pathophysiology and clinical implications of perioperative fluid management in elective

surgery

acknowledgements Dpt of Surgical Gastroenterology, Hvidovre University HospitalHenrik Kehlet, MD, DMSc, Professor ( now: Section of Surgical Pathophysiology, Rigshospitalet )Jens Andersen and all doctors working in the colorectal section and with outpatient patients Research nurses: Lotte Valentiner, Birthe Klarskov and Dorthe Hjort JakobsenNurses colorectal section 6-7 and 5-day unit Dpt of Anaesthesia, Hvidovre University HospitalClaus Lund, MD, DMSc, Nicolai Foss, MD, Billy Kristensen, MD, Lisbet Ravn, MD, Dorthe Stig Christensen, MDAnaesthesia nurses and doctors in the operating theatre and postoperative recovery Dpt of Clinical Physiology and Nuclear Medicine, Hvidovre HospitalJan Lysgård Madsen, MD, DMScLaboratory technicians: Ingelise Siegumfeld and Bente Pedersen 

Dpt of Orthopedic Surgery, Hvidovre University HospitalHenrik Husted, MDNurses at the alloplasty section Christer Svensén, MD, PhD Söder Sjukhuset, Karolinska Institute, StockholmRobert Hahn, MD, PhD Professor, Department of Anesthesiology, South Hospital, Stockholm, SwedenPeter Bie, MD, DMSc Department of Physiology and Pharmacology, University of Southern Denmark, Odense, Denmark. Peter Jensen, Kristine Grubbe Nielsen, Kasper G Bertelsen, Stinus Hansen, Tine Borup (former medical students)

Funding:University of Copenhagen (3-year)Danish Research CouncilHvidovre University HospitalDpt of Gastroenterology, Hvidovre University Hospital via the foundation for laparoscopic surgerySlagelse Sygehus

the main issues

which fluid? how much fluid?

how to measure

it?which surgical

procedure?

does it affect outcome?

examples of fluid administration in colonic surgery

0

4000

8000

12000

1940 1960 1980 2001

Infu

sion

vol

ume

(ml)

Holte, Sharrock and Kehlet, Br J Anaesth 2002; 89: 622

or

perioperative fluid excess may

be detrimental due to increased

functional demands of several

organ systems

main hypothesis

healthy volunteers+/- fluiddescribe effects of fluid infusions per se

prospective descriptive clinical studiesdescribe perioperative factors of importance for fluid management

randomized clinical studies+/- fluideffects on organ functions after intermediate and major surgery

1. Physiologic effects of intravenous fluid administration in healthy volunteers. Anesth Analg 2003

2. Liberal vs. restrictive fluid administration to improve recovery after laparoscopic cholecystectomy. A randomized, double-blind study. Ann Surg 2004

3. Influence of ”liberal” vs. ”restrictive” intraoperative fluid management on elimination of a postoperative intravenous fluid load. Anesthesiology 2007

4. Physiologic effects of bowel preparation. Dis Colon Rectum 20045. Epidural anesthesia, hypotension and changes in intravascular volume.

Anesthesiology 20046. Liberal or restrictive fluid administration in fast-track colonic surgery. A

randomized, double-blind study. Br J Anaesth 20077. Liberal vs. restrictive fluid management in knee arthroplasty. A randomized,

double-blind study. Anesth Analg 20078. Fluid therapy and surgical outcomes in elective surgery – a need for

reassessment in fast-track surgery. A systematic review. J Am Coll Surg 2006; 202: 971-89

the thesis

tentative conclusion minor surgery (duration < 30 min)

~1-2 liter fluid (crystalloid) to avoid dehydration improves outcome

• 12 healthy volunteers • + / - 3 L Ringer´s lactate• 2 day admission in hospital• mimicking gallbladder

surgery, no surgery performed

fluid infusion led to:• pulmonary function • weight

adverse physiologic effects over 24 hours

Holte et al., Anesth Analg 2003; 96: 1504

fluid administration in gallbladder surgery

• 48 patients• double-blind RCT•~3 l vs. ~1 l fluid leads to:

• stress response • physiologic functions • recovery • hospital stay

improvement in outcomeHolte et al. Ann Surg 2004: 240: 892

volume kinetics 4 h postop in lap cholecystectomy with 3 L vs. 1L Ringer´s lactate

Holte et al., Anesthesiology 2007; 106: 75

tentative conclusion moderate surgery (lap chole, lap hernia

etc)

<1 liter: dehydration 2-3 liter: optimal range

fluid administration in knee arthroplasty

• 48 patients• double-blind RCT

• 1,7 vs 4,3 l fluid leads to:

• vomiting • coagulation • no other differences

Holte et al., Anesth Analg 2007; 105: 465

which procedure?

minor surgery

no fluid shifts

often day-case

low complication rate

main outcomes: nausea, pain, same-day discharge

major surgery

internal fluid shifts

in-hospital

goal-directed vs. fixed-volume strategies

main outcomes: morbidity/mortality

?

effects of bowel preparation

Holte et al., Dis Col Rectum 2004; 47: 1397

• 12 volunteers• 60-67 years

bowel prep leads to: • weight • exercise capacity

clinically significant dehydration

basis (n=12) 90 min

activation of epidural

130 min

HES (n=6)

ephedrine (n=6)

plasma volumeerythrocyte volumehematocrite, MCVvolume kinetics

epidural anesthesia and intravascular volume

Holte et al., Anesthesiology 2004; 100: 281

main conclusion:

no differences in plasma volume

fluid administration in colonic surgery

• 32 patients• double-blinded RCT

• ~1,6 L vs. ~5 L cryst leads to:

• no difference in physiologic functions

• no difference in hospital stay

• increased morbidity with low volume??(3 vs. 0 anastomotic leakage)

Holte et al., Br J Anaesth 2007; 99: 500

”high” vs. ”low” fluid in abdominal surgery

• morbidity • hospital stay with ”high”

fluid • 5 of 8 studies

Lobo, Lancet 2002; 259: 1512Brandstrup, Ann Surg 2003; 235: 641Nisanevich, Anesthesiology 2005; 103: 24Kabon, Anesth Analg 2005; 101: 1546MacKay, Br J Surg 2006; 93: 1459McArdle, Ann Surg 2009; 250: 28Vermeulen, Trials 2009; 10: 50González-Fajardo, Eur J Endov Surg 2009; 37: 538

volumes in high vs. low fluid in major abd surgery – intraop

0

1000

2000

3000

4000

5000

6000

7000

0 1 2 3 4 5 6 7 8 9

high

lowLo

b o

Mac

Kay

Bra

ndst

rup

Nis

anev

ich

Kab

on

Hol

te

volu

me

(ml)

McA

rdle

Verm

eule

n

Gon

zále

z-F

ajar

do

fluid balance

definitions?fluid excesslow volume

high volumerestrictive

liberal

fluid deficit

fluid?? which fluid?

crystalloid, colloid,

balanced?

surgery?? which surgery?small hernia

pancreas cancer

no surgery – intensive care

when??

before/during/after surgery

how? goal-directed?fixed volumes ?

double-blinded

studies ?

very rarely

standardized patient

management?

information on postop period ?

volume

outc

ome

optimal range

optimal fluid management

Holte 2006 low volume?

Brandstrup 2003 high volume?

Brandstrup 2003 low volume Holte 2006 high volume?

tentative conclusion major surgery

<1,5 liter: functional hypovolemia/dehydration

1,5-5 liter: optimal range > 5 liter: fluid excess/overload

complications

which fluid?

crystalloids or colloids in elective non-cardiac surgery

no difference in clinical outcome no difference in physiologic

recovery systematic review of all available

RCTs (80) which amount of fluid to give?

Holte et al. J Am Coll Surg 2006; 202: 971

perioperative fluid therapy

fluid excess implication for postoperative

morbidity?•cardiac•pulmonary•gastro-intestinal (ileus)•wound healing•coagulation

fluid deficit implication for postoperative

morbidity?

•functional hypovolemia•delayed recovery•anastomotic problems?

6. Liberal or restrictive fluid administration infast-track colonic surgery: a randomized, double-blind study. Erratum in: Br J Anaesth 2008 Feb; 100(2): 284

3. Physiologic effects of bowel preparation. Dis Colon Rectum 2004; 47: 1400. GFR should read l/min/area

4. Liberal vs. restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: A randomized, double-blind study. Ann Surg 2004; 240: 897. * FVC 4h should beat FEV1 4h

errors

the future – how to measure fluid

status?

move beyond the wet vs. dry debate