Mehrdad Nikfarjam

Fluid Sparing Regimens in Surgery
Mehrdad Nikfarjam, MD, PhD, FRACS
Surgeon, HPB/Transplant unit, Austin Health &
Warringal Private Hospital
Program for Liver, Pancreas, and Biliary Disorders

Austin Hospital
2

• 40-50 Major liver
resections
• 50 Liver transplants
Liver Surgery

Pancreatic Surgery
• 30-40 major
pancreatic
resections
• Major vascular
reconstruction
surgery

Perioperative Fluids
What type of fluid
What crystalloid
What colloid
What haemodynamic goal
How much fluid

Wet, Dry or Something Else
Too low
• Circulatory
disturbance
• Shock
• Pre-renal
failure
Too high
• Oedema
• Respiratory
insufficiency
• Acute Coronary
Syndrome
Bellamy, MC. Br J Anaesth 2006; 97 (6): 755-7.
Curves
A: Hypothesized line of
risk
B: Division between
patient groups in a ‘wet
vs dry’ study
C: Division between
patient and groups in
an ‘optimized vs nonoptimized’
study

Terminology
• “Restrictive” therapy - 5-7ml/kg/hr
• “Standard” or “Liberal” -12-15ml/kg/hr
• “Goal directed therapy” setting a
haemodynamic goal (SVV,pulse pressure
variation, CO) and fitting the patient to the goal

Fluids
n=100
n=65 n=35

Postoperative weight gain
Chappel. Anesthesiology 2008; 109:723–40

Postoperative weight gain
Lowell. Crit Care Med 1990; 18:728–33

Why develop Fast track programs for major
hepatobiliary and pancreatic surgery
• Improved quality and outcomes
– Standardisation and optimisation
• Reduced resource availability
– Fewer hospital beds
– Decreased resources
• Financial
– reduced reimbursement
– increasing costs
• Competition
– Recognition as center of excellence

Pancreaticoduodenal Resection
• Whipple’s: en-bloc e/o pancreatic head, duodenum, common
bile duct, gallbladder and distal stomach
Morbidity 50-60%
Mortality 1-3%

University of Melbourne Department of Surgery
Pancreaticoduodenectomy Fast Track Protocol (Summary)
Day 0: Evening following surgery:
Strict anti-emetics and paracetamol
Out of bed 6 hours following surgery
Intravenous fluids 100ml/hr
Day 1: the first Post-op day:
Nasogastric tube removal.
Reduce intravenous fluids to 83 ml/hr
Stop antibiotics
Physiotherapy
Day 2: the second Post-op day:
Sips of fluids
Reduce Fluids to 42 ml/hr
Frusemide if in positive balance or weight gain
.
Day 3: the third Post-op day:
Clear fluids
Central line to be removed
Frusemide based on fluid balance and weight
gain
Day 4: the fourth post-op day:
Advance to soft diet as tolerated
Laxatives
Promotility agents as required
Epidural out by this day
Day 5: the fifth post-op day:
Drain amylase measurements
Clexane education
Day 6: the sixth post-op day:
Drain removal
Day 7: the seventh post-op day:
Discharge home
Clexane
Proton pump inhibitor
Laxatives
Creon

Major Pancreatic Surgery at
Austin
• Cases between August 2005 and December
2011 were identified
• Fast Track introduced August 2009
• All cases performed by Fellowship trained
specialist surgeons
• 126 Pancreaticodudenectomy procedures

Percentage (%)
Complications
P=0.002
76%
49%
Fast Track Standard
Group Group
N=39 N=87

Uncomplicated Cases
Overall
(n=41)
Fast track
group
(n=20)
Standard
group
(n=21)
p value
Male 25(61%) 13(65%) 12(57%) 0.606
Age 65(15-81) 68(45-81) 62(15-81) 0.130
BMI 25 (19-42) 25(19-42) 24(19-34) 0.531
ASA Class II 14(34%) 5(25%) 9(43%) 0.228
III 27(66%) 15(75%) 4(57%)
Biliary stent 10(24%) 8(40%) 2(10%) 0.032*
Diabetes 10(24%) 7(35%) 3(14%) 0.959
History of
4(10%) 2(10%) 2(10%) 1.000
pancreatitis
Pre-operative
Laboratory tests
Haemoglobin (g/l) 129(94-156) 125(94-151) 131(101-156) 0.389
WCC (x10 9 /l) 6.9(3.0-16.8) 6.6(3.4-11.7) 7.0(3.0-16.8) 0.489
Platelets (x10 9 /l) 286(161-744) 252(161-459) 304(171-744) 0.489
CRP (mg/l) 5(1-93) 5 (1-93) 6(1-23) 0.757
Bilirubin ( mol/l) 19(5-352) 48 (10-265) 17(5-352) 0.044*
Albumin (g/l) 35(13-46) 36 (29-44) 35 (13-43) 0.489
Creatinine ( mol/l) 69(28-156) 69(28-156) 69 (48-93) 0.794

Overall
(n=41)
Fast-track
group
(n=20)
Standard
Group
(n=21)
Difference
(p value)
Malignancy 34(83%) 18(90%) 16(76%) 0.240
Epidural anesthesia 27 (66%) 15 (75%) 12(57%) 0.228
Classic Whipple
procedure
32(78%) 20(100%) 12(57%) 0.001*
Estimated blood loss (ml) 450(300-
2000)
475(350-850) 450(300-2000) 0.874
Blood transfusions intraoperative
7(17%) 1(5%) 6(30%) 0.093
Operative time (hours) 7.5(3-12) 8(6-12) 7(3-10) 0.119
Feeding jejunostomy 10(24%) 0(0%) 10(48%)

Fluids administered (l)
Fluid Administered
P=0.643

Fluids Balance (L)
Fluid Balance
P=0.063
P=0.005
P=0.139
P=0.002
P=0.177

Overall
(n=41)
Outcomes
Fast-track
group (n=20)
Standard
group
(n=21)
Difference
(p value)
Days in ICU 1(1-13) 1(1-3) 1(1-13) 0.633
Nasogastric removal 19(48%) 19(95%) 0(0%)

Factors influencing length of stay (LOS)
8 days or
less LOS
(n=14)
More
than 8
days LOS
(n=27)
Univariate
Odds ratio p value
(Confidence
interval)
Multivariate
Odds ratio p value
(Confidence
interval)
Demographics
Male gender 9(64%) 16(59%) 1.2(0.3-4.7) 0.754
BMI ≥ 30 1(7%) 5(5%) 1.4(0.8-24.2) 0.823
Age ≥ 70 5(36%) 6(22%) 1.9(0.5-8.1) 0.355
Pre-operative 6(43%) 4(15%) 4.3(1.0-19.3) 0.064 3.1(0.5-21.7) 0.251
diabetes
ASA II 3(21%) 11(41%) 0.4(0.1-1.8) 0.305
Biliary stent 6(43%) 4(15%) 4.3(1.0-19.3) 0.064 1.9(0.3-12.8) 0.528
Bilirubin ≥ 60 6(43%) 6(22%) 2.6(0.7-10.6) 0.168
mol/l)
Albumin < 30 g/l) 2(14%) 5(19%) 0.4(0.1-4.4) 0.733
Epidural anesthesia 11(79%) 16(59%) 2.5(0.6-11.1) 0.216
Pathology
Malignancy 12(86%) 22(82%) 1.4(0.2-8.1) 0.733
R1 resection 4(29%) 5(19%) 1.8(0.4-8.0) 0.461

8 days or
less LOS
(n=14)
More than
8 days
LOS
(n=27)
Univariate
Odds ratio
(Confidence
interval)
p value
Time ≥ 8 hours 2(14%) 5(19%) 0.4(0.1-4.4) 0.733
Blood loss ≥ 6(43%) 6(22%) 2.6(0.7-10.6) 0.168
600ml
Intra-op blood
transfusion
1(7%) 6(22%) 0.3(0-2.5) 0.389
Classic Whipple 13(92%) 19(70%) 5.4(0.6-49.2) 0.131
Feeding
jejunostomy tube
Fast-track
recovery
Blood
transfusion postoperative
Negative fluid
balance day 1
Negative fluid
balance day 2
Negative fluid
balance day 3
Multivariate
Odds ratio
(Confidence
interval)
p value
0(0%) 14(45%) 1.6(1.2-2.1)# 0.017* 0.0(N/A) 0.99
13(93%) 7(26%) 37(4.1-338.1)

Epidural and outcomes
• Epidural use in 27 or 41 cases (66%)
• Fast track 15 (75%) versus 12 (57%)
standard group (p=0.228)
• No difference fluid administration or
balance
• Epidural failure in 16 of 27 (59%)

Reasons for Epidural failure
(n=16)
• Incomplete block 12 (75%) cases
• Technical catheter issues 3 (19%) cases
• Uncontrolled hypotension 1 case

Epidural use during pancreaticoduodectomy
Zea N, Conwa W, Owen G et al.. Digestive disease week 2012
New Orleans, USA
• 100 Consecutive cases (50 PCA / 50 Epidurals)
• Longer start time to surgery (75 min versus 61 min p=0.005).
• Higher day 1 fluid requirement (3.9 L versus 3.1; P=0.001)
• More frequent intra-operative hypotension
• Trend towards higher transfusion rates in epidural group (56%
versus 38%) p=0.071
• Higher rate of urinary tract infections (6(12%) versus 1(2%);
p=0.067)
• 20% discontinuation due to hypotension

World J Surg (2012) 36:993–1002
• 179 patients
• 1.5 complications versus 2.2 complications per patient
• Reduced infective complications (15% versus 27%,;
p=0.04)
• Greater CD3+ T cell suppression in standard group

Perioperative Fluids
What type of fluid
What crystalloid
What colloid
What haemodynamic goal
How much fluid

How do we optimise fluid
• No clear answers
• “Static” measures CVP, PAOP: late
responders
• “Dynamic” measures: SV: respond early
• Goal: best volume-cardiac ratio

CVP does not predict fluid
responsiveness
Conclusions: Very poor relationship between CVP and blood
volume. CVP should not be used to make clinical decisions
regarding fluid management.

Pressures Do Not Predict Fluid
Responsiveness
• Osman, et al. CCM 2007
• Cardiac filling pressures did
not predict fluid responders
from non-responders.
Sensitivity and
Specificity ≈ 50-55%

Pressure ≠ Flow
• Resuscitation of MAP does not restore
microcirculation
Arterial blood pressure alone is an insensitive indicator of
tissue hypoperfusion.

Anaesthesia for major hepatobiliary
surgery
35

Anaesthesia Goals
Mobilisation & Control of
inflow and outflow
Resection Phase
Confirmation of haemostasis
& closure
Haemodynamic goals to
facilitate surgery
- Blood loss during hepatic
resection: mainly from major
hepatic veins or IVC
- Pringle manoeuvre (total inflow
occlusion of PV & HA) =
decrease of CO by 20-30% =
CVS compromise
- Total hepatic vascular occlusion
(tumours close to IVC) :
occlusion supra & infrahepatic
IVC & hepatic pedicle = up to
60% decrease in CO
Reduction of intrahepatic
pressure
• Early fluid restriction
• Low CVP (evidenced based)
- Venesection & autologous
normovolaemic haemodilution
- Lower haematocrit (N= 29%,
if CVS disease, else as low as
24%)
• 15 deg reverse trendelenberg
• Venodilatation (GTN)
• Diuretics
Haemodynamic goals to
facilitate surgery
- Argon Beam veins
- Coagulation & fibrin glues
- Restoration of circulating
blood volume
• Return of autologous blood
• Cautious additional fluid
intervention (RBC, colloid,
crystalloid)
• Normal CVP
• Avoidance of volume
overload

Goal Directed Therapy: Proven Outcomes
Using a treatment protocol with haemodynamic monitoring
consistently leads to improved clinical outcomes.
41

• Goal directed therapy versus liberal fluid therapy:
- Reduction of pneumonia
- Less pulmonary oedema
- Earlier return of bowel function
- Shorter length of hospital stay

Perioperative Fluids
What type of fluid
What crystalloid
What colloid
What haemodynamic goal
How much fluid

Guidelines on Intravenous Fluid Therapy for Adult
SUrgical Patients, 2008
The British Association for Parenteral and Enteral Nutrition
The Association for Clinical Biochemistry
The Association of Surgeons of Great Britain and Ireland
The Renal Association
The Intensive Care Society
Recommendation 1:
“AVOID 0.9% (normal) saline” = “hyperchloraemic”
acidosis
“Replace with balanced salt solutions”

Outcomes
Balanced crystalloid solutions:
• Fewer complications
• Fewer postoperative infection
• Fewer renal failure requiring dialysis
• Fewer blood transfusion
• Fewer electrolyte disturbance
• Lower acidosis
• Fewer intervention

Balanced Crystalloids
Plasma Plasma-Lyte Hartmanns
Normal
Saline
mmol/L mmol/L mmol/L mmol/L
Sodium 136 – 145 140 129 154
Potassium 3.5 – 5.0 5.0 5.0
Magnesium 0.8 – 1.0 1.5
Calcium 2.2 – 2.6 2.5
Chloride 98 – 106 98 109 154
Acetate 27
Gluconate 23
Lactate 29
osmolarity mOsmol/l 290 – 310 295 274 308
pH 7.4 7.4 5.5-6.2 5.5-6.2

Rational choice of fluids
Normal acid base status:
Hartmann’s
Pre-existing metabolic
acidosis/liver/cardiac:
Pre-existing metabolic
alkalosis:
Raised ICP:
Renal Tx
PlasmaLyte
Normal saline
PlasmaLyte or NS
Balanced

Colloids
Plasma Gelofusine Albumin (20%) Albumin (4%) Voluven VoluLyte
mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L
Sodium 136 – 145 154 50 140 154 137
Potassium 3.5 – 5.0 4
Magnesium 0.8 – 1.0 0
Calcium 2.2 – 2.6 0
Chloride 98 – 106 120 0 128 154 110
Acetate 34
Gluconate 0
Lactate 0
SID (mEq/L) 42 50 40 12 0 31

N Engl J Med. 2012 Jul 12;367(2):124-34
• Fluid resuscitation in the ICU with either
6% HES 130/0.4 or Ringer’s acetate
• Higher rate of renal replacement therapy
• Trend towards increased bleeding
• Higher rate of death at 90 days

Conclusions
• Patient specific & surgery specific goals
• Multimodal haemodynamic monitoring
• Avoid excess fluids and aim to achieve neutral fluid
balance post surgery
• Not all IV fluids are created equal
• Enhanced recovery (Fast Track program) package is key
to optimizing patient outcomes
• Develop treatment protocols to improve patient outcomes