Transcript Perioperative Fluid Management and Clinical Outcomes in Adults

Welcome to Chiangmai
Improving Postoperative
Outcomes by
Rational Fluid Management
Srirath Chaiyaphruk MD
July 16th, 2008ใ
Sleep
Effective circulating volume
Hemodynamic stability
Adequate tissue perfusion
Volume
Management
Pain
Relief
Muscle
Relaxation
Five major aspects are of importance
when volume replacement is considered
• 1. The type of fluid must be decided,
• 2. The amount of fluid must be defined,
• 3. The criteria for guiding volume therapy
must be defined,
• 4. Possible side effects should be considered,
• 5. Costs are of importance.
Types of fluid must be decided,
IV Fluid Used
• Crystalloids
–
Dextrose in water
•
•
•
–
Saline
•
•
•
–
Isotonic (0.9% or “normal”)
Hypotonic (0.45%, 0.25%)
Hypertonic
– Albumin
• 5% in NS
• 25% (Salt Poor)
– Gelatin
– Dextrans
– HES
Combo
•
•
•
–
D5W
D10W
D50W
• Colloids
D5 1/2NS
D5 NS
D10 NS
Balanced
Ringer’s lactate
(K, HCO3, Mg, Ca)
• Blood
- PRC
- Bl Components
Colloids do not improve outcome
• Meta-analysis showed a 12.3%
worsened mortality with
colloids in multiple trauma
• Saline solutions may produce
hyperchloremic acidosis
Colloids versus Crystalloids and tissue oxygen tension in
patients undergoing major abdominal surgery
Lang, K. et al. Anesth Analg 2001;93
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids and Renal Dysfunction
Boldt & Priebe, A and A 2003
• 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.
The Cochrane Database of Systematic Reviews 2004,
Issue 4. I Roberts, P Alderson, F Bunn, P Chinnock, K Ker, G Schierhout
Colloids compared to crystalloids
Albumin or plasma protein fraction. Nineteen trials ; 7576 patients. RR was 1.01 (95%
CI 0.92 to 1.10).
Hydroxyethyl starch. Ten trials ; 374 randomised participants. RR was 1.16 (95% CI
0.68 to 1.96).
Modified gelatin. Seven trials ; 346 randomised participants. RR was 0.54 (95% CI
0.16 to 1.85).
Dextran. Nine trials ; 834 randomised participants. RR 1.24 (95% CI 0.94 to 1.65).
Colloids in hypertonic crystalloid compared to isotonic crystalloid
Eight trials ; 1283 randomised participants. RR was 0.88 (95% CI 0.74 to 1.05).
Authors' conclusions: There is no evidence that resuscitation
with colloids reduces the risk of death, compared to resuscitation
with crystalloids, in patients with trauma, burns or following
surgery. It is hard to see how their continued use in these patients
can be justified outside the context of randomised controlled trials.
A Comparison of Albumin and Saline for Fluid
Resuscitation in the Intensive Care Unit
N Engl J Med. 2004 May 27;350(22):2247-56.
Conclusions In patients in the ICU, use of either 4 percent
albumin or normal saline for fluid resuscitation results in
similar outcomes at 28 days.
Albumin administration improves organ function in critically ill
hypoalbuminemic patients: A prospective, randomized, controlled,
pilot study Crit Care Med 2006;
34:2536–2540
Marc-Jacques Dubois, Carlos Orellana-Jimenez, Christian Melot, Daniel De Backer, Jacques Berre,
Marc Leeman, Serge Brimioulle, Olivier Appoloni, Jacques Creteur, Jean-Louis Vincent.
Patients: All adult patients with a serum albumin concentration <30 g/L
Interventions: The 100 patients were randomized to receive 300 mL of 20% albumin
solution on the first day, then 200 mL/day provided their serum albumin
concentration was <31 g/dL (albumin group), or to receive no albumin (control
group).
Measurements and Main Results: The primary outcome was the effect of
albuminadministration on organ function as assessed by a delta SOFA score
from day 1 to day 7. …
Conclusions:
Albumin administration
may improve organ function in
hypoalbuminemic critically ill
patients.It results in a less positive
fluid balance and a better tolerance
to enteral feeding.
2007; 106:85–91
Background:
Excessive production of matrix metalloproteinase 9 (MMP-9)
is linked to tissue damage and anastomotic leakage after large
bowel surgery. [*]Hence, the aim of this study was to verify
whether different strategies of fluids administration can reduce
MMP-9 expression.
[*]
Stumpf et al. Changes of the extracellular matrix as a risk
factor for anastomotic leakage after large bowel surgery. Surgery
2005
2007; 106:85–91
These effects are probably related to
Better perfusion and oxygenation of the organs
Decreased endothelial damage
Decreased systemic inflammation and its
consequences
Conclusions: HES 130/04
decreases the circulating levels of MMP-9
( MATRIX METALLOPROTEINASES )
in patients undergoing abdominal surgery.
• Which fluid?
– Which fluid compartment is predominantly
affected?
– Need evaluation of other
acid/base/electrolyte/nutrition issues.
• How much volume?
– Need estimate of fluid deficit (volume status )
1/3
(15L)
Plasma
3L
Capillary
Endothelium
Interstitial
Compartment
10L
Blood
Cells 2L
Intracellular Compartment
2/3 (30L)
Cell Membrane
Fluid Distribution in a 75-kg Adult
Colloid
Saline
Glucose
Plasma
3L
Capillary
Endothelium
Interstitial
Compartment
10L
Blood
Cells 2L
Intracellular Compartment
30L
Cell Membrane
Fluid Distribution in a 75-kg Adult
From: Grocott: Anesth Analg, Volume 100(4).April 2005.1093-1106
Colloid
3L /3L = 100 %
Saline
3L / 15 L =20 %
Glucose
3L / 45L = 7 %
Fluid Distribution in a 75-kg Adult
Composition of Body Fluids:
Cations
150
Anions
100
50
0
ClHCO3-
Ca 2+
Mg 2+
Protein
50
ICF
150
PO4
Organic
anion
3-
K+
100
ECF
Na+
•
Osmolarity = solute/(solute+solvent)
(Plasma = 290~310 mosmol/L)
• Osmolality = solute/solvent (mosmol/Kg )
• Tonicity = effective osmolality
• Serum osmolality
= 2 X serum sodium + BUN + glucose
3
18
Na+
50
100
150
ClHCO3-
Ca 2+
Mg 2+
K+
PO43Organic
anion
Protein
IC
F
50
E
C
F
100
0
Anions
Cations
150
Regulation of Fluids:
Hydrostatic pressure v.s. Oncotic pressure
 Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv ∝ [ ( Pc - Pi ) - σ( πc - πi ) ]
Net
Hydrostatic
Pressure
Net flow
of Fluid
Net
Oncotic
Pressure
( Reflection coefficient)
Capillary Wall
Permeability
Fluid Replacement Products
• Crystalloids – Ionic solutions that contain small molecules and are
able to pass through semipermeable membranes
– Isotonic solutions: given to expand the ECF volume
– Hypotonic solutions: given to reverse dehydration
– Hypertonic solutions: given to increase the ECF volume and decrease
cellular swelling
• Colloids – solutions that contain high molecular weight proteins or
starch, do not cross the capillary semipermeable membrane, and
remain in the intravascular space (pulling fluid out of the intracellular and
interstitial space) for several days
–
–
–
–
Albumin
Gelatin
Dextran
HES
Contents of common crystalloids
Solution
Electrolyte content
Osmolality
(mmol/L)
(mosmol/Kg)
Saline 0.9%
Na+
154
Cl-
154
308
Saline 0.45%
Na+
77
Cl-
77
154
Glucose 4%/
saline 0.18%
Na+
31
Cl-
31
284
Glucose 5%
Na+
Nil
Cl-
Nil
278
Hartman’s
solution
Na+
K+
Ca2+
131
5
4
Cl112
HCO329
(as lactate)
281
Glucose
Solution Electrolyte content
(mmol/L)
Osmolality
(mosmol/Kg)
Glucose 4%/ Na+ 31
saline 0.18%
Cl- 31
284
Na+ Nil
Cl- Nil
278
Glucose 5%
Dextrose solutions
(1) 5% Dextrose (often written D5W) – Think of it as ‘Sugar
and Water’
•
Primarily used to maintain water balance in patients who are
not able to take anything by mouth( Dehydrated Patient );
Commonly used post-operatively in conjuction with salt retaining
fluids ie saline; Often prescribed as 2L D5W: 1L N.Saline
[‘Physiological replacement’ of water and Na+ losses]
•
Provides some calories [ approximately 10% of daily
requirements].
•
Regarded as ‘electrolyte free’ – contains NO Sodium, Potassium,
Chloride or Calcium
•
If you infuse glucose 5% 1000ml, the glucose will enter the cell
and be metabolised
•
The water expands both ECF and ICF in proportion to their
volumes
•Distribution: app. 7% Intravascular
•When infused is rapidly redistributed into the intracellular space;
App. 7% stays in the intravascular space therefore it is of limited use
in fluid resuscitation.
•For every 100ml blood loss – need >1000ml dextrose replacement
7 % retained in intravascular space
•Common cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline / 5
Similar indications to 5% dextrose; Provides Na+ 30mmol/l
and Cl- 30mmol/l Ie a sprinkling of salt and sugAar!
Primarily used to replace water losses post-operatively
Limited indications outside of post-operative replacement –
‘Neither really saline or dextrose’;
Advantage – doesn’t commonly cause water or salt overload.
Saline Solution
Solution
Electrolyte content
(mmol/L)
Saline 0.9% Na+ 154 Cl- 154
Osmolality
(mosmol/Kg)
308
Saline Solutions
(1) 0.9% Normal Saline – Think of it as ‘Salt and water’
• Principal fluid used for intravascular resuscitation and replacement
of salt loss e.g diarrhoea and vomiting
• Contains: Na+ 154 mmol/l, K+ - Nil, Cl- - 154 mmol/L
Plasma =95 -105 mmol / L
• Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosis
• IsoOsmolar ( Slightly Hyperosmolar308 mosm / L)compared to
normal plasma
• Distribution: Stays almost entirely in the Extracellular space Of 1
litre – 800ml Extra cellular fluid; 200ml intravacular fluid
• So for 100ml blood loss – need to give 500ml N.saline [only 20%
remains intravascular]
2) 0.45% Normal saline = ‘Half’ Normal Saline =
HYPOtonic saline
•Reserved for severe hyperosmolar states E.g. H.O.N.K
and severe dehydration
•Leads to HYPOnatraemia if plasma sodium is normal
•May cause rapid reduction in serum sodium if used in
excess or infused too rapidly. This may lead to cerebral
oedema and rarely, central pontine demyelinosis ; Use with
caution!
HYPERtonic saline
1.8, 3.0, 7.0, 7.5 and 10% Saline
• Reserved for plasma expansion with colloids
• In practice rarely used in general wards; Reserved for high
dependency, specialist areas.Use in Prehospital
Resuscitation for Burn and Trauma
• Distributed almost entirely in the ECF and
intravascular space. This leads to an osmotic gradient
between the ECF and ICF, causing passage of fluid into the
EC space. This fluid distributes itself evenly across the ECF
and intravascualr space, in turn leading to intravascular
repletion.
• Decrease Edema ( Tissue and Cerebral )
• Large volumes will cause HYPERnatraemia and
IC dehydration.
Hartman’s Solution
( Ringer’s Lactate)
Solution
Electr olyte content
(mmol/L)
Hartman’s Na+ 131
solution
K+
5
Ca2+ 4
Osmolality
(mosmol/Kg)
Cl- 112
HCO3-29
(as lactate)
281
Ringer’s Lactated Solution
= Balanced Salt Solution
•Principal fluid used for intravascular resuscitation
•Contains: Na+ 131 mmol/l, K+5 mmol/L ,Ca+4 mmol/L,
Cl - 112 mmol/L, HCO3 -29 mmol/L
•IsoOsmolar ( Slightly Hypoosmolar 273 mosm / L
Plasma =95 -105 mmol / L )compared to normal plasma
•Not be used in Cerebral edema trend
•Large Volume -- Metabolic Alkalosis
•Hypoperfusion - Lactic Acidosis
Colloid solutions
• The colloid solutions contain particles which do not settle and
cannot be separated out by ordinary filtering or centrifuging
as can those of a suspension such as blood Do not readily cross
semi-permeable membranes such as the capillary membrane
• Thus the volume infused stays (initially) almost entirely within
the intravascular space
• Stay intravascular for a prolonged period compared to crystalloids
• However they leak out of the intravascular space when the
capillary permeability significantly changes e.g. Severe trauma
or sepsis
• Until recently they were regarded as the gold standard for
intravascular resuscitation
• Because of their gelatinous properties they cause platelet
dysfunction and interfere with fibrinolysis and coagulation factors
(factor VIII) – thus they can cause significant coagulopathy in
large volumes.
What is the ideal colloid ?
One which displays the following in plasma replacement:
1.Rapidly replaces blood volume losses.
2.Restores the haemodynamicbalance.
3.Normalizes microcirculatory flow.
4.Have a sufficiently long intravascular life.
5.Improves haemorrheology.
6.Be readily metabolized, readily excreted and well tolerated.
􀂊
7.Be free of side effects, especially regarding haemostasisand
anaphylactoidreactions.
8.Be cost effective and contribute to blood savings.
National Research Council USA (1963)
􀂊Unfortunately NO colloid fits into all the criteria,
all of the time.
􀂊Idea is to use the best colloid for the patient, to
achieve the desired effect with the least amount
of side-effects.
Synthetic Colloid
1915
World WarⅠ
1945
World WarⅡ
Gelatin
DEXTRAN
1960
HES
War In Vietnam
Gelofusin 1965
1980
New Generation HES
HAES-steril
2000
A Class of Its Own
Magnitude of
PVE
Inflammatory
Cell Function
Hemostasis
Fluids
Hemorrheology
Duration of PVE
Anaphylactoid /
Anaphylactic
Reac.
Magnitude of
PVE
•Specific Properties
•Amount of Colloid Particles ( % )
Colloid is governed by rate of colloid
Duration of molecule loss from circulation and
PVE
by their metabolism. Rate of loss
through into the interstitial space
and through the renal glomerulus determined by
molecular size (weight) and surface charge
characteristics. Rate of metabolism is governed by
specific chemical qualities of molecules (e.g., HES
C2/C6 ratio and resistance to hydrolysis). Most useful
descriptors of duration of PVE are the intravascular
half-life and the fraction of administered volume
retained in the circulation after a specific time.
Properties of resuscitation fluids
Crystalloid
Gelatin
Albumin
HES
Molecular Weight
60 da
30-35 kda
69kda
130-450 kda
2 - 4 hrs
4 - 12 hrs
Volume Effect
10-20 mins
รูปที่ 16
1 - 2 hrs
Properties of resuscitation fluids
0.9 % Saline 58 Da
Very large volumes required
Massive sodium, chloride and water load
Saline cannot be excreted easily
Interstitial oedema
Properties of resuscitation fluids
4% Gelatine 30,000 Da
Volume expansion lasts 1-2 hours
Large volume required
Sodium, chloride ( K, Ca )
Properties of resuscitation fluids
4.5% Albumin 68,000 Da Volume expansion lasts 2-4 hours
Risk of Transmitted Dis.
Expensive
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluids
HES 200,000 Da 0.5
substitution
Volume expansion lasts 6 h
Low, Med, High Molecular Weight
Anti-inflammatory, less capillary leak
- Reduce whole blood viscosity by simple
Hemorrheology
hemodilution, improving blood-flow
characteristics The magnitude of this effect
• Lower-MW (30,000–40,000 Da) HES and Dextran products
that produce a large initial increment in intravascular volume
therefore, a larger hemodilution effect.
• Higher-MW Dextrans and HES cause an increase in
plasma viscosity
• Larger-MW dextrans (e.g., Dextran 70) and Gelatins also
tend to cause red cell aggregation
• Lower-MW dextrans (e.g., dextran 40), starches, and human
albumin solution tend to cause reduced red blood cell
aggregation and plasma viscosity results in increased flow
HMw HE( Dex )
Decrease
Increase
Over all
Haemodilution
Effect
-Simple hemodilution of clotting factors and
Hemostasis
colloid-specific effect increasing evidence
that crystalloid hemodilution can induce a
hypercoagulable state ( clinical significance is uncertain )
- Gelatins appear to have the least effect on hemostasis;
Urea-Linked > Modified
- HES solutions have varying effects on hemostasis dependent
on Mw ( higher-MW> Medium >/= low-MW )
-Dextrans are more significant hemostatic derangements and
are effective antithrombotic agents
low-MW dextrans increase microvascular flow by platelet
disaggregation and have specific effects on several components
of the hemostatic system Red cell aggregation is also reduced
Inflammatory
Cell Function
Dextran and HES molecules may also
have specific antiinflammatory effects, including
reducing postischemic leukocyte-endothelial
interactions and platelet adhesiveness
Pentafraction is also believed to have specific benefits in retaining fluid
within the capillaries, probably by physically plugging endothelial pores,
in situations in which capillary leak occurs
- Anaphylaxis or anaphylactoid events have been
described in association with all of the semisynthe- tic
colloids and albumin.
- The incidence of severe reactions (life-threatening
events; e.g., shock, life-threatening smooth muscle spasm, or cardiac or
respiratory arrest) is probably more frequent for gelatins, urea-linked
1/2000 > succinylated Gelatin 1/13000 per year (most frequent
reported incidence <0.35%) and dextrans (<0.28%)
than for albumin (<0.1%) or HES (<0.06%)
- The advent of dextran 1 hapten treatment has significantly reduced the risk
of dextran-related anaphylactic events to <0.0015%
- A significant incidence of itch has been noted with HES products
- Slow infusion at the beginning (10 -20 ml ) ,then observe for allergic S / S
Anaphylactoid /
Anaphylactic
Reac.
Allergic Reactions with Colloid Solutions
Allergic reactions (%)
Allergic Reaction with Colloid Solution
0,4
0,2
0
Gelatin
Dextran
Albumin
HES
Prospective multi-center-trial (~ 20.000 patients)
Laxenaire et al., Ann Fr Anes Réanim 1994
Crystalloids and colloids
Crystalliod
Colloid
Intravascular persistance Poor
Good
Haemodynamic
stabilisation
Transient
Prolonged
Required infusion volume
Large
Moderate
Risk of tissue oedema
Obvious
Insignificant
Enhancement of
capillary perfusion
Poor
Good
Risk of anaphylaxis
Nil
Low to
moderate
Plasma colloid osmotic
pressure
Reduced
Maintained
Cost
Inexpensive
Expensive
Balanced Versus Unbalanced Fluids
• 0.9% saline and of colloids dissolved in isotonic saline is
•
•
•
•
associated with the development of hyperchloremic metabolic
acidosis due to the high chloride load
Balanced or physiological fluids that contain inorganic ions
(calcium, potassium, or magnesium), molecular glucose, or buffer
components, such as bicarbonate or lactate, and that have a
smaller chloride concentration are not associated with the same
disturbance of acid/base physiology
Balanced crystalloid solutions (e.g., Hartmann’s
solution/Ringer’s lactate).
Balanced colloid solution presented (e.g., Hextend; 6% HES in a
balanced electrolyte solution)
Balanced solutions, when compared with those randomized to
saline-based fluids
- Less impairment of hemostasis
- Improved gastric perfusion
- Renal function may also be better preserved
Hypertonic Fluids
• Hypertonic 1.8% 3% 5% 7.5% 10% (600–2400 mOsm/L) crystalloid
and colloid solutions have been introduced for certain clinical
indications
• Advantage of these solutions is that a small volume of
administered fluid will provide a significant Plasma Volume
Expansion.
• The high osmolarity of these solutions draws tissue fluid into the
intravascular space and thus should minimize tissue edema,and
cerebral edema in patients who are at risk of this complication
• Limited use in the perioperative setting
• Use in the management of burn patients and in prehospital
resuscitation of trauma victims
• Single-dose administrations.
• Short Duration app. 30 – 60 mins ; Plus colloid to maintain duration
7.2% NaCl + 6% HES-200 or 7.5% NaCl + 6% dextran 70
• Hypertonic solutions are often considered to be irritants to veins
because of their high osmolarity, and it is recommended that they
be given into large veins or centrally
Fluid Therapy
• Quantitative
Considerations are concern in fluid Management
( Volume )
• Qualitative
Considerations oxygen-carrying capacity,
coagulation, electrolyte and acid-base balance,
and glucose metabolism are also of critical
importance.( Type )
Fluid amount must be defined
Arkilic CF, Taguchi A, Sharma N, et al.
Supplemental perioperative fluid administration
increases tissue oxygen pressure.
Surgery 2003;133:49–55 Accepted 15 August 2003.
Methods. Fifty-six patients undergoing colon resection were
randomly assigned to conservative (8 mL·kg−1·h−1, n = 26) or
aggressive (16 to 18 mL·kg−1·h−1, n = 30) fluid management.
During surgery and postanesthetic recovery, subcutaneous PsqO2
was measured . Cap. Bl. flow was evaluated postoperatively
Data were analyzed and considered statistically significant.
Results. Hemodynamic and renal responses were similar
Intraoperative tissue oxygen tension was significantly greater
in patients given supplemental fluid .
Postoperative PsqO2 and capillary blood flow were also greater
in the supplemental fluid patients
http://www.health.auckland.ac.nz/aumsa/images/Fluid%20Management.pdf
Major elective
gastrointestinal surgery: does fluid restriction improve outcome?
Dr A Gobindram, Dr S Gowrie-Mohan
British Journal of Hospital Medicine, Vol. 68, Iss. 3, 08 Mar 2007, pp 168 – 168
Controversy regarding fluid therapy for major surgery dates
back to the 1950s and is largely based on two differing
concepts: the first, that the metabolic and stress response to
surgery causes water and sodium retention, and the second,
that there is redistribution of fluid into a hypothetical
‘third space’ leading to a fall in intravascular volume.
Aggressive perioperative fluid resuscitation is the standard of
care provided by many anaesthetists, however, evidence
seems to suggest that this is flawed. Unfortunately, answer
is not as simple as following a restrictive fluid regimen
• Which fluid?
– Which fluid compartment is predominantly
affected?
– Need evaluation of other
acid/base/electrolyte/nutrition issues.
• How much volume?
– Need estimate of fluid deficit (volume status )
Adverse outcomes
Inadequate or Excessive fluid
administration
•Inadequate
fluid administration can lead to a reduced
effective circulating volume, diversion of blood toward
vital organs (brain and heart) and away from nonvital
organs (gut, skin, and kidneys), and inadequate tissue
perfusion of the nonvital organs
•Excess
- Fluid increased pressure in venous circulation
and results in loss of fluid from the intravascular space
into interstitial (extracellular) space leads pulmonary and
peripheral edema and consequent compromise of
systemic and/or local tissue oxygenation
Decrease wound healing
- Intestinal edema is associated with impaired
gastrointestinal function tolerance for enteral nutrition
an increased the development of bacterial translocation,
and the development of multiple organ dysfunction
syndrome
Conventional clinical assessment
1. Urine Output
500 ml/24hrs.(20ml/hr Adult ), 1ml/hr Neonate, 0.5mi/hr Child
2. Supine hypotension
Heart Rate =/> 20/ min. Dec. Sys=/> 20mmHg
3. Laboraory evidence
3.1 Hematocrit ;
3.2 BUN 8.0-20 mg/dl
3.3 Creatinine 0.5-1.5 mg/dl
Creatinine Clearance ( > 30 % )
BUN : Creatinine 10-20 ( more in Infant )
+ Urine sodium & Urine Osmolarity
Dehydration
Factors Affecting the Amount of
Intraoperative Fluid Administration
• Preoperative IVV
• Preoperative
cardiovascular
function
• Anesthetic technique
• Anesthetic agent
pharmacology
• Patient position
• Thermoregulation
• Operative fluid
administration
• Duration of surgery
•
•
•
•
•
•
•
•
•
Operative site
Surgical technique
Splanchnic ischemia
Intraoperative
cardiac function
Capillary
permeability
Endotoxemia
Proinflammatory
cytokines
Sepsis
Allergic/anaphylactic
reactions
• Preoperative IVV
•Hypovolemia Must be treated
•
•Dehydration Need more time to correct
•
•
•
•
•
•
Preoperative cardiovascular
function
Anesthetic technique
Anesthetic agent pharmacology
Patient position
Thermoregulation
Operative fluid administration
Duration of surgery
•
•
•
•
•
•
•
•
•
Operative site
Surgical technique
Intravascular depletion
Splanchnic
ischemia
Water
Depletion
Intraoperative cardiac function
MAP= CO x SVR
•Thirst
Capillary permeability
Hemodynamic effects
Endotoxemia•Hypernatremia
• BP HR JVP
Proinflammatory cytokines
• Cool extremities
Sepsis E.C.F. depletion
• Reduced sweating
Allergic/anaphylactic
reactions
•Skin turgor, sunken
• Dry mucus membranes
eyeballs
•Weight
•Hemodynamic effects
•Chr. Hypertension
Inc SVRHypovolemia
•Preoperative IVV
•Preoperative
cardiovascular function
•Anesthetic technique
•Anesthetic agent pharmacology
•Patient position
•Thermoregulation
•Operative fluid administration
•Duration of surgery
•Operative site
•Surgical technique
•Splanchnic ischemia
•Intraoperative cardiac function
•Capillary permeability
•Endotoxemia
•Proinflammatory cytokines
•Sepsis
•Allergic/anaphylactic reactions
Existence of congestive heart failure
and pulmonary edema
•Need close and Invasive monitoring
•Preoperative IVV
•Preoperative cardiovascular function
•Anesthetic technique and agent pharmacology
•Patient position
•Thermoregulation
•Operative fluid administration
•Thiopental , propofol, decrease SVR
•Duration of surgery
(etomidate, ketamine, and high-dose opioids)
•Operative site
•Surgical technique •Muscle relaxants may release histamine
•Splanchnic ischemia
(curare, atracurium) and decrease SVR
•Intraoperative cardiac function
or produce venous pooling due to
•Capillary permeability
•Endotoxemia
loss of muscle tone.
•Proinflammatory cytokines
•All volatile inhalation anesthetic agents
•Sepsis
•Allergic/anaphylacticreduce
reactionsSVR and decrease contractility
•Epidural and subarachnoid (spinal) blocks,
accompanying sympathetic nervous blockade
produce vasodilation with severe hypotension
in the hypovolemic patient.
•Hemorrhage, loss of ascites or pleural fluid
fluid shifts with redistribution or loss from
•Preoperative IVV
•Preoperative cardiovascular function operative sites
•Amount & Duration of Tiss. Trauma
•Anesthetic technique
•Administration of large quantities of fluid
•Anesthetic agent pharmacology
into sites prostate resection,
•Patient position
• Patient positioning,Prone,Sitting
•Thermoregulation
Surgical packing and retraction
•Operative fluid
• Fluid shifts with redistribution or loss
administration
from operative sites,
•Duration of surgery
•Operative site
•Surgical technique
•Splanchnic ischemia
•Intraoperative cardiac function
•Capillary permeability
•Endotoxemia
•Proinflammatory cytokines
•Sepsis
•Allergic/anaphylactic reactions
Introaperative Clinical
Asessment
•
•
•
•
•
•
Vital Sign Monitoring,
Estimate Blood Lost + Haematocrit
Urine Output
CVP / PAOP
Arterial Line / Blood Gas
Mixed venous hemoglolim desaturation
Urine output
•
A monitor of renal perfusion only, urine output is often
used as a guide to adequacy of cardiac output as the
kidney receives 25% of cardiac output. When renal
perfusion is adequate urine output will > 0.5 ml/kg/h.
•
< 0.5 ml/kg/h.
Low Perfusion ,inc Stress -> inc. ADH
Positive P Vent -> dec. Atrial Natriuretic Peptide
• Use of Diuretics such as Frusemide, Hyperglycemia and
Dopamine abolishes its usefulness as a
haemodynamic monitor.
=
Urine
Output
Central Venous Pressure Catheter
(CVP)
• Principle : Measures of CVP but is useful
to determine relative fluid balance
• Utility
Relative measurement of fluid status
Allows large volume fluid administration
Administration of potent vasoconstrictors
epinephrine, norepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
• Utility
Trends in cardiac output
Intravascular volume status (CVP)
Assists diagnosis of pulmonary edema vs
ARDS
Large fluid volume administration
Administration of potent vasoconstrictors
Epinephrine
Norepinephrine
Mixed venous oxygen saturation
(Sv'O2)
Has been used as a measure of adequacy of tissue perfusion.
varies directly with cardiac ouput, Hb and arterial
saturation and inversely with metabolic rate .Normal is
approximately 75% but falls when oxygen delivery falls or tissue
oxygen demand increases. When it falls as low as 30% oxygen
delivery is insufficient to meet tissue oxygen demand and there is
an increased potential for anaerobic metabolism and lactic
acidosis can be measured either continuously using a fibre-optic
Swan-Ganz catheter or by taking blood samples from the distal
lumen of the Swan-Ganz catheter and measuring the saturation
in a co-oximeter. At the low PvO2 in mixed venous blood the
calculated saturations produced by blood gas machines are not
accurate.
Measurement of Tissue
Perfusion
Gastrointestinal tonometry
Laser Doppler flowmetry
Microdialysis catheters
Near-infrared spectroscopy
Transcutaneous oxygen measurements
tissue pH monitors
No interventional study has demonstrated any
improvement in outcome
Heart Rate
Skin
Perfusion
CVP
Urinre
Out Put
Blood
Pressure
Cardiac
Out Put
Perioperative Fluid Requirements
• NPO and other deficits: NG suction, bowel
prep
• Maintenance fluid requirements
• Third space losses
• Replacement of blood loss
• Special additional losses
NPO and other deficits
• NPO deficit = number of hours NPO x
maintenance fluid requirement.
• Bowel prep may result in up to 1 L fluid loss.
• Measurable fluid losses, e.g. NG suctioning,
vomiting, ostomy output.
Maintenance Fluid Requirements
• Insensible losses such as evaporation of water from
respiratory tract, sweat, feces, urinary excretion.
Occurs continually.
• Adults: approximately 1.5-2 ml/kg/hr
• “4-2-1 Rule”
-
4 ml/kg/hr for the first 10 kg of body weight
2 ml/kg/hr for the second 10 kg body weight
1 ml/kg/hr subsequent kg body weight
Extra fluid for fever, tracheotomy, denuded surfaces
Third Space Losses
• Isotonic ( Abnormal ) transfer of ECF from
functional body fluid compartments to nonfunctional compartments.
• Depends on location and duration of surgical
procedure, amount of tissue trauma, ambient
temperature, room ventilation.
Replacing Third Space Losses
• Superficial surgical trauma: 1-2 ml/kg/hr
• Minimal Surgical Trauma: 3-4 ml/kg/hr
- head and neck, hernia
• Moderate Surgical Trauma: 5-6 ml/kg/hr
- hysterectomy, chest surgery
• Severe surgical trauma: 8-10 ml/kg/hr (or more)
- AAA repair, nehprectomy
Other factors
• Ongoing fluid losses from other sites:
- gastric drainage
- ostomy output
- diarrhea
• Replace volume per volume with crystalloid
solutions ;
Type replacement depend on Type of lost
General guidelines for blood
• When haemodynamically stable
– Rare to need blood if Hb > 10g/dl
– Usual to need blood is Hb < 70g/dl
• Level depends on co-morbidities
• Sign of Oxygen Saturation Dec.
Allowable Blood Loss (ABL)
Hct patient - Hct target
( 21, 30 )
Hct patient
20 -30 % Lost
X
EBV
Blood Loss
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution Volume/Normal PV
5% D/W dis. Intravascular,
Interstitial,
Intracellular
( 7-10%)
1:10+
(20-30%)
0.9% NSS dis. Intravascular, Interstitial,
Colloid / Blood dis. Intravascular (100%) 1:1
1:3-5
Conflicting results from different
studies are most likely due to variations
• Clinical protocols,
• Selection of patients
• Type & Duration of Surgery
• Type & Volume of Fluid administration
Goal-Directed Therapy
Goal-Directed Therapy
Clinical
{
Titration of fluids
Physiologically relevant end-points
Outcome
Using appropriate monitoring
Goal-directed intraoperative fluid administration
reduces length of hospital stay after major surgery
Gan TJ, et al. Anesthesiology 2002;97:820
100 patients with anticipated blood loss greater
than 500ml
Standard care or protocol group
Higher SV, CO at the end of surgery
Earlier oral intake, earlier discharge, shorter
hospital stay, fewer PONV
The Fluid Challenge & Blood
Pressure Measurement
A fixed volume
of Fluid over
10-15 min
CVP
PAOP
Observation
A sustained
increase of
≥ 3 mm Hg
Intra-vascular Volume
Systolic and Pulse Pressure
Variation
Pressure variation with respiration
Michard F, et al. Am J Respir Crit Care Med
2000;162:134
Bennett-Guerrero E, et al. Mt Sinai J Med
2002;69:96
Normal value
< 10 mmHg
The changes in arterial blood pressure during the respiratory cycle.
Systolic Pressure Variation (SPV) is the sum of delta Up (ΔUp)
and delta Down (ΔDown) as measured from the apnoeic baseline. PA is
arterial pressure, PAW is airway pressure, SPMax is maximum systolic
pressure, SPMin is minimum systolic pressure.
Displays of the system when
1500 mL of blood was lost (A),
and when 1200 mL of blood
was transfused (B)
in a patient undergoing
Th8 laminectomy.
On-line Monitoring of Systolic Pressure Variation
Yoshihisa Fujita, Atsuo Sari, and Tokunori Yamamoto
Dept of Anesthesiology and ICM Dept of Urology, Kurashiki-City, Okayama, Japan
A Starling Curve of Left Ventricular Stroke Volume (SV) against Left
Ventricular End Diastolic Pressure (LVEDP) demonstrating the change in
stroke volume that occurs with positive pressure ventilation (A-B-A). The
starting position on the curve determines the magnitude of the change in
SV, and hence the stroke volume variation. Following intra-vascular
volume expansion and movement up the curve, the magnitude of change
in SV decreases during the respiratory cycle (CD-C).
Oesophageal Doppler.
Oesophageal Doppler. (a) Schematic representation of oesophageal
Doppler probe in a patient, demonstrating the close relation between
oesophagus and descending thoracic aorta. (b) Characteristic velocity
waveform obtained in the descending aorta. The spectral representation
shows that most red blood cells (orange-white color) are moving at the
maximum velocity (close to the green envelope) during systole, and that
diastolic flow is minimal
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=137448
The Fluid Challenge & Blood
Flow Measurement
•5 studies available
Stroke
Volume
Intra-vascular Volume
The relationship between LVEDP and LVEDV depends on
the compliance of the LV. A fall in compliance (reflected by
a shift from curve B to curve A) will result in a change in LVEDV
at any given pressure. Thus, in the example shown, the same
LVEDP may represent either a high LVEDV or a low LVEDV
depending on the compliance of the ventricle
Conclusion
• Crystalloid and colloid
• Balanced versus saline-based fluids
• Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler.
- Etc.
Fluid Therapy
• Quantitative ( Volume )
• Qualitative
Considerations oxygen-carrying capacity,
Effective circulating
volume
coagulation, •electrolyte
and acid-base
balance, • Hemodynamic stability
•
Adequate
tissue
perfusion
and glucose metabolism are also of critical
importance.( Type )
Thank You