DrRichardGordon-Williams

ST7inAnaesthesiaUCLHospitals

AnIntroductiontoAnaesthesia2019

•  Crystalloid•  Colloids

•  Synthetic•  Human(Blood/Albumin)

•  Isotonic/Iso-osmolar•  Balanced

TheGreatDebate

AnalogycourtesyofProfMythen

Itswhatyoudowiththem

NICEGuidelines-takehome

•  Doesnotapplytopatientduringperioperativeperiod•  AdvisedProtocoldrivenfluidmanagement

BUT5Rsisagoodapproach

1.  Resuscitation

2.  RoutineMaintenance

3.  Replacement

4.  Redistribution

5.  Reassessment

Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is hypovolaemic and needs fluid resuscitation Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP <100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per min; NEWS ≥5; 45o passive leg raising suggests fluid responsiveness.

Can the patient meet their fluid and/or electrolyte needs orally or enterally?

Assess the patient’s likely fluid and electrolyte needs x History: previous limited intake, thirst, abnormal losses, comorbidities. x Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension. x Clinical monitoring: NEWS, fluid balance charts, weight. x Laboratory assessments: FBC, urea, creatinine and electrolytes.

Does the patient have complex fluid or electrolyte replacement or abnormal distribution issues? Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other complex issues.

Reassess the patient using the ABCDE approach Does the patient still need fluid resuscitation? Seek expert help if unsure

Initiate treatment x Identify cause of deficit and respond. x Give a fluid bolus of 500 ml of crystalloid

(containing sodium in the range of 130–154 mmol/l) over less than 15 minutes.

Ongoing abnormal fluid or electrolyte losses Check ongoing losses and estimate amounts. Check for: x vomiting and NG tube loss x biliary drainage loss x high/low volume ileal stoma

loss x diarrhoea/excess colostomy

loss x ongoing blood loss, e.g.

melaena x sweating/fever/dehydration x pancreatic/jejunal fistula/stoma

loss x urinary loss, e.g. post AKI

polyuria.

Algorithm 3: Routine Maintenance

Give maintenance IV fluids Normal daily fluid and electrolyte requirements: x 25–30 ml/kg/d water x 1 mmol/kg/day sodium, potassium*, chloride x 50–100 g/day glucose (e.g. glucose 5% contains

5 g/100ml).

Reassess and monitor the patient Stop IV fluids when no longer needed. Nasogastric fluids or enteral feeding are preferable when maintenance needs are more than 3 days.

Existing fluid or electrolyte deficits or excesses Check for: x dehydration x fluid overload x hyperkalaemia/

hypokalaemia

Estimate deficits or excesses.

Redistribution and other complex issues Check for: x gross oedema x severe sepsis x hypernatraemia/

hyponatraemia x renal, liver and/or

cardiac impairment. x post-operative fluid

retention and redistribution

x malnourished and refeeding issues

Seek expert help if necessary and estimate requirements.

Give a further fluid bolus of 250–500 ml of crystalloid

>2000 ml given? Seek expert help

Algorithm 2: Fluid Resuscitation

Algorithm 4: Replacement and Redistribution

No

Yes

No

Yes

No

Ensure nutrition and fluid needs are met Also see Nutrition support in adults (NICE clinical guideline 32).

Yes

Yes

Prescribe by adding to or subtracting from routine maintenance, adjusting for all other sources of fluid and electrolytes (oral, enteral and drug prescriptions)

Yes

Monitor and reassess fluid and biochemical status by clinical and laboratory monitoring

Yes

No

No

No

Does the patient have signs of shock?

Algorithm 1: Assessment

Algorithms for IV fluid therapy in adults

*Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids containing 20 mmol and 40 mmol of potassium in a 24-hour period).

Potassium should not be added to intravenous fluid bags as this is dangerous.

‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016) © National Institute for Health and Care Excellence 2013. All rights reserved.

Wearethe“experts”

TooFast,Slowitdown

TooSlow,Speeditup

GraphofDistributionoffluidgivenacrosscentresforcolorectalsurgery

FindReference

Largevariationin”expert”opinioninperioperativefluidmanagement

Casestudy1

•  28yearold60kgMale,F&W•  Electiveremovalofmetalwork(approx.1hour)

Whatshouldwehang?

A.  NothingB.  500mlBag

C.  1LBagD.  1Latinduction&

further1Lintra-op

WhichFluid?A.  NothingB.  HartmannsC.  NormalSalineD.  5%DextroseE.  0.45%Saline+4%

Dextrose

ElectiveSurgery&EnhancedRecovery

•  Peri-operativelossescannowbeminimal–  Lackofexcessivebowelprep–  Decreasedstarvation–  CHOloading–  EarlyE&D

•  Resuscitationminimal~120ml(2hourfluidfasting)

•  Routinemaintenance~60ml•  Replacelosses-SuperficialSurgery

~0ml•  Littleredistributionoffluidin

electivesurgery~0ml

•  Midazolam2ml

•  Fentanyl4ml

•  Propofol20ml

•  Cefuroxime20ml

•  Atracurium5ml

•  Ondansetron4ml

•  Dexamethasone2ml

•  Paracetamol100ml

•  Diclofenac3ml

•  Reversal2ml

•  Flush>20ml

TOTAL>180mlTOTAL180ml

Casestudy2

•  28yearold60kgMaleinA&Ewith?perforatedDuodenalUlcer.HR126,BP78/43,Dry,pH7.28,BE-6.4,Lact4.0,Na144,K3.4,Hb142

Whatshouldwehang?

A.  NothingB.  500mlBag

C.  1LBagD.  1Latinduction&

further1Lintra-op

WhichFluid?A.  NothingB.  HartmannsC.  NormalSalineD.  5%DextroseE.  0.45%Saline+4%

Dextrose

PopQuiz

•  HowmanyBagsofReadySaltedCrispsareequivalenttoa1LbagofNormalSaline?

A. 5B. 10C. 15D. 20E. 25

DosethatmakesthePoison

•  0.9%NaCl1Lcontains:o  158mmolNa++Cl-

o  Equalto9gSalto  ReadySalted=0.45go  DoubleourRDA(4g)!o  70pperLitre

o  20PacketsofCrisps

•  DangersofNormalSalineo  Waterfollowssalt

o  Fluidoverloado  Infusion0.9%NaClcauses

reductioninrenalbloodflowandtissueperfusion1

o  ChloriderestrictivefluidregimenleadstoareductionAKIandneedforRRT2

GoalDirectedFluidTherapy

•  Wedothisalready–HR,BP,UO,Lactate,BXS

•  Wehavegadgetstohelpoptimise:–  LiDCO–  PiCCO– ODM–  Echo–  SwingonArterialline(PulsePressureVariation)

•  ButneedstobeacorrelateofCO(NotCVP)

GoalDirectedFluidTherapy

EstimationoffluidrequirementsinsurgeryGoaldirectedfluidtherapyCardiacoutputmonitoringorsurrogatesDon’tforgetUO,Bloodgasesetc

ThePerioperativePeriod

•  Theintra-operativeperiodisadropintheocean

•  RoutineMaintenance

•  Replacelosses(NG,Drains)•  Oralmaintenanceandreplacementoflossesisthegoal

•  Tryandstopfluidsasearlyaspossible

Casestudy2continued•  Afterresuscitationhehascomeforalaparotomy,over-sew&washout.

•  Thereis1.5Lofbloodstainedfluidinthesuction.MAPis59mmHg.HbonABG74.SVV18%.

Whatshouldwedo?A.  ReassessB.  Further250mlbolusesguidedbyCardiacOutput

monitoringC.  Transfusionof1unitofBloodD.  PutoutamajorHaemorrhageCallE.  StartNoradrenaline

TransfusionOverview

•  Oxygendeliverytotissues(O2Flux)＝ CardiacOutputxOxygencontentofblood

•  HeartandBrainaremostsensitivetohypoxia

•  Buttheycomewithrisks–  Acuteimmunehaemolyticreaction,TRALI,GvHD,Cancerprogression,

FEOverload

HbxSa02+pO2

PatientBloodManagement

•  “evidence-based,multidisciplinaryapproachtooptimisethecareofpatientswhomightneedtransfusion…”

•  Preoperative

–  Detectionofanaemia,optimisationHb,Feinfusions

•  Intraoperative

–  Bloodconservation•  Tranexamicacid/Cellsalvage/Surgicaltechnique/Warming

–  Transfusiontriggers•  Patientsabilitytocompensateforanaemia(cardiorespiratorydisease)•  Rateofongoingbloodloss

•  Likelihoodoffurtherbloodloss•  Balanceofrisksvsbenefitsoftransfusion

•  Postoperative–  Singleunittransfusionpolicy

414

·

Februar y 11, 1999

The New England Journal of Medicine

gan-failure scores of 7 were assigned to all patientswho died within 30 days after admission to the in-tensive care unit, the number of patients with mul-tiorgan failure was substantially increased in bothgroups, and the results were marginally better in therestrictive-strategy group (20.6 percent vs. 26.0 per-cent, P=0.07). Similarly, when all patients who diedwere given a multiple-organ-dysfunction score of24, the total scores (P=0.03) and the changes in thescores from base line (P=0.04) were significantlylower in the restrictive-strategy group (Table 2).

Cardiac events, primarily pulmonary edema andmyocardial infarction, were more frequent in the lib-eral-strategy group than in the restrictive-strategygroup during the stay in the intensive care unit(P<0.01) (Table 3). However, there were no signifi-cant differences in the rates of cardiac events (41 per-cent in the restrictive-strategy group and 44 percentin the liberal-strategy group, P=0.86), infectiouscomplications (3 percent and 4 percent, respectively;P=1.00), or multiorgan failure (37 percent and 32percent, respectively; P=0.59) in the 48 hours pre-ceding death among the patients who died (Table 4).

Subgroup Analyses

When the patients were analyzed according to age(<55 years vs. »55 years) and APACHE II score(«20 vs. >20), there were no significant differencesin base-line characteristics. In the restrictive-strategygroup, 173 patients were younger than 55 years, 207patients had an APACHE II score of 20 or less, 151patients had cardiac disease, 100 had a traumatic in-jury, and 114 had a severe infection or septic shock.In the liberal-strategy group, 161 patients wereyounger than 55 years, 217 had an APACHE IIscore of 20 or less, 175 had cardiac disease, 100 hada traumatic injury, and 104 had a severe infection orseptic shock. All outcomes in the two transfusion-strategy groups were similar for the patients whowere older than 55 years and for those with anAPACHE II score of more than 20 (P>0.36). How-ever, 30-day mortality was significantly lower in therestrictive-strategy group than in the liberal-strategygroup among the patients with an APACHE II scoreof 20 or less (8.7 percent vs. 16.1 percent; 95 per-cent confidence interval for the absolute difference,1.0 to 13.6 percent; P=0.03) and among the pa-tients who were less than 55 years of age (5.7 per-cent vs. 13.0 percent; 95 percent confidence interval,1.1 to 13.5 percent; P=0.02). There were no signif-icant differences in 30-day mortality between treat-ment groups in the subgroup of patients with a pri-mary or secondary diagnosis of cardiac disease (20.5percent in the restrictive-strategy group and 22.9percent in the liberal-strategy group; 95 percentconfidence interval for the difference, ¡6.7 to 11.3percent; P=0.69), in the subgroup of patients withsevere infections and septic shock (22.8 percent and

Figure 2. Kaplan–Meier Estimates of Survival in the 30 Days af-ter Admission to the Intensive Care Unit in the Restrictive-Strat-egy and Liberal-Strategy Groups.Panel A shows the survival curves for all patients in the studygroups. Panel B shows the survival curves in the subgroup ofpatients with an APACHE II score of 20 or less. Panel C showsthe survival curves in the subgroup of patients who wereyounger than 55 years.

50

100

0

Patients Younger than 55 Years

30

60

70

80

90

5 10 15 20 25

Days

Liberal-!transfusion!

strategy

P=0.02

Restrictive-!transfusion!

strategy

Sur

viva

l (%

)50

100

0

Patients with APACHE II Score «20

30

60

70

80

90

5 10 15 20 25

Days

Liberal-!transfusion!

strategy

P=0.02

Restrictive-!transfusion!

strategy

Sur

viva

l (%

)

50

100

0

All Patients

30

60

70

80

90

5 10 15 20 25

Days

Liberal-!transfusion!

strategy

P=0.10

Restrictive-!transfusion!

strategy

Sur

viva

l (%

)

A

C

B

The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on July 17, 2017. For personal use only. No other uses without permission.

Copyright © 1999 Massachusetts Medical Society. All rights reserved.

TransfusionTriggers

•  Hb>10 NO

•  Hb<7YES

•  Hb7-10 MAYBEo  ?Cardiopulmonary

reserve

o  ?Symptomaticpatients

MassiveTransfusion

•  Replacementofonebloodvolumeina24hourperiod

•  Transfusionof>10unitsin24hours

•  Transfusionof4ormoreunitswithin1hourwhenongoingneedisforeseeable

•  Replacementof>50%ofthetotalbloodvolumewithin3hours

•  Obstetrics–  >2000ml–  >150mls/min–  Uncontrolled/ongoing

Logistics

GetsomeHelp….

•  MajorHaemorrhageCall•  Two14GIVcannulae–  Resuscitatewithwarmedcrystalloid/colloid–  Warmpatient–  Considerinvasivemonitoring:arterialline+central

venousaccess•  FBC,ABG/VBG>Hb,K+,Ca+•  Coagulationscreen/TEG•  X-match•  Repeatafterproducts/4hourly•  Askforproductsearly–FFPtakes30minstothaw!!•  Mayneedtogivebloodproductsbeforeresultsare

available

Haemorrhagespiral

0

20

40

60

80

100

25° 27° 29° 31° 33° 35° 37°

Temperature

Fact

or A

ctiv

ity

II

V

VII

VIIIIX

X

XI

XII

GoalsinMassiveTransfusion

•  PackedRedCells– Haematologist

– BloodBank– Porter– ProductChecking–  Infusing– Recording– TestsofHb

OxygenDelivery

•  Surgeon/Radiologist•  ClottingProducts– Platelets– Clottingfactors– Fibrin(ogen)– Stopfibrinolysis– Calcium

– Heat

MakeaClot

Products

•  CodeRedPackA:

–  6unitsRBC

–  4unitsFFP

•  CodeRedPackB:

–  6unitsRBC

–  4unitsFFP

–  1poolplatelets

–  2poolscryoprecipitate

•  Platelets

–  Targetpltcount>100x109/lformultiple/CNStrauma,>50inothersituations

•  FFP

–  AimforPT/APTT<1.5xcontrol

•  Cryoprecipitate

–  Aimforfibrinogen>1g/L

–  Higherinobstetrics

•  Calcium+TranexamicAcid1g

TopTips

1.  DoIneedfluid?2.  AvoidhighChlorideload3.  UseGoalDirectedFluidTherapy4.  Avoidpost-operativefluidsifpossible5.  Massivetransfusioninalogisticalproblem–

gethands6.  Avoidcoldfluidsthatdon’tcarryclotorblood

Thankyou