Perioperative Fluid Management

R3

Several area of research

The kinetics of plasma volume expansion(PVE) produced by intravenous fluid The use of systemic oxygen delivery as a goal of resuscitation the effects of fluid therapy on cerebral hymodynamics

The kinetics of plasma volume expansion produced by intravenous fluids

Prediction of plasma volume expansion using static assumption

static effect of fluid infusion on PVE PVE = volume infused x (PV/Vd)
Ex) 500ml blood loss with LRS or 0.9% saline. Vd= ECV ; 500 = vloume infused x (3/14) ; 2.3l infused volume necessary

Fluid distribution volume

The rate fluid filters through capillary membrane into the interstitial space
Q = kA [(Pc Pi) +

(i-c)]

Q = fluid filtration k = the capillary hydrostatic pressure(conductive of water) A = the area of the capillary membrane Pc = capillary hydrostatic pressure Pi = interstitial hydrostatic pressure = the reflection coefficient for albumin i = interstitial colloid oncotic pressure c = capillary colloid oncotic pressure

Fluid filtration
Ex) Increasing Pc or decreasing c - water and sodium ; filtered more rapidly than protein - resulting in preservation of Pc, dilution i , enhancement of lymphatic flow, preservation of the oncotic pressure gradient, the most powerful factor opposing fluid filtration

Prediction of plasma volume expansion using kinetic analysis

Same purposes as pharmacokinetic analysis of drug concentration Estimation of the PVE and rates of clearance of infused fluid The effects of fluid infusion must be inferred from changes in the concentration of other variables
Blood water concentration, serum albumin concentration, and total Hb

Prediction of PV expansion using kinetic analysis

Small proportion of crystalloid remaining in the vascular tree after equilibration

Fluid requirement in the surgery and trauma

Acute sequestration of interstitial fluid ;trauma, hemorrhage, tissue manipulation. during the first 10dys after resuscitation from massive trauma
- decrease in ICV, increase in total body weight, increase in IFV.

third postoperative day

- accumulated fluid mobilize and return to the PV - Hypervolemia and pulmonary edema ; cardiovascular and renal system cannot compensate

Systemic oxygen delivery as a goal of fluid resuscitation

Relation among postoperative complication ( ARF, hepatic failure, sepsis) and systemic oxygen delivery ; unrecognized, subclinical tissue hypoperfusion

Systemic oxygen delivery(1)

DO2 = Q x CaO2 x 10
DO2; systemic oxygen delivery Q; cardiac output CaO2 ; arterial oxygen content

DO2
; regulated through dilatation and constriction of vascular bed in response to change in regional and systemic oxygen consumption

Systemic oxygen delivery(2)

Average Q and DO2
greater in high-risk surgical patient

Heyland et al
achieving recommended goal of cardiac index, oxygen delivery, oxygen consumption did not reduce mortality rate but improve outcome in surgical patient if treatment started before op

Boyed et al
- 107 high-risk surgical patient ; DO2 > 600mlO2.m.min treatment - decrease in the mortality rate

Systemic oxygen delivery(3)

Particular importance ; catecholamin used influence outcome Wilson et al
; inotropic support with dopexamine ; fewer complication and shorter hospital stays

Systemic oxygen delivery(4)

Aggressive elevation in DO2
; harmful

Gattinoni et al and Metrangolo et al

; treatment supposed to increase oxygen delivery did not reduce mortality or morbidity rate in sepsis

Some clinician
; increase oxygen delivery to specific target may be detrimental ; therapeutic intervention(dobutamin not dopexamin) disrupt individual organ function

The effect of fluid therapy on cerebral hemodynamic

After simple hemorrhagic shock
;conventional fluid resuscitation increases ICP but does not consistency restore CBF

The influence of resuscitation fluids on clinical outcome of patients with head injury requires continued investigation

The normal BBB

highly impermeable to sodium small changes in serum sodium exert greater osmotic pressure gradients than do large changes in serum protein concentrations enhances the influence on brain water of changes in serum sodium hypotonic solutions are more likely to increase the brain water content than 0.9% saline or colloid dissolved in 0.9% saline

After traumatic brain injury

BBB damaged Drummond et al
; after traumatic brain injury

- clloid osmotic pressure influence brain water accumulation

Hypertonic salt solutions

;acutely reduce brain water and therefore tend to reduce ICP ;In animal with intracranial mass lesions and hemorrhagic shock - also improved regional CBF and cerebral oxygen delivery

Hypertonic solution for prehospital resuscitation

Vassars et al
; compared 250ml LRS, 7.5% saline with 6% dextran 70 for prehospital resuscitaion of trauma patient ; no overall difference in mortality rate ; in the subset of patient with severe head injury - 7.5% saline in 6% dextran 70 ; 32% survival - LRS ; 16% survival

Hypertonic solution for prehospital resuscitation

Simma et al
; children with severe head injury to receive either hypertonic saline or LRS ; hypertonic saline
- fewer intervention to maintain ICP< 15mmHg, fewer overall complication

; survival and duration of hospital stay similar

Fluid management
Current regimens ; sufficient to restore systemic perfusion in most patient
undergoing surgery

Important question
; frequency of complication of current fluid therapy ; the comparative advantage of different fluid formulation