Fluid Management

Tong Joo (TJ) Gan, MD, FRCA, FFARCS(I) Professor of Anesthesiology

Vice Chairman Clinical ResearchDuke University Medical Center

Durham, North Carolina

It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.

Dr. Gan has received grants/research support from Acacia, Baxter, Durect, Eisai, and NICOM. He has received honoraria from Baxter, Eisai, Fresenius, Hospira, and Xanodyne.

Faculty Disclosure

Educational Learning Objectives

• Describe the importance of improving time to gastrointestinal recovery that occurs postsurgery and consider how this affects length of hospital stay and overall quality of patient care

• Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures

• Describe how interprofessional collaboration surrounding gastrointestinal surgery can result in better alignment with current surgical quality measures and formulate strategies to integrate this into current practice

Patient Case

• 68-year-old female, 100 kg, admitted for partial open colectomy

• Past medical history– Known cardiac risk factors– Insulin-dependent diabetes mellitus– Hypertension – Vasculitis

• General anesthesia• Fentanyl 100 mcg and midazolam 2 mg

premedication• Celecoxib 400 mg • Induction with propofol• Intubated with succinylcholine• Muscle relaxation maintained with

cisatracurium

Patient Case – Anesthetic Plan

• Anesthesia maintained with sevoflurane, air and oxygen

• Continuous infusion of fentanyl 0.03 mcg/kg/min• Forced air warming using Bair Hugger®

temperature management system

Patient Case – Intraoperative Anesthesia

Potential Benefits of Cardiac Output and Stroke Volume Monitoring

• Monitor intraoperative dynamic hemodynamic parameters

• Optimize fluid status• Avoid long period of hypovolemia• Avoid excess fluid administration• Identify causes of low urine output

• Heart rate• Indirect blood pressure• Continuous ECG• Arterial line• 2–16 G peripheral intravenous catheters• Urinary catheter for measuring urine output• Continuous arterial wave cardiac output

(FloTrac system – flow-based hemodynamic monitoring)

Patient Case – Intraoperative Monitoring

• 500 mL fluid bolus in the preop holding area to rehydrate following bowel prep

• Continuous infusion of lactated Ringer’s solution at 4 ml/kg/h

• Goal directed fluid management using A-line minimally invasive cardiac output monitoring to target stroke volume variation (SVV) < 13%

Patient Case – Fluid Management

• Colloid– Voluven® administered at 250 mL aliquots to keep

stroke volume variation < 13% Variety of hydroxyethyl starch Newer generation with lower molecular weight (eg,

Voluven®) associated with less coagulation disturbances

– Continuous cardiac output monitoring with FloTrac system

Patient Case – Fluid Management

Pharmacology of Starch

Classification Molecular Weight (kDal)

Degree of Substitution

Examples

High MW > 450 0.7 Hespan™ Hextend™

Medium MW200–280 0.5 Elo-HAES™

HAES-steril™

Pentalyte™

Low MW 70–130 0.4 Voluven®

Westphal M, et al. Anesthesiol. 2009;111:187-202.Boldt J, Suttner S. Minerva Anesthesiol. 2005;71:741-758.

• Patient received 5 boluses of Voluven® 250 mL each when SVV > 13%

• Urine output averaged 50 mL/hr• BP maintained within 130/75 mm Hg, HR 83/min• Bispectral index between 50-60 to maintain

adequate levels of anesthesia

Patient Case – Fluid Management

SVV: stroke volume variation

SVV = 17

SVV = 8

SVV = 16

SVV = 12

SVV = 15

SVV = 8

250 mL Voluven® fluid challenge

Does perioperative goal-directed fluid therapy impact postoperative bowel function

or length of stay?

Perioperative Goal-directed Therapy

Goal-directed Fluid Therapy (GDT) – FloTrac-driven Goals

• Single center, prospective, randomized trial• 60 high-risk patients for major abdominal surgery• Control group (standard management)

– MAP between 65–90 mm Hg– CVP between 8–12 mm Hg– Urine output > 0.5 mL/kg/h

• GDT group (cardiac index-based intraoperative optimization protocol)– Cardiac index > 2.5 L/min/m2 using FloTrac monitor

• Primary outcome: length of stay (LOS)

Mayer J, et al. Critical Care. 2010;14:R18.

Goal-directed Fluid Therapy With FloTrac Stroke Volume Variation

StandardN = 30

GDTN = 30

P value

LOS (Days) 19(14-23.5)

15 (12-17.75)

0.006

Complications 15 (50%) 6 (20%) 0.03

Dobutamine (mcg/kg/h)

4.1 ±19 30.4 ± 50.5 0.01

Colloid (mL) 817 ±467 1188 ±550 0.006

Mayer J, et al. Critical Care. 2010;14:R18.

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

Goal-directed Fluid Management

*median (interquartile range)‡Mann-Whitney U test/Χ2 test/Fisher’s exact test†Mean (standard deviation)

Goal-directed Fluid Therapy

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

Goal-directed Fluid Therapy

• Numerous studies have demonstrated goal-directed fluid therapy improves bowel function and shortens hospital length of stay

• Recent meta-analyses demonstrated goal- directed fluid therapy reduces

major and minor gastrointestinal dysfunction

Goal-directed Fluid Therapy

Giglio MT, et al. Br J Anaesth. 2009;103:637-646.

Goal-directed Fluid Therapy Meta-analysis of Randomized Controlled Trials

Giglio MT, et al. Br J Anaesth. 2009;103:637-646.

Goal-directed Fluid Therapy Meta-analysis of Randomized Controlled Trials

Hospital Length of Stay

Complications

Abbas SM, et al. Anaesthesia. 2008;63:44-51.

Goal-directed Fluid Therapy Systematic Review

Goal-directed Fluid TherapyLength of Stay

WMD -2.94 (-4.22, -1.66) P < 0.00001

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

Does excess crystalloid administration improve postoperative bowel recovery?

Fluid Management – Crystalloids

Volume of Crystalloids and Weight Gain

Chappell D, et al. Anesthesiology. 2008;109:723-740.

Colloids vs CrystalloidsPatients Undergoing Major Elective Noncardiac Surgery

% of patients *P < 0.05

*

**

Moretti E, et al. Anesth Analg. 2003;96:611-617. LR: lactated Ringer’s solution

0

10

20

30

40

50

60

70

80

Nausea Vomiting Antiemetic

Hetastarch/LR

LR

n = 10

IV Fluid and Salt Restriction

• MOA: salt/water restriction improves canine gastric emptying time

• Lobo compared standard (≥ 3L/D fluids; 154 mmol Na+) with restricted (≤ 2L/D fluids; 77 mmol Na+) protocols after open hemicolectomy

• Significantly more complications in standard treatment group

Solid lines are medians, shaded areas IQRs, and whiskers extreme values

Differences between medians for solid and liquid phase T50 were

56 min (95% CI: 12-132)

and

52 min (95% CI: 9-95),

250

200

150

100

50

0

n = 10

P = 0.028

Standard group Restricted group

Solid Phase Gastric Emptying Time(T50 min)

200

150

100

50

0

n = 10n = 10

P = 0.017

Standard group Restricted group

Liquid Phase Gastric Emptying Time(T50 min)

Lobo DN, et al. Lancet. 2002;359:1812-1818.

MOA = mechanism of action

IV Fluid and Salt Restriction

StandardSalt and

Fluid Restriction

P value

Flatus 4 3 0.001

Stool 6.5 4 0.001

Length of Stay 9 6 0.001

Complications 7 1 0.01

Lobo DN, et al. Lancet. 2002;359:1812-1818.

Positive salt and water balance causing a weight gain of 3 kg following elective colonic resection is associated with delayed recovery of GI function, increased complication rate, and increased length of stay.

• Elective intraabdominal surgery• Crystalloid: lactated ringers• Randomized into 2 groups

– Liberal fluid regimen: 10 ml/kg and 12 ml/kg/h– Restricted regimen: 4 ml/kg/h

• Primary outcome: death or complications

Liberal Group Restrictive Group

Intraoperative volume received (mL)

3878 ± 1170 1408 ± 946*

Patients with complications

31% 17%**

Time to bowel movement (days)

6 (4-9) 4 (3-9)*

Hospital stay (days)

9 (7-24) 8 (6-21)†

*P < 0.001; **P < 0.05; †P = 0.01

• Excess crystalloid (in particular excess salt and water) administration has been associated with weight gain and postoperative bowel dysfunction. Delay in bowel recovery translates into delay in hospital discharge

Fluid Management – Crystalloids

Patient Case – Hospital Course

• Patient’s pain was well-controlled with PCA fentanyl

• Postoperative Day 3: patient tolerating semi solid, NG tube removed; PCA discontinued, patient treated with ibuprofen and Vicodin® PRN

• Postoperative Day 4: advanced to solid diet, tolerated well, full bowel function established, started ambulation

• Postoperative Day 5: hospital discharge

Summary

• Fluid management plays an important role in the postoperative outcome and bowel function

• Goal-directed fluid administration promotes earlier bowel function and shorten length of stay

• Avoiding crystalloid excess is associated with earlier return to bowel function