2. GOAL-DIRECTED THERAPY
Goal – improved tissue perfusion and clinical outcome
Based on measuring key physiologic variables
Cardiac output or
Global O2 delivery
Achieved with
administering fluids, and
possibly inotropes, vasopressors, vasodilators, and
RBCs
Targets are defined physiologic endpoints and not dependant on
objective assessments of fluid status.
3. TECHNIQUES USED FOR PERIOPERATIVE GDT:
Pulmonary artery catheter (PAC)
Gold standard hemodynamic monitor,
provides measured and derived values for Left and right heart filling pressures, mixed
and central venous saturations and CO.
Esophageal Doppler monitor (EDM)
ultrasound measurement of descending aorta blood velocity=> SV => CO
Partial CO2–rebreathing technique [noninvasive cardiac output (NICO)],
Lithium dilution [lithium dilution cardiac output (LiDCO)]
Plethysmography and
Gastric tonometry
Thoracic Bioimpedance (non-invasively measures SV & CO through 4 surface ECG
electrodes)
4. TARGETS FOR GOAL-DIRECTED THERAPY ARE AS
FOLLOWS:
Arterial blood pressure and waveform analysis (MAP >65 mm Hg)
CVP (8-10 cm H2O)
Echocardiography (No regional wall motion abnormalities)
Lactate (<2.0 mmol/L)
O2 extraction and venous O2 saturation (SvO2) or central venous
saturation (ScvO2)
5. APPROPRIATE FLUID SELECTION
Crystalloids or Colloids for Intravascular Plasma Volume
Expansion.
Crystalloids = most rational choice
replacement of evaporative losses,
maintenance fluid requirements, and
expansion of the entire extracellular fluid volume,
Choice for plasma volume replacement not clear.
Saline-Based or Balanced Solutions?
Intraop Isotonic saline => postop hyperchloremic acidosis
Excess NaCl and water load excreted slowly
Rational to use Balanced Crystalloids
6. TYPICAL PRACTICAL APPROACH
Preoperative
Oral clear fluid intake until 2 hours preop.
Bowel prep in selected cases only and an infusion of 1 to 2 L of
balanced crystalloid with K+ supplementation for adequate hydration in
such cases.
Chronic comorbidities assessment for influence on fluid and electrolyte
balance.
7. Emergency surgery
Acute disturbances of fluid compartments.
Timely resuscitation guided by rational physiologic endpoints
trends in blood pressure and heart rate
Lactate
urine output, and
mixed or central venous O2 saturations.
Upper GI losses quantified and replaced with isotonic saline.
Lower GI losses with balanced crystalloid.
K+ should be supplemented as appropriate.
Preoperative
8. Intraoperative
Balanced crystalloid used to replace the ongoing water and electrolyte losses.
Hypotension by anesthesia is related to vasodilation and reduced inotropy, if
needed vasopressors can be used.
Fluid therapy in high risk patients guided by
invasive CVP monitoring for early recognition of overt hypovolemia and
markers of global tissue perfusion, like lactate and acid-base status.
9. In certain orthopedic and intraabdominal operations CO optimized by
titrating boluses of a suitable colloid
Blood loss replaced with colloid or blood and blood products
depending on the volume lost.
Crystalloid used as an alternative for intravascular plasma volume
expansion.
Overall the goal is to achieve euvolemia by the end of surgery or the
early postop period.
10. Postoperative
Assessment of fluid status made based on
clinical examination and
lactate,
central or mixed venous saturations, and
cardiac output variables.
If euvolemic then early oral intake is well tolerated and safe
In patients requiring ongoing IV therapy in postop phase:
1. Monitor for hyponatremia and other electrolyte derangements.
2. Fluid requirements should be strictly divided into three categories:
11. A. “Pure” maintenance requirements
(saltpoor, modest volume of free water to account for the postoperative state of salt and water
retention)
• 1500 to 2500 mL or 1 to 1.2 mL/kg/hr of fluid with 50 to 100 mEq Na+ & 40 to 80 mEq K+
should be given in first 24 hours
B. Replacement of ongoing losses
Assessment of IV volume status and adequacy of organ perfusion.
Losses from the GI tract replaced with isotonic saline or balanced crystalloid with K+.
Losses to third spaces with a mixture of colloid and crystalloid
Blood loss replaced with colloid, blood, or blood products, and definitive intervention.
C. New requirements (resuscitation)
Postop complications; hemorrhage (absolute hypovolemia) or acute sepsis (relative or
absolute hypovolaemia).
Postop oliguria, particularly in the first postop 24 hours.
Large volumes of fluid challenge are inappropriate and may aggravate postop positive fluid
and Na+ balance.
13. HEART FAILURE
Goals => Preserve CO, preload, contractility, and afterload.
Ventricles poorly compliant and require adequate preload and adequate diastolic
filling time.
Excessive volume infusion and preload => Impaired contractility and worsening CO
Invasive monitoring with either EDM/ PAC for fluid therapy
Restrictive Fluid therapy or GDT is preferred.
Striking a balance between hypovolemia and hypervolemia is particularly
important in patients with heart failure,
14. KIDNEY DISEASE
Preop assessment should focus on
the adequacy of chronic dialysis in attaining euvolemia, and
estimating the normal volume of native urine output.
Comorbidities should be assessed and optimized.
Surgery undertaken in a facility where preop and postop dialysis or
hemofiltration done.
In elective surgery, preop dialysis timed such that the patient enters
the intraop phase with a normal blood volume
15. Hypervolemia => risk for pulmonary and peripheral edema, hypertension, and
poor wound healing.
Hypovolemia => risk for anesthesia-related hypotension and inadequate tissue
perfusion.
Dialysis the day prior to allow equilibration of fluid and electrolyte.
Electrolytes on the morning of surgery ( ideal K+ value after dialysis is low-to-
normal range. )
In emergency surgery, NO sufficient time for dialysis, electrolyte abnormalities
must be managed conservatively, intraop fluid balance.
16. UPPER GASTROINTESTINAL LOSS
Progressive dehydration => Increased aldosterone secretion => Na+ is
retained at the expense of K+ and H+ ions, (hypokalemia, and
metabolic alkalosis with a paradoxically aciduria)
Correction => Gradual rehydration with isotonic saline and K+
supplementation and changing to dextrose- containing saline
depending on electrolyte analysis.
17. SEPSIS AND ACUTE LUNG INJURY
The pragmatic targets for patients with sepsis who have tissue
hypoperfusion (blood lactate conc. at or >4 mmol/L) or hypotension
persisting after Initial IV fluid Challenge:
CVP 8 to 12 mm Hg (12 to 15 mm Hg in patients on Ventilation)
MAP 65 mm Hg or greater
Urine output 0.5 mL/kg/hr or greater
ScvO2 > 70% (or mixed venous O2 saturation > 65%)
18. Current recommendations to attain these goals
30 mL/kg of suitable crystalloid
Albumin along with vasopressors and inotropes
RBC transfusion.
Patients with established ARDS for surgical procedures.
Focus of fluid therapy is the fine balance between avoiding an
increase in lung edema while maintaining adequate tissue
perfusion.
Early goal-directed fluid therapy may prevent ALI/ARDS
In established ALI/ARDS a fluid-conservative approach is the
minimum requirement
19. BURNS
IV fluid therapy is generally instituted for burns of greater than 15%
total body surface area in adults and 10% total body surface area in
children
Parkland Burn Fluid Resuscitation Formula
First 8 hours: 2 mL/kg × % TBSA (lactated Ringer solution)
Next 16 hours: 2 mL/kg × %TBSA (lactated Ringer solution)
Next 24 hours: 0.8 mL/kg × %TBSA (5% dextrose) + 0.015 mL/kg × %TBSA (5%
albumin)
20. Down-titration of fluid volumes if UO is adequate (0.5 to 1 mL/kg/hr)
Excessive fluid administration (“fluid creep”) may cause
Pulmonary edema
Fasciotomies in nonburned muscle compartments
Raised IOP
Conversion of superficial to deep burns
Intraabdominal hypertension and compartment syndrome
Haifa formula (New Practice)
Plasma (cc) - 1.5 x % TBSA x body weight (kg) + RL (cc) - 1 x % TBSA x body weight
(kg).
Half fluid in first 8 hr and the other half in the next 16 hr
In the subsequent 24 hr, we give half the amount estimated for the first day.
The sufficiency of the fluid is judged mainly on the basis of urine output.
21. HEPATIC FAILURE
Progressive liver disease and cirrhosis cause
peripheral vasodilation and
relative intravascular depletion (total body Na+ and water are retained with
ascites and edema )
Aim is reduction of total body salt and water
[dietary fluid and salt restriction, diuretics (spironolactone and loop diuretics),
and intermittent or continuous drainage of ascites]
Excessive isotonic saline => salt and water overload=> further ascites
and edema formation.
Approach => Assess volume status and replace losses with
appropriate volumes of isotonic crystalloid, colloid, or blood but avoid
salt and water overload.
22. Large-volume (>6 L) ascites drainage => hemodynamic instability =>
Albumin is more effective than saline.
Lactate and other buffered fluids may be used in hepatic failure,
although their metabolism may be slowed in advanced liver disease.
In decompensated liver disease with encephalopathy, raised ICP may
be present and osmotherapy, such as hypertonic saline or mannitol
should be used to bring plasma Na+ into the high-normal range.
In chronic compensated liver disease, a degree of hyponatremia is well
tolerated and does not require acute correction.
23. OBSTETRICS
PIH & PREECLAMPSIA
A clear association between positive fluid balance and the incidence of
pulmonary edema in this condition
Restricted volumes of IV crystalloid (80 mL/hr), and fluid balance observed
carefully.
Oliguria not treated by administration of large volumes of fluids if kidneys
normal .
Blood loss replaced with an appropriate volume of crystalloid, colloid, or
blood, depending on magnitude.
Invasive monitoring can be used to direct fluid therapy in severe
preeclampsia.
24. GERIATRIC:
Decrease in TBW, GFR, urinary concentrating ability, aldosterone, thirst mechanism, free-water
clearance.
Increase in antidiuretic hormone (ADH), atrial natriuretic peptide (ANP)
Renal capacity to conserve sodium is decreased.
Tendency to lose sodium in the setting of inadequate salt intake.
Decreased thirst response => risk for dehydration and sodium depletion.
Diminished ability to respond to an increased salt load => increased Na+ retention during the
periop period.
Volume expansion SHOULD BE DONE CAREFULLY
BLOOD BY BLOOD in periop settings.
25. PEDIATRICS
Holliday and Segar in 1957=> 4-2-1 volume calculation for maintenance fluid
requirements for
insensible losses and
urinary losses
Glucose-based solutions intraop to reduce high risk for preop hypoglycemia after
prolonged fasting and
Postop maintenance fluids based on the 4-2-1 calculation using hypotonic
crystalloids.
Paeds population considered at risk for preop dehydration by fasting (limited urinary
concentrating ability and ongoing insensible losses because of large body surface
area.)
Intraop replenishment of these volumes using isotonic salt solution
26. Re-evaluation
Longer preop fasting discouraged carbohydrate-containing—fluids up to 2 hours before
surgery.
Preop hypoglycemia incidence is infrequent (<2.5%) & related to
inappropriately prolonged fasting
premature infants,
neonates who are SGA, or
those with poor nutritional status.
Surgery + Glucose-containing solutions => hyperglycemia => Complications
osmotic diuresis
electrolyte abnormalities => adverse neurologic outcomes (ischemia or hypoxia)
Glucose-free balanced crystalloid solutions should be used intraop, except in those at
particularly high risk for hypoglycemia.
Surgical stress and presence of pain and hypovolemia => SIADH => water retention and
hypoosmolar hyponatremia with hypotonic solutions in significant volumes.
27. Proposed strategies to avoid this
Using half to two thirds of calculated 4-2-1 formula maintenance fluids,
Avoiding the hypotonic fluids (4% dextrose with 0.18% NaCl)
Returning to oral fluids as early as possible
Ensuring euvolemia to minimize the ADH response
Not confusing maintenance requirements with ongoing losses (e.g., GI or blood),
which should be replaced by isotonic crystalloids, colloids, or blood
Checking electrolytes at least daily in those still receiving IV fluids.
Isotonic saline “safer” for postop maintenance, but risk of Na+ overload and
hyperchloremic acidosis.
Dearth of data on colloid volume expansion and goal-directed fluid therapy.
29. NEUROSURGERY
Rational management =>
maintain baseline blood volume and cerebral perfusion
avoid decreases in serum Na+, osmolality, and oncotic pressure.
Specific management may be required in:
1. Increased ICP:
Mannitol and hypertonic saline given by bolus.
Hypertonic saline superior to mannitol.
Restrictive fluid strategies advocated in severe traumatic brain injury.
2. Cerebral vasospasm: “triple-H” therapy
Hypervolemia, Hemodilution, Hypertension
3. Intacranial pathologic condition CAUSE cerebral salt wasting, diabetes insipidus,
SIADH.
Albumin is => increase in mortality in traumatic brain injury.
30. TRAUMA
Goal=> Hemostasis then restoration of normal circulating volume and tissue perfusion
Permit hypovolemia to achieve cerebration rather than normotension, maintain SBP of
70 to 80 mm Hg in penetrating trauma, or
90 mm Hg in blunt trauma.
Rapid radiologic or surgical damage control intervention.
Large volumes of IV crystalloids or colloids in early resuscitation will cause hemodilution and dilute
clotting factors, and saline-based fluids may aggravate the acidosis .
pRBCs, FFP and platelets replaced early. “High” ratios of FFP to pRBC (e.g., 1:1 to 1:2) are
associated with the best outcomes
Avoidance hyponatremia and hypoosmolality to minimize cerebral edema in isolated head
injuries with a MAP >90 mm Hg.
31. FREE TISSUE FLAP SURGERY
Flap blood flow depends on
systemic blood pressure
blood viscosity
Hypervolemic hemodilution has traditionally been used
Conservative fluid strategy improves flap outcome by avoiding
reduction in O2 carrying capacity and potential for flap edema
Large volumes of crystalloid — favoring increased capillary filtration —
AVOIDED and colloids used for blood volume expansion.
32. INTRATHORACIC PROCEDURES
Any procedure within the thorax can lead to postoperative respiratory
problems, including ARDS and acute lung injury (ALI).
There are reduced pulmonary complications with restrictive fluid
strategies.
The use of diuretics to actively target fluid balance, degree of
cardiovascular support, and presence or of epidurals helps
Improved pulmonary outcomes in those treated with a restrictive
rather than liberal fluid regimen.
Cautious approach to fluid administration is recommended, both to
minimize pulmonary complications and to avoid anastomotic edema.
33. MAJOR INTRAABDOMINAL SURGERY
Fluid losses during surgery are caused by
prolonged peritoneal exposure,
significant blood loss, and
acute drainage of tumor-related ascites.
Difficult to quantify, so cardiac output monitoring, CVP, arterial pressure monitoring
and serial blood gas analysis is valuable.
Intraoperative drainage of ascites may require large volumes to replace the ongoing
loss.
Consequence of fluid redistribution is electrolyte abnormalities; e.g. hypokalemia
and hypomagnesemia .
34. RENAL TRANSPLANT
The key goals are
ensure adequate renal perfusion to support early graft function
avoid fluid therapy side effects
CVP-guided intraop fluid therapy, large volumes of crystalloid (up to 60 to 100 mL/kg) to achieve
CVP of 10-12 mm Hg or higher before reperfusion.
Recently, more conservative goals, like crystalloids at15 mL/kg/hr or more, for CVP of 7-9 mm
Hg with no increase in graft failure.
Balanced crystalloid solutions or K+ free buffered dialysate solutions used.
The role of colloids not clear(concerns over renal toxicity of starches).
Postop fluid therapy should aim baseline requirements and the ongoing losses resulting from
urine production.
35. LIVER TRANSPLANT
Guided by invasive monitoring like pulmonary artery catheterization.
During phase I (preanhepatic), large-volume blood loss and fluid shift resulting from
drainage of ascites.
During phase II (anhepatic) a major reduction in venous return and CO if the IVC,
portal vein, and hepatic artery are cross-clamped. Crystalloid and colloid infusion
required with vasopressors to maintain arterial pressure.
Phase III (reperfusion) acute rise in CVP, hepatic congestion and right heart strain.
Systemic vasodilation and cardiac suppression leads to hypotension requiring
vasopressor or inotrope. Fluids should be restricted
Ongoing infusion of fluids, red cells, and blood products should be guided by clinical
blood loss, maintaining a hematocrit of 26% to 32% .
36. TRANSFUSION THERAPY
- 60% of transfusions occur perioperatively.
- responsibility of transfusing perioperatively is with the anesthesiologist.
WHEN IS TRANSFUSION NECESSARY?
“Transfusion Trigger”: Hgb level at which transfusion should be
given.
Varies with patients and procedures
37. LIBERAL VERSUS RESTRICTIVE TRANSFUSION STRATEGY
Restrictive policy = BT only when the Hb value is 7 to 8 g/dL or less.
Liberal policy = BT when the Hb value is 9 to 10 g/dL or greater.
If no clinical advantages with the liberal transfusion policy, perhaps the restrictive
approach should be used.