Volume therapy in cardiac surgery patients

2. GOALS FOR CARDIO-CIRCULATORY THERAPY
The goal of fluid management
and inotropic and vasoactive drug therapy
in post-operative cardiac surgery patients
is to achieve sufficient tissue perfusion
and a normalization of oxidative metabolism.
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

3. GOALS FOR CARDIO-CIRCULATORY THERAPY
Cardiac output and oxygen supply are dependent on
adequate intravascular volume and cardiac function.
The following parameters are recommended as goals
for postoperative cardiovascular therapies.
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

4. GOALS FOR CARDIO-CIRCULATORY THERAPY
Parameters recommended:
• MAP >65 mm Hg
• Cardiac Index >2.0 L/min/m2
• SvO2 >65%
• PAD 10–15 mm Hg
• CVP 8–12 mm Hg (dependent on ventilation mode)
• Lactate <3 mmol/L
• Diuresis >0.5 ml/kg BW/h
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

5. GOALS FOR CARDIO-CIRCULATORY THERAPY
Blood Pressure targets during the first 48 hours:
• Normal (MAP >65 mm Hg) Default BP goal
• High (MAP >75 mm Hg) Age >75
Poorly controlled HTN
Pre- or postop- renal impairment
Uncorrected carotid artery stenosis
Pre- or postop- ischemic stroke
• Low (MAP 55-60 mm Hg) Age <50 (with low preop- BP)
High bleeding risk
Surgery for chronic valve regurgitation
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:295-297.

6. GUIDELINES FOR INTENSIVE CARE
IN CARDIAC SURGERY PATIENTS
• Hemodynamic monitoring
• Volume-therapy
• Treatment with inotropic drugs and vasopressors
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.

7. GOALS FOR CARDIO-CIRCULATORY THERAPY
Fluid management:
• In cardiac surgery patients it is common to have relative or absolute volume
deficiency in the early post operative phase.
• First line treatment in cardiac surgery intensive care medicine consists in the use
of artificial colloid solutions.
• Medium molecular weight HES derivatives (Voluven) are preferred.
• Crystalloid solutions are the second choice of volume substitution.
• Plasma volume substitution with human albumin is no longer used in 50% of
cardiac surgery intensive care units.
Kastrup M, et al. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-
operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand.
2007;51:347-58.

8. GOALS FOR CARDIO-CIRCULATORY THERAPY
High molecular weight HES (Hespan):
• High molecular weight HES (>200 kDa) 10% preparations (Hespan)
is associated with increased postoperative bleeding.
• High molecular weight HES, hyperoncotic colloids and 10% and 20% albumin,
are associated with increased risk of hyperoncotic renal failure.
• Hespan is contraindicated in patients with severe increases of Na & Cl.
Rioux JP, et al. Pentastarch 10% is an independent risk factor of acute kidney injury following cardiac
surgery. Crit Care Med. 2009;37:1293-8.

9. GOALS FOR CARDIO-CIRCULATORY THERAPY
Medium molecular weight HES (Voluven):
• Medium molecular weight HES (130 kDa) 6% (Voluven)
is not associated with increased postoperative bleeding.
• Medium molecular weight HES (130 kDa) 6% (Voluven)
is not associated with increased risk of hyperoncotic renal failure.
• There is no scientific evidence to support the use of the more expensive albumin
over medium molecular weight (130 kDa) 6% HES preparations.
Kasper SM, et al: Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion
requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at
recommended doses. Anesthesiology 2003;99:42-47.

10. GOALS FOR CARDIO-CIRCULATORY THERAPY
Hydroxyethyl starch (HES 130/0.4 or Voluven):
Boldt J, et al: Volume therapy in cardiac surgery: Are Americans different from Europeans?
J Cardiothorac Vasc Anaesth. 2006;20:98-105.

11. GOALS FOR CARDIO-CIRCULATORY THERAPY
Hydroxyethyl starch (HES 130/0.4 or Voluven):
• Standard Dilution:
[6 g] [100 ml NS]
• Usual dosage:
500 - 1000 mL/day
• Continuous infusion during or after operation
• In 100 patients undergoing CABG, an infusion of up to 50 ml/kg of HES 130/0.4
did not increase blood loss and transfusion requirements.
Kasper SM, et al: Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion
requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at
recommended doses. Anesthesiology 2003;99:42-47.