|
Post by katevaughn on May 31, 2018 16:15:44 GMT -5
This month's journal club is presented by Moishe. He chose an excellent article that delves into the beneficial and harmful effects of fluid administration. This is an often “hot” topic that offers many opportunities for discussion. This article touches on the latest recommendations that we can use as a guide on a daily basis. Specifically, it discusses: • If albumin is more efficacious than crystalloid for resuscitation. • The pivotal role that glycocalyx plays in redefining the Starling equation. • The best and worst crystalloid solution to use for resuscitation. Here is a link to the article. Please click download full-text PDF in the top right corner. The two questions to encompass within your discussion: 1: Do you resuscitate based on the classic 4:2:1 rule; do you think this is currently the most evidenced-based view? If not, then what are your parameters for resuscitation? 2: At JHH, albumin is used quite often. Do you feel this is evidence-based? Can albumin possible be more harmful than crystalloid for our patients.
|
|
|
Post by Jennifer Hannon on Jun 1, 2018 7:32:22 GMT -5
Great fluid update article Moishe! Thanks! I found it interesting that there still is no benefit to colloid vs. crystalloid but we do use albumin sooo much. I still resuscitate based on the 4:2:1 rule with regard to individualized patient history. By 10am most NPO deficits are at least 1500 so I try to shoot for roughly that in healthy patients by the first 1.5 into the surgery. Obviously it changes with kidney function, age and liver/lung/type of surgery, but I feel the good ol' 4:2:1 is still great. I feel the use of albumin is evidenced based and helpful in ERAS cases especially. As with everything we give there is a risk with albumin, and the origin of the albumin can add to the risk; human 5% mostly aligned to our makeup . For ex: I wouldn't give albumin in a sickle cell patient I limit the absolute total to 1500ml and it's easy to remember since that's the 4:2:1 number after 10am too! Hydration is an antiemetic so during emergence I let it roll in to catch up my totals if needed.
|
|
|
Post by LarSharVeA Bennett on Jun 4, 2018 15:17:45 GMT -5
In my opinion, the 4:2:1 rule is antiquated and goal directed therapy is superior in fluid resuscitation measures. In fact, the updated Nagelhout says something similar. One could argue that a young healthy cardiovascular and pulmonary system could tolerate extra fluid to prevent/treat/control many different variables, however, I think that is partly a con of the anesthesia mentality: we aim to fix everything! If I personally came in for surgery at 0800, one might deem it necessary to replace a fluid deficit as of midnight, when on a daily basis, I am in fact npo past 2100. Instead, it would be sage to administer (me) maintenance fluid and perhaps a small amount in addition to maintenance to increase preload that has been attenuated by anesthesia induced vasodilation.
I find it rather intriguing that the jury is still out on albumin administration. I personally use it with the rationale that it stays intravascular approximately three times longer than crystalloids and with the goal of balancing hydrostatic and oncotic pressure. Like everything else we do, there is not a one size/one drug/one anesthesia plan that fixes all so even with all of the studies presented, I think albumin has it place and should be used on a case by case basis.
|
|
|
Post by Jocelyn Datud on Jun 10, 2018 8:22:43 GMT -5
This is a very helpful article in our practice. Nice pick!
Research with regards to crystalloids vs colloids and crystalloids vs crystalloids can be very challenging especially with our septic patients. This article however emphasized on individualized fluid replacement. Just like how we deliver our anesthetic, I fluid resuscitate them based on their co-morbities and what type of procedure are they having. With the rise of fluid goal directed therapy, I am more inclined to see patient's response to fluid bolus then start from there. Aside from their VS and in some cases- SVV, SV, CO, I also base my fluid resuscitation on their urine output.
With regards to albumin, I completely agree with LarSharVeA's statement. The debate between crystalloids vs colloids is still on going. But until we have definite answer, I am still using albumin as an adjunct in fluid replacement.
|
|
|
Post by faresha on Jun 10, 2018 16:56:31 GMT -5
1. I don't resuscitate based on the classic 4:2:1 rule. I'm not sure if I think it is the most evidence based view but know it is not the most practical view. Fluid resuscitation is very case specific. If you follow this rule in a Neuro case know that the Surgeon will put you out of his room. If you follow this rule on a prone case, know that you will have severe facial/orbital edema. I used the vital signs and case type as a guide for fluid resuscitation.
2. I don't think the use of albumin is evidence-based. Yes, it can be more harmful than crystalloid but it can also be life-saving in the appropriate case/situation.
|
|
|
Post by dahlia on Jun 11, 2018 10:05:25 GMT -5
After reading this article, it mentioned in many occasions, this was looking at ICU patients with sepsis or those admitted in ERs during resuscitation. It did not seem to address active bleeding (massive transfusion protocol scenarios) where up to 15L blood loss is occurring and resuscitation is of great concern. It did mention that resuscitation with end organ perfusion should be a goal of IV fluid management (I agree) and that timing is of essence when deciding how to resuscitate (I agree). I argues the questionable effectiveness of albumin (I disagree) in comparison to crystalloid. In the OR, evidence based experience and practice has shown immediately that during hemodynamic changes, albumin is most helpful to prevent over resuscitation with crystalloid especially if many more hours are to go during the case. In response to your questions, I feel the 4:2:1 rule is important in pediatric cases. I always use this calculation to determine my maintenance rate but bolus when the patient has unstable blood pressure (in addition to IA decrease, other measures, etc.). I agree the 4:2:1 for adults would over resuscitate and cause unnecessary edema. Albumin in conjunction with crystalloid is beneficial for long surgical procedures, with large 3rd space losses. Looking at urinary output, hemodynamic response to stress and to how much crystalloid replacement is already given considering how much longer to go is a guide to know when and how much to give. In summary I also agree with the article, goal directed therapy for IVF makes a more conservative approach to resuscitation.
|
|
|
Post by vaniamilnes on Jun 11, 2018 13:39:45 GMT -5
1. This is a great topic. I am mostly in peds and this has come up on multiple occasions. I do use the 4:2:1 rule but I also judge fluids on the case and the patient specifically.
2. I rarely use albumin and if I do its usually for teens or older, and for longer big cases with blood loss or fluid restrictions. I still think it is a decent alternative to very large volumes of crystalloid and I find that BP will often respond favorably.
|
|
|
Post by chrisdiem on Jun 20, 2018 14:22:03 GMT -5
1: Do you resuscitate based on the classic 4:2:1 rule; do you think this is currently the most evidenced-based view? If not, then what are your parameters for resuscitation?
— I do not resuscitate based on the 4-2-1 rule. As mentioned by others it is often not the safest or most practical option. As is with everything I go case by case with fluid administration having overall idea of my fluid plan based on case and patient comorbidities. Example healthy kid that is hypotensive give 10ml/kg if that fixes it good. If not give another 10ml/kg and reassess. On the other hand I healthy kid that is hemodynamically stable during the case I will not administer the same amount of fluid. I always base my parameters off of the situation at hand for the patient.
2: At JHH, albumin is used quite often. Do you feel this is evidence-based? Can albumin possible be more harmful than crystalloid for our patients
— I agree that albumin is used often at JHH. I use albumin as a tool when deemed necessary. In pediatrics we rarely use albumin but rather crystalloid only until the need for blood products as they have a healthy heart and circulatory system that can tolerate the additional volume of crystalloid over colloid. However, in a cardiac patient that has a low EF less is more for volume expansion so it is useful. As someone mentioned although albumin also shifts out of intravascular space it does hang for about 3 times longer so can be helpful in a situation where you need rapid and profound volume expansion.
|
|
|
Post by darolyn on Jun 21, 2018 20:08:39 GMT -5
This is a good read. I remember in one of clinical sites that did big gastric cases the use of Hetastarch was employed for volume repletion. By the time I finished anesthesia program and was working at my first job I suggested hetastarch for volume resuscitation and learned why it was not considered as the best option due to coagulopathy. My parameters for resuscitation are kind of based on the 4:2:1 rule at least for determining the fluid deficit and where the patient should be during the length of the case. I think in the adult population we tend to underresuscitate. I agree Hopkins culture loves albumin. I consider it when the clinical picture shows the patient to be in need of something more than crystalloid boluses. According to the article crystalloids particularly NS may not always be advantageous for some populations as well.
|
|
|
Post by BelindaG on Jun 25, 2018 11:47:49 GMT -5
1. I use the 4:2:1 rule as a guide for for fluid resuscitation and then tailor to each patient using a more goal-directed manner to target the specific needs of each patient related to their need, comorbidities and case type/length of case which is what I think most providers try to do. 2. The most recent research shows Albumin to be harmful in TBI patients but otherwise no strong evidence for surgical cases. It works well in long cases with significant 3rd spaces loses.
|
|
|
Post by BrittneyKeating on Jun 27, 2018 7:30:13 GMT -5
I tend not to utilize the classic 4:2:1 rule for volume resuscitation, as I think it lends to either under- or over- resuscitating in most patients. Mostly, I utilize a goal directed approach to fluid resuscitation, which provides for better volume resuscitation in the event of massive blood loss, and supports the anesthesia provider in considering specific case-related and patient-related factors/co-morbidities. Individualizing fluid therapy based on hemodynamic stabilization and patient response, as in goal directed fluid therapy, requires the anesthesia provider to remain vigilant of the surgical procedure and patient hemodynamics, rather than just administering fluid according to a pre-calculated number. I have used the Edwards Vigileo monitor which provides SVV, CI, SVO2 and SVRI, and allows for immediate feedback in regards to patient response to fluid. While I do not think this is a necessary monitor in every case where goal directed fluid therapy is being utilized, I do think it is helpful to see a patient’s hemodynamic response at this level when patient’s have poor cardiac function, or massive inflammatory processes and are requiring massive volume resuscitation.
I agree that albumin is used quite often at JHH. I noticed shortly after joining the team here at Hopkins that I used albumin more at this institution than any other medical center where I did my nurse anesthesia training. I think this has to do with the length of time for many of the surgical cases, acuity of patients, and blood loss/need for massive volume resuscitation. As Belinda mentioned in her post, albumin has been shown to be detrimental in patients with traumatic brain injury. For this reason, I avoid administering albumin for this patient population, but I have found it extremely useful as a fluid of choice in goal directed fluid therapy for most other adult patient populations. Additionally, the harm/risks of albumin must be weighed against the harm/risks of other crystalloid. As the article mentioned, ND has long been known to be associated with increased risk of hyperchloremic metabolic acidosis, which can result in decreased renal blood flow and renal cortical hypoperfusion.
|
|
|
Post by Chuck Eder on Jun 29, 2018 22:40:13 GMT -5
1. As most have already stated, using the 4-2-1 resus model for every case is not very practical. I typically will use it more when doing large abdominal or big back cases, those that typically are very long with many fluid shifts. It is not very practical with certain cases such as neuro or neck dissection cases. It is definitely a case by case judgment that takes into account co-morbidities and post op goals.
2. Over the last 3-4 years it seems as though albumin is the wonder fluid to give to most patients that need fluid replenishment. The type of fluid replacement has evolved over the years. Just 8-10 years ago we were using NS and hetastarch. Now its P-lyte and albumin. Albumin can be used with most cases with minimal side effects. Co-morbitidites always factor into your fluid replacement strategy.
|
|