Fluid therapy in the surgical patient in our environment. About Fluid Day Study

Colomina, M.J.; Guilabert, P.; Ripollés-Melchor, J.; Jover, J.L.; Basora, M.; Llau, J.V.; Casinello, C.; Ferrandis, R.
doi:10.1016/j.redare.2018.12.002
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the patient&#39;s preoperative hydration and volume status are not known&#46; In addition&#44; the best way to achieve and monitor preoperative fluid replacement targets has yet to be established&#44; and many targets that are theoretically possible cannot be monitored in practice&#46; The main objective is nearly always to optimize cardiac preload&#46; It is important to emphasize that optimization does not necessarily mean maximization&#44; despite being frequently interpreted in this way&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> In stable surgical patients&#44; fluid exchange-related physiological changes are usually minimal&#44; so replacement should also be kept to a minimum&#46; Even so&#44; there is clear evidence that fluid replacement strategies differ between anaesthesiologists and surgeons in the same centre&#44; and between different hospitals&#44; and are mainly determined by &#8220;habit&#8221; and not by the real needs of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Fluids administration methods also vary greatly&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;7</span></a> Indications for fluids and control of the effects of fluid replacement are not standardized&#44; and can therefore lead to inter-professional variations&#46; Historically&#44; administration of intravenous fluids to treat hypovolaemia has been guided by measuring pulse rate&#44; blood pressure&#44; and central venous pressure&#46; However&#44; this approach lacks the sensitivity and specificity needed to identify plasma volume deficit&#44; and leads to inappropriate&#44; and in many cases excessive&#44; fluid administration&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> Although changes over time in heart rate&#44; blood pressure and central venous pressure are the main markers of the effect of fluid administration on vascular filling&#44; they are influenced by other factors and do not exhibit a linear relationship with cardiac output or tissue perfusion&#46; Therefore&#44; absolute values of these parameters may not give a reliable picture of the need for intravenous fluid administration&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> The introduction of minimally invasive techniques&#44; such as transoesophageal Doppler or pulse contour analysis for measuring stroke volume and cardiac output&#44; has made allowed clinicians to adjust fluid requirements more accurately to the needs of each patient&#46; Clinical trials have shown that fluid therapy guided by measurements of dynamic parameters gives significantly better clinical outcomes than those based on traditional monitoring methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">8&#44;9</span></a> This beneficial effect is probably related to prompt measures to adjust fluid administration to the specific requirements of the patient&#44; instead of following fixed fluid replacement rules&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> The individual parameters used to guide fluid therapy are measures of cardiovascular function&#44; and vary in each monitoring system&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> In practice&#44; goal directed fluid therapy &#40;GDFT&#41; involves the repeated intravenous administration of small boluses of fluids&#44; often colloids&#44; until certain a target or plateau has been reached&#46; A baseline infusion of crystalloids is usually administered&#46; Several randomized trials and subsequent meta-analyses in various surgical settings have that GDFT confers clear clinical benefits&#44; such as reduction in postoperative morbidity and length of hospital stay compared to traditional and liberal fluid therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">9&#8211;11</span></a> In addition&#44; recent guidelines recommend using other parameters to control macro- and microcirculation&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> However&#44; this approach is still not widespread in high-risk surgical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This situation&#44; coupled with the need to understand and evaluate usual surgical practice in Spain&#44; has prompted the Haemostasis&#44; Transfusion Medicine and Fluid Therapy division of SEDAR to develop the Fluid Day project&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Fluid Day is a project carried out by SEDAR to evaluate fluid management strategies used by anaesthesiologists in adult patients during the perioperative period of scheduled and urgent surgery&#46; The project will also evaluate the impact of the administration of the different types of fluids and blood products&#44; fluid management monitoring strategies&#44; the use of vasoactive support&#44; and the implementation of GDTF protocols&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The Fluid Day project will provide information about perioperative fluid therapy in Spain&#44; detailing how anaesthesiologists administer each type of fluid during both the intraoperative and postoperative period&#44; and will give insight into the factors determining these choices&#46; Fundamentally&#44; and in practical terms&#44; our aim is to answer the &#8220;4 Ds&#8221;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Drug</span>&#58; type of solution infused&#46; There is still no general consensus on the best solution to use in each surgical scenario and patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dose</span>&#58; volume of solution needed&#46; This will depend on the clinical scenario and the patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Duration</span>&#58; how long to administer fluids&#44; and the best method&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Disconnection or termination</span>&#58; the best moment to stop fluid administration&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">This is a multicentre&#44; observational&#44; prospective study that will take place on 2 alternate days in all the Spanish hospitals that have chosen to participate&#46; The study will collect data on the fluid therapy administered to real patients by anaesthesiologists on duty on these dates and during a maximum follow-up period of 24<span class="elsevierStyleHsp" style=""></span>h&#44; provided the patient is supervized by the anaesthesiology service&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Conducting research in Spain is no easy task&#46; Unfortunately&#44; we anaesthesiologists are relatively unaccustomed to research&#44; because our work has always been fundamentally hand-on&#46; There is a growing demand for anaesthesiologists in all hospitals and all specialties&#44; and this makes it particularly difficult to devote part of our time to anything other than purely care-related activities&#46; The lack of a research culture&#44; and consequently research training&#44; and the pressures of work in our field are the main barriers in this respect&#46; However&#44; on the bright side&#44; a growing number of anaesthesiologists are willing to participate in multicentre clinical studies in order to contribute to the evolution of anaesthesiology&#59; proof of this new trend has been the positive response to this project More than one hundred hospitals have joined the project&#44; and we believe that this is an example of how scientific societies should promote the advancement of science and help create a research culture&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">For all these reasons&#44; we believe that the effort involved in carrying out a project of such magnitude is amply justified&#44; and we encourage all anaesthesiologists to continue in this line&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Colomina MJ&#44; Guilabert P&#44; Ripoll&#233;s-Melchor J&#44; Jover JL&#44; Basora M&#44; Llau JV&#44; et al&#46; Estado actual de la fluidoterapia en el paciente quir&#250;rgico en nuestro medio&#46; A prop&#243;sito del estudio <span class="elsevierStyleItalic">Fluid Day</span>&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;119&#8211;121&#46;</p>"
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