CON: Fluid restriction for cardiac patients during major noncardiac surgery should be replaced by goal-directed intravascular fluid administration.
ABSTRACT oncerns have been expressed that over- hydration may result in pulmonary edema, car- diac complications, delayed recovery of gastro- intestinal motility, compromised tissue oxygenation, wound healing problems, and blood coagulation im- pairment (1-3). Patients with a cardiac comorbidity undergoing major noncardiac surgery may be partic- ularly vulnerable and, therefore, perioperative fluid restriction might appear to be beneficial. However, there are at least 4 prospective random- ized trials showing that a goal-directed perioperative plasma volume expansion decreases major postoper- ative morbidity and the duration of hospitalization significantly (4-7). In all these studies, stroke volume in the descending aorta was assessed by esophageal Doppler monitoring. Two hundred mL of colloids were given over 10 min and stroke volume was as- sessed every 15 min. This was repeated until no fur- ther increase in stroke volume was detected. Indeed,
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ABSTRACT: Age-related changes in skin contribute to impaired wound healing after surgical procedures. Changes in skin with age include decline in thickness and composition, a decrease in the number of most cell types, and diminished microcirculation. The microcirculation provides tissue perfusion, fluid homeostasis, and delivery of oxygen and other nutrients. It also controls temperature and the inflammatory response. Surgical incisions cause further disruption of the microvasculature of aged skin. Perioperative management can be modified to minimize insults to aged tissues. Judicious use of fluids, maintenance of normal body temperature, pain control, and increased tissue oxygen tension are examples of adjustable variables that support the microcirculation. Anesthetic agents influence the microcirculation of a combination of effects on cardiac output, arterial pressure, and local microvascular changes. The authors examined the role of anesthetic management in optimizing the microcirculation and potentially improving postoperative wound repair in older persons.Anesthesiology 11/2013; · 5.16 Impact Factor
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ABSTRACT: Background/Purpose Ideal fluid management during surgery still poses a clinical dilemma gauging the benefits and adverse effects. This randomized controlled trial compared the tissue perfusion and coagulation profiles under clinically equivalent hydroxyethyl starch (HES 130/0.4) and lactated Ringer's solution (LR). Methods Eighty-four patients undergoing major abdominal surgery were randomized to receive either HES or LR. Tissue perfusion parameters using heart rate, arterial blood pressure, central venous pressure, cardiac index, stroke volume index, and central venous oxygen saturation were measured at T0 (baseline), T1 (start of surgery), T2 (1 hour after start of surgery), and T3 (end of surgery). Coagulation parameters using thrombelastography (TEG) were measured at T0 (baseline), T4 (after 15 mL/kg fluid transfused), and T5 (24 hours after baseline). Results The total amount of fluid administrated was 1547.9 ± 424.0 mL in HES group and 2303.1 ± 1033.7 mL in LR group (p < 0.001). The parameters of tissue perfusion and TEG did not differ significantly between groups at any time point except for a transient decrease in clot kinetic and clot strength at T4 for HES group. There was no significant difference in blood loss and consumption of blood products between the two fluids. Conclusion HES 130/0.4 is a more efficient intravascular volume expander to maintain tissue perfusion than conventional crystalloid. Transient hypocoagulability induced by HES 130/0.4 does not warrant excessive blood loss and blood transfusion.Journal of the Formosan Medical Association. 07/2014; 113(7):429-435.
- Revista medica de Chile 09/2011; 139(9):1157-1162. · 0.36 Impact Factor
CON: Fluid Restriction for Cardiac Patients During Major
Noncardiac Surgery Should be Replaced by Goal-Directed
Intravascular Fluid Administration
Donat R. Spahn, MD, FRCA, and Pierre-Guy Chassot, MD
intestinal motility, compromised tissue oxygenation,
wound healing problems, and blood coagulation im-
pairment (1–3). Patients with a cardiac comorbidity
undergoing major noncardiac surgery may be partic-
ularly vulnerable and, therefore, perioperative fluid
restriction might appear to be beneficial.
However, there are at least 4 prospective random-
ized trials showing that a goal-directed perioperative
plasma volume expansion decreases major postoper-
ative morbidity and the duration of hospitalization
significantly (4–7). In all these studies, stroke volume
in the descending aorta was assessed by esophageal
Doppler monitoring. Two hundred mL of colloids
were given over 10 min and stroke volume was as-
sessed every 15 min. This was repeated until no fur-
ther increase in stroke volume was detected. Indeed,
higher Doppler cardiac outputs were observed at the
end of surgery in the goal-directed perioperative
plasma volume expansion groups (4,5,7). Interest-
ingly, the reduction of duration of hospitalization was
2 days in general surgery in relatively young and
healthy patients (mean age, 55–60 yr) (4), 4 days in
cardiac surgery in 65-yr-old patients (7), and 4 to 8
days in 75- to 85-yr-old patients undergoing proximal
femoral fracture repair (5,6). Older age and increasing
comorbidity thus does not seem to limit but rather to
increase the benefit of a goal-directed perioperative
plasma volume expansion.
It is important to note that, first, supplemental fluid
was not just given on a routine basis but administered
goal-directed, the goal being the optimization of the
stroke volume as assessed by esophageal Doppler
monitoring (4–7). Second, goal-directed fluid therapy
reduces postoperative morbidity more when done
with colloids than with crystalloids (8), potentially
hydration may result in pulmonary edema, car-
diac complications, delayed recovery of gastro-
havebeen expressedthat over-
related to a lesser development of intestinal edema in
patients treated with colloids (9). This appears to be
particularly relevant in gastrointestinal surgery, where,
in the context of “fast-tracking,” intraoperative fluid re-
striction has become a hot topic (3). Crystalloid fluid
restriction and the individualized goal-directed admin-
istration of colloids thus are not opposing but rather
Esophageal Doppler monitoring used in the afore-
mentioned studies is easy to learn, but it is not widely
used and lacks validation. In contrast, arterial cathe-
ters are used extensively in daily practice, are easy to
place, and are rarely associated with serious compli-
cations. They continuously display the arterial wave-
form on the screen. The differential pressure between
systolic and diastolic values, the pulse pressure, and
the area under the curve, both easy to evaluate by
visually analyzing the curve, are proportional to the
actual blood volume pulsed toward the periphery.
Mechanical ventilation interferes with cardiac filling
and induces variations in stroke volume (10). The
degree of stroke volume variation is proportional to
the degree of hypovolemia and has been shown to
accurately forecast fluid responsiveness (10–13).
In contrast, central venous and capillary wedge
pressures are poor markers of volume status because
the relationship between pressure and volume, or
compliance of the cardiac chambers, cannot be deter-
mined clinically (14). Moreover, the compliance curve
is nonlinear. At low volume, filling pressure variations
are minimal in comparison with volume changes;
their sensitivity for hypovolemia thus is low. At high
filling pressure, however, the relationship is clinically
useful because volume changes are associated with
significant pressure changes (Fig. 1); the measurement
of filling pressures gives an accurate image of the
upper limit of fluid administration in patients with
cardiac dysfunction and may serve to avoid over-
hydration once stroke volume has been optimized
(Fig. 1). If cardiac compliance is abnormal, such as in
diastolic dysfunction, the filling pressure will be much
higher than expected for the same filling volume (Fig.
1). Most of the studies on invasive monitoring, such as
Swan-Ganz catheters in noncardiac surgery, have
given disappointing results because their populations
Accepted for publication October 17, 2005.
Address correspondence and reprint requests to Donat R. Spahn,
MD, FRCA, Professor and Chairman, Department of Anesthesiol-
ogy, University Hospital Lausanne (CHUV), CH – 1011 Lausanne,
Switzerland. Address e-mail to email@example.com.
©2006 by the International Anesthesia Research Society
Anesth Analg 2006;102:344–6 0003-2999/06
have not been selected and because the retrieval of the
monitored data has not been accompanied by a goal-
directed protocol of fluid administration (15–17). In ad-
dition, more complications were observed in the group
with invasive monitoring (18).
The cardiac dysfunction in a given patient may be
diastolic, systolic, or both. In each case, their optimal
end-diastolic wall stress, or filling volume, has a rela-
tively narrow range. Outside this range, their stroke
volume and cardiac output decrease by insufficient
wall stress in case of hypovolemia (Frank-Starling
phenomenon), or by congestive failure in case of hy-
pervolemia. In general, patients with a significant car-
diac dysfunction are exquisitely sensitive to volume
variations, which should be minimized.
How should we thus proceed practically? After an-
esthesia induction many patients are in a situation of
functional hypovolemia or reduced effective preload
from anesthetic vasodilatation and positive pressure
ventilation (10). These patients are thus on the ascend-
ing limb of the Frank-Starling curve and will benefit
from individualized goal-directed intravascular fluid
administration (Fig. 1), which moves them to the right
of their end-diastolic volume – stroke volume relation-
ship close to their optimum stroke volume (Fig. 1).
Once stroke volume has been optimized, this position
needs to be maintained and filling pressure monitored
to avoid over-filling resulting in severe complications
such as pulmonary edema (2). In addition, optimum
cardiac filling will prevent tachycardia from hypovo-
lemia, which dramatically increases the myocardial
oxygen consumption, and is particularly dangerous in
patients with or at risk of coronary artery disease.
It needs to be stressed once more that advanced
monitoring alone is neither sufficient nor beneficial. In
contrast, such monitoring may be associated with
complications in patients with cardiac comorbidities
undergoing noncardiac surgery (15,18). Only combin-
ing monitoring with a clear management algorithm
aiming at the optimization of the stroke volume with
colloid boluses in the presence of a knowledgeable
anesthesiologist (19) will improve the outcome of pa-
tients with concomitant cardiac disease undergoing
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EDITORIALS ANESTH ANALG