Perioperative Fluid Management

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Perioperative FluidManagement

• Fred Rotenberg, MD
• January 10, 2007

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Goals of Fluid Administration

• O2 delivery / blood flow - perfusion
• Maintain electrolyte composition,
• Glycemia,
• Body temperature

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O2 Delivery

• DO2 Q x CaO2
• CaO2 SaO2, CO, Hgb
• CO SV x HR
• SV preload, afterload, contractility

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Frank Starling Curves
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Maximizing CO
Frank Starling Curves

• Slope of curve is EF
• Good ventricles are preload dependent
• Poor ventricles are afterload dependent (not
  preload dependent)

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For Low SV / CO

• Good LV function -gt give fluid
• Poor LV function -gt Inotropes
• Vasodilators
• Diuretics

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How much to give and when to give it

• IT DEPENDS-
• Type of patient
• Type of surgery
• Amount of trauma
• Acute injury vs. elective
• Anesthetic, positioning
• Who you listen to

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Classic fluid management

• Deficits
• Maintenance
• 3rd Space
• Blood loss

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Deficits

• Estimate
• Preop NPO (hourly maintenance x duration)
• Preop bowel preparation (1-1.5L)
• Preop blood loss (trauma) or fluid loss (burns)
• Typically replaced over first 2-4 hours

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Maintenance

• (4-2-1 rule)
• 4 ml/kg/hr for first 10 kg of body weight
• 2 ml/kg/hr for 2nd 10 kg of body weight
• 1 ml/kg/hr for each kg of body weight above 20 kg
• Based on water loss from burning calories
• from Holliday and Segar

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Replace fluid losses

• Third space 2-10 ml/kg/hr
• Blood losses
• 3 to 1 ratio of crystalloid to EBL
• 1 to 1 for colloid or blood
• (or hypertonic saline)

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Surgical Trauma Third Spacing

• Capillary and Endothelial injury leak
• Sequestration of fluid into tissues
• i.e. TRAUMA causes FLUID Retention
• Creation of nonfunctional component of ISF
• Return of fluid from this third space 1-4 days
  after surgery

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Surgical Trauma 3rd space

• Shires Annals of Surgery 1961
• Minor (lt 200cc EBL) vs Major (gt200cc EBL)
• No fluids administered for at least 2 hours
• Measured Functional Extracellular Fluid
• Minor Surgery had minimal changes in ECF 1.4
• Major Surgery had 0-28 changes in ECF
• Conclusions
• Change in ECF secondary to redistribution
• Change not related to blood loss
• Change correlate with amount of trauma to tissues
• Retractors and manipulation

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Distribution of Fluid
3RD SPACE
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Healthy outpatients minor procedure

• 1 vs 2 liters of fluid
• Decrease thirst, dizziness, drowsiness pain and
  nausea
• Reduce time til discharge
• May improve respiratory function post operatively

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Outpatient ASA I-II for Lap CCY

• More generous fluids (15 vs 40 ml/kg for the
  case)
• Improved post op pulmonary fxn
• Improved exercise tolerance
• Improve nausea, well being, dizziness,
  drowsiness, fatigue, balance
• Holte et al. Ann Surg 2004

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Risks of Excess Fluids

• Interstitial edema
• Impaired cellular metabolism
• Poor wound healing
• Decreased pulmonary compliance
• Heart failure overload
• Delayed return of bowel function
• Hemodilution

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Specific Scenarios

• Postoperative weight gain
• Pulmonary surgery
• Hepatic surgery
• Vascular surgery
• Hip surgery
• Trauma
• Neurotrauma

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Postoperative Weight Gain

• Lowell et al CCM 1990
• 48 patients admitted to SICU
• 40 of patients had gt 10 weight gain
• Weight gain related to
• Mortality
• RBC transfusion
• FFP transfusion
• Mechanical Ventilation
• When matched to controls, fluid administration
  was significant variable

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Restricted fluids in Intra-abdominal Surgery

• Restricted 4 ml/kg/hr (e.g. 850ml) vs.
• Liberal 10 ml/kg bolus 12 ml/kg/hr (e.g.
  3200)
• Earlier bowel function and hospital discharge,
  less weight gain with restriction
• Nisanevich et al. Anesth 2005

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Pulmonary Surgery

• Miller et al Annals Thoracic Surg 2002
• 115 completion pneumonectomies
• PPE occurred in 15 with Mortality of 43
• Mortality related to Fluid administration 12
  hours 1800 vs 2500
• 24 hours 2300 vs 2800

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Hemodilution Cardiac Effects

• Mangano NEJM 1991, JACC 1991
• 83/474 cardiac events (17) noncardiac surgery
• 30/84 CHF (35)
• 1-3 days postop vascular patients more frequent
• Speculation related to greater fluid
  administration to patients at risk
• Nelson CCM 1993 vascular surgical patients
• Worse outcome with Hct lt 28
• Speculation Due to hemodilution
• Spahn JTCVS 1993 19 dogs with acute LAD
  occlusion
• Ischemia with hemodilution to Hgb 7.5 gm/dl
• Baron Anesth 1987
• Epidural dosing and fluid loading (500 cc) in
  patients with WMA
• Mangano Circ 1980 and Dehert Anesth 1999
• Impaired contractile response to fluid bolus
  (500-1500) or leg elevation when compared to
  Phenylephrine

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Hepatic ResectionLow CVP Technique

• Melendez et al J Am Coll Surg 1998
• Low CVP technique 496 resections
• IVF 1 cc/kg/hr and boluses as needed
• NTG, dopamine, mannitol as needed
• Urine output gt 25 cc/hr
• SBP gt 90 mmHg
• CVP lt 5 mmHg
• Results
• Reduction in EBL and transfusion
• One patient with renal failure due to
  aminoglycoside
• Improved visualization of surgical field
• Reduces pressure in hepatic tissues

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Hip Replacement

• Sharrock Br J Anaesth Reg Anesth
• 987 surgeries
• Spinal/Epidural hypotension (mBP 50-55mmHg)
• Fluid restriction to minimize perioperative CHF
• Epinephrine as needed to maintain BP and CO
• Improved Outcome
• 2 myocardial infarction
• Reduction in EBL and transfusions compared to
  controls
• 0 renal failures
• 3 deaths (0.4)

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Trauma Scoop and Run

• Bickell NEJM 1994
• 598 penetrating torso injuries pre SBP lt 90 mmHg
• Immediate (309) vs Delayed (298) fluid
  resuscitation
• Outcome
• Preop Fluid 2500cc vs 350cc
• Less periop blood transfused 2070cc vs 1720cc
• Improved pulmonary function
• Decreased mortality

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WHATS DIFFERENT BETWEEN OUTPT AND INPT?

• I.E. THE PREOP CONDITION OF THE PT
• THE EXTENT OF TRAUMA (AND 3RD SPACE LOSS)
• THE ABILITY TO HANDLE FLUIDS
• THE ANESTHETIC EFFECTS

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Effects of Anesthesiatransient

• Regional
• Vasodilation - venous pooling
• General
• Myocardial depressants
• Vasodilation
• Reductions in natriuretic hormone
• Increase in Anti-diuretic hormone
• Mechanical Ventilation
• Decrease in venous return
• FLUID ELIMINATION IS GREATER POST-OP
• BUT THE RATE OF ELIMINATION IS NOT RELATED TO AMT
  OF FLUID ADMINISTERED

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Isoflurane

• Promotes extravascular fluid accumulation
• during crystalloid loading (i.e. 3rd space loss)
• Not related to mechanical ventilation
• Is this due to increased ADH, ANP?
• Reduces GFR by 30-50
• Renal blood flow by 40-60
• Urine output by 65

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Fluids? Drugs? Both?

• Volume status? HX PE LABS
• I.E. What is hypovolemia?
• - Check neck veins, urine volume and color
• Labile blood pressure suggests hypovolemia
• The Rotenberg Rule when the HR is higher than
  the systolic BP -gt give fluid
• Respiratory variation in BP or pulse ox pleth

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Monitors

• Skin color, reperfusion, mucous membranes, weight
  change
• HR, BP (systolic pressure variation)
• Is/Os Fluid Administration, Urine output,
  Blood loss
• ETCO2 PaCO2-ETCO2
• CVP, PAP, PCWP, CO, MvO2
• TEE Doppler CO measurements

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Arterial vs Plethysmographic Dynamic Indices for
Testing Fluid Administration in Hypotensive
Patients

• Only ½ of hypotensive pts increase CO s/p fluid
  challenge
• BP and plethysmographic variation w/ PPV predicts
  responsiveness to fluids
• Anes Anal 1031478 (Dec06)

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ART BP
SaO2 PLETH
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Predicting response to fluids

• ?Baseline BP - X
• ? Baseline HR - X
• ? Baseline Filling pressures - X
• Baseline CI !
• ?Respiratory variation of BP or SaO2 pleth
• Response to fluid loading of the above !

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Goal directed TherapyDoes it make a difference?
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Goal directed fluid therapy

• Hemodynamics / systolic pressure variation
• CVP / PCWP
• Cardiac output / SV
• O2 delivery (CO plus SaO2)
• Fluids plus inotropes -

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Fluids plus Inotropes

• Pushing O2 delivery gt 600ml O2.m2/min
• (eg CI3L/min/m2 HgB14 SaO298)
• May decrease mortality and morbidity
• Dopexamine better than Epi
• Aggressive management should be instituted early

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Guided Fluid administration

• Relatively small increase in fluids given (i.e.
  200- 500 ml using CVP 1 L using PA)
• May reduce post op renal insufficiency
• No major benefit as long as central hemodynamics
  are maintained
• Using DOPPLER - May provide quicker return of
  bowel function and hospital discharge less
  complications
• No improvement in mortality

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Timing of fluids

• Preop fluids retained shorter than intra-op
  fluids
• I.e. Surgical fluids are retained
• Scoop and run vs. early fluid administration

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Choice of fluids

• Crystalloids
• Colloids
• Blood products
• Whole blood
• PRBC
• FFP
• Platelets

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Colloids do not improve outcome

• Meta-analysis showed a 12.3 worsened mortality
  with colloids in multiple trauma
• Saline solutions may produce hyperchloremic
  acidosis

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Colloids and Renal Dysfunction

• The dehydrated patient who receives considerable
  amounts of (hyperoncotic) colloids is especially
  at risk for developing ARF. It may be advisable
  to administer colloid in addition to, rather than
  in lieu of, crystalloids. Boldt Priebe, A and A
  2003

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3rd space
Interstitial fluid
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Hypertonic (hyperosmolar) solutions

• Temporarily shifts water from intracellular and
  interstitial space to intravascular space
• Reduces CSF secretion rate

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Limit volume of Hypertonic Saline

• 1 liter of 3 max
• Too much 3 may
• Cause rebound intracranial hypertension
• Cause hyperchloremic acidosis, hypokalemia
• Cause intracellular dehydration
• Hyperchloremia may cause renal vasoconstriction

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Clinical Studies of Hypertonic Saline

• Efficacious for hypotensive brain injured pts in
  transfer to hospital
• Lesser amount of cerebral edema
• May reduce ICP where mannitol has failed
• Improves CO /reduces SVR better than LR
• Promotes diuresis, reduces edema
• Increased serum sodium (to 150s) is well
  tolerated

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Clinical Studies of Hypertonic Saline

• 1919 Weed and McGibben effective in reducing
  ICP
• 1992 Fisher decreases ICP following head trauma
  in kids
• 1997 Wade et al 2 fold improved survival in
  adult trauma pts

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Summary

• 1 Healthy pts minimal trauma -gt
• be generous
• 2 Sicker patients significant trauma -gt
• be stingy
• In this 2nd case goal directed therapy maybe
  helpful. (Resp variation in sys BP, SaO2 pleth.)

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My Recipe

• If you need fluid -
• 2 L of Ringers, then 500 ml of 3 saline
• Then, consider blood products or colloid