perioperative fluid management - the issues

perioperative fluid therapy - the issues

perioperative fluid theraypy - three main issues

what type of fluid to give?

which amount of fluid to give?

when to give it?

perioperative fluid therapy

fluid excess implication for postoperative

morbidity?•cardiac•pulmonary•gastro-intestinal (ileus)•wound healing•coagulation

optimal regimen/preop optimization ?

fluid deficit implication for postoperative

morbidity?

•functional hypovolemia•delayed recovery•anastomotic problems?

examples of fluid administration in cholecystectomy

0

1000

2000

3000

4000

1963 1966 1967 1992 1995

Infu

sion

vol

ume

(ml)

Roth et al., Ann Surg 1969; 62: 1Petros et al., Surg Gyn Obstet 1992; 174: 497Glaser et al., Ann Surg 1995; 221: 372

examples of fluid administration in colonic surgery

0

4000

8000

12000

1940 1960 1980 2001

Infu

sion

vol

ume

(ml)

Holte, Sharrock and Kehlet, Br J Anaesth 2002; 89: 622

high-volume regimensvascular surgery – aorta 6-7 liters vascular surgery – peripheral 6-7 litersmajor abdominal 5 literslaparoscopic cholecystectomy 4 liters

low-volume regimenslung surgery 0-1 liters

Jordan et al., Eur Resp J 2000; 15: 790Holte, Sharrock and Kehlet, Br J Anaesth 2002; 89: 622

examples of fluid administration

why administer fluids?

• correct preoperative fluid deficits • support hemodynamics under

anesthesia • control hemodynamics postoperatively • avoid blood transfusion • fear of postoperative renal failure • maintain high CVP

perioperatively fluid excess – implications for

postoperative morbidity?• cardiac• pulmonary• gastro-intestinal (ileus)• wound healing• coagulation


175

min *

**

*

0

2

4

6

8

10

gastricemptying

flatus bowelmovement

hospital stay

time

(day

s)

high fluidlow fluid

Lobo et al., Lancet 2002; 359: 1812

• randomized, controlled trial• 2*10 patients• colonic surgery

postoperative fluid regimens:high fluid: > 3L/daylow fluid: < 2L/day

* p< 0,05

fluid administration and postoperative ileus

73 m

in

fluid overload

O2 diffusion tissue

oxygen tension

collagen formation


0

5

10

15

20

0 1 2 3 4 5 6days after operation

wei

ght c

hang

e ab

ove

norm

al (%

)

no fluid60-70 mL/kg

Chan et al., Br J Surg 1983; 70: 36

fluid sequestration in rabbit small-bowel anastomoses

fluid administration and DVT

*

0

10

20

30

40

50

% w

ith D

VT

• 2*30 patients• randomized trial• major surgery• ”wet” or ”dry” fluid

regimens

• 30% vs. 7% DVT with ”wet” vs. ”dry” fluid regimen

drywet

Janvrin et al., Br J Surg 1980; 67: 690

* p<0,05

• decrease in pulmonary function • persistent weight gain after 24 hours• improved thirst and fatigue • no difference in exercise capacity• no difference in dizziness

infusion of 3 l fluid in healthy volunteers leads to:

Holte et al., Anesth Analg 2003; 96: 1504

fluid administration in minor surgery

Holte and Kehlet, Acta Anaesth Scand 2002; 46: 2089Ali et al., Anaesthesia 2003; 58: 780Magner et al., Br J Anaesth 2004; 93: 381

~ 10 randomized studies in minor surgery

1-2 litres of fluid administered to correct dehydration

improvements in: dizziness, drowsiness, nausea, vomiting

fluid administration in cholecystectomy (intermediate surgery

• 48 ASA I-II patients• lap. cholecystectomy• randomize to:

– 15 ml/kg Ringer´s lactate intraop. (~1 liter)

– 40 ml/kg Ringer´s lactate intraop. (~3 liters)

• double-blinded• 175 ml water preop• only morning sessions• standardized

perioperative management

Holte et al. Ann Surg 2004: 240: 892

weight

**

0,5

1

1,5

2

2,5

4 24

Time (hours)

Weig

ht d

iffer

ence

(kg)

Low fluid High fluid


hormonal responses – aldosterone

* p<0,05 increase# p<0,05 decrease

* p<0,05 vs. preop

*

*

0

20

40

60

80

100

baseline 0 1 2

time (hours postoperatively)

aldo

ster

one

(pg/

ml)

low fluidhigh fluid

* p<0,05 vs. preop


subjective parameters

nausea dizziness thirst drowsiness wellbeing

effects of high vs. low fluid administration 0-4 hours postop

p<0,05

in high fluid group:


15 ml/kg Ringer

40 ml/kg Ringer p value

fulfilling discharge criteria (PADDS> 9) at day of surgery 67% 96% 0,01

discharge at day of surgery 65% 95% 0,02

discharge data


principles of volume kinetic analysis

• infusion of a crystalloid load

• repeated sampling of Hgb

• curves of plasma dilution

• not physical volumes• V ~ plasma volume

v ~ interstitial volume

Hahn et al., Br J Anaesth 1997; 78: 144

volume kinetic analysis in clinical studies

Sjostrand et al., Br J Anaesth 2004; 92: 485 Ewaldsson et al., Anesthesiology 2005; 103:460Hahn et al., Br J Anaesth 1997; 78: 144

volume kinetics 4 h postop in lap cholecystectomy with 3 L vs. 1L Ringer´s lactate

Holte et al (Anesthesiology in press)

fluid administration in knee arthroplasty

• 48 ASA I-III patients• knee alloplasty• spinal/epidural anesthesia• randomize to:

– restrictive fluid (~1,7 L IV)

– liberal fluid (~4,3 L IV)

– 1000 ml oral intake on day of op in both groups

• double-blinded• standardized

perioperative management

Holte et al., Anesth Analg 2007; 105: 465

fluid strategies in major surgery

goal-directed strategies

”high vs. low” fixed infusion strategies

fast track colonic surgery – fluid therapy

• intraoperative fluid administration– 1500 ml saline– 500 ml colloid

• postoperative fluid therapy– prinicipally no IV fluids– daily weight– only IV fluid on specific indication

• hypovolemia• insufficient oral intake

preoperative information

stressreduction

pain relief mobilization early feeding

fast-track programs

reduced complications and accelerated convalescence

Basse et al., Ann Surg 2000; 232: 51Basse et al., Ugeskr Laeger 2001; 163: 913

fast-track colonic surgerypostoperative hospital stay (incl. day of surgery)

0

20

40

60

2 3 4 5 6 7 9 11 62postoperative day of discharge

num

ber o

f pat

ient

s

n=100

Basse et al., Ann Surg 2000; 232: 51Basse et al., Ugeskr Laeger 2001; 163: 913

median 2 days (48 hours)

12,2

11,2

12,8

11,7

14,2

0 7 14 21dage

UK France Germany Italy Spain

postoperative hospital stay after colonic surgery

no GI tubes

magnesia

fast-track programmes – importance of traditions in the perioperative course

• GI tubes• drains• bladder catheter• feeding policy• mobilization• “restrictions”

Kehlet, Br J Anaesth 1997; 78: 606Kehlet and Wilmore, Am J Surg 2002; 183: 630

fast-track vs. conventional colonic surgery, 2*130 patienter, 2 hospitals

fast-track conventional page 74 72 nsASA p<0,05epi (days) 2 3 p<0,05iv fluid>24t 8% 80% p<0,05GI tube p<0,05bladder catheter

p<0,05

defecation (day) 2 4,5 p<0,05

Basse et al., Dis Col Rect 2004; 47: 271

fast-track vs conventional care after colonic resection

• increased mobilisation (~30 h/ week)• preserved lean body mass• reduced hypoxaemia/improved pulm

function• preserved cardiovascular response to

exercise

Basse Br J Surg 2002;89:446

why is early enteral nutritionnot instituted ?

PONV and ileus use of nasogastric tubes ”traditions” fear of complications lack of knowledge of advantages

routine use of GI tubes in elective abdominal surgery?

no – no effect on ileus no – contributes to fever/atelectasis > 20 randomized trials

Cheatham Ann Surg 1995;221:469

routine drainage in gastrointestinal surgery ?

cholecystectomy: no pancreas/gastric: short < 4 days ? small intestine: no colon: no rectum (TME): 1-2 days ? does not prevent anastomotic problems !

Kehlet & Wilmore, Am J Surg 2002; 183: 630

bowel preparation in elective colonic surgery ?

no – preoperative klysma sufficient in rectal surgery (TME) – not established documentation from RCTs and meta-

analysis

Wille-Jørgensen Dis Colon Rectum 2003; 46: 1013Zmora Ann Surg 2003; 237: 363

• significant weight loss (1,2 kg) despite 2600-3720 ml fluid intake per day

• significant decrease in exercise capacity (9%)

• no difference in orthostatic tolerance

• no difference in plasma and extracellular volumes

bowel preparation leads to:

Holte et al., Dis Col Rectum 2004; 47: 1397

Here is a ticket for the bus. When you wake up, your will be in a bus on

your way home.

”fixed infusion” strategies

• ”fixed” fluid infusion rates given throughout surgery

• continued postoperatively in very few studies

fluid administration in colorectal surgery (RCT 141 pt)

**

*

01020304050

Death

Overal

l com

plica

tions

Major com

plica

tions

Minor c

ompli

catio

ns

patie

nts

with

com

plic

atio

ns

Low volume ( 2,7 l)High volume (5,4 l)

* p< 0,05

Brandstrup et al. Ann Surg 2003; 238: 641

* p< 0,05

fluid administration in colonic surgery (RCT 253 pt)

no difference in:

•nausea/vomiting•tolerance of food•hospital stay

* p< 0,05

0

5

10

15

20

woundinfections

wound healingscores

patie

nts/

wou

nd h

ealin

g sc

ores

low volume (3,1 l)

high volume (5,7)

Kabon et al., Anesth Analg 2005: 101: 1546

fluid administration in colonic surgery – a physiologic study

• 32 ASA III patients• colonic resection• randomize to:

– restrictive fluid (~1,6 L IV)

– liberal fluid (~5 L IV)

– 1500 ml oral intake on day of op in both groups

• double-blinded• standardized

perioperative management with fast-track surgery

Basse et al., Ann Surg 2000; 232: 51Holte et al., Br J Anaesth 2007; 99: 500

RESTRICTIVE FLUID LIBERAL FLUID

None 10 ml/kg liter Ringer lactatePreload

7 ml/kg/h Ringer 1st hourIntraoperative fluid 5 ml/kg/h Ringer 2nd hour 18 ml/kg/h Ringer

Voluven: 7 ml/kg Voluven: 7 mg/kg

No IV fluids postoperatively10 ml/kg liter Ringer in the PACU. After that no iv fluids postoperatively

Day of surgery On the ward: On the ward:2 protein drinks + 600 ml water =1 liter oral on the day of surgery.

2 protein drinks + 600 ml water =1 liter oral on the day of surgery.

Holte et al., Br J Anaesth 2007; 99: 500

weight* p<0,05 between groups

*

*

*

0,5

1

1,5

2

2,5

6 24 48

Time (hours postoperatively)

Wei

ght d

iffer

ence

(kg)

Low fluidHigh fluid

* p<0,05

Holte et al. (submitted)

hormonal responses - ADH

* p<0,05 increase# p<0,05 decrease

0

10

Baseline 6 24

Time (hours postoperatively)

AD

H (p

g/m

l)

Low fluidHigh fluid

* p<0,05 vs. preop*

* *

*


complication data restrictive liberal p value

patients with complications

6 1 0,08

Restrictive Liberal p value

Complications (no)

Cardiovascular

Respiratory 5 1

Anastomotic leakage 3 0

Wound dehisc/inf 2 0

Bleeding 1 0

Renal failure 2 0

Total complications 18 1 <0,01

5 0


fluid administration in colonic surgery

• ~1,6 L vs. ~5 L cryst leads to:

• no difference in physiologic functions

• no difference in hospital stay

• increased morbidity with low volume??(3 vs. 0 anastomotic leakage)


volume

outc

ome

optimal range

optimal fluid management

Holte 2006 low volume?

Brandstrup 2003 high volume?

Brandstrup 2003 low volume Holte 2006 high volume?

goal-directed strategies

• fluid infusions guided by esophageal Doppler

• given as boluses (500ml colloid) to maximize stroke volume and aortic blood flow

an example from orthopedic surgery

• randomized, controlled trial

• 40 patients with femoral fracture

• control group: 1 l crystalloid

• "fluid group": 725 ml crystalloid + 750 ml colloid

stroke volume and cardiac output significantly improved in fluid group

Sinclair et al., BMJ 1997; 315: 909

reduction in hospital stay in fluid group (20 days vs. 12 days)

current conclusion fluid in major surgery:

<1,5 liter: functional hypovolemia/dehydration

1,5-5 liter: optimal range > 5 liter: fluid excess/overload

complications

crystalloids or colloids in elective non-cardiac surgery no difference in clinical outcome no difference in physiologic

recovery systematic review of all available

RCTs (80)

which amount of fluid to give?Holte et al. J Am Coll Surg 2006; 202: 971

fluid management

tentative conclusions


fluid excess implication for postoperative

morbidity?•cardiac•pulmonary•gastro-intestinal (ileus)•wound healing•coagulation

optimal regimen/preop optimization ?

fluid deficit implication for postoperative

morbidity?

•functional hypovolemia•delayed recovery•anastomotic problems?


compensation fordehydration/preop

optimisation

improved outcome Holte & Kehlet

Acta Anaesth Scand 2002; 46: 1084

”large” volumes

morbidity (cardio. pulm, ileus, thrombo-embolic)

Brandstrup et al., Ann Surg 2003; 641 Holte et al., Br J Anaesth 2002;89:622

optimal procedure- specific regimen ?

in fast-track surgery?Grocott et al., Anesth Analg 2005; 100: 1093

final conclusions – consensus statement London 2006

• more opinion than evidence in current fluid literature

• insufficient data on which to base evidence-based guidelines

rational perioperative fluid management?

randomized studies – goal-directed or ”total volume” : pathophysiology

randomized outcome studies – high vs. low and goal-directed

procedure-specific and fast-track

perioperative fluid management - the issues

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