02 tuong phan
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Modern perioperative fluid management
Dr Tuong PhanStaff Specialist Anaesthetist, Dept
Anaes and Pain MedicineSt Vincent’s Hospital Melbourne
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Disclosures:Grant funding from ANZCA, and St Vincent’s Research FundRELIEF - Site Investigator St Vincent’s Melbourne
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“modern fluid management”
1. What’s wrong with traditional practice?1. What’s wrong with traditional practice?
3. Fluid optimisation – Goal directed fluid therapy3. Fluid optimisation – Goal directed fluid therapy
4. Time to change practice?4. Time to change practice?
2. Fluid restriction2. Fluid restriction
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Fig 1 ECV changes in human beings during hemorrhagic shock or operative procedures measured with the 35 SO 4 -tracer. Note that the quality of the trials was very disparate and direct comparison of the results cannot be performed (see the text and Tables ...
Birgitte Brandstrup , Christer Svensen , Allan Engquist
Hemorrhage and operation cause a contraction of the extracellular space needing replacement—evidence and implications? A systematic review
Surgery, Volume 139, Issue 3, 2006, 419 - 432
Myths: “third space”Myths: “third space”
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Myths: “third space”Myths: “third space”
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Oliguric normovolemic patients do not increase their urine output in response to fluid bolus.
Myth: urine output is a good target for resuscitationMyth: urine output is a good target for resuscitation
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Renal function– Hyperchloremic renal vasoconstriction
(Animal)– Human studies longer to micturition and
decreased diuresis cf Hartmann’s like solution
Gut– Human volunteers higher incidence of
abdominal discomfort– Dec gastric perfusion
Haemostasis– Possible inc blood product and blood loss– TEG: saline prolongation until clot
formationObserved electrolyte and acid base deficits which is readily treated with balanced fluids
– Association with negative outcomes
“Evidence for harm: normal saline”“Evidence for harm: normal saline”
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“Evidence for harm: starch colloids”“Evidence for harm: starch colloids”
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“modern fluid management”
1. What’s wrong with traditional practice?1. What’s wrong with traditional practice?
3. Fluid optimisation – Goal directed fluid therapy3. Fluid optimisation – Goal directed fluid therapy
4. Time to change practice?4. Time to change practice?
2. Fluid restriction2. Fluid restriction
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Evidence for harm: “HYPERvolemia”Evidence for harm: “HYPERvolemia”
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Evidence for harm: “HYPERvolemia”Evidence for harm: “HYPERvolemia”
Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003 Nov;238(5):641–8..
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Evidence for harm: “HYPOvolemia”Evidence for harm: “HYPOvolemia”
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A trial in perioperative fluid therapy
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Inclusion criteria
1. All elective abdominal or pelvic surgery >2hours, LOS >3 days Colectomy, oesophagectomy, gastrectomy,
pancreatectomy, open vascular, open urology
1. At least one “at risk” criteria Age>70, IHD, CCF, DM, Cr >200, BMI>35, albumin
<30, AT <12
1. Or at least 2 or more risk factors ASA 3-4, COAD, BMI 30-35, PVD, Hb<100, Cr 150-
199, AT 12-14
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Primary endpoint
Disability free survival up to 1 year (WHODAS)
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RELIEF: Conclusive evidence
1500 1500
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“modern fluid management”
1. What’s wrong with traditional practice?1. What’s wrong with traditional practice?
3. Fluid optimisation – Goal directed fluid therapy3. Fluid optimisation – Goal directed fluid therapy
4. Time to change practice?4. Time to change practice?
2. Fluid restriction2. Fluid restriction
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“Optimal Fluid therapy”
Opt
imum
Incr
easi
ng
Mor
bidi
ty
HypervolemiaHypovolemia
Editorial “Wet, dry or something else?”
Bellamy, BJA 97 (6), Dec2006
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Goal directed therapy
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The effect of ODM optimisation on post-op morbidity and complications
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Part
icip
ants
Part
icip
ants
Inte
rven
tion
Inte
rven
tion
Enhanced recovery after surgery protocolASA 1 to 3
Restrictive fluid therapyvsDoppler targeted fluid therapy
Stratified: No Stoma vs Stoma
Hyp
othe
sis
Hyp
othe
sis
Intra-operative Doppler targeted fluid therapy improves outcomes in elective major colorectal surgery within an ERAS program
REStrictive OR Targeted fluid therapy “RESORT”:
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RESORT
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Oesoph Doppler
Hypotension ORSVI <35mls ORFTc <360msec
∆SV >10% = fluid responsive
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Intraop crystalloid
Intraop colloid
Cumulative intraop fluid
Cummulative to day 2 post op
Restrictive 1570 (909) 171 (272) 1769 (1066) 4679 (2425)
Doppler guided
1545 (686) 556 (530) 2115 (817) 5481 (2151)
ns <0.001 0.008 0.016
Selected intra operative, post operative and cumulative fluid administered in restricted and goal directed arms, by volume and type
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Frequency of boluses
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start endSVI 43.41 51.6 0.0011
CI 3.1 4.6 0.0553FTc 338 366 0.0038
star
t
end
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Length of stay (days)
Medically ready length of stay (days)
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p=0.007
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RES Doppler RES Doppler RES Doppler
StudynSurgery
ASAStoma rate LOS median 5 6 5 5 6 6.5
No Pt with Cx % 73% 70% 30% 32% 52% 60%Clavien Dindo grade III-V
9 7 9 1
Patients with major Cx
8 (10%) 10 (14%) 4 (8%) 1 (2%)
incl rectal and stoma
1-3 (exclude 4)
excl rectal and
22% 29%
Srinivasa BJS 2012Brandstrup 2012
BJA Phan 201485 150 100
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LiDCOrapidTM
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Date of download: 7/24/2014Copyright © 2014 American Medical
Association. All rights reserved.
From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery: A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305
Participant Flow
Figure Legend:
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Date of download: 7/24/2014Copyright © 2014 American Medical
Association. All rights reserved.
From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery: A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305
Results for Secondary Outcomes
Figure Legend:
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Date of download: 7/24/2014Copyright © 2014 American Medical
Association. All rights reserved.
From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery: A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305
Cumulative Incidence of Mortality Up to 180 Days After Surgery Using a Cardiac Output–Guided Hemodynamic Therapy Algorithm Intervention vs Usual Care
Figure Legend:
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Date of download: 7/24/2014Copyright © 2014 American Medical
Association. All rights reserved.
From: Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery: A Randomized Clinical Trial and Systematic ReviewJAMA. 2014;311(21):2181-2190. doi:10.1001/jama.2014.5305
Meta-analysis of Number of Patients Developing Complications After SurgerySize of data markers corresponds to weighting for each component trial.aNew trials identified in updated literature search.
Figure Legend:
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“Optimal Fluid therapy”In
crea
sing
M
orbi
dity
HypervolemiaHypovolemia
Opt
imum
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modern fluid management
1. No Preload1. No Preload
3. Replacement of losses with titrated BOLUSES of colloid or crystalloid Treat hypotension and normovolemia with vasopressors
3. Replacement of losses with titrated BOLUSES of colloid or crystalloid Treat hypotension and normovolemia with vasopressors
4. Encourage early oral intake of fluids4. Encourage early oral intake of fluids
2. Intraoperative: 5-8mls/kg/hr of balanced crystalloid maintenance (Hartmann’s or Plasmalyte)
2. Intraoperative: 5-8mls/kg/hr of balanced crystalloid maintenance (Hartmann’s or Plasmalyte)
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modern fluid management1. Use preload sensitive parameters to guide optimal fluid therapy for high risk patients
Doppler technique
Respiratory coupled parameters of Pulse Pressure Variation or Stroke Volume Variation (Systolic Pressure Variation or Plethysmographic Variation Index)
1. Use preload sensitive parameters to guide optimal fluid therapy for high risk patients
Doppler technique
Respiratory coupled parameters of Pulse Pressure Variation or Stroke Volume Variation (Systolic Pressure Variation or Plethysmographic Variation Index)
2. Ignore urine output as haemodynamic goal2. Ignore urine output as haemodynamic goal
3. Develop audit for outcomes and processes 3. Develop audit for outcomes and processes
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modern fluid management1. What’s wrong with traditional practice?
Understand the limitations of volume resuscitationSurrogate endpoints
1. What’s wrong with traditional practice?Understand the limitations of volume resuscitationSurrogate endpoints
3. Fluid optimisation – Goal directed fluid therapyCorrection of hypovolemia will always be an important principal of perioperative resuscitation
3. Fluid optimisation – Goal directed fluid therapyCorrection of hypovolemia will always be an important principal of perioperative resuscitation
4. Time to change practice? YES“Lack of evidence should not be misused as justification for continuing current arbitrary decision making” Jacob et al, Lancet 2007
4. Time to change practice? YES“Lack of evidence should not be misused as justification for continuing current arbitrary decision making” Jacob et al, Lancet 2007
2. Fluid restrictionHypervolemiaSalt and water load
2. Fluid restrictionHypervolemiaSalt and water load