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Intraoperative Use of Crystalloids

M. Verhaegen

Anesthesiology

UZ KU Leuven

Intraoperative IV Fluid Therapy:Historical Perspective (1)

Fluid restriction

Postoperative Salt Intolerance(Coller et al, Ann Surg 1944, 119: 533-541)

No isotonic saline solution or Ringerssolution should be given during the day ofoperation and during the subsequent firsttwo postoperative days

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Fluid restriction

Trauma/surgery: large fluid deficits Acute Changes in Extracellular Fluid Associated

with Major Surgical Procedures(Shires et al., Ann Surg 1961, 154: 803-810)

Major surgery is associated with significant

functional extracellular fluid volume deficits Replace with large volumes of balanced

electrolyte solutions


Fluid restriction

Trauma/surgery: large fluid deficits

Crystalloid / colloid controversy More recent concepts of intraoperative

crystalloid administration

Problems associated with specificcomponents and/or their concentration

Sodium, chloride, lactate

Kinetic principles of fluid therapy

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Body fluids: VolumeCompositionConcentration

Microcirculatory organ perfusion

O2-delivery

Cellular function

Organ function

Body Fluid Compartments

Total body water = 60 % of body weight (BW)

2/3

Intracellular water= 40 % of BW

1/3

Extracellularwater

= 20 % of BW

Plasma (4 % of BW)

Extracellularwater

= 20 % of BW

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Body Fluid Compartments: Composition

2716Protein (g/dl)

2275Phosphorus (mEq/l)

282410Bicarbonate (mEq/l)

1101054Chloride (mEq/l)

2250Magnesium (mEq/l)

33

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Starlings Equation

Q = kA [ ( Pc - Pi ) + ( i - c ) ] (mEq / L)Q = fluid filtrationk = capillary filtration coefficient

A = area of the capillary membranePc = capillary hydrostatic pressure

Pi = interstitial hydrostatic pressure = reflection coefficient for albumini = interstitial colloid osmotic pressurec = capillary colloid osmotic pressure

Osmolality (mOsm/kg)

281.3282.6Total

0.21.2Protein

281.1281.4[Na+] (non-protein)

ISFPlasma

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5429.15454.2Total

3.923.2Protein

5425.25431.0[Na+] (non-protein)

ISFPlasma

25.1 mmHg

Osmotic pressure (mmHg)

Capillary

Ar ter ial Veno us

Interstitium

Lymphatic

drainage

Pc =

40 mmHgPc =

10 mmHg

c = 23 mmHg

Pi = 2 mmHgi = 4 mmHgFiltration Absorption

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Intraoperative Fluid Therapy

Basal fluid requirements

Correction of preoperative fluid deficits

Fasting

Disease-related fluid losses

Intraoperative fluid losses

Blood loss Redistribution: Third space fluid loss

Other fluid losses

Basal water losses parallel energy expendituresMaintenance fluids (hospitalized pts): 100 ml/100 kcal/d

From Holliday MA and Segar WE, Pediatrics (1957), 19

1000

1500

1700

1900

2100 2300

2500

Computed need foraverage hospital patients

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501 ml/kg/h> 20

202 ml/kg/h11 - 20

404 ml/kg/h0 10

70 kgVolumeWeight (kg)

Total 110 ml/h

4-2-1 rule

IntraoperativeBasal Fluid Requirements

Volume 4-2-1 rule

Increased

Composition Electrolytes

Sodium: 1 mEq/kg/d

Potassium: 0.7 mEq/kg/d

Glucose?

Replacement fluid D5W (+ electrolytes)

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Intraoperative Glucose

Indicated in type I diabetes mellitus

2-3 g/kg/d

Indicated if risk of hypoglycemia

TPN

Insulinoma

Prolonged (> 24 h) fasting Avoid if risk of cerebral ischemia

Hyperglycemia-induced cerebral acidosis

Correction ofPreoperative Fluid Deficit

Preoperative fasting fluid deficit

Basal maint. fluids/h x npo period (h)

1st

hour: 50 % of deficit 2nd hour: 25 % of deficit

3rd hour: 25 % of deficit

Additional fluid deficits

Disease-related fluid losses

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Elhakim et al., Acta Anaesth Scand (1998), 42

Time

VASfor nausea

(mm)

1 h 2 h 4 h 6 h 24 h 48 h 72 h0

5

10

15

20

25

30

Crystalloid

No crystalloid

**

*

**

* P>0.05

Elhakim et al., Acta Anaesth Scand (1998), 42* P>0.05

No crystalloidCrystalloid

1048 - 72 h

3024 - 48 h

806 - 24 h

004 - 6 h

102 - 4 h

220 - 2 h

806 h 3 d

34Day unit (6 h)

Vomiting (n)

*

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Surgical Fluid Losses (1)

Blood loss

Redistribution and subsequent loss ofextracellular and intracellular fluid

Replacement with crystalloids

Volume crystalloid:blood

3:1 to 5:1 (even 7:1) Composition

NaCl 0.9 %

Balanced electrolyte solution

Cervera et al., Am J Surg (1975), 129

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Surgical Fluid Losses (2)

Redistribution: Third space fluid loss

Sequestered extracellular fluid

Volume related to surgical trauma Minor: 2 - 4 ml/kg/h

Intermediate: 4 - 8 ml/kg/h

Major: 8 - 15 ml/kg/h

Replacement fluid NaCl 0.9 %

Balanced electrolyte solution

Roberts et al., Ann Surg (1985), 202

187 113253 50Duration (min)

10.6 1.912.3 7.0ECV postop (l)

12.5 2.412.5 2.3ECV preop (l)

530 921660 96Fluid (ml)

D5WLactated Ringers

* P

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Intraoperative Crystalloid Therapy:Lack of Good Target Points (1)

Cardiovascular parameters

ECG

Blood pressure

Central venous pressure

Pulmonary artery catheter

Transesophageal echocardiography

Perfusion directed therapy

Fluid overload


Cardiovascular parameters

Perfusion directed therapy

Global Lactate

Regional: Gastrointestinal Gastrointestinal Pco2 tonometry

Organ specific Kidney: urine output

Fluid overload

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Fluid overload

Intraoperative absorption of irrigating fluidsduring endoscopic surgery

Transurethral resection of the prostate

Hysteroscopic surgery

Absorption can be accurately monitored

Fatal postoperative pulmonary edema inhealthy (?) persons

Arieff, Chest 1999; 115 (5)

Fatal Postoperative Pulmonary Edema:Pathogenesis and Literature Review(Arieff: Chest 1999, 115: 1371-1377)

Fatal postoperative pulmonary edema

13 patients (incidence of 0.02 %) 10 generally healthy

3 serious associated medical conditions

Age 38 21 y

Within 3 postoperative days Range: 3 to 66 h, mean SD: 27 20 h

No predictive variables

No predictive warning signs Cardiorespiratory arrest first clinical sign in 8 pts

Fluid overload as single cause Mean net fluid retention of 7.0 4.5 l first 27 h postop

(24 % increase of total body water)

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Intraoperative Crystalloid Therapy:Problems

Serum osmolality

Effects on brain water and ICP

Hyperchloremic metabolic acidosis

Lactate

Adverse pharmacologic effects?

Acute Effects of Changing Osmotic Pressurein the Cerebral Capillaries

18654545640282.6292.6[Na+] 5 mEq/l

2302301.2Protein

4604602.4Protein x 2

054545454282.6282.6[Na+],protein,

non-protein

(Pl.-IF)IFPlasmaIFPlasmaOsmoles

Osm.Press.

Osmot. pressure(mmHg)

Osmolality(mOsm/kg)

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I.V. Fluids: Osmolality

308308Normal saline

254273Lact. Ringers

Osmolality

(mOsm/kg)

Osmolarity

(mOsm/L)

Williams et al., Anesth Analg 88 (1999)

-0.04#

0.04#

7.38

7.43

7.38

7.44

7.42

7.41

Whole blood pH

NS

LR

1 2*

-1 2*

141 2

140 2

141 2

139 2

140 2

140 1

Serum [Na+] (mEq/l)

NS

LR

0 4*

-4 3*

290 5

287 4

289 5

285 5

288 5

288 4

Serum osmolal. (mOsm/kg)

NS

LR

T2-T1T3T2T1

* P

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The Effect of the Reduction of Colloid Oncotic Pressure,

with and without Reduction of Osmolality, on Post-Traumatic Cerebral Edema.(Drummond et al.: Anesthesiology 1998, 88)

Blood Hetastarch Saline Half saline

Percussed hemisphere

Contralateral hemisphere81

80

79

78Percentw

aterbyweight

*

*

*

*

* P < 0.05 vs corresponding hemisphere in blood and hetastarch group

Drummond et al., Anesthesiology 88 (1998)

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Hyperchloremic Metabolic Acidosis

Dilutional acidosis

Metabolic acidosis resulting from rapidadministration of fluids that contain near-physiologic concentrations of sodiumaccompanied by anions (usually chloride)other than bicarbonate or bicarbonate

precursors, such as lactate.(D.S. Prough, Anesthesiology 2000)

Dose-dependent

Acidosis Associated with Perioperative Saline Administration.Dilution or Delusion?

(Prough: Anesthesiology 2000, 93, editorial)

20.422.925.2Liskaser

18.418.623.5Scheingraber

21.020.425.0McFarlane

21.621.023.6Rehm

25.025.127Waters

ActualPredictedFirst author

After infusionBeforeinfusion

[HCO3-] (mEq/l)

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Rapid Saline Infusion Produces Hyperchloremic Acidosis inPatients Undergoing Gynecological Surgery.(Scheingraber et al.: Anesthesiology 1999, 90)

1 075 799717 459Urine output (ml)

704 447962 332Estimated blood loss(ml)

67 1871 14Volume after 120 min

(ml/kg)

138 20135 23Time of infusion (min)

Lact. Ringers(n = 12)

Saline

(n = 12)

Scheingraber et al., Anesthesiology 90 (1999)

106104115104Chloride(mM)

12.5 1.815.8 1.411.8 1.416.2 1.2Anion gap(mM)

23.0 1.123.3 2.018.4 2.023.5 2.2Bicarbonate(mM)

120 min0 min120 min0 min

Lactated Ringer sSaline

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Lactated RingersNormal saline

7.50

7.45

7.40

7.35

7.30

7.25

7.20

0 30 60 90 120 min 0 30 60 90 120 min

0 30 60 90 120 min0 30 60 90 120 min

50

46

42

38

34

30

26

4

0

-4

-8

-12

3.0

2.5

2.0

1.5

1.0

0.5

0.0

mmHg

mmol/l

mmol/l

pH Carbon dioxide

Base excess Lactate

# # #

####*

#*

#* #*

*

*

** *

** *

* P

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Change(mmol/l)from0

tominute120

Saline group Ringer group

0

-5

-10

BicHH

BicHH

SID

SID

Prot-Prot-

BicS

BicS

0

-5

-10

Bicarbonate calculationBicHH = Henderson-Hasselbach equationBicS = Stewart formula

Stewarts Modelof Acid-Base balance

Independent variables affecting [H+]

pCO2

Total concentration of weak acids Strong ion difference (SID)

= [strong cations] [strong anions] Strong electrolytes dissociate completely

when in water

= [Na+] + [K+]+ [Mg2+]+[Ca2+] [Cl-] [XA]

SID decrease = acidosis

SID increase = alkalosis

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Liskaser et al.: Role of Pump Prime in the Etiology andPathogenesis of Cardiopulmonary Bypass-AssociatedAcidosis (Anesthesiology 2000; 93) (1)

CPB pump prime fluids

Group I (n=11): 500 ml Haemaccel1000 ml Ringers Injection

Group II (n=10): 1500 ml Plasmalyte 148

Blood sampling

t1 = immediately before CBP

t2 = 2 min after CBP at full flows

t3 = end of the case

Liskaser et al., Anesthesiology 93 (2000)

230Gluconate

270Acetate

3.00Mg2+

06.8Ca2+

54.4K+

98151Cl-

140146Na+

Group II

Plasmalyte 148(mEq/l)

Group I

Ringers Injection

Haemaccel (mEq/l)

Strong ion

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8.208.70

7.4015.00

11.409.80

III

Anion gap(mEq/l)

-0.65

2.32

-3.65

-3.20

0.95

1.17

I

II

Base excess(mM)

23.65

25.88

20.35

20.77

25.20

25.38

I

II

Bicarbonate(mM)

7.40

7.44

7.36

7.39

7.40

7.40

I

II

pH

t3t2t1

Median value of variable

GroupMeasuredvariable

Liskaser et al.: Role of Pump Prime in the Etiology andPathogenesis of Cardiopulmonary Bypass-AssociatedAcidosis (Anesthesiology 2000; 93) (2)

Physicochemical analysis Strong ion difference apparent (SIDa)

SIDa = [Na+]+[K+]+[Mg2+]+[Ca2+]-[Cl-]

Strong ion difference effective (SIDe) Contribution of weak acids to the electrical

charge equilibrium in plasma (Figgesmathematical model)

Strong ion gap (SIG)

SIG = SIDa SIDe lactate

Normal 0 Positive = unmeasured anions

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5.105.744.35SIG (mEq/l)

32.1627.0935.94SIDe (mEq/l)

36.8632.5340.42SIDa (mEq/l)

-0.65-3.650.95Base excess(mM)


3.174.793.36SIG-lactate(mEq/l)

22.0018.0031.50Albumin (g/l)

108.50113.00103.50Cl- (mM)

t3t2t1Measuredvariable

Group I: Haemaccel and Ringers Injection


4.6412.854.02SIG (mEq/l)

23.5017.0028.50Albumin (g/l)

2.32-3.201.17Base excess

(mM)39.2139.6139.43SIDa (mEq/l)

2.2911.362.33SIG-lactate(mEq/l)


34.4027.3935.55SIDe (mEq/l)

103.00101.50104.00Cl- (mM)

t3t2t1

Measuredvariable

Group II: Plasmalyte

113.00

32.53

5.74

4.79

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Replacing 1 Liter of Blood Loss withCrystalloid (3:1)

273 l of lactated Ringers

1653 l of NaCl 0.9 %

Excess chloride load

(mmol)

Crystalloid

Hyperchloremic Metabolic Acidosis:Therapy

Switch to balanced electrolyte solution

Lactated Ringers

Plasmalyte Hyperventilation

pH > 7.2 and preferably > 7.3

Furosemide

(Fresh frozen plasma)

Transfusion criteria

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IV Fluid Solutions: Lactate

Substrate for bicarbonate production

Adverse effects? (animal studies)

Increased apoptosis (GI tract, liver)

Rate-dependent immune suppression

(Panic disorder panic attack?) Neurobiological basis is unclear

Plasma Volume Expansion (PVE):Static Concept

Plasma volumePVE = Volume infused x

Distribution vol.

Distribution volume:

D5W = total body water

Lactated Ringers = extracellular vol.

NaCl 0.9% = extracellular vol.

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2 800

2 800

42 000

14 OOO

Distr. vol.(ml)

1 000

1 000

1 000

1 000

PV(ml)

-750250Alb. 25 %

1000Alb. 5 %

9 3003 70014 000D5W

3 7004 700LR

ICV(ml)

IFV(ml)

Vol. inf.(ml)

Plasma volume x Distribution volumeVolume infused =

Plasma volume

Svensn et al., Anesthesiology (1997), 87

S-albumin B-hemoglobin B-water

TIME (min)Dilutionofpla

smavolume

0.25

0.20

0.15

0.10

0.05

0

Acetated Ringers

0 60 120 180

Dextran 70

0 60 120 180

0.20

0.15

0

0.05

0.10

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One-compartment Volume of Fluid Space Model

K i V V

Kb

Kr(V - V)

V

V = expandable space of volume

V = target volume

Ki = constant fluid infusion rate

Kb = basal rate of fluid elimination(perspiration, basal diuresis)

Controlled rate of fluid eliminationproportional by a constant Kr tothe relative deviation ofv fromV


Two-compartment Volume of Fluid Space Model

The net rate of fluid exchange between the 2 compartments isproportional to the difference in relative deviations from thetarget volumes by a constant Kt

Ki V1V1

KbKr(V1 - V1)

V1

Kt

V2 V2

Secondary fluid space


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Plasma Volume Expansion (PVE):Kinetic Analysis

Bolus of fluid

Peak effects

Rates of clearance

Infusion of fluid necessary to maintainPVE at a certain level

Effects of anesthesia, surgery andtrauma on fluid requirements

Usefull during severe pathophysiologicdisturbances?

0 20 40 60 80 100 120Time (min)

0 20 40 60 80 100 120Time (min)

0.2

0.15

0.10

0.05

0

0.2

0.15

0.10

0.05

0

Plasmadilu

tion,(vV)/V

Single bolus of Ringers40 ml/min for 40 min

Bolus + continuous infusionof Ringers at 25 ml/min

Hahn and Svensen, Br J Anaesth (1997), 79

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Hahn and Svensen, Br J Anaesth (1997), 79

V1 V2

-900 ml-450 ml

-0 ml

-900 ml-450 ml

-0 ml

Dilution

(Bloodhemoglobin)

0.3

0.2

0.1

0

0.3

0.2

0.1

0

Central fluid space Peripheral fluid space

0 50 100 150 0 50 100 150

Time (min) Time (min)

Drobin and Hahn, Anesthesiology (1999), 90

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Volume Kinetics of Ringers Solution during Induction ofSpinal and General Anaesthesia.(Ewaldsson and Hahn: Br J Anaesth 2001, 87)

20 ml/kg of Ringer acetate over 60 min (0.33 ml/kg/min)

Spinal (n=10) or general (n=10) anesthesia

20 min after start of infusion

Ephedrine 5-10 mg IV ifSAP < 60 % of baseline

Parameters

Blood hemoglobin concentration

Every 3 min during 60 min

Urine output Additional patients (n=5)

350 ml of Ringers over 2 min immediately after spinalfollowed by Ringers at 0.33 ml/kg/min

Volume Kinetics of Ringers Solution during Induction ofSpinal and General Anaesthesia.(Ewaldsson and Hahn: Br J Anaesth 2001, 87)

Results

Infused fluid handled in similar way for spinal andgeneral anesthesia groups

Most patients: two-volume model Small central volume compartment

Reduced rate of equilibrium between thecompartments

Infused fluid primarily in central blood volumeduring onset of anesthesia

V1 increase by 125-150 ml in 5-10 min requires veryhigh infusion rate just after induction of anesthesia

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Ewaldsson and Hahn, Br J Anaesth (2001), 87

Spinal anesthesia

Rapid infusion group

0.33 ml/kg/min during 60 min

0.33 ml/kg/min during 40 min350 ml over 2 min

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