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,
- BJA British Journal of Anaesthesia 11/2002; 89(4):622-32. · 4.24 Impact Factor
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ABSTRACT: Pulmonary edema is a known postoperative complication, but the clinical manifestations and danger levels for fluid administration are not known. We studied (1) 13 postoperative patients (11 adult, 2 pediatric) who developed fatal pulmonary edema, and (2) one contemporaneous year of inpatient operations at two university teaching hospitals to determine the clinical manifestations, causes, epidemiology, and guidelines for fluid administration. Retrospective analysis of 13 patients with fatal postoperative pulmonary edema and one contemporaneous year of major inpatient surgery. Thirteen patients had net fluid retention of at least 67 mL/kg in the initial 24 postoperative hours and developed pulmonary edema. Ten were generally healthy while three had serious associated medical conditions. There was no measurement, laboratory value, or clinical finding predictive of impending pulmonary edema. The most common clinical manifestation following the onset of pulmonary edema was cardiorespiratory arrest (n = 8). Patients had metabolic acidosis (pH = 7.15 +/- .33), hypoxia (PO2 = 45 +/- 18 mm Hg), and normal electrolytes. The diagnosis of pulmonary edema was established by chest radiograph and confirmed by autopsy and pulmonary artery pressure (21 +/- 4 mm Hg). The mean net fluid retention was 7.0 +/- 4.5 L (90 +/- 36 mL/kg/d) and exceeded 67 mL/kg/d in all patients. Autopsy revealed pulmonary edema with no other cause of death. Among 8,195 major operations, 7.6% developed pulmonary edema with a mortality of 11.9%. Extrapolation to the 8.2 million annual major surgeries in the United States yields a projection of 8,000 to 74,000 deaths. Pulmonary edema can occur within the initial 36 postoperative hours when net fluid retention exceeds 67 mL/kg/d. There are no known predictive warning signs and cardiorespiratory arrest is the most frequent clinical presentation. The monitoring systems currently in use neither detect nor predict impending pulmonary edema, and as yet, there are no known panic values for excessive fluid administration or retention.Chest 06/1999; 115(5):1371-7. · 5.85 Impact Factor
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ABSTRACT: Fluid therapy is one of the most controversial topics in perioperative management. There is continuing debate with regard to the quantity and the type of fluid resuscitation during elective major surgery. However, there are increasing reports of perioperative excessive intravascular volume leading to increased postoperative morbidity and mortality. Recent evidence suggests that judicious perioperative fluid therapy improves outcome after major elective gastrointestinal surgery. The observed benefits may not be solely attributable to crystalloid restriction but also to the use of colloids instead. Some clinically useful guidelines based on the studies discussed in this review include avoidance of deep general anesthesia and elimination of preload for patients who receive epidural analgesia. A balanced approach to fluid management is recommended, with colloids administered to provide hemodynamic stability and maintain urine output of 0.5 mL x kg(-1) x h(-1) and crystalloids administered only for maintenance. In addition, blood loss may be replaced with colloid on a volume-to-volume basis. Furthermore, predetermined algorithms that suggest replacement of third space losses and losses through diuresis are unnecessary. Significant reduction in crystalloid volume can be achieved without encountering intraoperative hemodynamic instability or reduced (i.e., < 0.5 mL x kg(-1) x h(-1)) urinary output just by avoiding replacement of third space losses and preloading. Finally, there is a need for well-controlled studies in a well-defined patient population using clear criteria or end-points for perioperative fluid therapy.Anesthesia & Analgesia 08/2005; 101(2):601-5. · 3.30 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 firstname.lastname@example.org.
©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