DR.N.KANAGARAJAN
SENIOR CONSULTANT
DEPT OF CARDIAC ANESTHESIA
ICVD, MADRAS MEDICAL MISSION HOSPITAL
CHENNAI.
INTRODUCTION
 Perioperative fluid therapy Much controversy / Effects on the outcome inconclusive
 Intravenous fluid resuscitation :
(a) fluid and electrolytes required for normal existence
(daily maintenance) and
(b) resuscitation or replacement of abnormal losses.
 The “Recipe Book” approach
Callum KG et al (1999)
“
Errors in fluid management (usually fluid
excess) were the most common cause of
perioperative morbidity and mortality ”
(National Confidential Enquiry into Perioperative Deaths)
1.PREOPERATIVE FLUID DEFICIT
2.INSENSIBLE LOSS
3.VOLUME AND ELECTROLYTES LOST
THROUGH BODY SECRETIONS
4.BLOOD LOSS
MONITORING:
a)Cardiac filling pressures:
 CVP / PAOP or Wedge pressure.
b)Static Volumetric variables:
 i)Left ventricular end-diastolic volume(LVEDV)
 ii)Global end-diastolic volume(GEDV)
c)Dynamic variable
 Stroke Volume Variation(SVV).
Cardiac output & MVO2.
BODY FLUID COMPARTMENTS
RECOMMENDED APPROACH TO PERIOPERATIVE FLUID
MANAGEMENT
A) CRYSTALLOID SOLUTIONS
VOLUME EFFECT OF CRYSTALLOIDS
B) COLLOID SOLUTIONS:
 Has an oncotic pressure similar to that of plasma.
 Remain within the intravascular space for a
relatively long time
WHY DO WE NEED COLLOIDS?
B. COLLOIDS
ALBUMIN
 There is no evidence to support routine
administration of albumin in hypovolemic states.
 Albumin administration may be beneficial in
certain groups of critically ill patients.
 Least Effective colloid
DEXTRANS
6% dextran 70 10% dextran
40
Mean molecular weight
(Dalton).
Volume effect
(hours)(Approx.).
70,000
40,000
5
3-4
100
175-(200)
1.5
1.5
Volume efficacy(%)(Approx.).
Maximum daily dose(g/kg).
GELATINS
Urea-crosslinked
Gelatin.
Cross linked
Gelatin
Succinylated
Gelatin
Concentration (%)
3.5
5.5
4.0
Mean molecular
weight(Dalton)
35000
30000
30000
Volume
1-3
effect(hours)(approx)
1-3
1-3
Volume
efficacy(%)(approx.)
80
80
80
Osmolarity
301
206
274
HYDROXYETHYL STARCHES
Importance of physicochemical characteristics
Degree of
hydroxyethylation
Duration of volume effect
Concentration
Initial values of volume
effect
Substitution pattern
Serum kinetics
C2/C6 RATIO
Intravascular half life
Molecular weight
Volume half life
CONCENTRATION
AND SOLVENT
MOLAR
SUBSTITUTION
C2/C6
RATIO
MAXIMUM
DAILY DOSE
ml/kg
HES
6% SALINE 480
450/0.7
HES
6% SALINE 200
200/0.5
10% SALINE
HES
6% SALINE 130
130/0.42
0.7
5:1
20
0.5
5:1
33
0.42
6:1
20
50
HES
130/0.4
0.4
9:1
50
6% SALINE
MEAN
MOLECULAR
WEIGHT
130
10% SALINE
HES
130/0.4
6%BALANCED 130
SOLUTIONS
33
0.4
9:1
50
THIRD GENERATION HES 130/0.4
(Anesth Analg 2008;107:382–90)
Conclusion :
Blood loss and transfusion requirements can be
significantly reduced in patients undergoing major
surgery when using third generation HES 130/0.4
(Voluven) compared to second generation starch HES
200/0.5.
HES130/0.4 and HES 200/0.5 similar regarding
volume efficacy in other studies,
HES 130/0.4 should be preferred to less rapidly
metabolizable HES solutions in prevention and
treatment of perioperative hypovolemia, especially if
large volumes are required.
Conclusion: Voluven® (HES 130/0.4) and hetastarch
are equally efficacious plasma volume substitutes
however, HES 130/0.4 has a lesser effect on
coagulation.
(Anesthesiology 2007;106:1120-7)
Accumulation and Tissue storage
 Tetrastarches - Less tissue accumulation and even in
high doses pruritus is a not a clinical problem
Effect on Plasma bilirubin:
 Potato-derived HES 130/0.42 are the only tetra starch to
be absolutely contraindicated in patients with severe
hepatic impairment.
Conclusion:
The administration of HES had no influence on renal
function or need for RRT
B J Anaesth 2007,98:216=24
Critical Care 2010, 14:R40
Conclusions: Volume expansion with low volume
HES 130 kDa/0.4 was not associated with AKI.
Godet G et al
 Safety of HES 130/0.4 (Voluven®) in patients with
preoperative renal dysfunction undergoing abdominal
aortic surgery: a prospective, randomized, controlled,
parallel-group multicentre trial.
Euro J Anaesthesiol (2008), 25:986-994.
 Sixty-five patients were randomly allocated to receive
either 6% hydroxyethyl starch (Voluven®; n = 32) or 3%
gelatin (Plasmion®; n = 33) for perioperative volume
substitution. At baseline, renal function was
impaired in all study patients
CONCLUSION
The choice of the colloid had no impact on renal
safety parameters and outcome in patients with
decreased renal function undergoing elective abdominal
aortic surgery.
Special patient groups:
 The waxy maize-derived tetra starch HES 130/0.4
has a well-documented safety profile in elderly
patients.
 Waxy maize-derived HES 130/0.4 is the only
third generation HES with controlled clinical data
in children.
BOLDT J et al(2008)
Prospective,randomised study
50 patients aged 80 years-cardiac surgery using
CPB
Preop Serum albumin 3.5 mg/dL received either
5% Human Albumin or 6% HES 130/0.4
(Anesth Analg 107:1496 –1503)
Conclusion:
In patients aged 80 yr showing hypoproteinemia before
surgery, a HA-based intravascular volume replacement strategy
was without benefit compared to 6% HES 130/0.4 with regard
to inflammatory response, endothelial activation and kidney
function.
SÜMPELMANN R et al
Hydroxyethyl starch 130/0.42/6:1 for perioperative
plasma volume replacement in children: preliminary
results of a European prospective multicenter
observational postauthorization safety study (PASS)
(Paediatric Anaesth 2008;18:929-33)
 316 patients (Day of birth – 12 years)
 All types of surgery including cardiac surgery
 The mean volume of infused HES 130/0.42 was
11 ± 4.8 ml·kg−1 (range, 5–42)
CONCLUSION
Moderate doses of HES 130/0.42 help to maintain
cardiovascular stability and lead to only moderate
changes in hemoglobin concentration and acid–base
balance in children.
The probability of serious ADRs is lower than 1%.
HES 130/0.42 for PVE seems to be safe and effective
even in neonates and small infants with normal renal
function and coagulation.
Effect on microcirculation and Oxygenation:
 Third generation HES 130/0.4 has positive effects on
tissue oxygenation and microcirculation in patients
undergoing major abdominal surgery.
 Improved micro perfusion and reduced endothelial
swelling.
(Kimberger O et al Anesthesiology 2009)
(Anesth & Analg 2003;96:936-943)
CONCLUSIONS.
In cardiac surgery patients aged 80 years, volume therapy
with HES 130/0.4 6% was associated with less marked
changes in kidney function and a less marked
endothelial inflammatory response than gelatin 4%.
(Br J Anaesth 2008; 100: 457–64)
Boldt J et al. Br J Anaesth 2008; 100: 457–64
CARRIER
SOLUTIONS
Typically occurs only after the infusion of more than
3 l of normal saline
 In a study involving 81 patients undergoing elective valve
surgery or coronary artery bypass grafting, the waxy maizederived tetra starch HES 130/0.4 was compared in two forms,
either in a saline solution (Voluven®) or in a balanced
solution (Volulyte®).
 The authors concluded that it is probably unnecessary to use
balanced solutions if only moderate infusions are required,
whereas balanced colloids can be used to reduce
chloride load when large volumes are required.
CONCLUSION:
Optimization of perioperative fluid management may
include a combination of fixed crystalloid administration
to replace extravascular losses and avoiding fluid excess,
together with individualized goal-directed colloid
administration to maintain a maximal stroke volume.
Acta Anesthesiol Scand 2009;53:843-851
Critical Care 2009, 13:R40
SUMMARY AND CONCLUSIONS :
 The goal is to maintain the effective
circulatory volume while avoiding interstitial
fluid overload whenever possible.
 Weight gain in elective surgical patients should
be minimized in an attempt to achieve a ‘zero
fluid balance status’.
 Third generation HES (waxy maize starch- HES
130/0.4) are suitable to achieve this goal.