fluid management / perioperative caredr robin correa frca perioperative care dr robin correa frca...

Fluid Management / Perioperative Care Dr Robin Correa FRCA

Perioperative Care

Dr Robin Correa FRCAConsultant Anaesthetist

23 March 2011


Perioperative Care

Preoperative Care- Fluid optimisation and nutrition- Assessment

Intraoperative Care- Antibiotic and thromboprophylaxis- Sterilisation, disinfection and antisepsis- Transport, positioning, scrubbing up, instruments, incisions,

closures, drains, stomas and sutures

Postoperative Care- Drain, fluid and acid – base management, pain, surgical

complications and critical care


Fluid Management

• Introduction

• Fluid compartments

• Stress response and fluid

• GIFTASUP recommendations


Introduction

• Fluid and electrolyte balance consists of :

- external balance between the body and its environment

- internal balance intravascular, interstitial and intracellular

compartments

• Twenty four hour requirements in normal adult are 25 – 35 mL/kg or 1.5 – 2.5 L of water with 70 mmol of sodium and 40 - 80 mmol of potassium

• Fluid requirements sometimes classified as that for replacement, maintenance and resuscitation


Introduction

• Crystalloid solutions contain low molecular weight salts or sugars which dissolve completely in water and pass freely between intravascular and interstitial compartments

• Colloid solutions contain larger molecular weight substances that do not dissolve completely and remain for a longer period in the intravascular compartment


Fluid compartments


Fluids Fluid Sodium

mmol/LPotassiummmol/L

Chloridemmol/L

Osmolaritymosm/L

Plasma 136-145 3.5-5.0 98-105 280-300

Hartmann’s 131 5.0 111 275

Dextrose 4%saline 0.18%

30 0 30 283

5% Dextrose 0 0 0 278

Gelatine 4%(Gelofusine)

145 0 145 290

0.9% Saline 154 0 154 308


Fluids

Volume effect (%)

Average MW (kDa)

Circulatory half life

Gelatins 80 35 2 – 3 hrs

Dextran 70 120 41 2 – 12 hrs

6% HESHydroxyethyl Starch

100 70 Up to 17 days


Stress response and fluid

• Along with other hormones, stress response to surgery releases vasopressin and triggers the RAAS (renin – angiotensin – aldosterone system)

• Net effect is an increase in body water with the retention of sodium

and excretion of potassium. Oliguria is common which is accompanied by a reduced capacity of kidney to dilute or concentrate urine

• A catabolic state from surgery results in an increased production of urea and other metabolites which compete with electrolytes (mainly Na+ and Cl-) for excretion by the kidney

• Recovery phase is characterised by a diuresis with loss of both sodium and water


GIFTASUP

• GIFTASUP (October 2008) - British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients

• A 1997 UK study showed that postoperative patients were frequently in positive fluid balances of 7 litres or more with a sodium load

of 700 mmol

• In the US, excessive fluid administration causing pulmonary oedema has been blamed for 8315 patient deaths a year

• A postal survey of 710 consultant surgeons revealed that PRHO’s were most commonly responsible for fluid prescription


GIFTASUP

Recommendation 1 Normal Saline is Abnormal

Recommendation 2 Dextrose can be dangerous

Recommendation 3 Equal electrolytes by any route

NB – words in red are an aide memoire and do not form part of the GIFTASUP document


GIFTASUP

Recommendation 1 (Normal Saline is Abnormal)

Evidence level 1b

Because of the risk of inducing hyperchloraemic acidosis in routine

practice, when crystalloid resuscitation or replacement is indicated,

balanced salt solutions e.g. Ringer’s lactate/acetate or Hartmann’s

solution should replace 0.9% saline, except in cases of hypochloraemia

e.g. from vomiting or gastric drain


GIFTASUP Normal Saline is Abnormal

• 0.9% saline contains supranormal amounts of Na+ and Cl-

(154 mmol/L each ) compared to physiological concentrations

(140 and 95 mmol/L respectively)

• A sodium load can be difficult to excrete especially in the oliguric phase of the stress response

• Hyperchloraemia causes renal vasoconstriction and a reduced glomerular filtration rate

• Excess serum sodium can aggravate interstitial oedema caused by capillary endothelial leaks


GIFTASUP

Recommendation 2 (Dextrose can be dangerous)

Evidence level 1b

• Solutions such as 4% /0.18% dextrose/saline and 5% dextrose

are important sources of free water for maintenance, but should

be used with caution as excessive amounts may cause

dangerous hyponatraemia, especially in children and the elderly

• These solutions are not appropriate for resuscitation or

replacement therapy except in conditions of significant free

water deficit e.g diabetes insipidus


GIFTASUP

Recommendation 3 (Equal electrolytes by any route)

Evidence level 5

• To meet maintenance requirements, adult patients should receive

sodium 50-100 mmol/day, potassium 40-80 mmol/day in 1.5 - 2.5

litres of water by the oral, enteral or parenteral route (or a

combination of routes)

• Additional amounts should only be given to correct deficit or

continuing losses. Careful monitoring should be undertaken using

clinical examination, fluid balance charts, and regular weighing

when possible


Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’" study

M. C. Bellamy Wet, dry or something else? Br. J. Anaesthesia 2006 97: 755-757


Oesophageal Doppler


LiDCO Rapid


GIFTASUPPostoperative fluid management• Details of fluids administered must be clearly recorded and

easily accessible

• When patients leave theatre for the ward, HDU or ICU their volume status should be assessed

• In patients who are euvolaemic and haemodynamically stable a return to oral fluid administration should be achieved as soon as possible

• In patients requiring IV maintenance fluids, these should be sodium poor and of low enough volume until the patient has returned their sodium and fluid balance over the peri operative period to zero


Scenario 1

80 yr old female for elective total hip arthroplasty

Scheduled last on PM list but starved from 1800 hrs

previous day

Start Hartmann’s 1 litre to run over 6 hours


Scenario 2

50 yr old male on ward after elective hemi colectomy

6 hrs prior

Urine output 50 mls in the last 3 hours

Check vitals

Look for overt signs of bleeding

Fluid challenge 250 mls crystalloid or colloid


Scenario 3

27 yr old postoperative lap appendicectomy. No overt

losses and patient looking well

Oral intake planned as sips of water next day

Maintenance fluid – aim for 1.5 – 2.5 L of water with

70 mmol of sodium and 40 - 80 mmol of potassium.

Hartmann’s / Dextrose saline with potassium chloride


Scenario 4

60 yr old male AP resection 4 days ago.

Hypotensive but feels warm to touch, anuric for last

5 hours

Check vitals and temperature

Judicious fluid challenge

Seek senior help early


Resources • Association of Surgeons of Great Britain and Ireland

http://www.asgbi.org.uk

• Intensive Care Society

http://www.ics.ac.uk

• NICE guideline (nutritional support)

http://www.nice.org.uk/Guidance/CG32

• Surgical Tutor

http://www.surgical-tutor.org.uk/default-home.htm?principles/postoperative/fluid_balance.htm~right


Summary

• Fluids are distributed into various body

compartments according to their solute molecular weight and content

• Normal saline is abnormal

• Fluid type and volume must always be tailored to clinical condition


‘Every time I learn something new, it pushes some old stuff out of my brain’


Perioperative Care

Preoperative Care- Assessment- Fluid optimisation and nutrition






Assessment

• Objectives of preoperative assessment

• Preoperative assessment clinics

Infrastructure

Personnel

Process

Pathways and basic investigations

• Special investigations

CPX testing


CPX


CPX

Cardio- Pulmonary Exercise Testing (CPET or CPX)

• The anaerobic threshold (AT) is the uptake of oxygen (ml/kg/min) at the point when there is a surge in CO2 production during increasing workload

• This reflects maximum ability of patient to increase oxygen delivery / consumption and cardiopulmonary fitness

• AT > 11 ml/kg/min can be used to categorise patients ‘fit’ for major abdominal surgery

• Postoperative mortality can be predicted from AT values and

presence of test ECG ischaemia


CPX

Older, P et al Chest 1999;116:355-362


Perioperative Care

Preoperative Care- Assessment- Fluid optimisation and nutrition






Antibiotic prophylaxis

• Principles

• NICE guidelines

• Department of Health (DH) guidelines



Principles• High circulating serum levels of antibiotics at the time of tissue

contamination

• Usually of limited duration e.g. 24 hours post op

• Extended duration (3 days or more)

Immunosuppressed patients

Malnourished patients

Patients with prosthetic implants e.g. heart valves

Established postoperative surgical infections


NICE guidelines Surgical Site Infection

http://www.nice.org.uk/Guidance/CG74 October 2008

Antibiotic prophylaxis• Give antibiotic prophylaxis to patients before:

– clean surgery involving placing a prosthesis or implant

– clean-contaminated surgery

– contaminated surgery

• Do not give antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery

• Use the local antibiotic formulary and consider potential adverse effects when choosing antibiotics


DH guidelinesClostridium Difficile Infection (CDI) : How to deal with the problemhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/

PublicationsPolicyAndGuidance/DH_093220 January 2009

Restrictive antibiotic guidelines should be developed by trusts

stressing the following recommendations:• Use narrow-spectrum agents for empirical treatment where

appropriate

• Avoid use of clindamycin and second- and third-generation cephalosporins, especially in the elderly

• Minimise use of fluoroquinolones, carbapenems and prolonged courses of aminopenicillins


Thromboprophylaxis

• Definitions

• Aetiology

• Methods

• NICE / DH guidelines


Thromboprophylaxis

• DefinitionsVenous thromboembolism (VTE) is the formation of a blood clot (thrombus) in a vein which may dislodge from its site of origin to cause an embolismMost thrombi occur in the deep veins of the legs; this is called deep vein thrombosis (DVT)Dislodged thrombi may travel to the lungs; this is called a pulmonary embolism (PE)

• Aetiology Series of contributing factors called Virchow's triad - alterations in blood flow (stasis) - injury to the vascular endothelium

- alterations in the constitution of blood (hypercoagulability)


ThromboprophylaxisMethods• Mechanical devices

Graduated compression stockings, pneumatic compression devices

• Drugs acting on the clotting cascadeHeparin unfractionated or low molecular weight (LMWH) - activates antithrombin IIIDabigatran etexilate – direct inhibitor of thrombin

• Antiplatelet drugsAspirin, Dipyridamole, Clopidogrel

• Drugs indirectly affecting clot formationDextran 70

• General measures Early mobilisation, foot elevation, hydration


Mechanical devices


NICE guidelines

Venous thromboembolism : reducing the risk

http://www.nice.org.uk/Guidance/CG92

January 2010


NICE guidelines

Care pathway Patient admitted to hospital

Assess VTE risk

Assess bleeding risk

Balance risks of VTE and bleeding. Offer VTE prophylaxis if appropriate.

Do not offer pharmacological VTE prophylaxis if patient has any risk factor

for bleeding and risk of bleeding outweighs risk of VTE

Reassess risks of VTE and bleeding within 24 hours of admission and whenever clinical situation changes.


DH guidelinesVenous thromboembolism (VTE) risk assessmenthttp://www.dh.gov.uk/en/Publicationsandstatistics/

Publications/PublicationsPolicyAndGuidance/DH_088215 March 2010

• All patients should be risk assessed on admission to hospital

• Any tick for thrombosis risk should prompt thromboprophylaxis according to NICE guidance.

• Patients should be reassessed within 24 hours of admission and whenever the clinical situation changes

• From 1st June 2010 all NHS Trusts are required to be able to demonstrate that more than 90% of their inpatients receive a Venous Thromboembolism Risk Assessment (VTE RA) on admission to hospital


Questions ?

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