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Fluid Management / Perioperative Care Dr Robin Correa FRCA
Perioperative Care
Dr Robin Correa FRCAConsultant Anaesthetist
23 March 2011
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Perioperative Care
Preoperative Care- Fluid optimisation and nutrition- Assessment
Intraoperative Care- Antibiotic and thromboprophylaxis- Sterilisation, disinfection and antisepsis- Transport, positioning, scrubbing up, instruments, incisions,
closures, drains, stomas and sutures
Postoperative Care- Drain, fluid and acid – base management, pain, surgical
complications and critical care
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Fluid Management
• Introduction
• Fluid compartments
• Stress response and fluid
• GIFTASUP recommendations
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Introduction
• Fluid and electrolyte balance consists of :
- external balance between the body and its environment
- internal balance intravascular, interstitial and intracellular
compartments
• Twenty four hour requirements in normal adult are 25 – 35 mL/kg or 1.5 – 2.5 L of water with 70 mmol of sodium and 40 - 80 mmol of potassium
• Fluid requirements sometimes classified as that for replacement, maintenance and resuscitation
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Introduction
• Fluid and electrolyte balance consists of :
- external balance between the body and its environment
- internal balance intravascular, interstitial and intracellular
compartments
• Twenty four hour requirements in normal adult are 25 – 35 mL/kg or 1.5 – 2.5 L of water with 70 mmol of sodium and 40 - 80 mmol of potassium
• Fluid requirements sometimes classified as that for replacement, maintenance and resuscitation
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Introduction
• Crystalloid solutions contain low molecular weight salts or sugars which dissolve completely in water and pass freely between intravascular and interstitial compartments
• Colloid solutions contain larger molecular weight substances that do not dissolve completely and remain for a longer period in the intravascular compartment
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Fluid compartments
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Fluids Fluid Sodium
mmol/LPotassiummmol/L
Chloridemmol/L
Osmolaritymosm/L
Plasma 136-145 3.5-5.0 98-105 280-300
Hartmann’s 131 5.0 111 275
Dextrose 4%saline 0.18%
30 0 30 283
5% Dextrose 0 0 0 278
Gelatine 4%(Gelofusine)
145 0 145 290
0.9% Saline 154 0 154 308
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Fluids
Volume effect (%)
Average MW (kDa)
Circulatory half life
Gelatins 80 35 2 – 3 hrs
Dextran 70 120 41 2 – 12 hrs
6% HESHydroxyethyl Starch
100 70 Up to 17 days
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Stress response and fluid
• Along with other hormones, stress response to surgery releases vasopressin and triggers the RAAS (renin – angiotensin – aldosterone system)
• Net effect is an increase in body water with the retention of sodium
and excretion of potassium. Oliguria is common which is accompanied by a reduced capacity of kidney to dilute or concentrate urine
• A catabolic state from surgery results in an increased production of urea and other metabolites which compete with electrolytes (mainly Na+ and Cl-) for excretion by the kidney
• Recovery phase is characterised by a diuresis with loss of both sodium and water
Fluid Management / Perioperative Care Dr Robin Correa FRCA
GIFTASUP
• GIFTASUP (October 2008) - British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients
• A 1997 UK study showed that postoperative patients were frequently in positive fluid balances of 7 litres or more with a sodium load
of 700 mmol
• In the US, excessive fluid administration causing pulmonary oedema has been blamed for 8315 patient deaths a year
• A postal survey of 710 consultant surgeons revealed that PRHO’s were most commonly responsible for fluid prescription
Fluid Management / Perioperative Care Dr Robin Correa FRCA
GIFTASUP
Recommendation 1 Normal Saline is Abnormal
Recommendation 2 Dextrose can be dangerous
Recommendation 3 Equal electrolytes by any route
NB – words in red are an aide memoire and do not form part of the GIFTASUP document
Fluid Management / Perioperative Care Dr Robin Correa FRCA
GIFTASUP
Recommendation 1 (Normal Saline is Abnormal)
Evidence level 1b
Because of the risk of inducing hyperchloraemic acidosis in routine
practice, when crystalloid resuscitation or replacement is indicated,
balanced salt solutions e.g. Ringer’s lactate/acetate or Hartmann’s
solution should replace 0.9% saline, except in cases of hypochloraemia
e.g. from vomiting or gastric drain
Fluid Management / Perioperative Care Dr Robin Correa FRCA
GIFTASUP Normal Saline is Abnormal
• 0.9% saline contains supranormal amounts of Na+ and Cl-
(154 mmol/L each ) compared to physiological concentrations
(140 and 95 mmol/L respectively)
• A sodium load can be difficult to excrete especially in the oliguric phase of the stress response
• Hyperchloraemia causes renal vasoconstriction and a reduced glomerular filtration rate
• Excess serum sodium can aggravate interstitial oedema caused by capillary endothelial leaks
Fluid Management / Perioperative Care Dr Robin Correa FRCA
GIFTASUP
Recommendation 2 (Dextrose can be dangerous)
Evidence level 1b
• Solutions such as 4% /0.18% dextrose/saline and 5% dextrose
are important sources of free water for maintenance, but should
be used with caution as excessive amounts may cause
dangerous hyponatraemia, especially in children and the elderly
• These solutions are not appropriate for resuscitation or
replacement therapy except in conditions of significant free
water deficit e.g diabetes insipidus
Fluid Management / Perioperative Care Dr Robin Correa FRCA
GIFTASUP
Recommendation 3 (Equal electrolytes by any route)
Evidence level 5
• To meet maintenance requirements, adult patients should receive
sodium 50-100 mmol/day, potassium 40-80 mmol/day in 1.5 - 2.5
litres of water by the oral, enteral or parenteral route (or a
combination of routes)
• Additional amounts should only be given to correct deficit or
continuing losses. Careful monitoring should be undertaken using
clinical examination, fluid balance charts, and regular weighing
when possible
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’" study
M. C. Bellamy Wet, dry or something else? Br. J. Anaesthesia 2006 97: 755-757
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Oesophageal Doppler
Fluid Management / Perioperative Care Dr Robin Correa FRCA
LiDCO Rapid
Fluid Management / Perioperative Care Dr Robin Correa FRCA
GIFTASUPPostoperative fluid management• Details of fluids administered must be clearly recorded and
easily accessible
• When patients leave theatre for the ward, HDU or ICU their volume status should be assessed
• In patients who are euvolaemic and haemodynamically stable a return to oral fluid administration should be achieved as soon as possible
• In patients requiring IV maintenance fluids, these should be sodium poor and of low enough volume until the patient has returned their sodium and fluid balance over the peri operative period to zero
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Scenario 1
80 yr old female for elective total hip arthroplasty
Scheduled last on PM list but starved from 1800 hrs
previous day
Start Hartmann’s 1 litre to run over 6 hours
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Scenario 2
50 yr old male on ward after elective hemi colectomy
6 hrs prior
Urine output 50 mls in the last 3 hours
Check vitals
Look for overt signs of bleeding
Fluid challenge 250 mls crystalloid or colloid
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Scenario 3
27 yr old postoperative lap appendicectomy. No overt
losses and patient looking well
Oral intake planned as sips of water next day
Maintenance fluid – aim for 1.5 – 2.5 L of water with
70 mmol of sodium and 40 - 80 mmol of potassium.
Hartmann’s / Dextrose saline with potassium chloride
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Scenario 4
60 yr old male AP resection 4 days ago.
Hypotensive but feels warm to touch, anuric for last
5 hours
Check vitals and temperature
Judicious fluid challenge
Seek senior help early
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Resources • Association of Surgeons of Great Britain and Ireland
http://www.asgbi.org.uk
• Intensive Care Society
http://www.ics.ac.uk
• NICE guideline (nutritional support)
http://www.nice.org.uk/Guidance/CG32
• Surgical Tutor
http://www.surgical-tutor.org.uk/default-home.htm?principles/postoperative/fluid_balance.htm~right
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Summary
• Fluids are distributed into various body
compartments according to their solute molecular weight and content
• Normal saline is abnormal
• Fluid type and volume must always be tailored to clinical condition
Fluid Management / Perioperative Care Dr Robin Correa FRCA
‘Every time I learn something new, it pushes some old stuff out of my brain’
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Perioperative Care
Preoperative Care- Assessment- Fluid optimisation and nutrition
Intraoperative Care- Antibiotic and thromboprophylaxis- Sterilisation, disinfection and antisepsis- Transport, positioning, scrubbing up, instruments, incisions,
closures, drains, stomas and sutures
Postoperative Care- Drain, fluid and acid – base management, pain, surgical
complications and critical care
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Assessment
• Objectives of preoperative assessment
• Preoperative assessment clinics
Infrastructure
Personnel
Process
Pathways and basic investigations
• Special investigations
CPX testing
Fluid Management / Perioperative Care Dr Robin Correa FRCA
CPX
Fluid Management / Perioperative Care Dr Robin Correa FRCA
CPX
Fluid Management / Perioperative Care Dr Robin Correa FRCA
CPX
Cardio- Pulmonary Exercise Testing (CPET or CPX)
• The anaerobic threshold (AT) is the uptake of oxygen (ml/kg/min) at the point when there is a surge in CO2 production during increasing workload
• This reflects maximum ability of patient to increase oxygen delivery / consumption and cardiopulmonary fitness
• AT > 11 ml/kg/min can be used to categorise patients ‘fit’ for major abdominal surgery
• Postoperative mortality can be predicted from AT values and
presence of test ECG ischaemia
Fluid Management / Perioperative Care Dr Robin Correa FRCA
CPX
Older, P et al Chest 1999;116:355-362
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Perioperative Care
Preoperative Care- Assessment- Fluid optimisation and nutrition
Intraoperative Care- Antibiotic and thromboprophylaxis- Sterilisation, disinfection and antisepsis- Transport, positioning, scrubbing up, instruments, incisions,
closures, drains, stomas and sutures
Postoperative Care- Drain, fluid and acid – base management, pain, surgical
complications and critical care
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Antibiotic prophylaxis
• Principles
• NICE guidelines
• Department of Health (DH) guidelines
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Antibiotic prophylaxis
Principles• High circulating serum levels of antibiotics at the time of tissue
contamination
• Usually of limited duration e.g. 24 hours post op
• Extended duration (3 days or more)
Immunosuppressed patients
Malnourished patients
Patients with prosthetic implants e.g. heart valves
Established postoperative surgical infections
Fluid Management / Perioperative Care Dr Robin Correa FRCA
NICE guidelines Surgical Site Infection
http://www.nice.org.uk/Guidance/CG74 October 2008
Antibiotic prophylaxis• Give antibiotic prophylaxis to patients before:
– clean surgery involving placing a prosthesis or implant
– clean-contaminated surgery
– contaminated surgery
• Do not give antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery
• Use the local antibiotic formulary and consider potential adverse effects when choosing antibiotics
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Antibiotic prophylaxis
Fluid Management / Perioperative Care Dr Robin Correa FRCA
DH guidelinesClostridium Difficile Infection (CDI) : How to deal with the problemhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_093220 January 2009
Restrictive antibiotic guidelines should be developed by trusts
stressing the following recommendations:• Use narrow-spectrum agents for empirical treatment where
appropriate
• Avoid use of clindamycin and second- and third-generation cephalosporins, especially in the elderly
• Minimise use of fluoroquinolones, carbapenems and prolonged courses of aminopenicillins
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Thromboprophylaxis
• Definitions
• Aetiology
• Methods
• NICE / DH guidelines
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Thromboprophylaxis
• DefinitionsVenous thromboembolism (VTE) is the formation of a blood clot (thrombus) in a vein which may dislodge from its site of origin to cause an embolismMost thrombi occur in the deep veins of the legs; this is called deep vein thrombosis (DVT)Dislodged thrombi may travel to the lungs; this is called a pulmonary embolism (PE)
• Aetiology Series of contributing factors called Virchow's triad - alterations in blood flow (stasis) - injury to the vascular endothelium
- alterations in the constitution of blood (hypercoagulability)
Fluid Management / Perioperative Care Dr Robin Correa FRCA
ThromboprophylaxisMethods• Mechanical devices
Graduated compression stockings, pneumatic compression devices
• Drugs acting on the clotting cascadeHeparin unfractionated or low molecular weight (LMWH) - activates antithrombin IIIDabigatran etexilate – direct inhibitor of thrombin
• Antiplatelet drugsAspirin, Dipyridamole, Clopidogrel
• Drugs indirectly affecting clot formationDextran 70
• General measures Early mobilisation, foot elevation, hydration
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Mechanical devices
Fluid Management / Perioperative Care Dr Robin Correa FRCA
NICE guidelines
Venous thromboembolism : reducing the risk
http://www.nice.org.uk/Guidance/CG92
January 2010
Fluid Management / Perioperative Care Dr Robin Correa FRCA
NICE guidelines
Care pathway Patient admitted to hospital
Assess VTE risk
Assess bleeding risk
Balance risks of VTE and bleeding. Offer VTE prophylaxis if appropriate.
Do not offer pharmacological VTE prophylaxis if patient has any risk factor
for bleeding and risk of bleeding outweighs risk of VTE
Reassess risks of VTE and bleeding within 24 hours of admission and whenever clinical situation changes.
Fluid Management / Perioperative Care Dr Robin Correa FRCA
DH guidelinesVenous thromboembolism (VTE) risk assessmenthttp://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_088215 March 2010
• All patients should be risk assessed on admission to hospital
• Any tick for thrombosis risk should prompt thromboprophylaxis according to NICE guidance.
• Patients should be reassessed within 24 hours of admission and whenever the clinical situation changes
• From 1st June 2010 all NHS Trusts are required to be able to demonstrate that more than 90% of their inpatients receive a Venous Thromboembolism Risk Assessment (VTE RA) on admission to hospital
Fluid Management / Perioperative Care Dr Robin Correa FRCA
Questions ?