Advancements in Volume Resuscitation and Colloids

Matthew S. Giuca, MD

Assistant Professor of AnesthesiologyStony Brook University Medical School

Nassau Anesthesia Associates Department of Anesthesia

Winthrop University Hospital

• No Disclosures or conflicts of interest

• Caveats…..

• Email: mgiuca@winthrop.org

• Grateful and honored

• Discuss Advancements in Volume Resuscitation management

• Explain the definition of a Colloid and discuss risks vs benefits of utilization

• Present evidence based expert opinions and journal articles that reflect international standards of care

• Discuss methodology and approach to different patient populations

• Get to the point quickly so you don’t miss any text messages

• Select a treatment that ameliorates end organ damage and has a favorable benefit to risk profile

• Evidence based

• Cost effective

• Upholds national and community standards

• Long track record in complex patient populations

• Prior to 1795 – • 1795 – First human to human blood transfusion? - Philip Syng Physick, an American physician from

Philadelphia, not published.• 1827 - Cholera epidemic strikes - Cholera started in India, spread to Russia by 1829 then England in

1831 and the United States by 1832 claiming thousands of lives. • 1829 - First documented blood transfusion - Williams Blundell (1790–1878), an English physician

and obstetrician• 1830 - First successful blood transfusion - Blundell successfully transfuses a woman dying of

severe postpartum hemorrhage • 1830 - First intravenous use of water - Herman and Jaehnichen, Russians physicians desperate in

the face of cholera • 1832 - First saline infusion - Thomas Latta injects 6 pints of a solution of 1⁄2 concentration of soda

and subcarbonate soda (58 mEq Na, 49 mEq Cl, 9 mEq HCO3). • 1833 - First successful saline infusion - Latta’s 2nd patient, 330 cm3 of fluid over 12 h and survives. • 1834 - First use of intravenous albumin - John Mackintosh, Scottish physician and student of Latta

comments that “it would be advisable to make the fluid resemble as much as possible the serum of blood, by adding albumin obtained from egg”.

• 1849 - Blood transfusions deemed acceptable - Walton, a famous English physician reviewed all transfusions to date and concluded the procedure a success with a mortality rate of 30%. He judged that the quantity of blood transfused should be no less than 6 oz and no more than 16 oz (roughly 1 unit blood).

• 1876 - Ringer’s solution introduced - containing 8 g NaCl, 0.3 g KCl and 0.33 g CaCl • 1894 - Citrate introduced as an anticoagulant - Sir Almroth Wright, an English

pathologist introduces the use of citrate as an anticoagulant• 1901 - Blood groups identified - Karl Landsteiner of Austria discovered three of the

four major blood groups and is awarded the Nobel Prize for his work in 1930. • 1907 - Blood groups identified - Jansky from Chekoslovakia discovers the fourth blood

group• 1908 - Blood typing become commercially available• 1932 - First blood bank established – Leningrad, 2 years later the first American blood

bank by Bernard Fantus. • 1930 – Rochester plastic needle - In 1950 David Masa, at the Mayo Clinic, introduced

the plastic needle, similar to today’s needles.

• Date: June 24 2013

• Recommendations for Health Professionals

• Do not use HES solutions in critically ill adult patients including those with sepsis, and those admitted to the ICU. Avoid use in patients with pre-existing renal dysfunction. Discontinue use of HES at the first sign of renal injury. Need for renal replacement therapy has been reported up to 90 days after HES administration. Continue to monitor renal function for at least 90 days in all patients. Avoid use in patients undergoing open heart surgery in association with cardiopulmonary bypass due to excess bleeding. Discontinue use of HES at the first sign of coagulopathy.

R. Phillip Dellinger, MD; Mitchell M. Levy, MD; Andrew Rhodes, MB BS3 et al..

• Hemodynamic Support and Adjunctive Therapy (Table 6) • G. Fluid Therapy of Severe Sepsis • We recommend crystalloids be used as the initial fluid of choice

in the resuscitation of severe sepsis and septic shock (grade 1B). • We recommend against the use of hydroxyethyl starches (HES)

for fluid resuscitation of severe sepsis and septic shock (grade 1B). (This recommendation is based on the results of the VISEP [128], CRYSTMAS [122], 6S [123], and CHEST [124] trials. The results of the recently completed CRYSTAL trial were not considered.)

1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults (grade 1B).

2. Not using erythropoietin as a specific treatment of anemia associated with severe sepsis (grade 1B).

3. Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).

4. Not using antithrombin for the treatment of severe sepsis and septic shock (grade 1B).

5. In patients with severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. We suggest prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D).

Com

plic

ation

s

Bellamy MC. Br J Anaesth. 2006;97:755-757.

Volume Load

OPTIMAL

EdemaOrgan dysfunctionAdverse outcome

HypoperfusionOrgan dysfunctionAdverse outcome

OverloadedHypovolemic

Cumulative Fluid Balance (day 4) Group Rosenberg AL, et al. J Intensive Care Med. 2009;24(1):35-46.

• Early goal-directed therapy for severe sepsi

- Rivers et al. New Engl J Med 345:1368-77, 2001

• Intra-operative goal-directed therapy

- Gan et al . Anesthesiology 97:820-6, 2002

• Post-operative resuscitation in high risk patients

- McKendry et al. Br Med J 329:258-65, 2004

- Pearse et al. Crit Care 9: R687-93, 2005

• SvO2: mixed venous oxygen saturationconsumption & delivery

• C(a-v)O2: arterial-venous oxygen content difference

consumption & cardiac output

• Lactate: the demand and need of the use of oxygen

consumption & cardiac output

• 

Hamilton M et al. Anesth Analg 2011;112:1392–402

Hamilton M et al. Anesth Analg 2011;112:1392–402

Other: FloTrac, LidCOplus,CVP/arterial line, DX2020.

between CVP and circulating blood volume

across a wide spectrum of clinical conditions

Pooled ROC curve was 0.56

Marik, PE. Chest 2008;134:172-178

Marik, PE. Chest 2008;134:172-178

Kumar et al. Crit Care Med 32:691-9, 2004

CVP

•RV dysfunction•Pulmonary hypertension•LV dysfunction•Tamponade & hyperinflation•Intravascular volume expansion

PAOP

•LV diastolic compliance•Pericardial restraint•Intrathoracic pressure•Heart rate•Mitral valvulopathy

• Stroke volume variation and pulse pressure variation

– Lithium indicator dilution (LiDCO) – Arterial pulse waveform

(APCO/FloTrac)

• Indicator/Thermodilution – Pulse contour (PiCCO) – Lithium indicator dilution

(LiDCO)

– NICO (CO2)

• Doppler – (EDM, UMSCOM, Hemosonic)

– Transesophageal echo

• Thoracicelectricalbioimpedence/bioreactance

• Pulse oximetry plethysmography (respiratory variation)

• Endorganperfusion– Gastric tonometer, Cytoscan

SVmax

SVmin

SVmean

Svmax - SVminSVV % =

SVmean

Preload

Stroke Volume

00

Preload Dependent

Preload Independent

On the Absorption of Fluids from the Connective Tissue Spaces.Starling EHJ Physiol. 1896 May 5; 19(4):312-26.

Great… now what?!?!

Spontaneous breathingOther Rythms - A-FibSmall Tidal Volumes

(8cc/kg IBW)

*Open Chest & IABP

common examples

SVV doesn’t predict Preload Responsiveness when there isn’t a

rhythmic interaction

So…

SVV is Based upon Rhythmic Interaction

between heart and lungs

Preload00

Normal

HF∆ SV ≥ 10%

∆ SV ≤ 10%

∆ SV

∆ SV

>13% >10%

“An interdisciplinary multimodal concept to accelerate postoperative convalescence and reduce general morbidity (including POI) by simultaneously applying several interventions”

Mattei P. World J Surg. 2006;30:1382-1391.Person B, Wexner S. Curr Probl Surg. 2006;43:6-65

What are the appropriate choices in constructing fast-track, multimodal protocols?

Preoperative Intraoperative PostoperativeIdentify patients Thoracic epidural Early Feeding

Educate about program Goal Directed Fluid Therapy Early mobilization

Screen for malnutrition Standard anesthetic protocol Optimize fluid regimen

Carbohydrate drink Antibiotics before incision Optimize analgesic regimen

Selective bowel preparation Thromboprophylasix No NG tube or urinary catheter

Background In total, 42 randomized controlled trials have

assessed the benefit of goal-directed therapy, spanning a wide range of high-risk surgeries

Of these, 39 have been included in one or more of 5 major meta-analyses

The total population included in these meta-analyses is 5,631 patients, of which 2,857 were randomized to GDT, and reaches back to 1985

Trials have reported different endpoints, and as such meta-analyses of specific endpoints are based on smaller sub-populations of studies

The literature review was current as of March 2012

Evidence Base Formal meta-analysis of effect size has shown

significant benefits for GDT in:

a) Total complications [Hamilton 2010]

b) Acute kidney injury [Brienza 2009]

c) Pneumonia [Dalfino 2011]

d) Surgical site infection [Dalfino 2011]

e) Urinary tract infection [Dalfino 2011]

f) Major GI complications [Giglio 2009]

g) Minor GI complications [Giglio 2009]

h) Length of hospital stay [Corcoran 2012]

Meta-analysis has also shown benefit in mortality, although only in older studies with high mort

• Available fluids for resuscitation have a long track record in medicine

• Starch based colloids are not recommended

• Data suggests that a goal directed approach decreases complications and length of stay

• Give as much resuscitation as you need… but as little as possible

Thank You