volume optimization in surgical patients philippe van der linden md, phd chu brugmann-huderf, free...

Volume Optimization in Surgical PatientsVolume Optimization in Surgical Patients

Philippe Van der Linden MD, PhDCHU Brugmann-HUDERF, Free University of Brussels

Intraoperative Fluid Management and Outcome

Randomized controlled studyElective abdominal surgery (N=152)

Intraoperative fluid regimen:- Restrictive: 4 ml/kg.h- Liberal: 10 ml/kg + 12 ml/kg.h

Strict algorithm for additional intraoperative fluids

Fewer complications in the restrictive group (13 vs 23: p=0.046)

Passed feces Hospital LOS0

4

8

12

16

20

24

Days

Restrictive (N=77) Liberal (N=75)

p< 0.001

p< 0.01

From Nisanevich V et al. Anesthesiology 103:25-32, 2005.

Oesophageal Doppler Fluid Management for Bowel Surgery

RCT: colorectal resection- Control: CVP: 12 -15 mmHg (N=64)- Doppler guided fluid protocol (N=64)

FluidsCrystalloids 3000 ml in each groupGelatins: 2000 vs 1500 ml (p<0.01)

Higher CO & DO2 at the end of surgery in the protocol group

Complications 24 vs 38 patients (p=0.013)

Full diet In hospital stay0123456789

10111213141516Days

Control Protocol

From Wakeling HG et al. Br J Anaesth 95:634-642, 2005.

p<0.001

p<0.001

Perioperative Fluid Management

Accurate dosing of fluid therapy

Accurate choice between the various available IV fluids

Perioperative Fluid Strategy

• In many cases, fluids are administered without adequate monitoring to guide volume

• This may result in adverse outcomes relating to either inadequate or excess fluid administration

• Complications associated with fluid therapy: 17%• Fluid overload: 7% • Hypovolemia: 11%


• Excessive fluid administration: Increased demand on cardiac function Increased risk of respiratory failure and pneumonia Inhibition of gastro-intestinal motilityDecreased tissue oxygenation with delayed wound

healing Increased risk of urinary retentionCoagulation disturbances


• Inadequate fluid administration:Reduced effective circulating volumeDiversion of blood toward vital organs Under-perfusion of « non vital » organs: gut,

kidneys, skinActivation of the sympathetic nervous and renine

angiotensin systems Increased inflammatory response


Activationof

the stress responseleads to

fluid retention

Effects of perioperative fluid administration onthis stress response are unclear


• Volume « optimization » will depend:Type of surgery Importance of the surgical insultPatient’s clinical conditions

Cardiorespiratory reserve Medical treatment Preoperative volume status Preoperative preparation

Volume «Optimization » in Surgical Patients

• Avoidance of dehydration• Maintenance of an « effective » circulating

blood volume• Prevention of « inadequate » tissue perfusion

Fluid Administration Strategies

The « recipe » book approach

From Grocott MPW et al. Anesth Analg 100:1093-106, 2005.

Peroperative Fluid Management: « The cook book approach »

Authors Procedure No patients

Duration (min)

Timing Crystalloids: volume (ml)

Colloids: volume (ml)

Outcome

Yogendran 1995

Ambulatory 200

29±2 Pre Restrictive: 164±28 Liberal: 1215±30 *

thirst, drowsiness and dizziness lower in the liberal group

Holte K 2007

Colonic 32

77-198 Intra Restrictive: 580-1500 Liberal: 2722-6500 *

Restrictive: 350-750 Liberal: 341-850

Transient improvement in pulmonary function, but tendency of increased morbidity in the restrictive group.

Holte K 2007

Orthopedic 48


Restrictive: 500 Liberal: 500

Hypercoagulability and vomiting in the liberal group. No difference in hospital stay

Holte K 2004

Cholecystec 48


postoperative organ function and hospital stay in the liberal group

Brandstrup 2003

Colo-rectal 172

90-390 Intra Restrictive: 1100-8050 Liberal: 2700-11080

Similar volume of HES 200/0.5 in both groups

postoperative complications in the restrictive group

Nisanevich 2005

Abdominal 152

268±112 Intra Restrictive: 1408±946 Liberal: 3878±1170 *

Earlier return in bowel function, post-operative complications and hospital stay in the restrictive group

Lobo 2002

Colonic 20

NA Post Restrictive: 116000 Liberal: 18000 *

Earlier return in bowel function and hospital stay in the restrictive group


Duration (min)



Outcome

Yogendran 1995

Ambulatory 200

29±2 Pre Restrictive: 164±28 Liberal: 1215±30 *

thirst, drowsiness and dizziness lower in the liberal group

Holte K 2007

Colonic 32


Restrictive: 350-750 Liberal: 341-850

Transient improvement in pulmonary function, but tendency of increased morbidity in the restrictive group.

Holte K 2007

Orthopedic 48


Restrictive: 500 Liberal: 500

Hypercoagulability and vomiting in the liberal group. No difference in hospital stay

Holte K 2004

Cholecystec 48


postoperative organ function and hospital stay in the liberal group

Brandstrup 2003

Colo-rectal 172

90-390 Intra Restrictive: 1100-8050 Liberal: 2700-11080

Similar volume of HES 200/0.5 in both groups

postoperative complications in the restrictive group

Nisanevich 2005

Abdominal 152

268±112 Intra Restrictive: 1408±946 Liberal: 3878±1170 *

Earlier return in bowel function, post-operative complications and hospital stay in the restrictive group

Lobo 2002

Colonic 20

NA Post Restrictive: 116000 Liberal: 18000 *

Earlier return in bowel function and hospital stay in the restrictive group



Intravascular pressure measurements




Intravascular pressure measurement

Systolic and pulse pressure variation


Systolic and Pulse Pressure Variations

Observation of systolic and pulse pressure variation in relation to variations of intrathoracic pressure resulting from mechanical ventilation

From Preisman S et al. Br J Anaesth 95:746-55, 2005.





« Fluid » challenge• Intravascular pressure measurement• Blood flow measurement


Fluid Challenge and Intravascular Pressure Measurement

Observation of the cardiac filling pressures (CVP and/or PAOP) response to a « fluid challenge » (fixed volume of colloid infused over 10 to 15 min)

Intraoperative Intravascular Volume Optimisation in Orthopedic Surgery

Prospective RCTElderly patients undergoing repair of proximal femoral fracture

- Control: conventional intraop fluid management (N=29)

- Protocol 1: colloid (4% MF gelatin) fluid challenge guided by CVP (N=31)

- Protocol 2: colloid (4% MF gelatin) fluid challenge guided by Doppler

(N=30)Fit for discharge

0

5

10

15

20

Days

Control Protocol 1 Protocol 2

From Venn R et al. Br J Anaesth 88:65-71, 2002.

*

* p<0.05 vs Control

*

Fewer patients in the protocol groupsexperienced severe intraoperativehypotension

Fluid Challenge and Measurement of Blood Flow

Observation of the blood flow (cardiac output or stroke volume) response to a « fluid challenge » (fixed volume of colloid infused over 10 to 15 min)

Perioperative colloids to maximize stroke volume (guided by oesophageal doppler)

6% HES 200/0.62:

Control (N= 30): 0-1800 mLProtocol (N= 30): 800-2400 mL

Gut mucosal hypoperfusion:56% vs 7% (p<0.001)

Perioperative Volume ExpansionDuring Cardiac Surgery

Morbidity (N)ICU LOS (d)

Hospital LOS (d)0

2

4

6

8

10

12

**

**

*

* p<0.05 ** p<0.01 vs controlFrom Mythen MG et al. Arch Surg 130:423-9, 1995.

range:1-111-1

range:5-485-9

Intraoperative Intravascular Volume Optimisation in Orthopedic Surgery

Prospective RCTPatients undergoing repair of proximal femoral fracture

- Control: conventional intraop fluid management (N=20)

- Study: colloid (starch) fluid challenge to maximize stroke volume (Doppler) (N=20)

Higher stroke volume and cardiac output in the study group Fit for discharge In hospital stay

0

10

20

30

40

50

60

Days

Control Study

From Sinclair S et al. BMJ 315:909-912, 1997.

* *

* p<0.05 vs Control

Perioperative Fluid Administration:The Goal-Directed Approach

Medline search from 1996 to 2006Nine studies

Hospital stay (7 studies) Postoperative complications (4 studies) PONV and ileus (3 studies)

Only oesophageal Doppler has been tested adequately

From Bundgaard-Nielsen M et al. Acta Anaesthesiol Scand 51:331-340, 2007.

Perioperative Fluid Administration:The Goal-Directed Approach

From Bundgaard-Nielsen M et al. Acta Anaesthesiol Scand 51:331-340, 2007.

Peroperative Fluid Management: « The Goal-Directed Therapy »


Duration (min)



Outcome

Noblett 2006

Colo-rectal 108

167±55 Intra Control: 2625±1004 Protocol: 2298±863

Control: 1209±824 Protocol: 1340±838

complications and hospital stay

Conway 2002

Bowel 57

140± 60 Intra Control: ±36 ml/kg Protocol: ±36 ml/kg

Control: 19±15 ml/kg Protocol: 28.0±16 ml/kg *

cardiac output in the protocol group 5 patients in the control group required ICU

Gan 2002

Uro/Gyneco 100


Control: 282±470 Protocol: 847±373 *

Earlier return in bowel function and hospital stay in the protocol group

Wakeling 2005

Bowel 128

157±-68 Intra Control: 3000 Protocol: 3000

Control: 1500 Protocol: 2000 *

postoperative complications and hospital stay in the protocol group

Sinclair 1997

Orthopedic 40

60-92 Intra Control: 700-1250 Protocol: 500-1000

Control: 0-450 Protocol: 550-950 *

Faster medically fit and hospital stay in the protocol group

Venn 2002

Orthopedic 90


Control: 319-476 Protocol: 1077-1336

Faster fit for discharge in the protocol group

Mythen 1995

Cardiac 60

150-330 Intra Control: 800-3000 Protocol: 200-1800 *


Gut mucosal perfusion, complications, ICU& hospital stay in the protocol group

McKendry 2004

Cardiac NA Post Control: 328±99 Protocol: 353±95


postoperative complications, ICU and hospital stay in the protocol group

Pearse 2005

General 122

NA Post Control:960±335 Protocol: 930±221




Duration (min)



Outcome

Noblett 2006

Colo-rectal 108


Control: 1209±824 Protocol: 1340±838


Conway 2002

Bowel 57

140± 60 Intra Control: ±36 ml/kg Protocol: ±36 ml/kg

Control: 19±15 ml/kg Protocol: 28.0±16 ml/kg *


Gan 2002

Uro/Gyneco 100




Wakeling 2005

Bowel 128

157±-68 Intra Control: 3000 Protocol: 3000

Control: 1500 Protocol: 2000 *


Sinclair 1997

Orthopedic 40




Venn 2002

Orthopedic 90


Control: 319-476 Protocol: 1077-1336


Mythen 1995

Cardiac 60

150-330 Intra Control: 800-3000 Protocol: 200-1800 *



McKendry 2004

Cardiac NA Post Control: 328±99 Protocol: 353±95


postoperative complications, ICU and hospital stay in the protocol group

Pearse 2005

General 122

NA Post Control:960±335 Protocol: 930±221



Doppler-Optimized Fluid Management During Elective Colorectal Resection

From Noblett SE et al.Br J Surg 93:1069-1076, 2006.

Double-blind RCT (N=108)- Control (n=52): routine management- Protocol (N=51): maximized stroke volume with colloid boluses based on oesophageal Doppler

Crystalloids Colloids- Control: 2625 ± 1004 ml - Control: 1209 ± 824 ml- Protocol: 2298 ± 863 ml - Protocol: 1340 ± 838 ml

0

5

10

15

2015

2

Postop complications (%)

Control Protocol

0

2

4

6

8

10

12 9

7

Hospital stay (median: days)

Control Protocol

Doppler-Optimized Fluid Management During Elective Colorectal Resection

From Noblett SE et al.Br J Surg 93:1069-1076, 2006.





« Fluid » challenge• Intravascular pressure measurement• Blood flow measurement

• Measurement of tissue perfusion


Measurement of Tissue Perfusion

Gastrointestinal tonometry

Laser doppler flowmetry

Near-infrared spectroscopy

Transcutaneous O2 measurements

Tissue pH monitors…

Preoperative Goal-Directed Fluid Optimization

Observational study (N=12) Preoperative maximization of stroke volume using

oesophageal doppler (OD) Comparison of the findings with:

Modelflow determined stroke volume Oesophageal doppler estimated corrected flow time (FTc) Central venous oxygen saturation (SvO2) Muscle and brain oxygenation (NIRS)

From Bundgaard-Nielsen M et al; Br J Anaesth 98:38-44, 2007.


Preoperative Goal-Directed

Fluid Optimization


Based on OD assessment, optimization of stroke volume was achieved after the administration of 400-800 ml of colloid.

The hypothetical volumes administered for optimization based upon Modelflow and SvO2 differed from OD in 10 and 11 patients respectively

Changes in FTc and NIRS were inconsistent with OD guided optimization


Peroperative Fluid Management

Authors Surgery (patients)

Time (min)

Strategy Outcome

Holte K 2007

Colonic 32

77-198 “cook book” Transient n pulmonary function, but tendency of increased morbidity in the restrictive group.

Holte K 2007

Orthopedic 48

41-127 “cook-book” Hypercoagulability and vomiting in the liberal group. No difference in hospital stay

Holte K 2004

Cholecystec 48

28-215 “cook book” postoperative organ function and hospital stay in the liberal group

Brandstrup 2003

Colo-rectal 172

90-390 “cook book” postoperative complications in the restrictive group

Nisanevich 2005

Abdominal 152

268±112 “cook book” post-operative complications and hospital stay in the restrictive group

Noblett 2006

Colo-rectal 108

167±55 SV optimization through OD


Conway 2002

Bowel 57

140± 60 SV optimization through OD


Gan 2002

Uro/Gyneco 100



Wakeling 2005

Bowel 128

157±-68 SV optimization through OD


Sinclair 1997

Orthopedic 40

60-92 SV optimization through OD


Venn 2002

Orthopedic 90



Mythen 1995

Cardiac 60



Authors Surgery (patients)

Time (min)

Strategy Outcome

Holte K 2007

Colonic 32

77-198 “cook book” Transient n pulmonary function, but tendency of increased morbidity in the restrictive group.

Holte K 2007

Orthopedic 48

41-127 “cook-book” Hypercoagulability and vomiting in the liberal group. No difference in hospital stay

Holte K 2004

Cholecystec 48

28-215 “cook book” postoperative organ function and hospital stay in the liberal group

Brandstrup 2003

Colo-rectal 172

90-390 “cook book” postoperative complications in the restrictive group

Nisanevich 2005

Abdominal 152

268±112 “cook book” post-operative complications and hospital stay in the restrictive group

Noblett 2006

Colo-rectal 108



Conway 2002

Bowel 57

140± 60 SV optimization through OD


Gan 2002

Uro/Gyneco 100



Wakeling 2005

Bowel 128

157±-68 SV optimization through OD


Sinclair 1997

Orthopedic 40



Venn 2002

Orthopedic 90



Mythen 1995

Cardiac 60



The Wet vs Dry Philosophy

« Most of the dry-supporting studies used fixed amounts of volume instead of a fluid

concept adapted to the patient need

(« goal-directed ») »

From Boldt J. Eur J Anaesthesiol 23:631-640, 2006.

Perioperative Fluid Management

Accurate dosing of fluid therapy

Accurate choice between the various available IV fluids

Colloids - Crystalloids Controversy

CRYSTALLOIDSPro

SafeLow cost

ConInterstitial oedema

COLLOIDSProVolume effect

ConSecondary effectsCost

Meta-analysis: Interpretation

Meta-analysis only analyzes existing data.

As such, a meta-analysis is hypothesis-generating

not

hypothesis-testing

Critical Appraisal of Meta-Analyses

Possible selection bias of included trialsResults of analysis may be similar... ...but interpretation can be quite different

Specific objections to meta-analyses on volume therapy:Mixing of patients with different diseasesDifferent kinds of infused fluidsOld studies (more than 15 years) included Mortality used as the endpoint in the meta-analyses...

... but not in most of the volume replacement studies

From Boldt J. Can J Anesth 51:500-513, 2004.

Intravenous Colloids: Physicians' Choices

Questionaire with 61 items

10% of frequent IV fluids prescribers in Ontario (N=364)

79% of the responding physicians used colloids:

Blood loss

COP manipulation

Choice between colloid products:

From Miletin MS et al. Intensive Care Med 28:917-924, 2002.

Intravenous Colloids: Physicians' Choices

Questionaire with 61 items

10% of frequent IV fluids prescribers in Ontario (N=364)

79% of the responding physicians used colloids:

Blood loss

COP manipulation

Choice between colloid products:

Marketing

Speciality

Location of practice

Clinical scenario

From Miletin MS et al. Intensive Care Med 28:917-924, 2002.

Volume «Optimization » in Surgical Patients

• Choice between the different solutionsPhysiological compartment that needs to be

restored (intravascular, interstitial, intracellular)Characteristics of the solutions

Pharmacokinetic and pharmacodynamic propertiesSide effectsCosts

Perioperative Fluid StrategyConclusions (1)

Preoperative fluid deficit must be compensated Replace water losses by crystalloids and plasma

losses by synthetic colloids Hartmann or Plasmalyte instead of NaCl 0.9%

Neurosurgery: avoid hypotonic solutions

Fluid strategy must be goal-oriented and adapted: To the patient To the surgical procedure

Type of fluids does notType of fluids does notinfluence outcomeinfluence outcome

Type of fluids does notType of fluids does notinfluence outcomeinfluence outcome

Goal-directed fluidGoal-directed fluidoptimizationoptimization

improves outcomeimproves outcome

Goal-directed fluidGoal-directed fluidoptimizationoptimization

improves outcomeimproves outcome

Some types of fluids allowSome types of fluids allowmore efficient goal-directedmore efficient goal-directed

fluid optimizationfluid optimization

Some types of fluids allowSome types of fluids allowmore efficient goal-directedmore efficient goal-directed

fluid optimizationfluid optimization

Thank you for your attention

?

Conclusions

Primary goals of volume therapy:To correct absolute or relative volume deficit in order to

optimize tissue oxygen delivery

The optimal amount rather than the type of fluid infusedwith a combination of colloids AND crystalloids

Conclusions

Primary goals of volume therapy:To correct absolute or relative volume deficit in order to

optimize tissue oxygen delivery

The optimal amount rather than the type of fluid infusedwith a combination of colloids AND crystalloids

Further studies are needed:to improve monitoring measures to recognize fluid deficits

and to guide volume therapyto better define patients who may benefit from a particular

kind of fluid

Goal-Directed Intraoperative Fluid Administration

Prospective RCTPatients undergoing major abdominal surgery

- Control: standard intraoperative care (N=50)

- Protocol: colloid (6% hetastarch in saline) fluid challenge to maximize stroke volume (Doppler) (N=50)

Higher stroke volume and cardiac output in the protocol group Oral intake In hospital stay

0

1

2

3

4

5

6

7

8

9

10

Days

Control Protocol

From Gan TJ et al. Anesthesiology 97:820-826, 2002.

*

* p<0.05 vs Control

*

volume optimization in surgical patients philippe van der linden md, phd chu brugmann-huderf, free...

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