Early Recovery after Surgery Fluid Management

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Early Recovery after Surgery Fluid Management
Dr Chris SnowdenConsultant Anaesthetist Freeman
HospitalNewcastle upon Tyne
AAA Newcastle May 2008
5/30/2008
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Colorectal Surgery ERAS Model

• Lower Abdominal surgery stress, pain relief
• Amenable to Minimal Invasive techniques
• Operative mortality lt5 - Improving ward
  management (rather than ITU)

Pearse et al, Crit Care 2006 10 R81.
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Elderly and ERAS

• Counterintuitive ?
• Colorectal Population
• 70 patients gt 65 yrs
• 2.5x Cancer risk (Age gt 80yrs)
• More to Gain ?

4
Age and Long Term Outcome
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but postoperative complications predict early
outcome

• 517 surgical pts Age gt 70 yrs
• Postoperative Renal (6.07), pulmonary (2.41)
  complications
• Malignancy Hx (2.40), ASA gtII (2.27), Neuro
  disease (1.59), Age (1.42)

Manku K Anes Analg 200396 583-9
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Major Complications in the Elderly
4315 pts Age gt 50 years
Polanczyk et al Ann Int Med 2001134 637-643
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POMS score
8
Minor Complications
Incidence complications
Complication
POMS (5 days)
POMS (8 days)
GI disturbance
55
51
Renal disturbance
26
21
Pain
23
22
Respiratory complication
17
25
Neurological
14
10
Infection Signs/Proven
12
13
Cardiovascular
9
9
Haematological
8
16
Wound Complication
3
12
Bennett-Guerrero et al Anesth Anlag 1999 89 514-9
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Enhancing Recovery
Extended Recovery
Minor Complications
Preop
Recovery
Surgery
Risk Assess Preop
Surgery
Surgery
Enhanced Recovery
Improved Care
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Improvements ?

• France
• 1421 pts Prospective
• 3.5 Mortality 35 Morbidity
• (Arch Surg 2005, 140, 3, 278-83)
• Copenhagen
• Mortality 3.3 (2/60)
• Serious complications (surgical, dehiscence,
  death) 8.3 (5/60)
• No Cardiopulmonary complications
• ? Readmissions (reduced to 20 to 11)
• (BJS 1999 Kehlet H BJS 2007 Anderson J)

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Enhanced Recovery Uptake

• Surgical Issues NESA Survey (Dr Pearson)
• Limited bowel prep 75
• Thromboprophylaxis 97
• No NG tube in-situ 74
• Early oral feed 78
• Early mobilisation 64
• Reviewing Existing Techniques
• Temperature regulation 100
• Pain management 100
• PONV prophylaxis 96
• Rapid Acting Drugs ?
• Uptake of new Techniques
• Anaesthetic-led preassessment 96 (4)
• Fluid optimisation 30

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Fluid Status and Elderly
Fluid Excess
Fluid Depletion
Elderly

• Reduced GFR
• Reduced Na/H2O and free water excretion
• ADH resistance

Reduced thirst mechanisms Self imposed
Abnormal ANP/aldosterone balance
Surgery
IV fluids Reduced clearance
Dehydration Anxiety, Temp Epidural
Outcome
Extracellular Oedema GI tract, pulmonary
Reduced blood volume and cardiac output Vital
Organ Diversion
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Dont Give IV fluids ?
Fluid
York Stone et al 2003
Worthing Wakeling et al 2005
Newcastle Noblett et al 2005
Overall colloid
2000 (1000-3000)
1500 (0-4000)
1000 (1000)
Blood Loss
700 (300-1300)
500 (975)
315 (713)
Crystalloid
2000 (1000-3000)
3000 (1187)
2500 (1000)
Overall Fluids
4000
4500
4000 (1500)
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Perioperative Fluid Restriction?

• RCT of the effect of postoperative intravenous
  fluid
• restriction on recovery after elective colorectal
  surgery
• (MacKay G et al BJS 2006 93 12 1469-74)
• 80 pts
• ASA 1-III Elective Colorectal surgery
• Restrictive vs Standard
• Regime
• 2 l water and 77mmol Na vs 3 l water and 154 mmol
  Na)
• Based on mls/kg
• Conclusions

• Effects of intravenous fluid restriction on
• postoperative complications comparison of two
• perioperative fluid regimens a randomized
  assessor-
• blinded multicenter trial.
• (Brandstrup et al Ann Surg. 2003 238649-50)
• 172 patients
• ASA I-III Elective Colorectal Surgery
• Restricted vs Standard
• Regime
• Intraop Complex (colloid vs crystalloid),
• (HES replacement vs predetermined crystalloid
  based on wt and duration of operation)
• Postop up to 2000 mls crytalloid vs colloid and
  glucose based on wt gain, Frusemide
• Conclusions
• Reduces overall complications
• Reduces Tissue healing
• Reduces Cardiopulmonary complications

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Liberal or restrictive fluid administration in
fast-track surgery RCT

• 32 Pts
• ASA I-III
• Mean Age 75yrs
• ERAS setting
• Crystalloid restriction
• Outcome measures
• Pulmonary function
• Exercise Capacity
• Hormonal response
• Overall complications
• Hospital stay

Holte K et al BJA 2007 (99) 4 500-8
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Results

• Total Fluid 1640 vs 5050 mls
• Minor improvements in postop FEV1/FVC in
  restricted group
• But
• Less overall complications in liberal group
• Reduced stress hormone response in liberal group
• Reduced LOS (including readmission time) in
  liberal group

Conclusion
Holte K et al BJA 2007 (99) 4 500-8
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Individualise Fluid Therapy
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Reducing Fluid-Induced Morbidity
Morbidity
Morbidity
Volume
Volume
Bellamy 2006 BJA 97 (6) 755-7
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Preoptimisation
The treatment groups, however, received an
average of 1500 ml of additional fluid.
Because of the low doses of inotropes used in our
study, we suggest that fluid optimisation is the
major contributor to improved oxygen delivery in
our patients.
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Correct Goals ?

• VO2 gt 170 ml/min/m2 DO2 gt 600 ml/min/m2
• Proportions of protocol patients (elective
  surgery) requiring fluid alone to achieve goals)
• Lobo et al 10 (elective only, avg. age 63)
• Wilson et al 35 (elective only, avg. age 71)

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ERAS and Fluids

• (1) Encourage homeostatic mechanisms
• Careful DOSA normal routines
• No prolonged preoperative starvation
• Preop Carbohydrate drinks
• Avoid use of preoperative IV fluids
• Encourage early postoperative oral intake
• Prevent PONV
• Avoid NG tubes
• Unrestrictive urine monitoring
• Mobilisation

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ERAS and Fluids (2) Intraoperative
Goal-Directed Fluid Therapy
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GDT Therapy

• Aim To optimise intravascular volume to ensure
  adequate tissue perfusion
• Measure relevant surrogate markers of
  intravascular volume
• Set goals for these markers relevant to
  individual
• Use fluid therapy to efficiently reach goals
• Continue therapy to maintain goals
• Perform this consistently with protocols
• Monitor relevant outcomes

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Non Invasive Goals
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BJA 2006
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Maintain the Goals
Optimisation Zone
Duration of Operation
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Consistency through Protocols
SV Increased by gt 10
FTc lt350ms
No
Yes
No
Yes
Colloid Challenge 7ml/kg First Bolus 3ml/kg
Subsequent Bolus
Colloid Challenge 3ml/kg
Yes
SV Increased by gt 10
FTc lt350ms
Yes
No
No
Monitor Ftc and SV
FTc lt350ms or SV Decrease gt10
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In Practice

• 108 Colorectal Pts
• RCT
• Double Blinded
• Age mean 65 yrs
• ASA 1-3
• APR, Anterior resection, Colectomy, Laparoscopic
• Op Duration mean 155 mins

Consecutive Patients
Major Colorectal Procedure
Doppler Insertion
R
Standard Fluid Management
Standard Fluid Management Colloid
Supplementation (Protocolised)
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Protocol Results
Intervention
Control
Protocol maintained significantly higher mean FTc
in the fluid supplementation group p 0.001
summary measures
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Hypovolaemia Prevention
Operation time spent with FTC gt 350ms
Intervention group retained at FTC gt 350ms for
significantly higher overall of operative time
than control group (82 vs 59 p gt0.001)
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Timing of Fluid Bolus

• 81 protocol driven boluses given
• 68 of pts in intervention group
• Majority boluses given in first hour
• Continual attention throughout

• More vasoconstrictor use in control group

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Haemodynamic Effect

• No difference at start of procedure
• Differences in values at end of procedure between
  groups (Ftc, SVI)
• Difference in overall change in CI between groups

Control
Intervention
FTc Start End
362.0 (7.6) 356.0 (8.2)
373.4 (8.2) 385.9 (5.3)
SVI Start End
45.8 (2.4) 43.3 (2.5)
46.1 (2.0) 50.8 (2.1)
CI Start End
3.1 (0.2) 3.2 (0.2)
3.2 (0.2) 3.9 (0.2)
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Effect of Optimisation

• Benefits by ensuring not hypovolaemic (Ftc gt350)
  in both groups
• 16 vs 7 increase in CI at any given time by
  directing SV
• Benefits multiplied by staying 20 longer above
  this zone

Cardiac Index
CI ( above baseline) - Median IQ range
FTC
Control
Fluid
gt 350ms i.e. No hypovolamia)
7 (0.40)
16 (0.40)
lt 350ms i.e. Hypovolaemia
-2 (0.34)
0 (0.39)
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Improved Morbidity
Control
Fluid
Sig
POSSUM Predicted Morbidity
44.6 (11-90)
40.7 (9-88)
NA
Actual Morbidity
43 23/53 30-58
22 12/54 12-26
0.03
Control
Fluid
Sig

• HDU use
• Unplanned (count)

8/53 (15)
0/54 (0)
0.004

• Planned (hrs)

24 (34)
24 (14)
NS
Death
1
0
NS
Noblett et al BJS 2005
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Overall hospital stay/Fit for Discharge
1.0
GROUP
Control
0.8
Fluid
of patients in hospital
0.6
of patients in Hospital
0.4
0.2
0.0
Stay (days)
0
10
20
30
40
50
Stay (days)
9.5 (7,11) days vs 7 (6,8) days p0.0004)
9 (7,11) days vs 6 (5,7) days p0.0003
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New Questions ?
Study
Regime
Benefits
Patients and ops
Fluid type
Protocols Goals
Fluid Amount
Mythen 1995
Protocol vs standard
LOS
cardiac
Colloid (HES)
SV
more
Sinclair 1997
Protocol vs standard
LOS
NOF
Colloid (HES)
FTC/SV
more
Venn 2002
Protocol vs standard
Fit for discharge
NOF
Colloid (Gelo)
FTC/SV/bolus
more
Gan 2002
Protocol vs intervention
LOS, diet
Surgical
Colloid (HES/RL)
FTC/SV
more
Conway 2002
Protocol vs standard
ITU need
colorectal
Colloid (HES)
FTC/SV
same
Wakeling 2005
Protocol vs standard
LOS, diet
colorectal
Colloid
CVP/SV
more
Noblett 2006
Protocol vs standard
LOS, morbidity, diet
colorectal
Colloid (Gelo)
FTC/SV
same
? Multiple populations
? Which
? Which ones, how quickly, what goals
? Amount Bolus/infuse
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Fluid Load or Targeted Volume expansion
Fluid
Control
Intervention
Sig
Intraop
Colloid from anaesthetist
1000 (3000)
1000 (2500)
lt0.05
Colloid from protocol
0
480 (780)
Overall colloid
1000 (1000)
1000 (1060)
NS
Overall colloid (Total/min operating )
7.46 (0.71)
9.32 (0.70)
NS
Blood Loss
315 (713)
580(700)
NS
Blood given
0 (0-200)
0 (0-250)
NS
Crystalloid
2500 (1000)
2000 (1500)
NS
Overall Fluids
4000 (1500)
3500(1700)
NS
Overall (Total/min operating)
24.1 (6.9)
25.6 (8.2)
NS
Postop
Overall (4 days)
9310 (5357)
8936 (5375)
NS
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Colloid vs CrystalloidSummary

• Normal saline is not normal!
• Colloids are more efficient at resuscitating the
  intravascular space
• Colloids increase COP and may reduce oedema
• Colloids improve microcirculatory flow and are
  more anti- than pro-coagulant
• Colloid usage is associated with less morbidity
  following major surgery
• Balanced Colloids may be the way forward

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Summary

• Elderly
• Postoperative complications have impact on early
  outcome
• Predilection to postoperative complications
• Fluid and ward challenged - Most to gain
• Fluid management is an important component of
  ERAS pathways
• Complex regimes
• Promote normal homeostasis
• GDFT
• Advances in flow monitors, protocols, fluid
  pathophysiology
• Individualised therapy
• Positive influence on enhanced recovery outcomes
• Unanswered questions
• Duration ?
• Mechanisms ?
• Select groups ?

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Goal Direction

• It is easy to confuse goals with tasks.
• the doctor, whose goal it is to keep you
  healthy, spends all of her time and energy curing
  your illness