943 N=987 N=554 Crystalloid administrated = crystalloid + medical dilution Total ml/Kg , Median [Q1;Q3] 5.26 [2.86;9.24] 4.62 [2.67;7.65] 5.56 [2.94;10.0] 6.90 [3.85;12.8] 8.73 [4.15;18.3] 5511 Total ml/Kg / h, Median [Q1;Q3] 3.92 [2.15;7.32] 3.90 [2.12;7.19] 3.96 [2.14;7.88] 4.01 [2.35;7.10] 3.88 [2.00;7.50] 5420 Total ml/Kg with medical dilution, Median [Q1;Q3] 5.56 [3.06;9.80] 5.00 [2.78;8.20] 5.92 [3.11;10.6] 7.40 [4.16;13.9] 9.21 [4.44;20.8] 5607 Corrected crystalloid administrated = crystalloid + medical dilution - estimated blood loss - urine output Total ml/Kg, Median [Q1;Q3] 3.53 [1.44;6.94] 3.37 [1.49;6.35] 3.64 [1.54;7.14] 3.79 [1.43;8.51] 4.05 [0.67;10.5] 5455 Total ml/Kg / h, Median [Q1;Q3] 2.80 [1.05;6.03] 3.06 [1.23;6.37] 2.71 [1.06;6.13] 2.47 [0.76;5.21] 1.97 [0.28;4.83] 5364 Total ml/Kg with medical dilution, Median [Q1;Q3] 3.87 [1.67;7.35] 3.68 [1.67;6.72] 4.05 [1.80;7.69] 4.24 [1.79;9.32] 4.61 [1.07;12.2] 5550
- 31. Fluid Day Study_MJ. Colomina et al._ 2019 Fluid Therapy management All Surgery Low- Intermediate & Patient Low Risk Surgery Low- Intermediate & Patient High Risk Surgery High-Very high & Patient Low Risk Surgery High-Very high & Patient High Risk N N=6246 N=3791 N=928 N=980 N=547 Basic Monitoring (NIBP,EGC, SpO2, Et.Co2), N (%) 6187 (99.1%) 3757 (99.1%) 917 (98.8%) 968 (98.8%) 545 (99.6%) 6246 Invasive BP, N (%) 630 (10.1%) 133 (3.52%) 122 (13.2%) 169 (17.3%) 206 (38.0%) 6215 VCP, N (%) 243 (3.91%) 40 (1.06%) 41 (4.43%) 61 (6.27%) 101 (18.6%) 6207 Urinary output, N (%) 1915 (30.9%) 830 (22.0%) 357 (38.6%) 415 (42.7%) 313 (57.4%) 6207 Avanced Hemodynamic Monitoring, N (%) 206 (3.32%) 32 (0.85%) 36 (3.90%) 53 (5.42%) 85 (15.6%) 6213
- 32. Fluid Day Study_MJ. Colomina et al._ 2019 Fluid Therapy management Surgery High-Very high Risk & Patient High Risk All N N=547 Basic Monitoring (PANI,EGC, SpO2), N (%) 545 (99.6%) 547 Avanced Hemodynamic Monitoring, N (%) 85 (15.6%) 546 Pulmonary Artery Catheter (PAC), N (%) 11 (12.9%) 85 Transpulmonary Thermodilution (TPT), N (%) 2 (2.35%) 85 Transesophageal Echocardiography (TEE), N (%) 51 (60.0%) 85 Transthoracic Echocardiography (TTE), N (%) 3 (3.53%) 85 Pulse wave contour analysis (PWC) invasive, N (%) 39 (45.9%) 85 Pulse wave contour analysis (PWC) non invasive, N (%) 4 (4.71%) 85 Esophageal Doppler, N (%) 2 (2.35%) 85 Other, N (%) 2 (2.35%) 85 Fluid challenge (1), N (%) 80 (14.7%) 543 Fluid challenge (2), N (%) 24 (30.0%) 80 Fluid challenge (3), N (%) 6 (26.1%) 23
- 33. Fluid Day Study_MJ. Colomina et al._ 2019 Fluid Therapy management All Surgery Low- Intermediate & Patient Low Risk Surgery Low- Intermediate & Patient High Risk Surgery High-Very high & Patient Low Risk Surgery High-Very high & Patient High Risk N N=6246 N=3791 N=928 N=980 N=547 Intraoperative Hemocomponents, N (%) 172 (2.79%) 18 (0.48%) 50 (5.44%) 24 (2.48%) 80 (14.8%) 6166 Fluid challenge (1), N (%) 396 (6.41%) 151 (4.03%) 88 (9.61%) 77 (7.93%) 80 (14.7%) 6174 Fluid challenge (2), N (%) 87 (22.2%) 21 (14.0%) 22 (25.3%) 20 (26.7%) 24 (30.0%) 392 Fluid challenge (3), N (%) 18 (21.4%) 3 (14.3%) 6 (30.0%) 3 (15.0%) 6 (26.1%) 84 Postoperative Hemocomponents, N (%) 80 (1.36%) 16 (0.44%) 24 (2.76%) 20 (2.20%) 20 (4.29%) 5868 Fluid challenge (1), N (%) 136 (2.32%) 42 (1.16%) 23 (2.66%) 28 (3.07%) 43 (9.21%) 5865 Fluid challenge (2), N (%) 36 (26.5%) 7 (16.7%) 8 (34.8%) 6 (21.4%) 15 (34.9%) 136 Fluid challenge (3), N (%) 6 (16.7%) 1 (14.3%) 1 (12.5%) 1 (16.7%) 3 (20.0%) 36
- 34. Discussion
- 35. The type of fluids: Crystalloids were used in 98.2% of surgeries. 79% of cases used balanced solutions, colloids in 8% of patients. Volume of fluids administered: Total ml/Kg / h: 5.15 [3.00;8.21] Total ml/Kg with medical dilution 7.44 [4.61;11.5] Fluid management: Surgery High-Very high & Patient High N=547 / 85 (15.6%) Surgery High-Very high & Patient Low N=980 / 53 (5.42%) Discusion Fluid Day Study_MJ. Colomina et al._ 2019
- 36. n(%) Exponentiated coefficients [IC95%] % change P-value ICC AIC N Surgery risk Intermediate vs Low 3768 (62.39%) 0.936 [0.915;0.958] -6.36 <0.001 0.055 35529 6039 High vs Low 962 (15.93%) 0.861 [0.837;0.885] -13.92 <0.001 Very high vs Low 520 (8.61%) 0.854 [0.826;0.882] -14.64 <0.001 Patient factors Age (yrs) scale(age) 0.985 [0.977;0.993] <0.001 0.056 35653 6039 scale(age)^2 1.009 [1.003;1.016] 0.006 ASA II vs I 3440 (56.96%) 0.934 [0.916;0.952] -6.59 <0.001 0.056 35541 6039 III vs I 1285 (21.28%) 0.888 [0.867;0.909] -11.24 <0.001 IV-V vs I 138 (2.29%) 0.786 [0.746;0.828] -21.4 <0.001 Commorbidity Y vs N 4256 (70.85%) 0.923 [0.908;0.939] -7.65 <0.001 0.057 35424 6007 Number of commorbidities 0.971 [0.967;0.976] -2.89 <0.001 0.058 34914 5930 Commorbidities > 3 vs <3 or not 718 (12.11%) 0.901 [0.881;0.922] -9.89 <0.001 0.057 34982 5930 Gender, Female vs Male 3087 (51.12%) 1.047 [1.031;1.062] +4.66 <0.001 0.056 35644 6039 Scale(Hb), preoperative 1.002 [0.992;1.013] +0.22 0.677 0.056 34418 5818 Factors associated with the variability of crystalloid use: % Univariate factors associated with crystalloids Fluid Day Study_MJ. Colomina et al._ 2019
- 37. Miller TE1, Myles PS. Perioperative Fluid Therapy for Major Surgery. Anesthesiology. 2019 May;130(5):825-832. doi: 10.1097/ALN.0000000000002603. Fluid Day Study_MJ. Colomina et al._ 2019 Dose: 7.14 mL[4.67;10.6] Dose: 7.40 mL [4.23;11.3] Dose: 8.74 mL [5.20;13.5] Dose: 8.33 mL [3.70;14.0] Avanced M: 32 (0.85%) FC: 151 (4.03%) Avanced M: 36 (3.90%) FC: 88 (9.61%) Avanced M: 53 (5.42%) FC: 77 (7.93%) Avanced M: 85 (15.6%) FC: 80 (14.7%)
- 38. Take messages at home: • There is a clear tendency to fluid overload patients in any type of surgery. • Balanced crystalloids are the most used in our daily practice, with minimum use of colloids. • The management of fluid therapy with monitoring should improve especially in patients and surgeries with high risk. Fluid Day Study_MJ. Colomina et al. _ 2019
- 39. We believe FLUID DAY STUDY is an example of collaborative research between different centers with the objective to answer a clinical question that could in the future be applied into clinical practice Fluid Day Study_MJ. Colomina et al._ 2019
Editor's Notes
- Good afternoon, Thanks to the scientific committee of this meeting for having invited me to participate and present the preliminary results of our study on the management of fluid therapy in the immediate intra and postoperative period.
- The Spanish Fluid day study has been designed by a magnificent team of anesthesiologists who are members of the hemostasis, transfusion medicine and fluid therapy section of the SEDAR. And thank you very much for their effort to carry out this study This study was supported by SEDAR.
- First, this is my conflict of interest
- The fluid therapy management during the perioperative period, as the editorial points out, may be more complex than we think. We have few good quality scientific studies and, most of them were dedicated especially to critical patients.
- But in the perioperative period there is increasing evidence that intraoperative fluid administration has a definitive effect on surgical patient outcomes there is a lower contribution of studies and the majority have focused on some specific type of surgery, for example abdominal surgery. Our question is How is fluid therapy managed in the usual surgical environment: Intraoperative and postoperative period until the first 24 hours
- Probably, The variability in the administration of perioperative fluid therapy has shown that it can have important repercussions in the immediate postoperative evolution, especially in certain types of complex patients and in highly complex surgeries. At least in moderate to high risk patients
- I am goin to comment two spanish studies
- At the same time, two studies published related at the variability in diffefrent scenarios Who included intraoperative period
- For that, We think that
- And our main questions focused on the following
- Methods: A multicenter prospective observational cross-sectional study - 24-hour Prevalence Cut off is proposed to evaluate the fluid therapy administered by anesthesiologists in surgical patients. The study will be carried out simultaneously in all hospitals that decide to participate throughout the Spanish territory and the follow-up period will be a maximum of 24 hours. T Two different weekly days will be chosen to include the maximum number of episodes and types of surgeries. Relevance: The clinical practice guidelines with their recommendations or suggestions offer a safety tool for patients based on current scientific evidence, hence the importance of its correct implementation. Sometimes problems of dissemination of information or limitations in the application of the same can cause that these objectives are not met.
- The variables that collect the clinical characteristics of the patients, the characteristics of the surgical process and the fluids used will be analyzed according to the type of variable. We recorded these data in both periods: Intra and postoperative periods.
- In order to classified the differents types of surgery, Risk factors that increase the likelihood of perioperative morbidity and mortality may include the patient’s underlying health problems as well as factors associated with each specific type of surgery. By combining risk scores for patient co-morbidity and the complexity of surgery, we can stratify overall risk and determine which patients should undergo more extensive preoperative evaluation.
- Risk factors that increase the likelihood of perioperative morbidity and mortality may include the patient’s underlying health problems as well as factors associated with each specific type of surgery. By combining risk scores for patient co-morbidity and the complexity of surgery, we can stratify overall risk and determine which patients should undergo more extensive preoperative evaluation.
- These were the preliminary results
- The majority of people included were men and women from forty to seventy years of age And moderate over weight
- Related to the type of surgery, lthe most prevalent Chedul
- Profile surgeries
- Crystalloids were used in 6203 (98.2%) interventions. In 25% of the interventions a single crystalloid was used, between 50% and 75% 2 crystalloids were used and in 25% of the interventions 2 crystalloids or more were used. The most commonly used crystalloid were the balanced ones. The same data was found for the postoperative period
- Colloids were used in 466 (7.51%) interventions. A single colloid was used in 75% of the interventions, and 1 or more colloids were used in 25% of the interventions. The maximum number of colloids used was 2 in the same intervention. The colloids most used were the HEA. 8.7% of patients very high risk 1% from total haigh risk recieved colloids
- Colloids were used in 466 (7.51%) interventions. A single colloid was used in 75% of the interventions, and 1 or more colloids were used in 25% of the interventions. The maximum number of colloids used was 2 in the same intervention. The colloids most used were the HEA.
- Probably, The variability in the administration of perioperative fluid therapy has shown that it can have important repercussions in the immediate postoperative evolution, especially in certain types of complex patients and in highly complex surgeries. At least in moderate to high risk patients
- P-value column: Factors statistically explained the volume of crystalloids administered. % Change column: In the categorical variables the% reduction or increase in the respect factor one of reference. In the non-standardized numerical variables the% reduction or increase of the factor for each unit of the factor. In standardized numerical variables the% reduction or increase of the factor for each standard deviation of the factor. ICC column: The% of the variability of crystalloids administration explained by the hospital where the intervention was performed For example: The complexity of the surgery explained the volume of crystalloids administered statistically significantly. The more complex the intervention, the less administration of crystalloids compared to low-risk surgeries. We see that in intermediate surgeries it was reduced by -6.36% with respect to low risk surgeries, in those of high risk it was reduced by -13.92% and in those of very high risk by -14.64%. Using the risk of surgery as the only explanatory variable, only 5.5% of the variability in colloid volume was explained by the hospital where the intervention was performed (CHF = 0.055)
- We have shown that there is variability in clinical practice,
- We have shown that there is variability in clinical practice and it's knowledge will help us to improve. Fortunately, conducting these high quality studies will help guide our practice in fluid therapy. The knowledge of these, and the reflexive inclusion of the key findings in contemporary practice, should improve the care of patients undergoing major surgery.