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18 Perioperative Fluid Management andVolume Assessment
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highlight the heterogeneity of the studies, such as the devices, algorithms, hemodynamic targets, and uid type, making it difcult to compare interventions and outcomes [76–78].
299
Fluid Management inSpecic Patient Populations
Liver Disease andHepatic Surgeries
Due to alterations in intravascular volume and uid shifts, this population is highly
susceptible to both hypervolemia and hypovolemia. Low albumin levels, malnutrition, and portal hypertension can further complicate volume status, resulting in the
development of ascites and edema [79]. In general, a more restrictive uid approach
is preferred to avoid deleterious effects of hypervolemia. If possible, CVP and arterial line monitoring should be maintained through the perioperative period to continually assess volume status [80]. When massive volumes of ascites are surgically
drained, reinfusion could be an option to minimize protein loss and hypovolemia.
However, due to high levels of cytokines in the uid and other mechanisms, fever
and coagulopathy could be a danger.
Ideally ascites should be controlled with diuretics, in the preoperative period.
The same tenants are generally followed for patients undergoing hepatic surgery,
including transplantation, with CVP monitoring and SVV often used to guide uid
administration [81–83].
Cardiac Surgery
GDT has emerged as a recommended approach for uid management [84]. GDT
involves using advanced hemodynamic parameters such as cardiac index and mixed
venous oxygenation to guide uid therapy during the perioperative period.
Furthermore, GDT can help prevent overzealous uid administration, which can
lead to uid overload, impaired organ function, and increased morbidity and mortality. Notably the use of GDT in cardiac surgery has been associated with reduced
incidence of acute kidney injury [16, 85]. Some groups advocate measuring kidney
stress biomarkers, and restricting GDT to positive cases. Such would avoid extra
uid administration to those patients that do not need them.
Thoracic Surgery
In patients undergoing lung resection surgery, uid management is challenging as
diseased lungs, surgical exposure, and other factors can lead to interstitial and alveolar edema. Additionally, use of dynamic parameters for GDT may be less reliable
during one lung ventilation. Again, a restrictive uid strategy is defended with
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R. Bangalore et al.
euvolemia being the goal, with special attention to avoid organ dysfunction, particularly kidney injury. ERAS guidelines support the use of balanced crystalloids over
normal saline in these patients [15].
References
1. Bellamy MC.Wet, dry or something else? Br J Anaesth. 2006;97(6):755–7.
2. Doherty M, Buggy DJ. Intraoperative uids: how much is too much? Br J Anaesth.
2012;109(1):69–79.
3. Holte K.Pathophysiology and clinical implications of peroperative uid management in elective surgery. Dan Med Bull. 2010;57(7):B4156.
4. Jacob M, Chappell D, Rehm M. The ‘third space’—fact or ction? Best Pract Res Clin
Anaesthesiol. 2009;23(2):145–57.
5. Voldby AW, Brandstrup B.Fluid therapy in the perioperative setting—a clinical review. J Int
Care. 2016;4(1)
6. Luckey AE.Fluid and electrolytes in the aged. Arch Surg. 2003;138(10):1055.
7. Junghans T, Neuss H, Strohauer M, etal. Hypovolemia after traditional preoperative care in
patients undergoing colonic surgery is underrepresented in conventional hemodynamic monitoring. Int J Color Dis. 2006;21(7):693–7.
8. Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M.A rational approach to perioperative uid management. Anesthesiology. 2008;109(4):723–40.
9. Jozwiak M, Monnet X, Teboul JL. Prediction of uid responsiveness in ventilated patients.
Ann Transl Med. 2018;6(18):352.
10. Danielsson EJD, Lejbman I, Åkeson J.Fluid decits during prolonged overnight fasting in
young healthy adults. Acta Anaesthesiol Scand. 2019;63(2):195–9.
11. Mendelson CL.The aspiration of stomach contents into the lungs during obstetric anesthesia.
Am J Obstet Gynecol. 1946;52:191–205.
12. Brady M, Kinn S, Stuart P.Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;(4):CD004423.
13. Anonymous. Practice guidelines for preoperative fasting and the use of pharmacologic agents
to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force
on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary
aspiration. Anesthesiology. 2017;126(3):376–93.
14. Smith I, Kranke P, Murat I, etal. Perioperative fasting in adults and children: guidelines from
the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28(8):556–69.
15. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, etal. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®)
Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg.
2019;55(1):91–115.
16. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations. JAMA Surg.
2019;154(8):755–66.
17. Gustafsson UO, Scott MJ, Hubner M, etal. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS). World J Surg. 2019;43(3):659–95.
18. Ljungqvist O, Scott M, Fearon KC.Enhanced recovery after surgery: a review. JAMA Surg.
2017;152(3):292–8.
19. Nelson G, Bakkum-Gamez J, Kalogera E, etal. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019
update. Int J Gynecol Cancer. 2019;29(4):651–68.
18 Perioperative Fluid Management andVolume Assessment
https://t.me/med1917
20. Joshi GP, Abdelmalak BB, Weigel WA, et al. 2023 American Society of Anesthesiologists
Practice Guidelines for preoperative fasting: carbohydrate-containing clear liquids with
or without protein, chewing gum, and pediatric fasting duration-a modular update of the
2017 American Society of Anesthesiologists Practice Guidelines for preoperative fasting.
Anesthesiology. 2023;138(2):132–51.
21. Thomas M, Morrison C, Newton R, Schindler E.Consensus statement on clear uids fasting
for elective pediatric general anesthesia. Paediatr Anaesth. 2018;28(5):411–4.
22. Morrison CE, Ritchie-McLean S, Jha A, Mythen M.Two hours too long: time to review fasting
guidelines for clear uids. Br J Anaesth. 2020:S0007-0912(19)31004-9.
23. Reithner L, Johansson H, Strouth L.Insensible perspiration during anaesthesia and surgery.
Acta Anaesthesiol Scand. 1980;24(5):362–6.
24. Lamke LO, Nilsson GE, Reithner HL.Water loss by evaporation from the abdominal cavity
during surgery. Acta Chir Scand. 1977;143(5):279–84.
25. Marik PE, Cavallazzi R.Does the central venous pressure predict uid responsiveness? An
updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774–81.
26. Vincent JL, Weil MH.Fluid challenge revisited. Crit Care Med. 2006;34(5):1333–7.
27. Guerin L, Monnet X, Teboul JL.Monitoring volume and uid responsiveness: from static to
dynamic indicators. Best Pract Res Clin Anaesthesiol. 2013;27(2):177–85.
28. Michard F, Teboul JL. Using heart-lung interactions to assess uid responsiveness during
mechanical ventilation. Crit Care. 2000;4(5):282–9.
29. Marik PE, Cavallazzi R, Vasu T, Hirani A.Dynamic changes in arterial waveform derived
variables and uid responsiveness in mechanically ventilated patients: a systematic review of
the literature. Crit Care Med. 2009;37(9):2642–7.
30. Shi R, Monnet X, Teboul JL. Parameters of uid responsiveness. Curr Opin Crit Care.
2020;26(3):319–26.
31. Kumar N, Malviya D, Nath SS, etal. Comparison of the efcacy of different arterial waveformderived variables (pulse pressure variation, stroke volume variation, systolic pressure variation) for uid responsiveness in hemodynamically unstable mechanically ventilated critically
ill patients. Indian J Crit Care Med. 2021;25(1):48–53.
32. Mathis MR, Schechtman SA, Engoren MC, etal. Arterial pressure variation in elective noncardiac surgery: identifying reference distributions and modifying factors. Anesthesiology.
2017;126(2):249–59.
33. Hadian M, Kim HK, Severyn DA, Pinsky MR.Cross-comparison of cardiac output trending accuracy of LiDCO, PiCCO, FloTrac and pulmonary artery catheters. Crit Care.
2010;14(6):R212.
34. Pinsky MR, Cecconi M, Chew MS, De Backer D, Douglas I, Edwards M, Hamzaoui O,
Hernandez G, Martin G, Monnet X, Saugel B, Scheeren TWL, Teboul JL, Vincent JL.Effective
hemodynamic monitoring. Crit Care. 2022;26(1):294.
35. Zhang Z, Lu B, Sheng X, Jin N.Accuracy of stroke volume variation in predicting uid
responsiveness: a systematic review and meta-analysis. J Anesth. 2011;25(6):904–16.
36. Myatra SN, Prabu NR, Divatia JV, Monnet X, Kulkarni AP, Teboul JL.The changes in pulse
pressure variation or stroke volume variation after a “tidal volume challenge” reliably predict
uid responsiveness during low tidal volume ventilation. Crit Care Med. 2017;45(3):415–21.
37. Chu H, Wang Y, Sun Y, Wang G.Accuracy of pleth variability index to predict uid responsiveness in mechanically ventilated patients: a systematic review and meta-analysis. J Clin Monit
Comput. 2016;30(3):265–74.
38. Cannesson M, Desebbe O, Rosamel P, et al. Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict uid
responsiveness in the operating theatre. Br J Anaesth. 2008;101(2):200–6.
39. Liu T, Xu C, Wang M, Niu Z, Qi D.Reliability of pleth variability index in predicting preload responsiveness of mechanically ventilated patients under various conditions: a systematic
review and meta-analysis. BMC Anesthesiol. 2019;19(1):67.
40. Monnet X, Teboul JL.Passive leg raising: ve rules, not a drop of uid! Crit Care. 2015;19(1):18.
301
302
https://t.me/med1917
41. Dave C, etal. Dynamic assessment of uid responsiveness in surgical ICU patients through
stroke volume variation is associated with decreased length of stay and costs: a systematic
review and meta-analysis. J Intensive Care Med. 2020;35(1):14–23.
42. Gavelli F, Teboul JL, Monnet X.The end-expiratory occlusion test: please, let me hold your
breath! Crit Care. 2019;23(1):274.
43. Gavelli F, Shi R, Teboul JL, Azzolina D, Monnet X.The end-expiratory occlusion test for
detecting preload responsiveness: a systematic review and meta-analysis. Ann Int Care.
2020;10(1):65.
44. Wang J, Zhou D, Gao Y, Wu Z, Wang X, Lv C. Effect of VTILVOT variation rate on the
assessment of uid responsiveness in septic shock patients. Medicine (Baltimore).
2020;99(47):e22702.
45. Blanco P.Rationale for using the velocity-time integral and the minute distance for assessing
the stroke volume and cardiac output in point-of-care settings. Ultrasound J. 2020;12(1):21.
46. Long E, Oakley E, Duke T, Babl FE, (PREDICT) PRiEDIC.Does respiratory variation in inferior vena cava diameter predict uid responsiveness: a systematic review and meta-analysis.
Shock. 2017;47(5):550–9.
47. Ciozda W, Kedan I, Kehl DW, Zimmer R, Khandwalla R, Kimchi A.The efcacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure.
Cardiovasc Ultrasound. 2016;14(1):33.
48. Antequera Martin AM, Barea Mendoza JA, Muriel A, etal. Buffered solutions versus 0.9%
saline for resuscitation in critically ill adults and children. Cochrane Database Syst Rev.
2019;7:CD012247.
49. Gottlieb M, Petrak V, Binkley C.Are balanced crystalloid solutions better than Normal saline
solution for the resuscitation of children and adult patients? Ann Emerg Med. 2020;75(4):532–4.
50. Self WH, Semler MW, Wanderer JP, etal. Balanced crystalloids versus saline in noncritically
ill adults. NEJM. 2018;378(9):819–28.
51. Finfer S, Micallef S, Hammond N, etal. Balanced multielectrolyte solution versus saline in
critically ill adults. NEJM. 2022;386(9):815–26.
52. Young P, Bailey M, Beasley R, etal. Effect of a buffered crystalloid solution vs saline on acute
kidney injury among patients in the intensive care unit: the SPLIT randomized clinical trial.
JAMA. 2015;314(16):1701–10.
53. Zampieri FG, Machado FR, Biondi RS, etal. Effect of intravenous uid treatment with a
balanced solution vs 0.9% saline solution on mortality in critically ill patients: the BaSICS
randomized clinical trial. JAMA. 2021;326(9):1–12.
54. Semler MW, Self WH, Wanderer JP, etal. Balanced crystalloids versus saline in critically ill
adults. NEJM. 2018;378(9):829–39.
55. Pfortmueller CA, Faeh L, Muller M, etal. Fluid management in patients undergoing cardiac
surgery: effects of an acetate-versus lactate-buffered balanced infusion solution on hemodynamic stability (HEMACETAT). Crit Care. 2019;23(1):159.
56. He H, Liu D, Ince C.Colloids and the microcirculation. Anesth Analg. 2018;126(5):1747–54.
57. Lewis SR, Pritchard MW, Evans DJ, etal. Colloids versus crystalloids for uid resuscitation in
critically ill people. Cochrane Database Syst Rev. 2018;8(8):CD000567.
58. Finfer S, Bellomo R, Boyce N, etal. A comparison of albumin and saline for uid resuscitation
in the intensive care unit. NEJM. 2004;350(22):2247–56.
59. Myburgh J, Cooper DJ, Finfer S, etal. Saline or albumin for uid resuscitation in patients with
traumatic brain injury. NEJM. 2007;357(9):874–84.
60. Caironi P, Tognoni G, Masson S, etal. Albumin replacement in patients with severe sepsis or
septic shock. NEJM. 2014;370(15):1412–21.
61. Frenette AJ, Bouchard J, Bernier P, etal. Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis. Crit Care. 2014;18(6):602.
62. Kingeter AJ, Raghunathan K, Munson SH, et al. Association between albumin administration and survival in cardiac surgery: a retrospective cohort study. Can J Anaesth.
2018;65(11):1218–27.
63. Evans L, Rhodes A, Alhazzani W, etal. Surviving sepsis campaign: international guidelines for
management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063–143.
R. Bangalore et al.
18 Perioperative Fluid Management andVolume Assessment
https://t.me/med1917
64. Brandstrup B, Tønnesen H, Beier-Holgersen R, etal. Effects of intravenous uid restriction on
postoperative complications: comparison of two perioperative uid regimens: a randomized
assessor-blinded multicenter trial. Ann Surg. 2003;238(5):641–8.
65. Tambyraja AL, Sengupta F, MacGregor AB, Bartolo DC, Fearon KC.Patterns and clinical
outcomes associated with routine intravenous sodium and uid administration after colorectal
resection. World J Surg. 2004;28(10):1046–51.
66. Grass F, Lovely JK, Crippa J, etal. Potential association between perioperative uid management and occurrence of postoperative ileus. Dis Colon Rectum. 2020;63(1):68–74.
67. Kubo Y, Tanaka K, Yamasaki M, etal. The impact of perioperative uid balance on postoperative complications after esophagectomy for esophageal cancer. J Clin Med. 2022;11(11):3219.
68. Shin CH, Long DR, McLean D, etal. Effects of intraoperative uid management on postoperative outcomes: a hospital registry study. Ann Surg. 2018;267(6):1084–92.
69. Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus liberal uid therapy for major
abdominal surgery. NEJM. 2018;378(24):2263–74.
70. Messina A, Robba C, Calabrò L, etal. Perioperative liberal versus restrictive uid strategies
and postoperative outcomes: a systematic review and metanalysis on randomised-controlled
trials in major abdominal elective surgery. Crit Care. 2021;25(1):205.
71. Melloul E, Lassen K, Roulin D, etal. Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg.
2020;44(7):2056–84.
72. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM.Perioperative uid management strategies in major surgery: a stratied meta-analysis. Anesth Analg. 2012;114(3):640–51.
73. Benes J, Giglio M, Brienza N, Michard F.The effects of goal-directed uid therapy based on
dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Crit Care. 2014;18(5):584.
74. Pearse RM, Harrison DA, MacDonald N, etal. Effect of a perioperative, cardiac output-guided
hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014;311(21):2181–90.
75. Messina A, Robba C, Calabrò L, etal. Association between perioperative uid administration
and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized
goal-directed trials in major visceral/noncardiac surgery. Crit Care. 2021;25(1):43.
76. Jessen MK, Vallentin MF, Holmberg MJ, etal. Goal directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis. Br J
Anaesth. 2022;128(3):416–33.
77. Wrzosek A, Jakowicka-Wordliczek J, Zajaczkowska R, etal. Perioperative restrictive versus goal-directed uid therapy for adults undergoing major non-cardiac surgery. Cochrane
Database Syst Rev. 2019;12:CD012767.
78. Ebm CC, Sutton L, Rhodes A, Cecconi M.Cost-effectiveness in goal-directed therapy: are the
dollars spent worth the value? J Cardiothorac Vasc Anesth 2014;28(6):1660–6.
79. Sun Y, Yang Z, Tan H.Perioperative nutritional support and uid therapy in patients with liver
diseases. Hepatobiliary Surg Nutr. 2014;3(3):140–8.
80. Muilenburg DJ, Singh A, Torzilli G, Khatri VP.Surgery in the patient with liver disease. Med
Clin North Am. 2009;93(5):1065–81.
81. Morkane CM, Sapisochin G, Mukhtar AM, etal. Perioperative uid management and outcomes in adult deceased donor liver transplantation—a systematic review of the literature and
expert panel recommendations. Clin Transpl. 2022;36(10):e14651.
82. Carrier FM, Chassé M, Wang HT, etal. Restrictive uid management strategies and outcomes
in liver transplantation: a systematic review. Can J Anaesth. 2020;67(1):109–27.
83. Yoshino O, Perini MV, Christophi C, Weinberg L.Perioperative uid management in major
hepatic resection: an integrative review. Hepatobiliary Pancreat Dis Int. 2017;16(5):458–69.
84. Osawa EA, Rhodes A, Landoni G, etal. Effect of perioperative goal-directed hemodynamic
resuscitation therapy on outcomes following cardiac surgery: a randomized clinical trial and
systematic review. Crit Care Med. 2016;44(4):724–33.
85. Romagnoli S, Rizza A, Ricci Z.Fluid status assessment and management during the perioperative phase in adult cardiac surgery patients. J Cardiothorac Vasc Anesth. 2016;30(4):1076–84.
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Chapter 19
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Perioperative Fluid Administration
andComplications inEmergency
Gastrointestinal Surgery
BirgitteBrandstrup andAnnMereteMøller
Introduction
The patients needing surgery in the emergency setting differ from the patients
in the elective setting in several ways: They are often in a septic state; they
might have massive blood, fluid, and/or electrolyte imbalances; surgery is lifesaving and might need to be performed as fast as possible and at least within a
few hours.
The literature on emergency surgery is often difcult to interpret, because
“emergency surgery” covers a wide range of very different diagnoses and surgical
procedures. Many national databases include surgery for abscesses, appendicitis,
and cholecystitis in the statistical analysis, giving better survival percentages.
Nowadays, the risk of death from acute appendicitis or cholecystitis is close to
zero. The mortality following surgery for bowel obstruction is also relatively low
(up to 10% after 30days [1, 2]) as is the risk of death from a bleeding ulcer [3, 4],
while the mortality following perforations of the intestinal tract regardless whether
the perforation is of the stomach or the colon continues to be high (30–40% after
B. Brandstrup (*)
Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals,
Holbæk, Denmark
Institute for Clinical Medicine, Faculty of Health, University of Copenhagen,
Copenhagen N, Denmark
e-mail: bbrn@regionsjaelland.dk
A. M. Møller
Institute for Clinical Medicine, Faculty of Health, University of Copenhagen,
Copenhagen N, Denmark
Department of Anesthesia, Herlev University Hospital, Herlev, Denmark
e-mail: ann.moeller@regionh.dk
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_19
305© The Author(s), under exclusive license to Springer Nature
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30days [2, 5, 6]). A condition with an even higher mortality is the patients with a
proximal thrombosis of the superior mesenteric artery, causing infarction of the
entire small bowel and the right side of the colon. Often it is impossible to save the
lives of these patients.
The inclusion or exclusion of these different patient categories and differences in
the ratios between them is vital for the comparison of results—a fact that is rarely
taken into account when comparing survival numbers between countries or
institutions.
Furthermore, national differences are present. This has many reasons ranging
from differences in distances to medical aid, the number of hospitals/health staff
per capita, to whether or not healthcare is free of charge or not. All these factors
are important because patients may give up beforehand to seek help, and the general health of the patients might be very different. Good access to healthcare
inuences whether co-existing medical conditions are well treated or not. In
many rst-world countries, on the other hand, the population is getting older, and
the patients often have multiple comorbidities—with a surgical emergency on top
of it all.
Another very important factor differing between countries and regions is the
presence of multi resistant bacteria in the environment. The surgical intervention needed for perforations of the colon illustrates this. In Denmark, even
medium sized perforations of the colon are well treated with laparoscopic lavage
and drainage only [7–9], while this is sometimes insufcient in other regions
[10, 11]. Scandinavian countries have a very low presence of multi-resistant
bacteria in the environment, rendering low-toxicity antibiotics to be effective
treatment.
B. Brandstrup and A. M. Møller
Correcting Preoperative Fluid andElectrolyte Imbalances
In a perfect world, uid and electrolyte imbalances are corrected before the surgery.
However, in emergency surgical situations, one must carefully weigh the risks of
delaying the surgery against the risks associated with anesthesia and surgery in the
presence of imbalances. In such circumstances, it may be necessary to initiate preoperative- and continue intraoperative correction of the condition. Especially in
patients with chronic electrolyte imbalances, one has no other choice than to do the
surgery and anesthesia with the imbalance present, because fast corrections are
more hazardous.
Patients with bowel obstruction have combined hypovolemia and dehydration.
Both can be corrected preoperatively relatively quickly. The correction of hypovolemia with isotonic uids has priority, but often a hypotonic uid containing glucose to correct the dehydration benets the patient as well.
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Hypovolemia
Hypovolemia remains a common cause of intraoperative death, and hypovolemia
should therefore be corrected preoperatively whenever possible. In subacute surgical conditions, correction of hypovolemia is usually unproblematic as it can be corrected relatively quickly. This goes for patients with bowel obstruction without risk
of intestinal ischemia. Here the surgery can often be postponed several hours, if the
correction of uid and/or electrolyte imbalances have priority. This illustrates why
the decision to operate immediately or later is a team effort between surgeons and
anesthetists, and why common decision-making is superior.
In cases of acute ongoing bleeding, the situation is challenging because volume
administration can never replace surgical hemostasis. Both procedures often need to
be performed simultaneously. Trauma centers prioritize to stabilize the patient’s
circulatory condition to the extent that vital functions are just maintained, allowing
for the patient to be transferred to the operating room (with systolic blood pressure
of 90mmHg or higher) [12, 13]. Cerebral perfusion continues at lower pressures in
supine patients [14].
Intensive Prehospital Treatment
In certain circumstances it increases both the complication rate and mortality, nominally in thoracic gunshot wounds [15]. A likely explanation is that volume replacement increases blood pressure, thus “ushing out” clots from the blood vessels and
causing re-bleeding before surgical hemostasis is achieved. In addition, both dilution of coagulation factors and uid overload may contribute to the observed harmful effect.
Likewise, research suggests blood pressure should not be raised to normal values
in patients with a ruptured aortic aneurysm (after animal experiments, a threshold of
systolic BP <95mmHg has been set [16]) to avoid re-bleeding, however the evidence
is low [17]. Re-bleeding can occur in the adventitia of the vessels (in dissecting aortic aneurysms), pericardium, thorax, or retroperitoneum, depending on the location
of the aneurysm. Bleeding into the pericardium carries a risk of cardiac tamponade.
It is likely that intravenous uid therapy, which increases blood pressure, can
cause similar re-bleeding in other conditions (pelvic fractures, liver injuries, etc.)
even if temporary hemostasis has been achieved. The rule is that the higher the
blood pressure, the greater the blood loss during ongoing bleeding, and the greater
the risk of re-bleeding in conditions with uncertain or inadequate hemostasis.
Such an effect is not seen in trauma cases where hemostasis is possible, for
example, in extremity injuries with the application of effective hemostatic pressure
(placement of a tourniquet).
All this circumstances notwithstanding, uncontrolled shock can rapidly lead to
organ failures and death; therefore, early uid administration is standard care for
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B. Brandstrup and A. M. Møller
patients who have lost massive amounts of blood or other uids and display markedly depressed hemodynamic ndings. A mean arterial pressure of 50–65mmHg
should be the general aim.
Management ofAcute Ongoing Bleeding
Administration of uids during acute major bleeding should be guided by thromboelastography (TEG) or thromboelastometry (ROTEM) [18]. TEG- or ROTEMguided transfusion strategies may reduce the need for blood products and improve
morbidity in patients with ongoing hemorrhage.
In acute bleeding, crystalloids are administered while waiting for blood products. Articial colloids such as hydroxyethyl starch are not recommended as they
might worsen dilutional coagulopathy by their adverse effects on brin polymerization and platelet aggregation.
Subsequently, blood loss is replaced with either whole blood or “blood component packs,” with regional variations in the ratio. In our routine the number of units is
dblood cells Fresh frozen plasma FFP Platelet concent
rrate1,
equivalent to whole blood transfusion.
In addition to the TEG/ROTEM, treatment is monitored using hemoglobin, international normalized ratio (INR), activated partial thromboplastin time (APTT),
brinogen, and platelet concentration.
We recommend giving platelets immediately, while erythrocytes and FFP are
given in separate IV lines. The strategy for replacement of blood loss during surgery
is summarized in Table19.1.
Table 19.1 Replacement of blood loss [19]
Loss in % of
blood volume
0–20% 0–1000mL Lactated or Acetated Ringers
20–40% 1000–2000mL Supplemental Human Albumin
40–80% 2000–4000mL Supplemental paced red blood
Thereafter For every 500mL Supplemental RBC
a
Human albumin should be used at the physician’s discretion. Current recommendations, such as
Clinical Guidelines for Human Albumin Use (
uploads/2020/07/2018- Albumin- Guideline.pdf), emphasize that no studies have convincingly
shown that human albumin confers survival advantages for conventional volume expansion
Loss in mL
(70–80kg person) Replacement Volume
a
solution
(HA)
cells (RBC) and HA
And fresh frozen plasma (FFP)
Platelets 1 for every 3 RBC and FFP
https://www.nppeag.scot.nhs.uk/wp- content/
500–3000mL
1000mL
3–4 portions RBC
(1000mL)
1000mL (HA)
1 portion (ca. 300mL)
1 portion (ca. 250mL)
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309
Anemia
Anemia is corrected both preoperatively and intraoperatively. Typically, a blood
hemoglobin level of >4.3mmol/L (7g/L) is aimed for in “healthy” individuals, and
>5.6mmol/L (9g/L) in patients with severe heart/lung disease [20].
If signicant blood loss is expected during the operation, a higher preoperative
hemoglobin level may be appropriate, but there is a lack of evidence supporting this.
In many institutions, transfusion is chosen when the intraoperative hemoglobin
level falls below 6 mmol/L (9.6 g/L), as operative bleeding is considered severe
acute bleeding.
Meeting theBasic Fluid andElectrolyte Requirements
oftheBody
The basic needs of patients undergoing surgery differ from those in normal conditions in three aspects:
1. Patients are instructed to fast.
2. Patients may experience trauma, inammation, or metabolic stress, leading to
the release of stress hormones, including aldosterone, which causes salt and
water retention. In turn cytokines in the same setting could be natriuretic, such
as TNF-alpha.
3. Patients are articially ventilated with 100% humidied air, thus water loss from
the airways are diminished.
Insensible perspiration is water loss through the skin and respiratory tract and is
the only pure water loss from the body. Approximately two-thirds of the volume
comes from the skin, while one-third comes from the respiratory tract [21]. Thus, in
patients on mechanical ventilation with 100% humidied air, the insensible perspiration from the respiratory tract is reduced by approximately one-third. Otherwise
the insensible perspiration is not much inuenced by surgery [22].
The insensible perspiration is dependent on the skin surface. However, calculating skin surface may not be practical in the daily clinical setting. Therefore an
approximation to body weight is made. This is introducing the mistake of underestimating the insensible perspiration for persons with a great skin surface relative to
body weight (children) and overestimating in the opposite context (persons with a
bodyweight >150kg). Knowing these limitations, the insensible perspiration is in
temperate climate very consistent [21] (10mL/kg/day), and if the patient is on a
ventilator using humidied air, 6.6mL/kg/day.
If the patient is not on a ventilator, an increase in body temperature (fever) leads
to an elevated respiratory frequency, however, the impact is minimal.
Sensible perspiration refers to visible sweat, which consists of salt and water and
is always hypotonic compared to extracellular uid. Exercise, elevated environmental
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