Presentation on theme: "DR.N.KANAGARAJAN SENIOR CONSULTANT DEPT OF CARDIAC ANESTHESIA"— Presentation transcript:
1 GOAL DIRECTED PERIOPERATIVE FLUID MANAGEMENT – DOES KIND OF FLUID MATTER? DR.N.KANAGARAJANSENIOR CONSULTANTDEPT OF CARDIAC ANESTHESIAICVD, MADRAS MEDICAL MISSION HOSPITALCHENNAI.
2 Perioperative fluid therapy - INTRODUCTIONPerioperative fluid therapy -Much controversy / Effects on the outcome inconclusiveIntravenous fluid resuscitation :(a) fluid and electrolytes required for normal existence (daily maintenance) and(b) resuscitation or replacement of abnormal losses.The “Recipe Book” approach
3 (National Confidential Enquiry into Perioperative Deaths) 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)
4 1. PREOPERATIVE FLUID DEFICIT 2. Insensible loss 3 1.PREOPERATIVE FLUID DEFICIT 2.Insensible loss 3.Volume and electrolytes lost through body secretions 4.BLOOD LOSS
19 ALBUMINThere 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
23 Importance of physicochemical characteristics Degree of hydroxyethylationDuration of volume effectConcentrationInitial values of volume effectSubstitution patternSerum kineticsC2/C6 RATIOIntravascular half lifeMolecular weightVolume half life
31 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.
32 Conclusion: Voluven® (HES 130/0 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 2007;106:1120-7)
33 Accumulation and Tissue storage Tetrastarches - Less tissue accumulation and even in high doses pruritus is a not a clinical problemEffect on Plasma bilirubin:Potato-derived HES 130/0.42 are the only tetra starch to be absolutely contraindicated in patients with severe hepatic impairment.
38 Euro J Anaesthesiol (2008), 25:986-994. Godet G et alSafety 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), 25: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
39 CONCLUSIONThe choice of the colloid had no impact on renal safety parameters and outcome in patients with decreased renal function undergoing elective abdominal aortic surgery.
40 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.
41 Prospective,randomised study BOLDT J et al(2008)Prospective,randomised study50 patients aged 80 years-cardiac surgery using CPBPreop Serum albumin 3.5 mg/dL received either 5% Human Albumin or 6% HES 130/0.4(Anesth Analg 107:1496 –1503)
42 Conclusion: In 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.
43 SÜMPELMANN R et alHydroxyethyl starch 130/0.42/6:1 for perioperative plasma volume replacement in children: preliminary results of a European prospective multicenter observational postauthorization safety study (PASS)(Paediatric Anaesth 2008;18:929-33)316 patients (Day of birth – 12 years)All types of surgery including cardiac surgeryThe mean volume of infused HES 130/0.42 was 11 ± 4.8 ml·kg−1 (range, 5–42)
44 CONCLUSIONModerate doses of HES 130/0.42 help to maintain cardiovascular stability and lead to only moderate changes in hemoglobin concentration and acid–base 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.
45 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.
49 EFFECT ON SYSTEMIC INFLAMMATION AND ENDOTHELIAL ACTIVATION
50 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: 457–64)
61 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.
63 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 2009;53:
67 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.