Insufficient
- GI dysfunction (postoperative ileus, PONV, anastomotic leak)6
- Infectious complication (tissue hypoperfusion)6,7
- Acute renal insufficiency or failure8
Intraoperative fluid management
Fluid management is key to ensuring adequate intraoperative pressure and flow. Both insufficient and excessive fluid administration put patients at risk of dangerous complications.1–4 However, differences in patients’ underlying needs and unique physiology can pose challenges to optimising fluid administration.5
Maintaining perfusion
Sufficient perfusion requires adequate arterial pressure and cardiac output (CO). Maintaining these parameters in the optimal range is key to maintaining adequate perfusion.
Variability in fluid management is associated with complications and negative outcomes
Both insufficient and excessive volume load can result in dangerous complications.1–4
Excessive
- Pulmonary edema11
- GI dysfunction (abdominal compartment syndrome, ileus, anastomotic leak)12–13
- Coagulopathy11
Variability exists in fluid administration practices, with 50% of patients outside the normal fluid range.14
Physiological variability between patients increases the complexity of fluid management and can be a barrier to fluid optimisation. Fluid responsiveness can vary by fluid type, volume, infusion time and consequent change in stroke volume – and only half of haemodynamically unstable patients are fluid responsive.5
Clinician as predictor of fluid variability
While patient physiology is one factor behind fluid variability, research shows a level of fluid variability between procedures that cannot be explained by these differences alone. One study showed that the top predictor of infusion volume was the attending clinician, suggesting that protocolisation can help reduce fluid variability.14
Reducing variability with advanced parameters
Dynamic and flow-based parameters enable an individualised approach to fluid administration.9
The advanced parameter SV can be optimised using the patient’s own Frank-Starling curve – a plot of SV vs. preload. SV is ideal when it resides at the shoulder of the Frank-Starling curve.
SV and SVV may help clinicians:
- Assess perfusion and fluid responsiveness
- Gain more informative and sensitive insights than traditional parameters
- Avoid excessive and insufficient fluid administration9
Improving patient outcomes with protocolisation
Protocolised fluid management uses cardiac output monitoring to optimise volume status and avoid perioperative hypotension.
However, the complex and intensive nature of individualised protocols often prevent clinicians from using them as frequently as they would prefer.15–17
In the above analysis of corrected crystalloid infusion rates at two institutions,
50% of patients received rates far above or below the median.
UCI has a specific protocol for crystalloid administration during prostatectomies,
and this group had the smallest range of any of the analysed procedures,
suggesting that directed protocols can be effective in reducing variability.14
In the above analysis of corrected crystalloid infusion rates at two institutions,
50% of patients received rates far above or below the median.
UCI has a specific protocol for crystalloid administration during prostatectomies,
and this group had the smallest range of any of the analysed procedures,
suggesting that directed protocols can be effective in reducing variability.14
Acumen AFM software lessens the clinical burden of – and improves adherence to – protocols by automating patient tracking to ensure optimal fluid range.15,17
Individualise fluid administration
Acumen AFM software uses an algorithm to make individualised fluid recommendations based on a patient’s haemodynamic data and past responses to fluid administration, simplifying protocolisation so you can optimise fluid administration.
Recommends
Acumen AFM software recommends boluses based on a machine learning algorithm that anticipates a change in a patient's SV response to fluid
Adapts
Throughout a procedure Acumen AFM software adapts to your patient by using their haemodynamic data and past responses to each bolus administered
Tracks
Automatically tracks volume administration and flow rate in real time* – helping you maintain a fluid strategy
*When used with Acumen IQ fluid meter and Acumen AFM cable
Keep your patients in the optimal fluid range.
Clinical education
Dive deeper into fluid management resources – and make the most of haemodynamic monitoring technology – with our extensive clinical education library.
Highlighted studies on fluid management
Perioperative Fluid Utilization Variability and Association With Outcomes: Considerations for Enhanced Recovery Efforts in Sample US Surgical Population
Thacker et al, 2015
Annals of Surger
Based on current practice of fluid use in US hospitals, Thacker et al conclude that fluid optimisation can decrease variability and improve outcomes.
Arterial Pressure Variation and Goal-Directed Fluid Therapy
Cannesson, 2010
Journal of Cardiothoracic Vascular Anesthesiology
Despite evidence that cardiac output optimisation can improve outcomes, it is rarely used in anesthesiology practice, with clinicians relying instead on qualitative methods.
Assisted Fluid Management Software Guidance for Intraoperative Fluid Administration
Maheshwari et al, 2021
Anesthesiology
In this multicenter, prospective, single-arm cohort evaluation, fluid boluses recommended by Acumen AFM software resulted in desired SV increase more often than clinician-initiated boluses.
Further research
Aya HD et al – British Journal of Anaesthesia, 2013
Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis
Martin et al – Perioperative Medicine, 2020
Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance
Miller et al – British Journal of Anaesthesia, 2021
Association between perioperative fluid management and patient outcomes: a multicentre retrospective study
Malbrain MLNG et al – Annals of Intensive Care, 2020
Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA)
Giglio MT et al – British Journal of Anaesthesia, 2009
Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials
Joosten et al – Journal of Clinical Monitoring and Computing
Practical impact of a decision support for goal-directed fluid therapy on protocol adherence: a clinical implementation study in patients undergoing major abdominal surgery
References
- Miller TE, Mythen M, Shaw AD, Hwang S, Shenoy AV, Bershad M, et al. Association between perioperative fluid management and patient outcomes: a multicentre retrospective study. Br J Anaesth. 2021 Mar;126(3):720-729.
- Ariyarathna D, Bhonsle A, Nim J, Huang CKL, Wong GH, Sim N, et al. Intraoperative vasopressor use and early postoperative acute kidney injury in elderly patients undergoing elective noncardiac surgery. Ren Fail. 2022 Dec;44(1):648-659.
- Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, et al. Restrictive versus liberal fluid therapy for major abdominal surgery. N Engl J Med. 2018 Jun 14;378(24):2263-2274.
- Thacker JK, Mountford WK, Ernst FR, Krukas MR, Mythen MM. Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample US surgical populations. Ann Surg. 2016 Mar;263(3):502-10.
- Martin GS, Kaufman DA, Marik PE, Shapiro NI, Levett DZH, Whittle J, et al. Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance. Perioper Med (Lond). 2020 Apr 21;9:12.
- Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2009 Nov;103(5):637-46.
- Johnson A, Ahrens T. Stroke volume optimization: the new hemodynamic algorithm. Crit Care Nurse. 2015 Feb;35(1):11-27.
- O'Leary MJ, Bihari DJ. Preventing renal failure in the critically ill. There are no magic bullets-just high quality intensive care. BMJ. 2001 Jun 16;322(7300):1437-9.
- Cannesson M. Arterial pressure variation and goal-directed fluid therapy. J Cardiothorac Vasc Anesth. 2010 Jun;24(3):487-97.
- Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006 Dec;97(6):755-7.
- Holte K. Pathophysiology and clinical implications of perioperative fluid management in elective surgery. Dan Med Bull. 2010 Jul;57(7):B4156.
- Wang P, Wang HW, Zhong TD. Effect of stroke volume variability- guided intraoperative fluid restriction on gastrointestinal functional recovery. Hepatogastroenterology. 2012 Nov-Dec;59(120):2457-60.
- Durairaj L, Schmidt GA. Fluid therapy in resuscitated sepsis: less is more. Chest. 2008 Jan;133(1):252-63.
- Lilot M, Ehrenfeld JM, Harrington B, Cannesson M, Rinehart J. Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis. Br J Anaesth. 2015 May;114:767-76.
- Joosten A, Hafiane R, Pustetto M, Van Obbergh L, Quackels T, Buggenhout A, et al. Practical impact of a decision support for goal-directed fluid therapy on protocol adherence: a clinical implementation study in patients undergoing major abdominal surgery. J Clin Monit Comput. 2019 Feb;33(1):15-24.
- Flick M, Joosten A, Scheeren T, Duranteau J, Saugel B. Haemodynamic monitoring and management in patients having noncardiac surgery. Eur J Anaesthesiol. 2023;2(1):e0017.
- Maheshwari K, Malhotra G, Bao X, Lahsaei P, Hand WR, Fleming NW, et al. Assisted fluid management software guidance for intraoperative fluid administration. Anesthesiology. 2021 Aug 1;135(2):273-283.
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