GOAL DIRECTED PERIOPERATIVE FLUID MANAGEMENT

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GOAL DIRECTED PERIOPERATIVE FLUID MANAGEMENT
DOES KIND OF FLUID MATTER?

• DR.N.KANAGARAJAN
• SENIOR CONSULTANT
• DEPT OF CARDIAC ANESTHESIA
• ICVD, MADRAS MEDICAL MISSION HOSPITAL
• CHENNAI.

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• INTRODUCTION
• Perioperative fluid therapy -
• Much controversy / Effects on the outcome
  inconclusive
• Intravenous fluid resuscitation
• (a) fluid and electrolytes required for normal
  existence (daily maintenance) and
• (b) resuscitation or replacement of abnormal
  losses.
• The Recipe Book approach

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• Callum KG et al (1999)
• Errors in fluid management (usually fluid
  excess) were the most common cause of
  perioperative morbidity and mortality
• (National Confidential Enquiry into
  Perioperative Deaths)

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• 1.PREOPERATIVE FLUID DEFICIT
• 2.Insensible loss
• 3.Volume and electrolytes lost through body
  secretions
• 4.BLOOD LOSS

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• MONITORING
•  a)Cardiac filling pressures
• CVP / PAOP or Wedge pressure.
• b)Static Volumetric variables
• i)Left ventricular end-diastolic volume(LVEDV)
• ii)Global end-diastolic volume(GEDV)
• c)Dynamic variable
• Stroke Volume Variation(SVV).
• Cardiac output MVO2.

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BODY FLUID COMPARTMENTS
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RECOMMENDED APPROACH TO PERIOPERATIVE FLUID
MANAGEMENT
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a) Crystalloid Solutions
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VOLUME EFFECT OF CRYSTALLOIDS
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• b) Colloid Solutions
• Has an oncotic pressure similar to that of
  plasma.
• Remain within the intravascular space for a
  relatively long time

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Why do we need colloids?
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B. COLLOIDS
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ALBUMIN

• There is no evidence to support routine
  administration of albumin in hypovolemic states.
• Albumin administration may be beneficial in
  certain groups of critically ill patients.
• Least Effective colloid

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• DEXTRANS

6 dextran 70 10 dextran 40
Mean molecular weight (Dalton). 70,000 40,000
Volume effect (hours)(Approx.). 5 3-4
Volume efficacy()(Approx.). 100 175-(200)
Maximum daily dose(g/kg). 1.5 1.5
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• GELATINS

Urea-cross-linked Gelatin. Cross linked Gelatin Succinylated Gelatin
Concentration () 3.5 5.5 4.0
Mean molecular weight(Dalton) 35000 30000 30000
Volume effect(hours)(approx) 1-3 1-3 1-3
Volume efficacy()(approx.) 80 80 80
Osmolarity 301 206 274
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HYDROXYETHYL STARCHES
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Importance of physicochemical characteristics
Degree of hydroxyethylation Duration of volume effect
Concentration Initial values of volume effect
Substitution pattern Serum kinetics
C2/C6 RATIO Intravascular half life
Molecular weight Volume half life
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CONCENTRATION AND SOLVENT MEAN MOLECULAR WEIGHT MOLAR SUBSTITUTION C2/C6 RATIO MAXIMUM DAILY DOSE ml/kg
HES 450/0.7 6 SALINE 480 0.7 51 20
HES 200/0.5 6 SALINE 10 SALINE 200 0.5 51 33 20
HES 130/0.42 6 SALINE 130 0.42 61 50
HES 130/0.4 6 SALINE 10 SALINE 130 0.4 91 50 33
HES 130/0.4 6BALANCED SOLUTIONS 130 0.4 91 50
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THIRD GENERATION HES 130/0.4
COAGULATION
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(Anesth Analg 200810738290)
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• Conclusion
• Blood loss and transfusion requirements can be
  significantly reduced in patients undergoing
  major surgery when using third generation HES
  130/0.4 (Voluven) compared to second generation
  starch HES 200/0.5.
• HES130/0.4 and HES 200/0.5 similar regarding
  volume efficacy in other studies,
• HES 130/0.4 should be preferred to less rapidly
  metabolizable HES solutions in prevention and
  treatment of perioperative hypovolemia,
  especially if large volumes are required.

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Conclusion Voluven (HES 130/0.4) and
hetastarch are equally efficacious plasma volume
substitutes however, HES 130/0.4 has a lesser
effect on coagulation.
(Anesthesiology 20071061120-7)
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• Accumulation and Tissue storage
• Tetrastarches - Less tissue accumulation and
  even in high doses pruritus is a not a clinical
  problem
• Effect on Plasma bilirubin
• Potato-derived HES 130/0.42 are the only tetra
  starch to be absolutely contraindicated in
  patients with severe hepatic impairment.

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KIDNEYS
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ConclusionThe administration of HES had no
influence on renal function or need for RRT
B
J Anaesth 2007,9821624
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Critical Care 2010, 14R40
Conclusions Volume expansion with low volume HES
130 kDa/0.4 was not associated with AKI.
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• Godet G et al
• Safety of HES 130/0.4 (Voluven) in patients
  with preoperative renal dysfunction undergoing
  abdominal aortic surgery a prospective,
  randomized, controlled, parallel-group
  multicentre trial.
• Euro J Anaesthesiol
  (2008), 25986-994.
• Sixty-five patients were randomly allocated to
  receive either 6 hydroxyethyl starch (Voluven
  n 32) or 3 gelatin (Plasmion n 33) for
  perioperative volume substitution. At baseline,
  renal function was impaired in all study patients

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• CONCLUSION
• The choice of the colloid had no impact on renal
  safety parameters and outcome in patients with
  decreased renal function undergoing elective
  abdominal aortic surgery.

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• Special patient groups
• The waxy maize-derived tetra starch HES 130/0.4
  has a well-documented safety profile in elderly
  patients.
• Waxy maize-derived HES 130/0.4 is the only third
  generation HES with controlled clinical data in
  children.

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BOLDT J et al(2008)
Prospective,randomised study 50 patients aged 80
years-cardiac surgery using CPB Preop Serum
albumin 3.5 mg/dL received either 5 Human
Albumin or 6 HES 130/0.4

(Anesth Analg 1071496 1503)
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ConclusionIn patients aged 80 yr showing
hypoproteinemia before surgery, a HA-based
intravascular volume replacement strategy was
without benefit compared to 6 HES 130/0.4 with
regard to inflammatory response, endothelial
activation and kidney function.
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• SÜMPELMANN R et al
• Hydroxyethyl starch 130/0.42/61 for
  perioperative plasma volume replacement in
  children preliminary results of a European
  prospective multicenter observational
  postauthorization safety study (PASS)
• (Paediatric
  Anaesth 200818929-33)
• 316 patients (Day of birth 12 years)
• All types of surgery including cardiac surgery
• The mean volume of infused HES 130/0.42 was
  11  4.8 mlkg-1 (range, 542)

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• CONCLUSION
• Moderate doses of HES 130/0.42 help to maintain
  cardiovascular stability and lead to only
  moderate changes in hemoglobin concentration and
  acidbase balance in children.
• The probability of serious ADRs is lower than 1.
• HES 130/0.42 for PVE seems to be safe and
  effective even in neonates and small infants with
  normal renal function and coagulation.

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• Effect on microcirculation and Oxygenation
• Third generation HES 130/0.4 has positive effects
  on tissue oxygenation and microcirculation in
  patients undergoing major abdominal surgery.
• Improved micro perfusion and reduced endothelial
  swelling.

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(Kimberger O et al Anesthesiology 2009)
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(Anesth Analg 200396936-943)
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EFFECT ON SYSTEMIC INFLAMMATION AND ENDOTHELIAL
ACTIVATION
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• CONCLUSIONS.
• In cardiac surgery patients aged 80 years, volume
  therapy with HES 130/0.4 6 was associated with
  less marked changes in kidney function and a less
  marked endothelial inflammatory response than
  gelatin 4.
• (Br J Anaesth 2008 100 45764)

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Boldt J et al. Br J Anaesth 2008 100 45764
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CARRIER SOLUTIONS
Typically occurs only after the infusion of more
than 3 l of normal saline
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BALANCED SOLUTIONS
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• In a study involving 81 patients undergoing
  elective valve surgery or coronary artery bypass
  grafting, the waxy maize-derived tetra starch HES
  130/0.4 was compared in two forms, either in a
  saline solution (Voluven) or in a balanced
  solution (Volulyte).
• The authors concluded that it is probably
  unnecessary to use balanced solutions if only
  moderate infusions are required, whereas balanced
  colloids can be used to reduce chloride load when
  large volumes are required.

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•  

GOAL DIRECTED FLUID ADMINISTRATION DOES
PERIOPERATIVE FLUID BALANCE (TYPE)
INFLUENCES POSTOPERATIVE OUTCOME?
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Conclusion Optimization of perioperative fluid
management may include a combination of fixed
crystalloid administration to replace
extravascular losses and avoiding fluid excess,
together with individualized goal-directed
colloid administration to maintain a maximal
stroke volume.
Acta Anesthesiol Scand 200953843-851
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Critical Care 2009, 13R40
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SUMMARY AND CONCLUSIONS
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• SUMMARY AND CONCLUSIONS
• The goal is to maintain the effective circulatory
  volume while avoiding interstitial fluid overload
  whenever possible.
• Weight gain in elective surgical patients should
  be minimized in an attempt to achieve a zero
  fluid balance status.
• Third generation HES (waxy maize starch- HES
  130/0.4) are suitable to achieve this goal.

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