FLUID MANAGEMENT – A BALANCED APPROACH

SYAFRI K.ARIF

DEPARTMENT OF ANESTHESIOLOGY , INTENSIVE CARE AND PAIN MANAGEMENT

FACULTY OF MEDICINE

HASANUDDIN UNIVERSITY

Learning Objectives

• Describe the consequences of hyper- and hypovolemia for surgical and critically ill patients

• Develop a fluid management strategy for individual patients

Fluid Balance

Outcome and Surgery• 48 million in-patient surgeries in the US in 2009

• High risk (> 5% mortality) surgery in the UK– 12% (24 M) of procedures

– 80% of mortality

• Moderate risk surgery: 40% (96 M)

• Data in Indonesia ??

• GI accounts for half of hospitalizations for complications (GI sensitive to hypovolemia, catecholamines)

• Complications – Increase the cost

– Often not directly related to the surgery

– Commonly involve multiple organ systems

– May involve systemic inflammatory response

Inpatient Surgery. http://www.cdc.gov/nchs/fastats/insurg.htm. Accessed February 2012.Pearse RM, et al. Crit Care. 2006;10(3):R81. Bennet-Guerrero E, et al. Anesth Analg. 1999;89(2):514-519.

Hemodynamic Monitoring During High-Risk Surgery

A Survey of ASA Members (Sept–Nov 2010)

Cannesson M, et al. Crit Care. 2011;15(4):R197.

CONCLUSION: No

Does Central Venous Pressure Predict Fluid Responsiveness?

Marik PE, et al. Chest. 2008;134(1):172-178.

Deficit or Excess Blood Volume

*

Hemodynamic Monitoring During High-Risk Surgery

A Survey of ASA Members (Sept–Nov 2010)

Cannesson M, et al. Crit Care. 2011;15(4):R197.

Hemodynamic Monitoring During High-Risk Surgery

A Survey of ASA Members (Sept–Nov 2010)

What parameter(s) is (are) involved in oxygen delivery to the tissues?

Do you believe that oxygen delivery to the tissues is of major importance in patients during high risk surgery?

Yes

Cannesson M, et al. Crit Care. 2011;15(4):R197.

CVP: Poor Target for Fluid Rx

Osman D, et al. Crit Care Med. 2007;35(1):64-68.

150 volume challenges; sepsis

Drives excessive fluid

Failure to resuscitate

Oxygen Delivery

DO2 = CO x Hb x 1.31 x SaO2

Non Invasive

Non Invasive?

mLO2/min g/L mLO2/gHb %L/min

Hemodynamic Assessment Tools

Palpate pulse

NBP

ECG

Arterial line

CVP

Minimally invasive CO

PA Cath

Less invasive

More invasive

TEE

Dynamic Parameters

• Systolic Pressure Variation (SPV)• Pulse Pressure Variation (PPV)• Stroke Volume Variation (SVV)

Dynamic Parameters Predict Fluid Responsiveness More Reliably Than

• PCWP

• CVP

• Cardiac output

• Intrathoracic blood volume

• Urine output

• Serum lactate, pH

• Cardiac end diastolic volume

Why?

• Pressure is not volume

• Only dynamic parameters such as SVV, PPV can tell you where the heart is on the Starling Curve!!

PPV/SVV and Diastolic LV Volume

LV Diastolic Volume

LV S

tro

ke V

olu

me

120 mmHg

40

Art

eri

al P

res

sure PPmax

PPmin

PPmax - PPmin

(PPmax + PPmin)/2∆PP =

Michard F, et al. Am J Respir Crit Care Med. 2000;162(1):134-138.

2 sec

PPV and Fluid Responsiveness

PPV = 32%

PPV = 5%

Pulse Pressure Variation

PPV Predicts Fluid Responsiveness More Reliably than Static Parameters

Sepsis with Acute Circulatory Failure

Michard F, et al. Am J Respir Crit Care Med. 2000;162(1):134-138.

100 – Specificity (%)

Sen

siti

vity

(%

)ΔPp

ΔPs

Pra

Ppao

*

Positive Pressure Breath

Mechanism of SVV

RV Afterload

RV Preload

LV Preload

Acute SV

DelayedSV

Empty Pulmonary Venous System

Intrathoracic Pressure

• 25 consecutive patients prior to CABG surgery• Anesthetized, mechanically ventilated • Tidal volume 8-10 ml/kg• CVP, PAC, SVV• Procedure

– Record baseline when stable

– All patients receive 500 ml hetastarch load

– Record data when stable

Cannesson M, et al. Anesth Analg. 2009;108(2):513-517.

Can SVV Predict Fluid Responsiveness? *

SVV and PPV Are Correlated and Predictive

Cannesson M, et al. Anesth Analg. 2009;108(2):513-517.

100 – Specificity (%)

Sen

siti

vity

(%

)

Bland Altman Analysis ROC Curves

ΔPP and SVV cutoffs = 10%

*

PVI Prediction of Volume Response

Cannesson M, et al. Br J Anaesth. 2008;101(2):200-206.

Responder

Non-Responder

500 ml hetastarch 6%, 10 min

SVV and PVI Predict ResponsivenessMV Patients Undergoing Major Surgery

Zimmermann M, et al. Eur J Anaesthesiol. 2010;27(6):555-561.

Conclusion: Both SVV and PVI indicate fluid responsiveness in mechanically-ventilated patients undergoing major surgery

Sen

siti

vity

1-Specificity

CVPPVI

SVV

• Most clinical studies done in well-defined populations– Controlled MV with no spontaneous breathing

– Tidal volumes (TVs) > 7 ml/kg

– No cardiac arrhythmias

Limitations of Dynamic Predictors *

The Present and Future

Volume response to treatment?Appropriate tissue oxygenation?

Is the heart pumping enough oxygenated blood for the body?

Is cardiac output sufficient? Are the individual tissues getting the oxygen they need?

Volume status-would it help to give fluid?

No

Not much

No

GlobalVenous O2

pH, Lactate

CO Measurement

Tissue O2

Microcirculation

DynamicParameters

Fluid Options

60% Fluids

40% Solids

67% Intracellular

33% Extracellular

67% Interstitial

33% Blood (70 cc/kg)

Na+ = 140 mEq/LCl- = 102 mEq/LSID = 38 mEq/L

Na+ = 154 mEq/LCl- = 154 mEq/LSID = 0 mEq/L1 liter 1 liter

PLASMA + NaCl 0.9%

SID : 38

Plasma NaCl 0.9%

2 liter

ASIDOSIS HIPERKLOREMIK AKIBAT PEMBERIAN LARUTAN Na Cl 0.9%

=

SID : 19 lebih asidosis

Na+ = (140+154)/2 mEq/L= 147 mEq/L

Cl- = (102+ 154)/2 mEq/L= 128 mEq/L

SID = 19 mEq/L

Plasma

Na+ = 140 mEq/L Cl- = 102 mEq/L SID= 38 mEq/L

Cation+ = 137 mEq/L Cl- = 109 mEq/L

Laktat- = 28 mEq/L SID = 0 mEq/L

1 liter

1 liter

PLASMA + Larutan RINGER LACTATE

SID : 38

Plasma Ringer laktatLaktat cepat dimetabolis

me

2 liter

=

Normal pH setelah pemberian RINGER LACTATE

SID : 34 lebih alkalosis dibanding jika diberikan NaCl 0.9%

Na+ = (140+137)/2 mEq/L= 139 mEq/L

Cl- = (102+ 109)/2 mEq/L = 105 mEq/L Laktat- (termetabolisme) = 0 mEq/L SID = 34 mEq/L

Plasma

[mmol/l] NS Ringer RL RA RFundin Plasma

Na+ 154 147 130 130 140 142

K+ 4.0 4 4 4.0 4.5

Ca2+ 2.25 2.7 2.7 2.5 2.5

Mg2+ 1.0 1.0 0.85

Cl- 154 156 108.7 108.7 127 103

HCO3 24

Lactate- -- -- 28.0 -- -- 1.5

Acetate- -- -- -- 28.0 24.0

Malate2- -- -- -- -- 5.0

BEpot -24 -24 3.0 2.5 0 0 ± 2

Tonicity [mOsm/l][mOsm/lkg)

304286

309 273256

273.4256

304286

308288

Electrolyte balance like in human plasma

=> physiological composition closely resembling humanplasma needed

Conventional infusion solutions can produce

a number of corrective effects –

both unwanted and unknown.

Balance solution - Plasmalike electrolytes

R. Zander, Fluid Management, 2009

RL and RA are more hypotonic compare to

NaCL 0.9% & RF

Balance solution - Low Oxygen consumption

To metabolize anions, the body needs O2

Normal O2-consumption: 18 l per hour

Total consumption of oxygen is reduced for about

30% in the acute phase!

Balance Kristaloid : Low Oxygen consumption

Compare to Ringer Lactate (RL) & Ringe Acetate (RA)

- Gentle on the liver

Acetate and Malate – unlike Lactate – are

metabolized in all organs and muscles

AcetateLactate

Hypotonic IV Fluids and Intracranial Pressure (ICP)

All body fluids have the same osmotic pressure as plasma (osmolality)

The rigidly shaped skull contains 3 incompressible fluid compartments (Brain, Blood, CNS)

Intracranial compartment responses to a change in plasma osmolality:

A decrease in plasma osmolality by approximately 3% (288 to 280 mosmol/kg H2O), invariably results in an increase in brain volume by 3%, causing a decrease in blood and/or CSF volume by as much as 30%.

288 to 280 mosmol/kg H2O

Gentle metablism anion (acetate – malate) due to :

- Low oxygen consumption - unlike Lactate : acetate – malate

are

metabolized in all organs and muscles

Isotonic, like plasma Minimal risk in critical ill,

pediatric/neonatus & brain trauma

• BEpot= 0 No change of patient’s acid-base

status

Electrolyte balance like in human plasma

does not affect electrolyte equilibrium

Ringerfundin, Crystalloid Balanced

36

Faktor yang mempengaruhi eliminasi preparat HES :

Molecular weight (Mw) / Berat Molekul (BM) :

Semakin kecil BM semakin mudah degradasi

Co. HES BM 200 kdl dan HES BM 130 kdl

Molar substitution (MS) / Derajat Subsitusi (DS) :

6 Hydroxyethyl per 10 glucose units MS = 6/10 = 0.6 : Semakin kecil MS semakin cepat.

Co. HES 200/ 0.5, HES 130/ 0.42

C2/C6 ratio:

ratio dari nomor substituents pada carbon atom nomor 2 kemudian 6

Semakin kecil rasio C2/C6 semakin cepat degradasi,

Co. 9:1 dan 6:1

MS >> C2/C6 > Mw

Effective and Safe HES 130/0.42/6:1 vs HES 200/0.5

Colloid HES in different solutions

Note especially

the differences

in sodium and

chloride content!

HES 130 in 0.9% saline: Venofundin Bbraun &

Voluven

Delaney AP et al. Crit Care Med. 2011;39(2):386-391.Supplement. http://links.lww.com/CCM/A220. Accessed February 2012.

Albumin in Sepsis Meta-analysis of Mortality

• Meta-analysis of RCTs comparing albumin with other fluid resuscitation regimens

• Overall OR for mortality = 0.76 (P = 0.015) with albumin compared with other resuscitation fluids• 6 studies from Boldt removed

Albumin Compared to Individual Fluid Regimens

Fluid Number of Studies

Total Participants

OR of Mortality with Albumin P-value

Crystalloid 7 144 0.78 0.04

Starch 12 463 1.04 0.84

Comparing Colloids

• Meta-analysis of 70 trials (4375 patients)– Pooled mortality RR

Alb/PPF vs HES: 1.14 (95% CI 0.91-1.43)• Boldt et al excluded: 0.97 (95% CI 0.70-1.35)

Alb/PPF vs gelatin: 0.97 (95% CI 0.68-1.39) Alb/PPF vs dextran: 3.75 (95% CI 0.42-33.09) Gelatin vs HES: 1.00 (95% CI 0.80-1.25)

• Conclusions– No definitive evidence that one colloid better

than any other– But very wide 95% CIs larger trials needed

Bunn F, et al. Cochrane Database Syst Rev. 2011;3:CD001319.

• Meta analysis of 8 RCTs1

– Trauma patients: crystalloids favored

– Non-trauma patients: colloids comparable

– Non-septic/elective Sx (BM intact): colloids also efficacious

• A systematic review of 37 RCTs2 does not support the continued use of colloids for volume replacement in critically ill patients

• A systematic review of 17 studies3: no overall difference in mortality, pulmonary edema, or length of stay between crystalloids and colloids in fluid resuscitation

1. Velanovich V. Surgery .1989;105(1):65-71. 2. Schierhout G, et al. BMJ. 1998;316(7136):961-964.3. Choi PT, et al. Crit Care Med. 1999;27(1):200-210.

Meta-Analysis: Colloid vs Crystalloid

• 38 trials involving 1589 patients included• No single fluid affected any outcome measure significantly

more than another fluid across a range of outcomes• No studies examining the effects of combination fluid

therapy; limited data on mortality• The review concluded that although the beneficial effects

of colloids were confirmed, further studies still required

Toomtong P, et al. Cochrane Database Syst Rev. 2010;1:2-CD000991.

Meta-Analysis: Colloid vs CrystalloidCochrane review of IV fluids for abdominal aortic surgery

Colloids vs Crystalloids in the ICU

• Meta-analysis of 65 trials

• Pooled mortality RR vs. crystalloids:

– All colloids combined: 1.01 (95% CI 0.92-1.10)

– HES: 1.18 (95% CI 0.96-1.44)

– Modified gelatin: 0.91 (95% CI 0.49-1.72)

– Dextran: 1.24 (95% CI 0.94-1.65)

– Dextran in hypertonic crystalloid: 0.88 (95% CI 0.74-1.05)

• Results unchanged after exclusion of Boldt et al

• Conclusion

– No evidence that colloids are more effective than

crystalloids in reducing mortality in people who are critically

ill or injured

Perel P, et al. Cochrane Database Syst Rev. 2011;3:CD000567.

•THANK YOU