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Great Debate Explores Controversies in Fluid Replacement

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CLINICAL ANESTHESIOLOGY
ISSUE: 7/2008 | VOLUME: 34:07

Great Debate Explores Controversies in Fluid Replacement

Larry Beresford

The wine metaphors came by the case at the Great American Fluid Debate. Blood replacement fluids were valued as vintage or cheap, and perioperative fluid management became as meticulous as viniculture. The fluid debate, held in March in conjunction with the 2008 annual meeting of the International Anesthesia Research Society (IARS), cosponsored by Duke University School of Medicine in Durham, N.C., and University College London (UCL) in England, engaged in a wide-ranging exploration of controversies and new developments in blood and fluid replacement strategies for various patients (e.g., being prepped for major surgery, undergoing surgery, waiting in the post-op ICU or emergency department, battling sepsis or other critical illnesses). Broad outlines of the debate were often characterized as liberal versus restrictive fluid replacement strategies. But according to Michael Monty Mythen, MD, professor of anesthesia and critical care at UCL, those terms are misnomers. Whether it is dousing the patient or withholding fluids according to a treatment philosophy that is labelled liberal or restrictive, no longer can you just hang up a bag of fluid and give the patient however much volume you think they need, Dr. Mythen said. Instead, the debate was more about goal-directed therapyreplacing fluids based on actual measured loss of fluid or volume and evidence-based targets. Dr. Mythen summarized it as putting the right fluid in the right place, at the right time and in the right volume. Technology Is Key Participants at the debate acknowledged the need for more clinical trials to expand the research base, identify optimal fluid management strategies and generate guidelines for physicians. The issues debated included: basic physiology and pharmacology of I.V. fluids and blood in health and disease; crystalloids versus colloids; clinical skill versus technology in guiding fluid replacement therapy; defining targets and outcomes for therapy in terms of hemodynamics, microcirculation, inflammation and organ function; oral fluid loadingby water or carbohydrate drinkimmediately prior to surgery; perioperative urine output; plasma volume expansion; hemoglobin optimization, blood preservation strategies and the use of artificial oxygen carriers; functional versus dysfunctional anemia; and effects of anesthesia on bleeding, stress and inflammation. The key to many of these questions lies in having the technology to accurately guide goal-directed therapy, Dr. James said. If youre not measuring blood flow during surgery, youre not doing your job as an anesthesiologist, Dr. Mythen added. Speakers agreed that optimizing fluid volume is a reachable goal attained by using advanced measurement technology, understanding the clinical data and then reacting appropriately. Technology discussed at the conference included the intraoperative esophageal Doppler probe, which provides continuous flow monitoring of the aorta in order to infer cardiac stroke volume, therefore aiding in optimization of intravascular volume. The Doppler probes, manufactured in England by Deltex Medical, are more widely used there than the United States, although Duke University Medical Center has three of them, said Tony Roche, MD, assistant professor of anesthesia at Duke and the debates course director. How Much Is Too Much? We agreed that preoperative dehydration is a phenomenon. Fluid overload is also a phenomenon. But what is too much, too little or

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Great Debate Explores Controversies in Fluid Replacement

just the right amount? Dr. James said. Avoiding unnecessary fluid is of proven benefit to some patients having surgery. Too much fluid is a bad thing, with lots of related complications. We also know that when we give fluid in the perioperative period, the liquid behaves differently because of the bodys response to anesthesia and the surgery. There is strong supportive evidence for a relatively conservative approach to fluid management. A reasonable goal is fluid maintenance, he concluded. Most speakers acknowledged the dangers of giving surgical or ICU patients either too much or too little replacement fluid. Specifically, they noted the negative consequences of hypovolemia and hypervolemia, such as organ hypoperfusion and edema, respectively. They emphasized the importance of fluid choice and that all of the usual optionsincluding crystalloids such as saline solution and lactated Ringers solution, colloids such as gelatins (not available in the United States), hydroxyethyl starches and albumin, plasma and artificial plasma replacementshave their pros, cons and appropriate uses. Indeed, a product as seemingly benign as normal saline solution can generate negative side effects such as metabolic acidosis. Even blood itself provoked lively debate. It is understood that transfused blood can be dangerous for the patient, and methods used to store it do harm to blood cells, said Mike James, MD, professor of anesthesiology at the University of Cape Town in South Africa. Yet even a strategy aimed at discouraging transfusions needs triggers to aid in recognizing when they are mandated. U.S. Obstacles Some of the fluid products and monitoring techniques discussed in Sonoma are more readily available in Europe than in the United States. Various reasons included the FDA approval process, toxicity concerns and health plan coverage practices. For example, the United States lags behind Europe in terms of approvals for and use of colloid products. Regarding the prohibitive costs of some of these products, When key opinion leaders at major university medical centers say the reason theyre not doing certain things is because they cant afford it, it makes the United States sound like an impoverished nation, Dr. Mythen said. The Great American Fluid Debate plans to revisit the topic at another debate in London this July, where a potential roundtable meeting of experts may generate guidelines and/or consensus statements, and at next years second Great American Fluid Debate, immediately prior to the IARS Congress in San Diego, March 12-13, 2009. For information, visit http://anesthesiology.duke.edu.

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