Fluid Management
Physiology of perfusion: pressure and flow

Adequate perfusion requires adequate arterial pressure and cardiac output (CO)

Cardiac Output (CO) = Stroke Volume x Heart Rate

To learn more about managing hypotension, click here.

Managing the flow component of perfusion

Maintaining patients in the optimal volume range is key. Using dynamic and flow-based parameters to guide fluid administration helps maintain patients in the optimal volume range.1

Insufficient volume administration is associated with:

  • GI dysfunction (postoperative ileus, PONV, upper GI bleeding, anastomotic leak)2
  • Infectious complication (tissue hypoperfusion)3
  • Acute renal insufficiency or failure4
Optimal Volume Load

Excessive volume administration is associated with:

  • Pulmonary edema5
  • GI dysfunction (abdominal compartment syndrome, ileus, anastomotic leak)5
  • Coagulopathy5
Individualizing volume management
fluid
fluid

Preload: the tension of myocardial fibers at the end of diastole, as a result of volume in the ventricle

Stroke Volume (SV): volume of blood pumped from the left ventricle per heartbeat

When managing perfusion, stroke volume can be optimized using the patient’s own Frank-Starling curve — a plot of stroke volume (SV) vs. preload.

Stroke volume is optimized when it resides at the shoulder of the Frank-Starling curve (refer to figure below).

The patient’s location on his or her Frank-Starling curve can be determined by measuring ∆SV in response to change in preload using:

Bolus fluid challenge

Passive leg raise (PLR)

Dynamic and flow-based parameters are more informative than conventional parameters in determining fluid responsiveness and may help you avoid excessive and insufficient fluid administration.7

Clinical studies have shown that conventional volume management methods, based on conventional parameters, are misleading and insensitive.6

Advanced hemodynamic parameters such as stroke volume (SV) and stroke volume variation (SVV), are key to optimal fluid administration.

SVV has been proven to be a highly sensitive and specific indicator for preload responsiveness when managing perfusion. As a dynamic parameter, SVV has been shown to be an accurate predictor of fluid responsiveness in loading conditions induced by mechanical ventilation.6,8,9

Recent research demonstrating the value of dynamic
and flow-based parameters
Reducing variability using perioperative
goal-directed therapy (PGDT)

Post-surgical complications have an impact on human life.10

Major complications occur in approximately 16% of surgeries.10

Independent of preoperative patient risk, the occurrence of even a single post-surgical complication within 30 days reduced median patient survival by 69%.11

Hemodynamic optimization through PGDT is demonstrated to reduce complications like acute kidney injury (AKI) and surgical site injury (SSI), as well as reduce length of stay, and associated costs in your moderate to high-risk surgery patients.12,13

Hemodynamic optimization through PGDT can:

Reduce post-surgical complications by an average of 32%14

Average reduce length of stay: 1+ days14, 15

Approximate extra cost of treating one post-operative complication in the United States: $18,00016

PGDT is a treatment protocol using dynamic and flow-based hemodynamic parameters with the objective of making the appropriate volume management decisions (e.g. fluid only when needed). PGDT can be implemented in a single procedure or as part of a larger initiative such as Enhanced Recovery After Surgery pathways.

50+ studies demonstrating the use of PGDT

50+ randomized controlled trials and 14+ meta-analyses have demonstrated clinical benefits of hemodynamic optimization over standard volume management.

Recent studies

Randomized Controlled Trials Showing a Benefit in
Perioperative Goal-Directed Therapy

More than 3000 patients have been enrolled in these 52 positive RCTs.

PAC, n = 8
(1175 patients)
Doppler, n = 12
(1145 patients)
Pulse Contour, n=29
(2621 patients)
A line, n = 1
(33 patients)
CVC, n = 2
(214 patients)
#Title, author and yearnParameters optimizedSurgeryToolMain benefits
1 Prospective trial of supranormal values of survivors as tderapeutic goals in high-risk patients. Shoemaker 1988 310 DO2 General PAC-1 "Morbidity Mortality (21vs34%) Cost-savings"
2 Preoperative optimization of cardiovascular hemodynamics improves outcomes in peripheral vascular surgery. Berlauk 1991 89 CI, PCWP, SVR Vascular PAC-2 Morbidity
3 Prospective trial of supranormal values as goals of resuscitation in severe trauma. Fleming 1992 67 DO2 Trauma PAC-3 Morbidity
4 A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk patients. Boyd 1993 107 DO2 General PAC-4 Morbidity Mortality (6vs22%) Cost-savings
5 Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Mythen 1995 60 SV Cardiac Doppler-1 Morbidity Hospital LOS
6 Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. Sinclair 1997 40 SV Hip Doppler-2 Hospital LOS
7 Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supra- normal oxygen delivery and consumption. Ueno 1998 34 DO2 Hepatectomy PAC-5 Morbidity
8 Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimization of oxygen delivery. Wilson 1999 138 DO2 General and vascular PAC-6 Morbidity Hospital LOS Cost-savings
9 A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Polonen 2000 393 SvO2 Cardiac PAC-7 Morbidity Hospital LOS
10 Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Lobo 2000 37 DO2 General PAC-8 Morbidity Mortality (16vs50%)
11 Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Venn 2002 59 SV HIP Doppler-3 Morbidity
12 Goal-directed Intraoperative fluid administration reduces length of hospital stay after major surgery. Gan 2002 100 SV General Doppler-4 Morbidity Hospital LOS
13 Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Conway 2002 57 SV Bowel Doppler-5 Morbidity
14 Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. McKendry 2004 174 SV Cardiac Doppler-6 Hospital LOS
15 Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Wakeling 2005 128 SV Bowel Doppler-7 Morbidity Hospital LOS
16 Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Pearse 2005 122 DO2 General LidCO-1 Morbidity Hospital LOS
17 Randomized clinical trial assessing the effect of Doppler- optimized fluid management on outcome after elective colorectal resection. Noblett 2006 108 SV Bowel Doppler-8 Morbidity Hospital LOS
18 "Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Chytra 2007" 162 SV Trauma Doppler-9 Morbidity Hospital LOS
19 Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Lopes 2007 33 PPV General A line-1 Morbidity Hospital LOS
20 Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Donati 2007 135 ERO2 General and vascular CVC-1 Morbidity Hospital LOS
21 Goal-directed intraoperative therapy based on Autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Mayer 2009 60 SVV, SVI, CI Abdominal FloTrac sensor-1 Morbidity Hospital LOS
22 Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Benes 2010 120 SVV, CI Abdominal and vascular FloTrac sensor-2 Morbidity
23 Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Jhanji 2010 135 SV, DO2 Abdominal LidCO-2 Morbidity
24 Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Cecconi 2011 40 DO2 Hip FloTrac sensor-3 Morbidity
25 A double-blind randomized controlled clinical trial to assess the effect of doppler optimized intraoperative fluid management on outcome following radical cystectomy. Pillai 2011 66 SV Cyctectomy Doppler-10 Morbidity
26 Haemodynamic optimisation in lower limb arterial surgery: room for improvement? Bisgaard 2012 40 SV, DO2 Vascular LidCO-3 Morbidity
27 "Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial. Ramsingh 2012" 38 SVV Abdominal FloTrac sensor-4 Morbidity Hospital LOS
28 Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. Scheeren 2012 40 SVV, SV Abdominal FloTrac sensor-5 Morbidity
29 Intraoperative fluid management in open gastrointestinal surgery: goal-directed versus restrictive. Zhang 2013 80 SVV, CI Thoracic FloTrac sensor-6 Morbidity
30 Individually optimized hemodynamic therapy reduces complications and length of stay in the Intensive Care Unit. Goepfert 2013 100 SVV, GEDI, CI, EVLW Cardiac PiCCO-1 Morbidity
31 Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Salzwedel 2013 160 PPV, CI Abdominal ProAQT-1 Morbidity Hospital LOS
32 Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. Zheng 2013 60 SVV, SVI, CI Abdominal FloTrac sensor-7 Morbidity Hospital LOS
33 Zakhaleva, J., et al., The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: a randomized controlled trial. Colorectal Dis, 2013. 15(7): p. 892-9. 91 SV Abdominal surgery TED Morbidity
34 "Peng, K., et al., Goal-directed fluid therapy based on stroke volume variations improves fluid management and gastrointestinal perfusion in patients undergoing major orthopedic surgery. Med Princ Pract, 2014. 23(5): p. 413-20." 80 SVV Orthopedic surgery PC FloTrac sensor GI recovery
35 "Zeng, K., et al., The influence of goal-directed fluid therapy on the prognosis of elderly patients with hypertension and gastric cancer surgery. Drug Des Devel Ther, 2014. 8: p. 2113-9." 60 SVV Gastrectomy PC FloTrac sensor Morbidity, hospital length of stay
36 Colantonio, L., et al., A randomized trial of goal directed vs. standard fluid therapy in cytoreductive surgery with hyper- thermic intraperitoneal chemotherapy. J Gastrointest Surg, 2015. 19(4): p. 722-9. 80 CI, SVI Cytoreductive surgery PC FloTrac sensor Morbidity, hospital length of stay
37 Funk, D.J., et al., A randomized controlled trial on the effects of goal-directed therapy on the inflammatory response open abdominal aortic aneurysm repair. Crit Care, 2015. 19: p. 247. 40 SVV, CI Vascular surgery PC FloTrac sensor Morbidity
38 "Mikor, A., et al., Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial. BMC Anesthesiol, 2015. 15: p. 82." 79 ScvO2 Abdominal surgery CVC Cevox Mortality and oxygen delivery
39 Han, G., et al., Application of LiDCO-Rapid in peri-operative fluid therapy for aged patients undergoing total hip replace- ment. International Journal of Clinical and Experimental Medicine, 2016. 9(2): p. 4473-4478. 40 SVV Orthopedic surgery "PC LiDCO rapid" Morbidity
40 Hand, W.R., et al., Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer. Head Neck, 2016. 38 Suppl 1: p. E1974-80. 94 SVV, CI, SVR Free tissue surgery PC FloTrac sensor ICU length of stay
41 Kapoor, P.M., et al., Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: “A clinical outcome and biomarker- based study”. Ann Card Anaesth, 2016. 19(4): p. 638-682. 130 SVV, CI, SVI, SVRI, DO2 Cardiac surgery "PC FloTrac sensor, Edwards oximetry CVC" ICU Length of Stay, Hospital Length of Stay
42 Kumar, L., S. Rajan, and R. Baalachandran, Outcomes associated with stroke volume variation versus central venous pressure guided fluid replacements during major abdominal surgery. J Anaesthesiol Clin Pharmacol, 2016. 32(2): p. 182-6. 60 SVV Abdominal surgery PC FloTrac sensor ICU Length of Stay
43 Osawa, E.A., et al., Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review. Crit Care Med, 2016. 44(4): p. 724-33. 126 CI, SVI Cardiac surgery "PC LidCO Rapid" Morbidity, ICU Length of Stay, Hospital Length of Stay
44 Yuanbo, Z., et al., ICU management based on PiCCO parameters reduces duration of mechanical ventilation and ICU length of stay in patients with severe thoracic trauma and acute respiratory distress syndrome. Annals of Intensive Care, 2016. 6(1): p. 113. 264 ITBVI, EVLWI, CI "ICU treatment of ARDS" PC PiCCO MV days, ICU Length of stay and Cost savings
45 Elgendy, M.A., I.M. Esmat, and D.Y. Kassim, Outcome of intraoperative goal-directed therapy using Vigileo/FloTrac in high-risk patients scheduled for major abdominal surgeries: A prospective randomized trial. Egyptian Journal of Anaesthesia, 2017. 86 SVV, CI, MAP Major abdominal surgery PC FloTrac sensor Morbidity, ICU length of stay
46 "Kapoor, P.M., et al., Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth, 2017. 20(1): p. 83-89." 163 "SVV, CI, ScvO2" Cardiac surgery VolumeView set, PC FloTrac sensor ICU Length of Stay, Hospital Length of Stay
47 "Kaufmann, K.B., et al., Oesophageal Doppler guided goal-directed haemodynamic therapy in thoracic surgery - a single centre randomized parallel-arm trial. Br J Anaesth, 2017. 118(6): p. 852-861." 100 "SV, CI MAP" Thoracic surgery TED Morbidity, Hospital Length of Stay
48 Liang, M., et al., Effect of goal-directed fluid therapy on the prognosis of elderly patients with hypertension receiving plasmakinetic energy transurethral resection of prostate. Int J Clin Exp Med, 2017. 10(1): p. 1290-1296. 60 SVV Urological- Prostate resection PC FloTrac sensor Morbidity, Hospital Length of Stay
49 Luo, J., et al., Goal-directed fluid restriction during brain surgery: a prospective randomized controlled trial. Ann Intensive Care, 2017. 7(1): p. 16. 145 SVV, CI Neuro- surgery PC FloTrac sensor ICU length of stay and costs, morbidity
50 Weinberg, L., et al., Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial. PLoS One, 2017. 12(9): p. e0183313. 52 SVV, CI Abdominal PC FloTrac sensor Morbidity, Hospital Length of Stay
51 Wu, C.Y., et al., Comparison of two stroke volume variation-based goal-directed fluid therapies for s upratentorial brain tumour resection: a randomized controlled trial. Br J Anaesth, 2017. 119(5): p. 934-942. 80 SVV Neuro- surgery PC FloTrac sensor ICU length of stay, morbidity
52 Wu, J., et al., Goal-directed fluid management based on the auto-calibrated arterial pressure-derived stroke volume variation in patients undergoing supratentorial neoplasms surgery. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERI- MENTAL MEDICINE, 2017. 10(2): p. 3106-3114. 66 SVV, CI, MAP Brain surgery PC FloTrac sensor Morbidity lactate

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References

  1. Benes, J., Giglio M., Michard, F. (2014) The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Critical Care, 18(5), 584
  2. Giglio, MT., Marucci, M., Testini, M., Brienza, N. (2009) Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia, 103(5), 637-46
  3. Johnson, A., Ahrens, T. (2015) Stroke Volume Optimization: The New Hemodynamic Algorithm. Critical Care Nurse, 35(1), 11-27
  4. O’Leary, M. (2001) Preventing renal failure in the critically ill. BMJ, 322(7300), 1437-1439
  5. Holte, K. (2010) Pathophysiology and clinical implications of perioperative fluid management in elective surgery. Danish Medical Bulletin, 57(7), B4156
  6. Berkenstadt, H., et al. (2001) Stroke Volume Variation as a Predictor of Fluid Responsiveness in Patients Undergoing Brain Surgery. Anesthesia & Analgesia, 92, 984-9
  7. Cannesson, M. (2010) Arterial pressure variation and goal-directed fluid therapy. Journal of Cardiothoracic and Vascular Anesthesia, 24(3), 487-97
  8. Peng, K., Li, J., Cheng, H., Ji, FH. (2014) Goal-directed fluid therapy based on stroke volume variations improves fluid management and gastrointestinal perfusion in patients undergoing major orthopedic surgery. Medical Principles and Practice, 23(5), 413-20
  9. Michard, F., Mountford, W., Krukas, M., Ernst, F., Fogel, S. (2015) Potential return on investment for implementation of perioperative goal-directed fluid therapy in major surgery: a nationwide database study. Perioperative Medicine, 4, 11. 
  10. Ghaferi, A., Birkmeyer, J., Dimick, J. (2009) Variation in hospital mortality associated with inpatient surgery. New England Journal of Medicine, 361(14), 1368-75
  11. Khuri, S., Henderson, W., DePalma, R., Mosca, C., Healey, N., Kumbhani, D. (2005) Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Annals of Surgery, 242(3), 326-41
  12. Aya, H., Cecconi, M., Hamilton, M., Rhodes, A. (2013) Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. British Journal of Anaesthesia, 110(4), 510-7
  13. Brienza, N., Giglio, M., Marucci, M., Fiore, T. (2009) Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Critical Care Medicine, 37(6), 2079-90
  14. Grocott, M., Dushianthan, A., Hamilton, M., Mythen, M., Harrison, D., Rowan, K. (2012) Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane Database of Systematic Reviews, 11, CD004082
  15. Corcoran, T., Rhodes, J., Clarke, S., Myles, P., Ho, K. (2012) Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesthesia & Analgesia, 114(3), 640-51
  16. Boltz, M., Hollenbeak, C., Ortenzi, G., Dillon, P. (2012) Synergistic implications of multiple postoperative outcomes. American Journal of Medical Quality, 27(5), 383-90
  17. CL Gurudatt. Perioperative fluid therapy: How much is too much? Indian J Anaesth. 2012 Jul-Aug; 56(4): 323-325

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