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 Ringers solution should be given during the day of operation and during the subsequent first two postoperative days

Intraoperative IV Fluid Therapy: Historical Perspective (2)

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

Intraoperative IV Fluid Therapy: Historical Perspective (3)

Fluid restriction Trauma/surgery: large fluid deficits Crystalloid / colloid controversy More recent concepts of intraoperative crystalloid administration
Problems associated with specific components and/or their concentration Sodium, chloride, lactate Kinetic principles of fluid therapy

Body fluids:

Volume Composition Concentration

Microcirculatory organ perfusion O2-delivery Cellular function Organ function

Body Fluid Compartments

Total body water = 60 % of body weight (BW)
2/3 1/3

Intracellular water = 40 % of BW

Extracellular water = 20 % of BW

Plasma (4 % of BW)

Body Fluid Compartments: Composition

Intracellular Extracellular Intravascular Sodium (mEq/l) Postassium (mEq/l) Calcium (mEq/l) Magnesium (mEq/l) Chloride (mEq/l) Bicarbonate (mEq/l) Phosphorus (mEq/l) Protein (g/dl) 10 140 <1 50 4 10 75 16 145 4 3 2 105 24 2 7 Interstitial 142 4 3 2 110 28 2 2

Plasma Osmolality
[Gluc] 18 [BUN] 2.8

Sosm (mOsm/kg H2O) = (2 x [Na+]) +

[Na+] in mEq/l Glucose in mg/dl Blood urea nitrogen in mg/dl

Starlings Equation
Q = kA [ ( Pc - Pi ) + ( i - c ) ] Q = k = A = Pc = Pi = = i = c =
(mEq / L)

fluid filtration capillary filtration coefficient area of the capillary membrane capillary hydrostatic pressure interstitial hydrostatic pressure reflection coefficient for albumin interstitial colloid osmotic pressure capillary colloid osmotic pressure

Osmolality (mOsm/kg)
Plasma [Na+] (non-protein) Protein Total 281.4 1.2 282.6 ISF 281.1 0.2 281.3

Osmotic pressure (mmHg)

Plasma [Na+] (non-protein) Protein Total 5431.0 23.2 5454.2 ISF 5425.2 3.9 5429.1

25.1 mmHg

Capillary

Pc = 40 mmHg
Arterial

Pc = 10 mmHg
Venous

c = 23 mmHg

Interstitium

Filtration

Pi = 2 mmHg i = 4 mmHg

Absorption

Lymphatic drainage

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 expenditures

Maintenance fluids (hospitalized pts): 100 ml/100 kcal/d

2500 2100 1900 1700 1500 1000 2300 Computed need for average hospital patients

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

4-2-1 rule
Weight (kg) 0 10 11 - 20 > 20 Volume 4 ml/kg/h 2 ml/kg/h 1 ml/kg/h 70 kg 40 20 50

Total 110 ml/h

Intraoperative Basal 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)

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 of Preoperative 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

30 25 20

Crystalloid No crystalloid

VAS for nausea 15 (mm)

10 5 0 * 1h * 2h 4h * * *

6 h 24 h 48 h 72 h

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

Vomiting (n) Crystalloid Day unit (6 h) 6h3d 0- 2h 2- 4h 4- 6h 6 - 24 h 24 - 48 h 48 - 72 h

* P>0.05

No crystalloid 3 8 2 1 0 8 3 1

4 0 * 2 0 0 0 0 0

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

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Surgical Fluid Losses (1)

Blood loss Redistribution and subsequent loss of extracellular 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: Intermediate: Major: 2 - 4 ml/kg/h 4 - 8 ml/kg/h 8 - 15 ml/kg/h

Replacement fluid
NaCl 0.9 % Balanced electrolyte solution

Lactated Ringers Fluid (ml) Duration (min) ECV preop (l) ECV postop (l) * **
P<0.05 between groups P<0.05 vs preop

D5W 530 92 * 187 113 12.5 2.4 10.6 1.9 **

1660 96 253 50 12.5 2.3 12.3 7.0

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

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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

Intraoperative Crystalloid Therapy: Lack of Good Target Points (2) Cardiovascular parameters Perfusion directed therapy
Global
Lactate

Regional: Gastrointestinal Organ specific

Gastrointestinal Pco2 tonometry Kidney: urine output

Fluid overload

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Intraoperative Crystalloid Therapy: Lack of Good Target Points (3)

Fluid overload
Intraoperative absorption of irrigating fluids during endoscopic surgery
Transurethral resection of the prostate Hysteroscopic surgery Absorption can be accurately monitored

Fatal postoperative pulmonary edema in healthy (?) 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 Pressure in the Cerebral Capillaries

Osmolality (mOsm/kg) Osmoles Plasma IF Osmot. pressure Osm. (mmHg) Press. Plasma IF (Pl.-IF)

[Na+],protein, non-protein [Na+] 5 mEq/l

282.6

282.6

5454

5454

292.6

282.6

5640

5454

186

Protein Protein x 2

1.2 2.4

0 0

23 46

0 0

23 46

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I.V. Fluids: Osmolality

Osmolarity (mOsm/L) Osmolality (mOsm/kg)

Normal saline Lact. Ringers

308 273

308 254

Volunteers: 50 ml/kg normal saline (NS) or lactated Ringers over 1 h

T1 Serum osmolal. (mOsm/kg) NS LR Serum [Na+] (mEq/l) NS LR Whole blood pH NS LR
* P<0.05 LR vs NS, # P<0.001 LR vs NS

T2

T3

T2-T1

288 5 289 5 290 5 0 4* 288 4 285 5 287 4 -4 3* 140 2 141 2 141 2 1 2* 140 1 139 2 140 2 -1 2* 7.42 7.41 7.38 7.44 7.38 7.43 -0.04# 0.04#

Williams et al., Anesth Analg 88 (1999)

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The Effect of the Reduction of Colloid Oncotic Pressure, with and without Reduction of Osmolality, on PostTraumatic Cerebral Edema. (Drummond et al.: Anesthesiology 1998, 88)

Percussed hemisphere 81 Percent water by weight Contralateral hemisphere

*
80

* *

79

78

Blood

Hetastarch Saline

Half saline

* 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 rapid administration of fluids that contain nearphysiologic concentrations of sodium accompanied 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) [HCO3-] (mEq/l) First author Waters Rehm Liskaser McFarlane Scheingraber Before infusion 27 23.6 25.2 25.0 23.5 After infusion Predicted 25.1 21.0 22.9 20.4 18.6 Actual 25.0 21.6 20.4 21.0 18.4

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Rapid Saline Infusion Produces Hyperchloremic Acidosis in Patients Undergoing Gynecological Surgery. (Scheingraber et al.: Anesthesiology 1999, 90) Saline (n = 12) Time of infusion (min) Volume after 120 min (ml/kg) Estimated blood loss (ml) Urine output (ml) 135 23 71 14 962 332 717 459 Lact. Ringers (n = 12) 138 20 67 18 704 447 1 075 799

Saline 0 min
23.5 2.2

Lactated Ringer s 0 min

23.3 2.0

120 min
18.4 2.0

120 min
23.0 1.1

Bicarbonate (mM) Anion gap (mM) Chloride (mM)

16.2 1.2

11.8 1.4

15.8 1.4

12.5 1.8

104

115

104

106

Scheingraber et al., Anesthesiology 90 (1999)

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Lactated Ringers Normal saline

7.50 7.45 7.40 7.35 7.30 7.25 7.20 0 4 0 30 60 90 120 min

pH
# # #
mmHg

50 46 42 38 34

Carbon dioxide

* * * *

30 26 0 3.0 30 60 90 120 min

Base excess
# # #
mmol/l

Lactate
#* #* #* #*

2.5 2.0 1.5 1.0 0.5 0.0 0 30

mmol/l

-4 -8 -12 0

* * *
90

*
120 min

30

60

60

90

120 min

* P<0.05 intragroup # P<0.05 intergroup

Scheingraber et al., Anesthesiology 90 (1999)

Lactated Ringers Normal saline

148

Sodium
mmol/l

120

Chloride
#* #* * #*

#*

mmol/l

144

#*

#*

#*

#*

115 110 105

140

136 0 45 40 35

*
30 60

*
90

*
120 min

100 0 17.5 15

*
30

*
90

60

120 min

Calculated SID
mmol/l

Prot* * * *

mmol/l

* *

#*

#*

12.5

*
10

30 25 0 30

* *
60 90

*
120 min

7.5 0 30 60 90 120 min

* P<0.05 intragroup # P<0.05 intergroup

Scheingraber et al., Anesthesiology 90 (1999)

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Change (mmol/l) from 0 to minute 120

Saline group
0 0

Ringer group
BicHH BicS

-5

BicHH

Prot- BicS

-5

SID

Prot-

-10

SID

-10

Bicarbonate calculation BicHH = Henderson-Hasselbach equation BicS = Stewart formula

Scheingraber et al., Anesthesiology 90 (1999)

Stewarts Model of 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 and Pathogenesis of Cardiopulmonary Bypass-Associated Acidosis (Anesthesiology 2000; 93) (1)

CPB pump prime fluids

Group I (n=11): 500 ml Haemaccel 1000 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

Strong ion Na+ ClK+ Ca2+ Mg2+ Acetate Gluconate

Group I Ringers Injection Haemaccel (mEq/l) 146 151 4.4 6.8 0 0 0

Group II Plasmalyte 148

(mEq/l)

140 98 5 0 3.0 27 23
Liskaser et al., Anesthesiology 93 (2000)

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Median value of variable Measured variable pH Bicarbonate (mM) Base excess (mM) Anion gap (mEq/l) Group I II I II I II I II t1 7.40 7.40 25.20 25.38 0.95 1.17 11.40 9.80 t2 7.36 7.39 20.35 20.77 -3.65 -3.20 7.40 15.00 t3 7.40 7.44 23.65 25.88 -0.65 2.32 8.20 8.70

Liskaser et al., Anesthesiology 93 (2000)

Liskaser et al.: Role of Pump Prime in the Etiology and Pathogenesis of Cardiopulmonary Bypass-Associated Acidosis (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 (Figges mathematical model) Strong ion gap (SIG) SIG = SIDa SIDe lactate Normal 0 Positive = unmeasured anions

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Group I: Haemaccel and Ringers Injection

Measured variable Cl(mM) Median value of variable t1 103.50 31.50 0.95 40.42 35.94 4.35 3.36 t2 113.00 18.00 -3.65 32.53 27.09 5.74 4.79 t3 108.50 22.00 -0.65 36.86 32.16 5.10 3.17

Albumin (g/l) Base excess (mM) SIDa (mEq/l) SIDe (mEq/l) SIG (mEq/l) SIG-lactate (mEq/l)

Liskaser et al., Anesthesiology 93 (2000)

Group II: Plasmalyte

Measured variable Cl(mM) Median value of variable t1 104.00 28.50 1.17 39.43 35.55 4.02 2.33 t2 101.50 113.00 17.00 -3.20 39.61 32.53 27.39 12.85 5.74 11.36 4.79 t3 103.00 23.50 2.32 39.21 34.40 4.64 2.29

Albumin (g/l) Base excess (mM) SIDa (mEq/l) SIDe (mEq/l) SIG (mEq/l) SIG-lactate (mEq/l)

Liskaser et al., Anesthesiology 93 (2000)

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Replacing 1 Liter of Blood Loss with Crystalloid (3:1) Crystalloid Excess chloride load (mmol)
165 27

3 l of NaCl 0.9 % 3 l of lactated Ringers

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

PVE = Volume infused x Plasma volume Distribution vol. Distribution volume: D5W = total body water Lactated Ringers = extracellular vol. NaCl 0.9% = extracellular vol.

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 Plasma volume x Distribution volume Volume infused = Plasma volume

PV (ml) LR D5W Alb. 5 % Alb. 25 % 1 000 1 000 1 000 1 000 Distr. vol. (ml) 14 OOO 42 000 2 800 2 800 Vol. inf. (ml) 4 700 14 000 1000 250 -750 IFV (ml) 3 700 3 700 9 300 ICV (ml)

Acetated Ringers Dilution of plasma volume

0.25 0.20 0.15 0.10 0.10 0.05 0 0 60 120 180 0.05 0 0 0.20 0.15

Dextran 70

60

120

180

TIME (min)
S-albumin B-hemoglobin B-water

Svensn et al., Anesthesiology (1997), 87

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One-compartment Volume of Fluid Space Model

V = expandable space of volume

V = target volume Ki V
V Ki = constant fluid infusion rate Kb = basal rate of fluid elimination (perspiration, basal diuresis)

Kb

Kr (V - V) V

Controlled rate of fluid elimination proportional by a constant Kr to the relative deviation of v from V

Svensn et al., Anesthesiology (1997), 87

Two-compartment Volume of Fluid Space Model

Ki

V1

V1

Kt

V2

V2

Kb

Kr(V1 - V1) V1

Secondary fluid space

The net rate of fluid exchange between the 2 compartments is proportional to the difference in relative deviations from the target volumes by a constant Kt
Svensn et al., Anesthesiology (1997), 87

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Plasma Volume Expansion (PVE): Kinetic Analysis

Bolus of fluid Peak effects Rates of clearance Infusion of fluid necessary to maintain PVE at a certain level Effects of anesthesia, surgery and trauma on fluid requirements Usefull during severe pathophysiologic disturbances?

0.2 0.15 0.10 0.05 0

Plasma dilution, (v V)/V

Single bolus of Ringers 40 ml/min for 40 min

0
0.2 0.15 0.10 0.05 0

20

40

60 80 Time (min)

100

120

Bolus + continuous infusion of Ringers at 25 ml/min

20

40

60 80 Time (min)

100

120

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

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

Central fluid space

Dilution (Blood hemoglobin)
0.3 0.2 0.1 0 0.3

Peripheral fluid space V2

-900 ml -450 ml -0 ml

V1
-900 ml -450 ml -0 ml

0.2 0.1 0

50

100

150

50

100

150

Time (min)

Time (min)

Drobin and Hahn, Anesthesiology (1999), 90

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Volume Kinetics of Ringers Solution during Induction of Spinal 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 if SAP < 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 spinal followed by Ringers at 0.33 ml/kg/min

Volume Kinetics of Ringers Solution during Induction of Spinal and General Anaesthesia. (Ewaldsson and Hahn: Br J Anaesth 2001, 87) Results Infused fluid handled in similar way for spinal and general anesthesia groups Most patients: two-volume model Small central volume compartment Reduced rate of equilibrium between the compartments Infused fluid primarily in central blood volume during onset of anesthesia V1 increase by 125-150 ml in 5-10 min requires very high infusion rate just after induction of anesthesia

31

Spinal anesthesia

0.33 ml/kg/min during 60 min 350 ml over 2 min 0.33 ml/kg/min during 40 min

Rapid infusion group

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

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