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.

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: $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


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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. Bellamy, M. (2006) Wet, dry or something else? British Journal of Anaesthesia, 97(6), 755-7

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