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PerioperativeFluidManagementinERPs

RobertH.Thiele,M.D.AssistantProfessorUniversityofVirginia

FirstDoNoHarm

• Intravenousfluidsshouldbeconsideredapharmacotherapeutic agent• Justlikeallpharmacotherapeutic agents,theycanbebothbeneficial,andharmful

Brandstrup etal.AnnSurg 238:641,2003

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FirstDoNoHarm

BellamyMC.BJA97:755,2006

Hypoperfusion Edema

WhatDoesn’tWork?

•MeanArterialPressure• ThereisNOmeaningfulcorrelationbetweenMAPandDO2• WhywouldyouexpectanarbitraryMAPtoimpactclinicaloutcomesintheperioperativeenvironment?

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WhatDoesn’tWork?

Asfar P.NEJM370:1583,2014

WhatDoesn’tWork?

• CentralVenousPressure

Marik P.Chest134:172,2008

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WhatDoesn’tWork?

• UrineOutput

AlpertRAetal.Surgery95:707,1984

WhyIsThisSoHard?

ChappellDetal.Anesthesiology109:723,2008

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WhyIsThisSoHard?

• “Researchsuffersfromalackofstandardization…• Investigatorshavenormallynamedtheirtraditionalregimenthestandardgroupandcompareditwiththeirownrestrictiveideas…• Arestrictiveregimeninonestudyisoftendesignatedasliberalinanothersetup…

• Thisshortcomingpreventsevenpromisingresultsfromimpactingdailyclinicalroutineandmakesanypoolingofthedataimpossible”

ChappellDetal.Anesthesiology109:723,2008

WhyIsThisSoHard?

Gan TJ.Anesthesiology 97:820,2002;Brandstrup etal.AnnSurg 238:641,2003

Hypoperfusion Edema

Gan(Control [4.6L]) Gan

(GDT [5.3L])

Brandstrup(“Restricted”

[3.8L])

Brandstrup(“Liberal”[6.2L])

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WhyIsThisSoHard?

• Howmuchfluidadministeredmaybelessimportantthanwhenitisgiven• Newfocus:willintravenousfluidimproveDO2?

IntraoperativeFluidManagement

• Paradigmshift• Willintravenousfluidimprovecardiacoutput?• Howdoweknowthis?

• 1)Measure“fluidresponsiveness”

• 2)Measurecardiacoutputcontinuously

ThieleRHetal.CanadianJournalofAnesthesia 62:169,2015

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TimingisImportant!

• Studiesutilizingfluidresponsivenessdemonstratenoconsistentimpactontotalfluidadministration• Buettner (systolicpressurevariation):

• Nodifferenceinfluidadministrationoroutcome• Benes(strokevolumevariation):

• Morefluidinthegoal-directedtherapy(GDT)group• FewercomplicationsandlowerlactateintheGDTgroup

• Forget(PVI):• 500mLlessfluidintheGDTgroup• Lowerlactateatalltimepoints

Buettner Metal.BJA 101:194,2008;BenesJetal.Crit Care14:R118,2010;Forget Petal.Anesth Analg 111:910,2010

Fluid“Optimization”(SV)

• Premise• MaintainingpatientsatthepeakoftheFrank-Starlingcurve willmaximizedeliveryofoxygenwithoutrequiringinitiationofvasoactivepharmacologicagents

• Process:• Giveasmallamountoffluid• Measurethechangeinstrokevolume• Whenstrokevolumenolongerresponds,theintravascularvolumeis“optimized”

• Disadvantages• Requiresaccuratemeasureofstrokevolume(e.g.esophagealDopplermonitoring[EDM])

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Fluid“Optimization”(Resp.Var.)

• Premise• Optimizing“recruitable”strokevolumebasedonrespiratoryvariation

• Arteriallinescommon(16%ofpatients)• Masimo PVIrelativelyinexpensiveandnon-invasive(canbeusedonalmostanypatient)

• Disadvantages• DoesnotactuallymeasurechangeinSV• MeaningconfoundedinpatientswithelevatedPVRorRVfailure• Onlyusefulinmechanicallyventilatedpatients• DoesnothavetheevidencebaseenjoyedbyEDM(yet)

EsophagealDopplercontinuouslymonitorscardiacoutputandtheresponsetovolumeadministration

“Pleth VariabilityIndex”monitors“fluidresponsiveness”continuouslybasedonthepulseoximeter waveform

ThieleRHetal.CanadianJournalofAnesthesia 62:169,2015

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ThieleRHetal.PerioperativeMedicine 5:24,2016

EDMandHospitalStay(RCTs)

RANDOMIZEDCONTROLLEDTRIALS

NineRCTsincluding945Subjects,weightedaverage3.2dayreductioninLOS

Year Author Patients n Outcome

1997 Sinclair Orthopedicsurgery 40 Reducedmeanstay9days

2002 Gan Majorelectivesurgery 100 Reducedmeanstay2days

2002 Venn Orthopedic 90 Reducedmeanstay6days

2005 Wakening Colorectal 128 Decreasedhospitalstay1.5days

2006 Noblett Colorectal 108 Reducedmeanstay2days

2007 Chytra Trauma 162 Reducedmeanstay5days

2011 Pillai RadicalCystectomy 66 Reducedmeanstay4days*(*NS)

2013 Jones LiverResection 91 Reducedmeanstay3days

2013 Li LiverResection 160 Reducedmeanstay1.1days

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SchematicofEnhancedRecoveryAfterSurgery(Source:NHSEnhancedRecoveryPartnership)

DoYouNeed WantADevice?

“150patientsundergoingelectivecolorectalsurgerywererandomizedtoreceivefluidtherapyaftereitherthegoal

ofnear- maximalSVguidedbyEDorthegoalofzerobalanceandnormalBW”

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DoYouNeed WantADevice?

SrinivasaBJS100:66,2013

“NotknownwhetherGDFTisofvaluewithinanERprotocolincorporatingfluidrestriction…electivecolectomy…85

patientswererandomized…”

DoYouNeed WantADevice?

• IsGDTsuperiortoa“restrictive”or“zerobalance”approach?• GDT(EDM)v.“zerobalance”(B,S)or“restrictive”(P)• Randomizedtrialsofcolorectalsurgicalpatients• Results(335patientsin3studies)• Nodifferencesincomplications• Nodifferenceinlengthofstay

BrandstrupBJA109:191,2012;SrinivasaBJS100:66,2013;PhanTDAnaesthIntCare42:752,2014

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DoYouNeed WantADevice?

Pearse RMetal.JAMA 311:2181,2014

Whichgroupwouldyouchoosetobein?

DoYouNeed WantADevice?

Pearse RMetal.JAMA 311:2181,2014

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DoYouNeed WantADevice?

• ManyindividualshavedemonstratedreducedLOSwithoutadvancedmonitoring• However,thedataonGDT(prospectiveRCTs)ismorecompellingthantheERASdata• Advancedmonitoringallowsyoutocomfortablyadoptafluidrestrictivestrategywithamarginofsafety• Youaremorelikelytodetecttherarepatientwhoisprofoundlyfluidresponsive• Thiswillnotbedetectedina100patientcase-controlstudy

Conclusions

• Intravenousfluidcancauseharm• Traditional(“static”)fluidmanagementstrategiesarebasedonflawedlogicandnotsupportedbymeaningfuloutcomesdata• Advancedhemodynamicmonitoring(“dynamic”indicatorsofvolume)havebeenshowntoimproveoutcomesinGDTstudies• WhetherornotthisholdstrueinthecontextofERASstudiesissomewhatcontroversial

• Fluidresponsivenessmonitorswillallowyoutodetecthypovolemia andprovideamarginofsafety• Ultimatelythedecisionabouthowtomanageintraoperativefluidsisbasedonanindividualizedcost-benefitratio

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Conclusions

ThieleRHetal.PerioperativeMedicine 5:24,2016