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Welcome to ChiangmaiWelcome to Chiangmai
Srirath Chaiyaphruk MD July 16th 2008ใ
Improving Postoperative Improving Postoperative Outcomes Outcomes byby
Rational Fluid ManagementRational Fluid Management
SleepSleep
PainReliefPain
ReliefMuscle
RelaxationMuscle
Relaxation
VolumeManagement
VolumeManagement
Effective circulating volume
Hemodynamic stability
Adequate tissue perfusion
Five major aspects are of importance when volume replacement is considered
bull 1 The type of fluid must be decided
bull 2 The amount of fluid must be defined
bull 3 The criteria for guiding volume therapy must be defined
bull 4 Possible side effects should be considered
bull 5 Costs are of importance
Types of fluid must be decided
IV Fluid Usedbull Crystalloids
ndash Dextrose in waterbull D5Wbull D10Wbull D50W
ndash Salinebull Isotonic (09 or ldquonormalrdquo)bull Hypotonic (045 025)bull Hypertonic
ndash Combobull D5 12NSbull D5 NSbull D10 NS
ndash Balanced Ringerrsquos lactate
(K HCO3 Mg Ca)
bull Colloidsndash Albumin
bull 5 in NS
bull 25 (Salt Poor)
ndash Gelatin
ndash Dextrans
ndash HES
bull Blood - PRC
- Bl Components
Colloids do not improve outcome
bull Meta-analysis showed a 123 worsened mortality with colloids in multiple trauma
bull Saline solutions may produce hyperchloremic acidosis
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Srirath Chaiyaphruk MD July 16th 2008ใ
Improving Postoperative Improving Postoperative Outcomes Outcomes byby
Rational Fluid ManagementRational Fluid Management
SleepSleep
PainReliefPain
ReliefMuscle
RelaxationMuscle
Relaxation
VolumeManagement
VolumeManagement
Effective circulating volume
Hemodynamic stability
Adequate tissue perfusion
Five major aspects are of importance when volume replacement is considered
bull 1 The type of fluid must be decided
bull 2 The amount of fluid must be defined
bull 3 The criteria for guiding volume therapy must be defined
bull 4 Possible side effects should be considered
bull 5 Costs are of importance
Types of fluid must be decided
IV Fluid Usedbull Crystalloids
ndash Dextrose in waterbull D5Wbull D10Wbull D50W
ndash Salinebull Isotonic (09 or ldquonormalrdquo)bull Hypotonic (045 025)bull Hypertonic
ndash Combobull D5 12NSbull D5 NSbull D10 NS
ndash Balanced Ringerrsquos lactate
(K HCO3 Mg Ca)
bull Colloidsndash Albumin
bull 5 in NS
bull 25 (Salt Poor)
ndash Gelatin
ndash Dextrans
ndash HES
bull Blood - PRC
- Bl Components
Colloids do not improve outcome
bull Meta-analysis showed a 123 worsened mortality with colloids in multiple trauma
bull Saline solutions may produce hyperchloremic acidosis
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
SleepSleep
PainReliefPain
ReliefMuscle
RelaxationMuscle
Relaxation
VolumeManagement
VolumeManagement
Effective circulating volume
Hemodynamic stability
Adequate tissue perfusion
Five major aspects are of importance when volume replacement is considered
bull 1 The type of fluid must be decided
bull 2 The amount of fluid must be defined
bull 3 The criteria for guiding volume therapy must be defined
bull 4 Possible side effects should be considered
bull 5 Costs are of importance
Types of fluid must be decided
IV Fluid Usedbull Crystalloids
ndash Dextrose in waterbull D5Wbull D10Wbull D50W
ndash Salinebull Isotonic (09 or ldquonormalrdquo)bull Hypotonic (045 025)bull Hypertonic
ndash Combobull D5 12NSbull D5 NSbull D10 NS
ndash Balanced Ringerrsquos lactate
(K HCO3 Mg Ca)
bull Colloidsndash Albumin
bull 5 in NS
bull 25 (Salt Poor)
ndash Gelatin
ndash Dextrans
ndash HES
bull Blood - PRC
- Bl Components
Colloids do not improve outcome
bull Meta-analysis showed a 123 worsened mortality with colloids in multiple trauma
bull Saline solutions may produce hyperchloremic acidosis
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Five major aspects are of importance when volume replacement is considered
bull 1 The type of fluid must be decided
bull 2 The amount of fluid must be defined
bull 3 The criteria for guiding volume therapy must be defined
bull 4 Possible side effects should be considered
bull 5 Costs are of importance
Types of fluid must be decided
IV Fluid Usedbull Crystalloids
ndash Dextrose in waterbull D5Wbull D10Wbull D50W
ndash Salinebull Isotonic (09 or ldquonormalrdquo)bull Hypotonic (045 025)bull Hypertonic
ndash Combobull D5 12NSbull D5 NSbull D10 NS
ndash Balanced Ringerrsquos lactate
(K HCO3 Mg Ca)
bull Colloidsndash Albumin
bull 5 in NS
bull 25 (Salt Poor)
ndash Gelatin
ndash Dextrans
ndash HES
bull Blood - PRC
- Bl Components
Colloids do not improve outcome
bull Meta-analysis showed a 123 worsened mortality with colloids in multiple trauma
bull Saline solutions may produce hyperchloremic acidosis
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Types of fluid must be decided
IV Fluid Usedbull Crystalloids
ndash Dextrose in waterbull D5Wbull D10Wbull D50W
ndash Salinebull Isotonic (09 or ldquonormalrdquo)bull Hypotonic (045 025)bull Hypertonic
ndash Combobull D5 12NSbull D5 NSbull D10 NS
ndash Balanced Ringerrsquos lactate
(K HCO3 Mg Ca)
bull Colloidsndash Albumin
bull 5 in NS
bull 25 (Salt Poor)
ndash Gelatin
ndash Dextrans
ndash HES
bull Blood - PRC
- Bl Components
Colloids do not improve outcome
bull Meta-analysis showed a 123 worsened mortality with colloids in multiple trauma
bull Saline solutions may produce hyperchloremic acidosis
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
IV Fluid Usedbull Crystalloids
ndash Dextrose in waterbull D5Wbull D10Wbull D50W
ndash Salinebull Isotonic (09 or ldquonormalrdquo)bull Hypotonic (045 025)bull Hypertonic
ndash Combobull D5 12NSbull D5 NSbull D10 NS
ndash Balanced Ringerrsquos lactate
(K HCO3 Mg Ca)
bull Colloidsndash Albumin
bull 5 in NS
bull 25 (Salt Poor)
ndash Gelatin
ndash Dextrans
ndash HES
bull Blood - PRC
- Bl Components
Colloids do not improve outcome
bull Meta-analysis showed a 123 worsened mortality with colloids in multiple trauma
bull Saline solutions may produce hyperchloremic acidosis
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Colloids do not improve outcome
bull Meta-analysis showed a 123 worsened mortality with colloids in multiple trauma
bull Saline solutions may produce hyperchloremic acidosis
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
21+21 case
Implantable oxygen sensor catheters
HES-based or RL-based fluid replacement
Better oxygen tension in colloid group
Colloids versus Crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Lang K et al Anesth Analg 200193
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Colloids and Renal DysfunctionBoldt amp Priebe A and A 2003
bull 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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
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 101 (95 CI 092 to 110)Hydroxyethyl starch Ten trials 374 randomised participants RR was 116 (95 CI 068 to 196)Modified gelatin Seven trials 346 randomised participants RR was 054 (95 CI 016 to 185)Dextran Nine trials 834 randomised participants RR 124 (95 CI 094 to 165)Colloids in hypertonic crystalloid compared to isotonic crystalloidEight trials 1283 randomised participants RR was 088 (95 CI 074 to 105)
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 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit
N Engl J Med 2004 May 27350(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 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Albumin administration improves organ function in critically ill
hypoalbuminemic patients A prospective randomized controlled
pilot study Crit Care Med 2006 342536ndash2540Marc-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 lt30 gLInterventions The 100 patients were randomized to receive 300 mL of 20 albuminsolution on the first day then 200 mLday provided their serum albuminconcentration was lt31 gdL (albumin group) or to receive no albumin (controlgroup)
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 hellip
Conclusions Albumin administration
may improve organ function inhypoalbuminemic critically ill patientsIt results in a less positive fluid balance and a better tolerance to enteral feeding
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
2007 10685ndash91
BackgroundExcessive 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 facto
r for anastomotic leakage after large bowel surgery Surgery 2005
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
2007 10685ndash91
These effects are probably related to Better perfusion and oxygenation of the organs Decreased endothelial damage Decreased systemic inflammation and its consequences
Conclusions HES 13004decreases the circulating levels of MMP-9 ( MATRIX METALLOPROTEINASES ) in patients undergoing abdominal surgery
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment23 (30L)23 (30L)
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
13 (15L)
Cell Membrane
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
PlasmaPlasma3L3L
Interstitial Interstitial CompartmentCompartment
10L10L
Intracellular CompartmentIntracellular Compartment30L30L
Blood Blood Cells 2LCells 2L
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
Capillary Capillary EndotheliumEndothelium
Capillary Capillary EndotheliumEndothelium
SalineSalineSalineSalineGlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
Cell Membrane
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Fluid Distribution in a 75-kg AdultFluid Distribution in a 75-kg Adult
SalineSalineSalineSaline
GlucoseGlucoseGlucoseGlucose
ColloidColloidColloidColloid
3L 3L = 100
3L 15 L =20
3L 45L = 7
From Grocott Anesth Analg Volume 100(4)April 20051093-1106
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Composition of Body FluidsComposition of Body Fluids
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein
0
50
50
100
150
100
150
Cations Anions
EC
FICF
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bull Osmolarity = = solutesolute(solute+solvent)(solute+solvent) (Plasma = 290~310 mosmolL)(Plasma = 290~310 mosmolL)bull Osmolality = solutesolventOsmolality = solutesolvent ((mosmolKg ))bull Tonicity = Tonicity = effective osmolality osmolalitybull Serum osmolality
= 2 X serum sodium + BUN + glucose 3 18
Ca 2+
Mg 2+
K+
Na+
Cl-
PO43-
Organic anion
HCO3-
Protein 0
50
50
100
150
100
150
Cations
Anions
ECF
ICF
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Regulation of FluidsRegulation of Fluids
Hydrostatic pressure vs Oncotic pressure Albumin is the major determining oncotic pressure
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Plasma Osmolarity
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]Jv prop [ ( Pc - Pi ) - σ( πc - πi ) ]
Starling Equation
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Net flow of Fluid
Net Hydrostatic
Pressure
Capillary Wall Permeability
Net Oncotic Pressure
( Reflection coefficient)
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Fluid Replacement Productsbull Crystalloids ndash Ionic solutions that contain small molecules and are
able to pass through semipermeable membranesndash Isotonic solutions given to expand the ECF volume
ndash Hypotonic solutions given to reverse dehydration
ndash Hypertonic solutions given to increase the ECF volume and decrease cellular swelling
bull Colloids ndash 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 daysndash Albumin
ndash Gelatin
ndash Dextran
ndash HES
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Contents of common crystalloids
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline 045 Na+ 77 Cl- 77 154
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Hartmanrsquos Na+ 131 Cl- 112 281solution K+ 5 HCO3
- 29 Ca2+ 4 (as lactate)
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Glucose
Solution Electrolyte content Osmolality (mmolL) (mosmolKg)
Glucose 4 Na+ 31 Cl- 31 284saline 018
Glucose 5 Na+ Nil Cl- Nil 278
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Dextrose solutions(1) 5 Dextrose (often written D5W) ndash Think of it as lsquoSugar
and Waterrsquobull 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 NSaline [lsquoPhysiological replacementrsquo of water and Na+ losses]
bull Provides some calories [ approximately 10 of daily requirements]
bull Regarded as lsquoelectrolyte freersquo ndash contains NO Sodium Potassium Chloride or Calcium
bull If you infuse glucose 5 1000ml the glucose will enter the cell
and be metabolised
bull The water expands both ECF and ICF in proportion to their
volumes
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bullDistribution app 7 Intravascular bullWhen infused is rapidly redistributed into the intracellular space App 7 stays in the intravascular space therefore it is of limited use in fluid resuscitation
bullFor every 100ml blood loss ndash need gt1000ml dextrose replacement 7 retained in intravascular spacebullCommon cause of iatrogenic hyponatraemia in surgical patient
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
(2) Dextrose saline 5 Similar indications to 5 dextrose Provides Na+ 30mmoll and Cl- 30mmoll Ie a sprinkling of salt and sugAarPrimarily used to replace water losses post-operativelyLimited indications outside of post-operative replacement ndash lsquoNeither really saline or dextrosersquo Advantage ndash doesnrsquot commonly cause water or salt overload
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Saline Solution
Solution Electrolyte content Osmolality
(mmolL) (mosmolKg)
Saline 09 Na+ 154 Cl- 154 308
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Saline Solutions
(1) 09 Normal Saline ndash Think of it as lsquoSalt and waterrsquobull Principal fluid used for intravascular resuscitation and replacement
of salt loss eg diarrhoea and vomitingbull Contains Na+ 154 mmoll K+ - Nil Cl- - 154 mmolL Plasma =95 -105 mmol Lbull Do not use more than 2 L to prevent Hyperchloraemic Metabolic
Acidosisbull IsoOsmolar ( Slightly Hyperosmolar308 mosm L)compared to
normal plasmabull Distribution Stays almost entirely in the Extracellular space Of 1
litre ndash 800ml Extra cellular fluid 200ml intravacular fluidbull So for 100ml blood loss ndash need to give 500ml Nsaline [only 20
remains intravascular]
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
2) 045 Normal saline = lsquoHalfrsquo Normal Saline = HYPOtonic salinebullReserved for severe hyperosmolar states Eg HONK and severe dehydrationbullLeads to HYPOnatraemia if plasma sodium is normalbullMay 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 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
HYPERtonic saline 18 30 70 75 and 10 Saline
bull Reserved for plasma expansion with colloidsbull In practice rarely used in general wards Reserved for high
dependency specialist areasUse in Prehospital Resuscitation for Burn and Trauma
bull 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
bull Decrease Edema ( Tissue and Cerebral )bull Large volumes will cause HYPERnatraemia and IC
dehydration
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Hartmanrsquos Solution( Ringerrsquos Lactate)
Solution Electr olyte content Osmolality
(mmolL) (mosmolKg)
Hartmanrsquos Na+ 131 Cl- 112 281
solution K+ 5 HCO3-29
Ca2+ 4 (as lactate)
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bullPrincipal fluid used for intravascular resuscitationbullContains Na+ 131 mmoll K+5 mmolL Ca+4 mmolL Cl - 112 mmolL HCO3 -29 mmolL
bullIsoOsmolar ( Slightly Hypoosmolar 273 mosm L Plasma =95 -105 mmol L )compared to normal plasmabullNot be used in Cerebral edema trendbullLarge Volume -- Metabolic AlkalosisbullHypoperfusion - Lactic Acidosis
Ringerrsquos Lactated Solution = Balanced Salt Solution
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Colloid solutionsbull 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
bull Thus the volume infused stays (initially) almost entirely within the intravascular space
bull Stay intravascular for a prolonged period compared to crystalloidsbull However they leak out of the intravascular space when the
capillary permeability significantly changes eg Severe trauma or sepsis
bull Until recently they were regarded as the gold standard for intravascular resuscitation
bull Because of their gelatinous properties they cause platelet dysfunction and interfere with fibrinolysis and coagulation factors (factor VIII) ndash thus they can cause significant coagulopathy in large volumes
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
1048714
What is the ideal colloid One which displays the following in plasma replacement
1Rapidly replaces blood volume losses
2Restores the haemodynamicbalance
3Normalizes microcirculatory flow
4Have a sufficiently long intravascular life
5Improves haemorrheology
6Be readily metabolized readily excreted and well tolerated
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
7Be free of side effects especially regarding haemostasisand anaphylactoidreactions
8Be cost effective and contribute to blood savings
National Research Council USA (1963)
1048714Unfortunately NO colloid fits into all the criteria all of the time 1048714Idea is to use the best colloid for the patient to achieve the desired effect with the least amount of side-effects
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
1980New Generation HES
1980New Generation HES
1915World WarⅠ
1915World WarⅠ
1945World WarⅡ
1945World WarⅡ
1960War In Vietnam
1960War In Vietnam
Gelatin Gelatin
DEXTRAN DEXTRAN
HES HES
HAES-steril HAES-steril
2000A Class of Its Own
2000A Class of Its Own
Synthetic Colloid
Gelofusin 1965
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
HemorrheologyHemorrheologyHemorrheologyHemorrheology Duration of PVEDuration of PVEDuration of PVEDuration of PVE
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell Function
HemostasisHemostasisHemostasisHemostasis
FluidsFluidsFluidsFluids
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Magnitude of Magnitude of PVEPVE
Magnitude of Magnitude of PVEPVE
bullSpecific Properties
bullAmount of Colloid Particles ( )
รปท 15
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Duration of Duration of PVEPVE
Duration of Duration of PVEPVE
Colloid is governed by rate of colloid molecule loss from circulation and 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 (eg HES C2C6 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 Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Properties of resuscitation fluids
Crystalloid Crystalloid GelatinGelatin Albumin HESAlbumin HES
60 da 30-35 kda 69kda 130-450 kda
10-20 mins 1 - 2 hrs 2 - 4 hrs 4 - 12 hrs
Molecular Weight
Volume Effect
รปท 16
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Properties of resuscitation fluidsProperties of resuscitation fluids
09 Saline 58 Da
Massive sodium chloride and water load
Very large volumes required
Saline cannot be excreted easily Interstitial oedema
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Properties of resuscitation fluidsProperties of resuscitation fluids 4 Gelatine 30000 Da
Volume expansion lasts 1-2 hoursVolume expansion lasts 1-2 hours
Sodium chloride ( K Ca )
Large volume required
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Properties of resuscitation fluidsProperties of resuscitation fluids
45 Albumin 68000 DaVolume expansion lasts 2-4 hoursVolume expansion lasts 2-4 hours
Expensive
Risk of Transmitted Dis
More albumin leaks out during inflammation
(Increase reflection coefficient )
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Properties of resuscitation fluidsProperties of resuscitation fluids HES 200000 Da 05 substitution Volume expansion lasts 6 hVolume expansion lasts 6 h
Anti-inflammatory less capillary leak
Low Med High Molecular Weight
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
HemorrheologyHemorrheologyHemorrheologyHemorrheology - Reduce whole blood viscosity by simple hemodilution improving blood-flow characteristics The magnitude of this effect bull Lower-MW (30000ndash40000 Da) HES and Dextran products that produce a large initial increment in intravascular volume therefore a larger hemodilution effectbull Higher-MW Dextrans and HES cause an increase in
plasma viscosity bull Larger-MW dextrans (eg Dextran 70) and Gelatins also
tend to cause red cell aggregation bull Lower-MW dextrans (eg 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
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
HMw HE( Dex ) Decrease
Increase
Over all Haemodilution
Effect
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
HemostasisHemostasisHemostasisHemostasis -Simple hemodilution of clotting factors and 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 gt Modified - HES solutions have varying effects on hemostasis dependent on Mw ( higher-MWgt Medium gt= 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 Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Inflammatory Inflammatory Cell FunctionCell FunctionInflammatory Inflammatory Cell FunctionCell 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
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
Anaphylactoid Anaphylactoid
Anaphylactic Anaphylactic ReacReac
- 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 eg shock life-threatening smooth muscle spasm or cardiac or respiratory arrest) is probably more frequent for gelatins urea-linked 12000 gt succinylated Gelatin 113000 per year (most frequent reported incidence lt035) and dextrans (lt028) than for albumin (lt01) or HES (lt006) - The advent of dextran 1 hapten treatment has significantly reduced the risk of dextran-related anaphylactic events to lt00015 - 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
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Allergic Reactions with Colloid SolutionsAllergic Reactions with Colloid Solutions
Laxenaire et al Ann Fr Anes Reacuteanim 1994
Prospective multi-center-trial (~ 20000 patients)
Gelatin Dextran Albumin HES
04
02
0
All
erg
icre
acti
on
s(
)Allergic Reaction with Colloid Solution
รปท 22
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Crystalliod ColloidIntravascular 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 NilLow to moderate
Plasma colloid osmotic pressure
Reduced Maintained
Cost Inexpensive Expensive
Crystalloids and colloids
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Balanced Versus Unbalanced Fluidsbull 09 saline and of colloids dissolved in isotonic saline is
associated with the development of hyperchloremic metabolic acidosis due to the high chloride load
bull 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 acidbase physiology
bull Balanced crystalloid solutions (eg Hartmannrsquos solutionRingerrsquos lactate)
bull Balanced colloid solution presented (eg Hextend 6 HES in a balanced electrolyte solution)
bull 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 bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Hypertonic Fluids bull Hypertonic 18 3 5 75 10 (600ndash2400 mOsmL) crystalloid
and colloid solutions have been introduced for certain clinical indications
bull Advantage of these solutions is that a small volume of administered fluid will provide a significant Plasma Volume Expansion
bull The high osmolarity of these solutions draws tissue fluid into the intravascular space and thus should minimize tissue edemaand cerebral edema in patients who are at risk of this complication
bull Limited use in the perioperative setting bull Use in the management of burn patients and in prehospital
resuscitation of trauma victims bull Single-dose administrations bull Short Duration app 30 ndash 60 mins Plus colloid to maintain duration 72 NaCl + 6 HES-200 or 75 NaCl + 6 dextran 70
bull 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
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Fluid Therapy
bull Quantitative Considerations are concern in fluid Management
( Volume )
bull 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
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Fluid amount must be defined
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Methods Fifty-six patients undergoing colon resection were randomly assigned to conservative (8 mLmiddotkgminus1middothminus1 n = 26) or aggressive (16 to 18 mLmiddotkgminus1middothminus1 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
Arkilic CF Taguchi A Sharma N et al Supplemental perioperative fluid administration increases tissue oxygen pressure Surgery 200313349ndash55 Accepted 15 August 2003
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
httpwwwhealthaucklandacnzaumsaimagesFluid20Managementpdf
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
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 ndash 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 lsquothird spacersquo 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
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bull Which fluidndash Which fluid compartment is predominantly
affected
ndash Need evaluation of other acidbaseelectrolytenutrition issues
bull How much volumendash Need estimate of fluid deficit (volume status )
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bullInadequate 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
Adverse outcomes Inadequate or Excessive fluid
administration
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bullExcess - 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 andor 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 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Conventional clinical assessment
1 Urine Output 500 ml24hrs(20mlhr Adult ) 1mlhr Neonate 05mihr Child
2 Supine hypotensionHeart Rate =gt 20 min Dec Sys=gt 20mmHg
3 Laboraory evidence 31 Hematocrit 32 BUN 80-20 mgdl 33 Creatinine 05-15 mgdl Creatinine Clearance ( gt 30 ) BUN Creatinine 10-20 ( more in Infant ) + Urine sodium amp Urine Osmolarity
Dehydration
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Factors Affecting the Amount of Intraoperative Fluid Administration
bull Preoperative IVVbull Preoperative
cardiovascular functionbull Anesthetic techniquebull Anesthetic agent
pharmacologybull Patient positionbull Thermoregulationbull Operative fluid
administrationbull Duration of surgery
bull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac
functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory
cytokinesbull Sepsisbull Allergicanaphylactic
reactions
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bull Preoperative IVVbull Preoperative cardiovascular
functionbull Anesthetic techniquebull Anesthetic agent pharmacologybull Patient positionbull Thermoregulationbull Operative fluid administrationbull Duration of surgerybull Operative sitebull Surgical techniquebull Splanchnic ischemiabull Intraoperative cardiac functionbull Capillary permeabilitybull Endotoxemiabull Proinflammatory cytokinesbull Sepsisbull Allergicanaphylactic reactions
bullHypovolemia Must be treated
bullDehydration Need more time to correct
bullChr Hypertension
Inc SVRHypovolemia
Water Depletion
bullThirst
bullHypernatremia
ECF depletionbullSkin turgor sunken eyeballs bullWeight bullHemodynamic effects
Intravascular depletionMAP= CO x SVR
Hemodynamic effectsbull BP HR JVPbull Cool extremitiesbull Reduced sweatingbull Dry mucus membranes
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bullPreoperative IVV
bullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
Existence of congestive heart failure and pulmonary edema
bullNeed close and Invasive monitoring
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bullPreoperative IVVbullPreoperative cardiovascular function
bullAnesthetic techniquebullPatient positionbullThermoregulationbullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullThiopental propofol decrease SVR (etomidate ketamine and high-dose opioids)
bullMuscle relaxants may release histamine (curare atracurium) and decrease SVR or produce venous pooling due to loss of muscle tone bullAll volatile inhalation anesthetic agents reduce SVR and decrease contractility bullEpidural and subarachnoid (spinal) blocks accompanying sympathetic nervous blockade produce vasodilation with severe hypotension in the hypovolemic patient
and agent pharmacology
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bullPreoperative IVVbullPreoperative cardiovascular functionbullAnesthetic techniquebullAnesthetic agent pharmacologybullPatient positionbullThermoregulation
bullOperative fluid administrationbullDuration of surgerybullOperative sitebullSurgical techniquebullSplanchnic ischemiabullIntraoperative cardiac functionbullCapillary permeabilitybullEndotoxemiabullProinflammatory cytokinesbullSepsisbullAllergicanaphylactic reactions
bullHemorrhage loss of ascites or pleural fluid fluid shifts with redistribution or loss from operative sites bullAmount amp Duration of Tiss TraumabullAdministration of large quantities of fluid into sites prostate resectionbull Patient positioningProneSittingSurgical packing and retractionbull Fluid shifts with redistribution or loss
from operative sites
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Introaperative Clinical Asessment
bull Vital Sign Monitoring
bull Estimate Blood Lost + Haematocrit
bull Urine Output
bull CVP PAOP
bull Arterial Line Blood Gas
bull Mixed venous hemoglolim desaturation
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Urine outputbull A monitor of renal perfusion only urine output is often used as a guide to adequacy of cardiac output as thekidney receives 25 of cardiac output When renal
perfusion is adequate urine output will gt 05 mlkgh
bull lt 05 mlkgh Low Perfusion inc Stress -gt inc ADH Positive P Vent -gt dec Atrial Natriuretic Peptide
bull Use of Diuretics such as Frusemide Hyperglycemia and Dopamine abolishes its usefulness as a haemodynamic monitor
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Urine Outpu
t
=
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bull Principle Measures of CVP but is useful to determine relative fluid balance
bull UtilityRelative measurement of fluid statusAllows large volume fluid administrationAdministration of potent vasoconstrictors
epinephrine norepinephrine
Central Venous Pressure Catheter(CVP)
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bull UtilityTrends in cardiac outputIntravascular volume status (CVP)Assists diagnosis of pulmonary edema vs ARDSLarge fluid volume administrationAdministration of potent vasoconstrictors
EpinephrineNorepinephrine
Pulmonary Artery Catheter (Swan-Ganz)
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Mixed venous oxygen saturation (SvO2)
Has been used as a measure of adequacy of tissue perfusionvaries 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 distallumen of the Swan-Ganz catheter and measuring the saturationin a co-oximeter At the low PvO2 in mixed venous blood thecalculated 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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
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 No interventional study has demonstrated any improvement in outcomeimprovement in outcome
No interventional study has demonstrated any No interventional study has demonstrated any improvement in outcomeimprovement in outcome
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Heart Rate
Blood Pressure
Cardiac Out Put
C V P
Urinre Out Put
Skin Perfusion
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Perioperative Fluid Requirements
bull NPO and other deficits NG suction bowel prep
bull Maintenance fluid requirements
bull Third space losses
bull Replacement of blood loss
bull Special additional losses
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
NPO and other deficits
bull NPO deficit = number of hours NPO x maintenance fluid requirement
bull Bowel prep may result in up to 1 L fluid loss
bull Measurable fluid losses eg NG suctioning vomiting ostomy output
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Maintenance Fluid Requirements
bull Insensible losses such as evaporation of water from respiratory tract sweat feces urinary excretion Occurs continually
bull Adults approximately 15-2 mlkghrbull ldquo4-2-1 Rulerdquo
- 4 mlkghr for the first 10 kg of body weight- 2 mlkghr for the second 10 kg body weight- 1 mlkghr subsequent kg body weight- Extra fluid for fever tracheotomy denuded surfaces
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Third Space Losses
bull Isotonic ( Abnormal ) transfer of ECF from functional body fluid compartments to non-functional compartments
bull Depends on location and duration of surgical procedure amount of tissue trauma ambient temperature room ventilation
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Replacing Third Space Losses
bull Superficial surgical trauma 1-2 mlkghr
bull Minimal Surgical Trauma 3-4 mlkghr- head and neck hernia
bull Moderate Surgical Trauma 5-6 mlkghr- hysterectomy chest surgery
bull Severe surgical trauma 8-10 mlkghr (or more)- AAA repair nehprectomy
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Other factors
bull Ongoing fluid losses from other sites- gastric drainage- ostomy output- diarrhea
bull Replace volume per volume with crystalloid solutions
Type replacement depend on Type of lost
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
bull When haemodynamically stable
ndash Rare to need blood if Hb gt 10gdl
ndash Usual to need blood is Hb lt 70gdl
bull Level depends on co-morbidities
bull Sign of Oxygen Saturation Dec
General guidelines for blood
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Hct patient - Hct target X EBV
Hct patient
Allowable Blood Loss (ABL)
20 -30 Lost
( 21 30 )
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Volume infused = Type Distribution of Fluid
Expected PV Lost X Distribution VolumeNormal PV
5 DW dis Intravascular Interstitial Intracellular
09 NSS dis Intravascular Interstitial
Colloid Blood dis Intravascular
Blood Loss
( 7-10)
(20-30)
(100)
110+
13-5
11
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Conflicting results from different studies are most likely due to variations bull Clinical protocols bull Selection of patientsbull Type amp Duration of Surgerybull Type amp Volume of Fluid administration
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Goal-Directed TherapyGoal-Directed Therapy
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Goal-Directed Therapy
Titration of fluids
Physiologically relevant end-points
Using appropriate monitoring Clinical
Outcome
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery
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
Gan TJ et al Anesthesiology 200297820Gan TJ et al Anesthesiology 200297820
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
The Fluid Challenge amp Blood Pressure Measurement
A fixed volume of Fluid over
10-15 min
Observation
A sustained
increase of
ge 3 mm Hg
CVPPAOPCVP
PAOP
Intra-vascular VolumeIntra-vascular Volume
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Pressure variation with respirationMichard F et al Am J Respir Crit Care Med 2000162134
Bennett-Guerrero E et al Mt Sinai J Med 20026996
Systolic and Pulse Pressure Variation
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Normal value lt 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 bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Displays of the system when 1500 mL of blood was lost (A) and when 1200 mL of bloodwas 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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
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
httpwwwpubmedcentralnihgovarticlerenderfcgiartid=137448
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
The Fluid Challenge amp Blood Flow Measurement
Intra-vascular VolumeIntra-vascular Volume
StrokeVolumeStroke
Volume
bull5 studies available
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
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
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Conclusionbull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
bull Crystalloid and colloid
bull Balanced versus saline-based fluids
bull Correct dosage of fluid improves outcome
Role of LV stroke volume
Titration for Max CO - CVP
- PAOP
- Oesophageal Doppler
- Etc
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Fluid Therapy
bull Quantitative ( Volume )
bull Qualitative
Considerations oxygen-carrying capacity
coagulation electrolyte and acid-base balance
and glucose metabolism are also of critical
importance( Type )
bull Effective circulating volumebull Hemodynamic stabilitybull Adequate tissue perfusion
Thank YouThank You
Thank YouThank You
