Goal Directed Fluid Therapy: An Essential Component of ERAS - PowerPoint Presentation

Slide1

Goal Directed Fluid Therapy: An Essential Component of ERAS

D. John Doyle MD PhDChief, Department of General AnesthesiaCleveland Clinic Abu Dhabi

No Conflicts of InterestNo Financial DisclosuresSlide2

This talk can be downloaded

http://tinyurl.com/pcylf8jSlide3

Some Take Home Points

The classical approach to fluid administration during surgery is flawed.Third-spacing is a myth.Fluid boluses may be harmful.CVP measurements are not as useful as we once thought and high CVP levels may be harmful.Earlier recommendations for fluid management in sepsis seem to be mistaken. Individualized goal-directed fluid therapy (GDFT) is recommended

, which may include zero-balance fluid management.Slide4

Let’s Start with a Cautionary TaleSlide5

2011 - A Cautionary Tale

Mortality

 after fluid bolusin African children with severe infection.N Engl J Med. 2011 Jun 30;364(26):2483-95.

“Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa.”Slide6

FEAST Trial

“Fluid Expansion As Supportive Therapy”Patients were children with infectious shock(e.g., from malaria); median age

24 months Inclusion criteria: Severe febrile illness AND

Impaired consciousness or respiratory distress ANDImpaired perfusion (including capillary refill time, tachycardia, thready radial pulse or lower limb temperature gradient)

In stratum A each

child was

randomised

to either

:

Bolus

0.9% Saline (20ml/kg over one hour) 

OR

Bolus

5% Albumin (20ml/kg over one hour) 

ORMaintenance fluids (2.5—4ml/kg/hour)Slide7

Results

Maintenance fluids conferred a 3.3% survival benefit at 48 hours over EITHER bolus albumin OR bolus saline. (p=0.01)The mortality at 48 hours was 7.3% for those who were given no bolus, vs 10.5% for either bolus fluids.

There was no differences between albumin and saline groups.Most deaths (87%) occurred

in the first 24 hours.

Cumulative

probability of

death

over time (hours)

Bolus

No BolusSlide8

Lessons Learned

This was a

landmark study investigating the effects of fluid boluses in the resuscitation of febrile children with poor perfusion.

The unexpected results require that we reassess our assumptions about fluid resuscitation.Slide9

http://www.edwards.com/devices/Hemodynamic-Monitoring/FloTracSlide10

Three schools

of thought for fluid therapy during major surgery The classical approach - results in a postoperative weight increase of 3–6

kg from replacement of fluid losses, including the so-called third-space losses. Still taught in some anesthesia textbooks.The fluid bolus approach - where

fluid boluses are given to reach near-maximal stroke volume, (e.g., as measured via esophageal Doppler),a

defined CVP

range,

a

defined ScvO2

range, etc.

The

restricted approach

-

where all measured fluid losses are replaced with a

goal of zero fluid balance

and without

the replacement of third-space losses. This approach is based on the hypothesis that excess fluid causes interstitial edema harmful for tissue healing and cardiac and pulmonary

function.Modified from: Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SÅ, Hansen B,

Møller

DR

,

Lundbech

LB, Andersen N, Berg V,

Thomassen

N, Andersen ST,

Simonsen L. Which goal

for fluid therapy during colorectal surgery is followed by the best outcome

: near-maximal

stroke volume or zero fluid balance? Br J

Anaesth

.

2012 Aug;109(2

):191-9

.Slide11

Which approach is best?Slide12

What about the classical approach?Slide13

The Problem with the Classical Approach: Third-Spacing is a

MythSlide14

Third-Spacing is a Myth

“In summary, a classic third space was never localized and only “quantified” with one specific method using certain conditions regarding sampling and equilibration times, implying serious concerns and weaknesses. All other methods using various tracers, multiple sampling techniques, longer equilibration times, or analysis of kinetics contradict the existence of a fluid-consuming third space. Taking all this into account, we have to conclude that a classic third space per se quantitatively does not exist.

It is currently not more than an ill-defined compartment thought to reflect an otherwise unexplainable perioperative fluid shift. Therefore, we suggest abolishing this mystery and sticking to the given facts: Fluid is perioperatively shifted within the functional extracellular compartment, from the intravascular toward the interstitial space”

Chappel D et. al. Anesthesiology 109, 723: 2008Slide15

What about the

fluid bolus approach?

Which parameter(s) to track?

BPCVP

PAP

PCWP

SvO2 / ScvO2

Systolic Pressure Variability

Pulse Pressure Variation

Bio-impedance stroke volume

Bio-reactance stroke volume

Esophageal Doppler

IVC ultrasound imaging

Urine output

Physical examinationSlide16

Some More Disappointing StudiesSlide17

ProCESS Investigators, Yealy DM, Kellum JA, Huang DT,

Barnato AE, WeissfeldLA, Pike F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI,Angus DC. A randomized trial of protocol-based care for early septic shock. NEngl

J Med. 2014 May 1;370(18):1683-93.

“In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.”

2014 -

ProCESS

TrialSlide18

INTERVENTIONS/ COMPARISONS

Protocol-based standard therapy n=446Early goal directed therapy (EGDT) n=439 (as per Rivers protocol)Usual care n=458  (at the discretion of the treating physician)

OUTCOMESPrimary outcome: No

difference in in-hospital death at 60 days:  EGDT 21%, Protocol 18.2%, Usual care 18.9%Secondary

outcome:

More

ICU admissions in the EGDT group: 

EGDT 91.3

%, Protocol

85.4

%, Usual care

86.2

%

2014 -

ProCESS

Trial

NEngl J Med. 2014 May 1;370(18):

1683-93Slide19

Protocol-based

standard therapySlide20

Rivers protocol - N

Engl

J Med 2001; 345:1368-1377Slide21

2014 -

ProCESS Trial

EGDT Highest Mortality

“In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.” Slide22

N

Engl J Med 2014;371:1496-506.

Early goal-directed therapy (EGDT) has been endorsed to decrease mortality among patients presenting with septic shock. However, in critically ill patients presenting to the emergency department with early septic shock, EGDT based on continuous ScvO

2 (central venous oxygen saturation) measurements did not reduce all-cause mortality at 90 days. Incorporating EGDT based on ScvO2

into guidelines is questionable.

2014 – ARISE TrialSlide23

The FENICE study

Evaluated approaches to fluid resuscitation in 46 countries and concluded that the “current practice and evaluation of fluid management in critically ill patients seems to be arbitrary… is not evidence-based

and could be harmful.” Cecconi M, Hofer C, Teboul JL, et al; FENICE Investigators and the ESICM Trial Group: Fluid challenges in intensive care: The FENICE study: A global inception cohort study. Intensive Care Med 2015; 41:1529–1537

2014Slide24

Time for a re-examinationSlide25

2015

Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy asan adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015Feb;62(2):158-68. Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways.

Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic

state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central

euvolemia

and to

avoid excess salt and water

. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an

individualized fluid management plan.

As part of this plan,

excess crystalloid should be avoided in all patients

. For low-risk patients undergoing low-risk surgery, a “zero-balance” approach might be sufficient. In addition, for most patients undergoing major surgery,

individualized goal-directed fluid therapy (GDFT) is recommended

. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated.

In the absence of other concerns, detrimental postoperative fluid overload is not justified and “permissive oliguria” could be tolerated

.Slide26

“Several recent studies performed to test the effectiveness of GDFT within an ERAS protocol have failed to find the same benefit on postoperative outcomes as that found in earlier studies. Perhaps this is not surprising, as significant improvement in perioperative fluid management within an ERAS protocol, particularly in the past 15 years, has facilitated significant improvement in the quality of care in control groups of fluid management studies

.”Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015 Feb;62(2

):158-68. Slide27

2016'Enhanced recovery after surgery'

(ERAS) protocols implement a series of peri-operative interventions intended to improve recovery after major operations, one aspect of which is fluid management. The pre-operative goal is to prepare a hydrated, euvolaemic

patient by avoiding routine mechanical bowel preparation and by encouraging patients to drink clear liquids up to two hours before induction of anaesthesia. The intra-operative goal is to achieve a 'zero' fluid balance at the end of uncomplicated surgery: goal-directed fluid therapy is recommended for poorly prepared or sick patients or those undergoing more complex surgery. The postoperative goal is eating and drinking without intravenous fluid infusions. Postoperative oliguria should be expected and accepted, as urine output does not indicate overall fluid status

. Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery.

Anaesthesia

. 2016 Jan;71

Suppl

1:40-5 Slide28

Fluid

Therapy for ERAS

Pre-operative goalsIntra-operative goalsPostoperative goals Slide29

Fluid Therapy for ERAS

“The pre-operative goal is to prepare a hydrated, euvolaemic patient by avoiding routine mechanical bowel preparation and by encouraging patients to drink clear liquids up to two hours before induction of anaesthesia.”

Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery. Anaesthesia. 2016 Jan;71 Suppl 1:40-5. Slide30

Fluid Therapy for ERAS

“The intra-operative goal is to achieve a 'zero' fluid balance at the end of uncomplicated  surgery; goal-directed

 fluid therapy is recommended for poorly prepared or sick patients or those undergoing more complex surgery.” Gupta R, Gan TJ. Peri-operative fluid management

to enhance recovery. Anaesthesia. 2016 Jan;71 Suppl 1:40-5. Slide31

Fluid Therapy for ERAS

“The postoperative goal is eating and drinking without intravenous fluid infusions. Postoperative oliguria should be expected and accepted, as urine output does not indicate overall fluid status.”Gupta R, Gan TJ.

Peri-operative fluid management to enhance recovery. Anaesthesia. 2016 Jan;71 Suppl 1:40-5. Slide32

A risk-adapted matrix to match monitoring needs to patient and surgical risk.

Miller

TE, Roche AM,

Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J

Anaesth

.

2015 Feb;62(2

):158-68.

Individualized goal-directed fluid therapy (GDFT

)Slide33

Perils of Aggressive Fluid Resuscitation

New evidence suggests that aggressive fluid resuscitation leads to severe tissue edema that compromises organ function and leads to increased morbidity and mortality

Marik PE: Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care 2014; 4:21 Kelm

DJ, Perrin JT, Cartin-Ceba R, et al: Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 2015; 43:68–73Slide34

Zero-Balance Fluid ManagementSlide35

Fluid Responsiveness and the Six GuidingPrinciples of Fluid Resuscitation

Paul E. Marik, Crit Care Med 2016 Slide36

Principle 1

Fluid boluses are most frequently given to hypotensive patients; however, only patients who are fluid responsive should be resuscitated with fluid boluses.Slide37

Principle 1

The only reason to give a patient a fluid challenge is to increase the stroke volume (SV); if this does not happen, fluid administration serves no purpose and may be harmful.

A patient is considered to be fluid responsive if the SV increases by at least 10% following a fluid challenge (usually 500 cc of crystalloid)

Marik PE, Monnet X, Teboul JL: Hemodynamic parameters to guide fluid therapy. Ann Intensive Care 2011; 1:1Slide38

Fluid Administration to Increase SV

Fluid administration will increase SV only if two conditions are met: [1] The fluid bolus increases the “stressed blood volume”

[2] Both ventricles are functioning on the ascending limb of the Frank-Starling curve.Marik PE. The physiology of volume resuscitation.

Curr Anesthesiol Rep 2014; 4:353–359Slide39

Principle 2

Although clinical signs, such as a hypotension, tachycardia, narrow pulse pressure, poor skin perfusion, and slow capillary refill, may be helpful for identifying inadequate perfusion, these signs are unable to determine volume status or

fluid responsiveness. Saugel B, Ringmaier S, Holzapfel K, et al: Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary

thermodilution-derived hemodynamic parameters in critically ill patients: A prospective trial. J Crit Care 2011; 26:402–410Slide40

Principle 2

Additionally….The CVP or change in CVP following a fluid challenge is not accurate in predicting fluid responsiveness (

Crit Care Med 2013; 41:1774–1781). The change in the mean arterial pressure (MAP) following a fluid bolus is also poorly predictive of fluid responsiveness

(Intensive Care Med 2015; 41:1247–1255).Ultrasonography of the IVC and its respiratory variation are no more predictive than the CVP for assessing fluid responsiveness (

Emerg

Med

Australas

2012; 24:534–539).Slide41

Principle 3

Passive leg raising (PLR) predicts whether cardiac output will increase with volume expansion

http://crashingpatient.com/resuscitation/predicting-fluid-responsiveness.htmSlide42

“In acute circulatory failure, passive leg raising (PLR) is a test that predicts whether cardiac output will increase with volume expansion 

[1]. By transferring a volume of around 300 mL of venous blood [2] from the lower body toward the right heart, PLR mimics a fluid challenge. However, no fluid is infused and the hemodynamic effects are rapidly reversible [1

],[3], thereby avoiding the risks of fluid overload. This test has the advantage of remaining reliable in conditions in which indices of fluid responsiveness that are based on the respiratory variations of stroke volume cannot be used [1], like spontaneous breathing, arrhythmias, low tidal volume ventilation, and low lung compliance.”

[1] Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR,

Teboul

JL. Passive leg raising predicts fluid responsiveness in the critically ill.

Crit

Care Med. 2006; 34:1402-1407.

[2] Jabot J,

Teboul

JL, Richard C, Monnet X. Passive leg raising for predicting fluid responsiveness: importance of the postural change. Intensive Care Med. 2009; 35:85-90.

[3]

Boulain

T,

Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest. 2002; 121:1245-1252.

Monnet X, Teboul

JL. Passive leg raising: five rules, not a drop of fluid

!

Crit

Care. 2015 Jan 14;19:18.

Slide43

Monnet X,

Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, Teboul

JL. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006; 34:1402-1407. Jabot J, Teboul JL, Richard C, Monnet X. Passive leg raising for predicting fluid responsiveness: importance of the postural change. Intensive Care Med. 2009; 35:85-90.

Boulain T, Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest. 2002; 121:1245-1252.

From

http

://www.ccforum.com/content/19/1/18Slide44

NoninvasiveReal-Time Cardiac OutputSlide45

Principle 4

The hemodynamic response to a fluid challenge is usually small and short lived.Example study: Nunes

et al. evaluated the effect duration of a fluid bolus in patients in shock. 65% of patients were fluid responders whose cardiac index increased by 25% at the end of the 30 min infusion. However

, the cardiac index had returned to baseline 30 minutes after the end of the infusion. (Ann Intensive Care 2014; 4:25) Slide46

Principle 5Most healthy humans

function on the ascending limb of the Frank-Starling curve; they have preload reserve and do not require fluid. Similarly, most critically ill and injured patients and patients undergoing surgery do not need to be pushed to the top of their Frank-Starling curve.

Patients should only receive a fluid bolus if they are preload responsive and expected to benefit from the fluid.Slide47
Slide48

Principle 6

High CVP levels are bad!“There are now compelling data that the primary hemodynamic goal in critically ill and injured patients and those undergoing surgery is an MAP of greater than 65 mm Hg and a CVP of less than 8 mm Hg. Remarkably, this CVP target contradicts current

guidelines that recommend targeting a CVP of greater than 8 mm Hg.”Slide49

Conclusions

The classical approach to fluid administration during surgery is flawed.Third-spacing is a myth.Fluid boluses may be harmful.CVP measurements are not as useful as we once thought.High CVP levels may be harmful.

Earlier recommendations for fluid management in sepsis seem to be mistaken. Individualized goal-directed fluid therapy (GDFT) is recommended, which may include zero-balance fluid management.

Almost everything you learned about perioperative fluid therapy is now suspect!Slide50

The End