Fluids

Jim Down

UCLH

Definitely worth getting to the top of the curve

Study mortality: 12.1% (0–32.4%)

Mortality

Post Hoc: Hospital Mortality

Duration of Hospital Stay

Renal Impairment

Grocott et al. Br J Anaesth. 2013 May 9. [Epub ahead of print]

“It is unlikely that the intervention causes harm. The balance of current evidence does …suggest that complications and duration of hospital stay are reduced.”

Recommendations

CardioQ-ODM

oesophageal doppler

monitor

• Recommendations

– The case for adopting the CardioQ-ODM in the NHS…– is supported by the evidence.

– There is a reduction in post-operative complications, use of central venous catheters and in-hospital stay (with no increase in the rate of re-admission or repeat surgery) compared with conventional clinical assessment with or without invasive cardiovascular monitoring.

– The cost saving per patient, when the CardioQ-ODM is used instead of a central venous catheter in the peri-operative period, is about £1100 based on a 7.5-day hospital stay.

– The CardioQ-ODM should be considered for use in patients undergoing major or high-risk surgery or other surgical patients in whom a clinician would consider using invasive cardiovascular monitoring.

Times to RfD and LOS were longer in GDT but did not reach statistical significance (median 6.8 vs 4.9 days 8.8 vs 6.7days).

Fit GDT patients had an increased RfD and LOS (median 7.0 vs 4.7 and 8.8 vs 6.0 days)

Despite SV higher in treatment arm

• The problem……

• 4010 vs 5306

• plus 1 litre pre-op

•

• Conway 4.2 L versus 5 litres (55 vs 64 mls/kg)

• Gan 4.4 L versus 5.4 L

• Wakeling 4.5L vs 5L (plus 1-2 litres pre – op)

• Noblett 3.8 vs 3.6 L … blood loss 50

True

• 2017

• 200 patients pre and post GDT.

• No difference mortality, morbidity LOS.

• SOC 2.6 L intra – op, vs GDT 2L (colloid reverse)

Recent studies.

Lidco

What about Sepsis:

New EGDT

• /

84,722 Colon surgery patients from 499 USA Centers

Median 3.1L < 1.7L >5.0L

%*

*

Thacker KM et al. (2014)

Convection

Diffusion

So what’s actually going on when someone comes for a major

operation?

Br J Anaesth. 2015 Jan 13. pii: aeu452. [Epub ahead of print]

Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis.

Lilot M, Ehrenfeld JM, Lee C, Harrington B, Cannesson M, Rinehart J.

“Individual providers ranged from 2.3 (sd 3.7) to 14 (sd 10) ml kg-1 h-1.

The final regression model strongly favouredpersonnel as predictors over other patient predictors.”

“a patient weighing 75 kg undergoing a 4 hprocedure with minimal blood loss could receive anything between 700 and 5400 ml of crystalloid during surgery, depending on their anaesthesiaprovider.”

Enhanced Recovery – Fluid management

✓ CHO pre-load drinks

✓ Clear fluids to 2hr pre-op

✓ Avoid crystalloid XS (esp. saline). ‘ Maintenance’ = 1-3 mlkg /h

✓ Individualized Goal Directed Fluid Therapy

✓ Minimum amount of fluid required to maintain homeostasis

✓ and central euvolaemia

✓ Immediate post op. drinking and eating

✓ i.v. down

✓ Mobilized

FEDORA

• 450 patients• Combination of SV, CI, MAP vs 5-7 mls/kg/hr• Fluids

– Intra-operative 1980 mls vs 1940 mls– Post op 1800 vs 1020 mls

• Complications 8.6% vs 16%, LOS lower– (only GI, only laparoscopic, AKI, ARDS, Pulm oedema,

pneumonia, deep site infection).

• Mortality unchanged.

• High risk elective abdominal surgery – >2 hrs

• 1 Yr disability free survival– AKI, RRT

– Septic complications

– Lactate, CRP peak, blood transfusion.

– ICU and Hosp LOS, unplanned ICU admission

Fluid regimes.

• Liberal

• Hartmans

• 10 ml/kg bolus

• 8 mls/kg/hr Intra op.

• ?Drop after 4 hrs

• 1.5 mls/kg/hr, 24 Post op

– Drop if overload

– Increase hypovol or BP

• Restrictive.

• ? Hartmans

• < 5 mls/Kg bolus

– (more if doppler indicated)

• 5mls/Kg/ hr Intra op

• 0.8mls/Kg /hr, 24 Post op

– Drop if overload

– Increase hypovol

– Pressors for BP.

Replace blood with colloids, Oliguria ignored.

Results

• 2983 patients

• 6.5 mls/kg/hr vs 10.9 mls/kg/hr intra-op

• 0.9 mls/kg/hr vs 1.5mls/kg/hr post op

• 4200mls 24 hrs vs 6600 mls 24 hrs

• Primary outcome no difference. (81.9% v 82.3%)

• AKI 8.6% vs 5.0% (P < 0.001)

• RRT 0.9% vs 0.3% (P = 0.048)

Conclusion of Paul Myles

• 10mls/kg Hartman’s bolus at induction

• 8mls/kg/hr intra-op (slowing after 4 hrs)

• 1.5mls/kg/hr for 24 hrs

• 3 hr case - 3 litres plus, 3 litres post op.

• Clinical skills on top.

2500 patients

8000 patients

Thank you