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
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