Big Back Wack... What fluids are you using?

[sevoflurane]

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79 y/o for T7-S1 post. spinal fusion. Moderate COPD- uses nebs but not on ATC O2.

Starting hemoglobin is 11.

What is your strategy and what do you like to use fluid wise for these cases?

Voluven, Albumin, HES, crystalloids (LR/NS), etc...

As always, your goal is to extubate at the end of the case.

You don't want your patient to wake up like this:

 

[ssmallz]

I don't think it matters too much which fluids you choose, more so how much you give. I would use a flowtrack and try to limit fluids to as little as possible. I would transfuse conservatively and maintain pressure with a neo drip PRN.

 

[WholeLottaGame7]

79 y/o for T7-S1 post. spinal fusion. Moderate COPD- uses nebs but not on ATC O2.

Starting hemoglobin is 11.

What is your strategy and what do you like to use fluid wise for these cases?

Voluven, Albumin, HES, crystalloids (LR/NS), etc...

As always, your goal is to extubate at the end of the case.

You don't want your patient to wake up like this:

I've noticed at our institution we are using a lot more albumin ever since the NEJM paper came out showing higher incidences of AKI in critically ill patients who received voluven. Not trying to start a journal club discussion over the applicability of the paper/findings, just making an observation.

Kind of along the lines of the ERAS protocol, I like running a background crystalloid infusion which doubles as carrier for the drips, while bolusing colloid to keep SVV around 10%. I'm also a little conservative on transfusions. Looooove cell saver for these cases.

 

[cincincyreds]

that looks like a patient that should still be intubated. How much edema is around her trachea?

 

[lobelsteve]

T7-S1 fusion?

Really? Expected benefit to the patient or only for the $urgeon?

Load the surgeon with ketamine and hide the patient for their own safety.

 

[sevoflurane]

T7-S1 fusion?

Really? Expected benefit to the patient or only for the $urgeon?

Load the surgeon with ketamine and hide the patient for their own safety.

👍

This dude legit.... but great response!

 

[sevoflurane]

that looks like a patient that should still be intubated. How much edema is around her trachea?

This is just a pic from the internet. If I ever see patients that look like this, I always sit them up for a while before I pull the tube.... always checking for my leak and @ what pressure I get that leak.

 

[alpha2agonist]

Rofl!!!!!

 

[dhb]

what do you like to use fluid wise for these cases?

Norepi and NaCl blood when needed

 

[proman]

Agree with something like Flotrac to limit fluids. In long cases with a lot of fluid loss I like to run a continuous infusion (~150-250 cc/hr of P-Lyte) and bolus on top, guided by something objective like the Flotrac or esophageal doppler etc, usually with 5% albumin. I stopped using starches after the Boldt fiasco. Starting hgb of 11 isn't really high enough to withstand a big back whack without transfusion.
A little bit of reverse T during the case goes a long way to prevent intraocular pressure increases and facial/trachea edema.

 

[sevoflurane]

I have to admit, I rarely need the aid of the Flotrack... but in certain cases I find them valuable.

This is one of those cases: COPD + potentially lots of fluids in a big spine case.

Props to Smallz and WhollattaGame for suggesting the Flotrack. 👍

We got into some bleeding intraop that was a bit more than the typical ooze one sees with these cases.

It's really nice to see how quickly the Flotrack picked it up compared to the CVP.
On the second pic, you can see where the CO and SV started to drop off and you can also see the response to prbc’s and colloids. Like WholattaGame, I also like SVV (stroke volume variance) but also like to monitor ScvO2. I’m not sure which one is more helpful. I must say I have a slight preference to SVV. In the heart room I like SvO2.

FWIW, in these types of cases I hang some LR and run it as my carrier (as mentioned above). Restrict my fluids and am more heavy on colloids than crystalloids as I don’t have to give as much volume. Eventually it equilibrates with the interstitium, but by then, you are in PACU, have the patient sitting up and have gravity on your hand keeping laryngeal/pulmonary edema at bay.

So what are you guys doing in your academic institutions/PP? Is Voluven falling out of favor now days? Voluven is way better than HES and @ least pretty comparable to albumin in patients w/o renal issues. Coagulopathy and anaphylaxis don’t seem to be a big concern compared to other starches.

The age old question...

 

[sevoflurane]

Agree with something like Flotrac to limit fluids. In long cases with a lot of fluid loss I like to run a continuous infusion (~150-250 cc/hr of P-Lyte) and bolus on top, guided by something objective like the Flotrac or esophageal doppler etc, usually with 5% albumin. I stopped using starches after the Boldt fiasco. Starting hgb of 11 isn't really high enough to withstand a big back whack without transfusion.
A little bit of reverse T during the case goes a long way to prevent intraocular pressure increases and facial/trachea edema.

Nice post proman.

I love sneaking in a little Reverse T burg...👍

Yeah... a lot of boggus studies out there... hence my question.

 

[WholeLottaGame7]

With regards to minimizing blood loss and thus reducing fluid administration, I've had a couple cases where we ran an amicar infusion, which definitely seemed to help and the surgeons absolutely loved. I couldn't quote you any papers without doing some research first, but just another thought to throw out there.

 

[deleted9493]

Edema's going to be present, no matter how fluid-restrictive you're able to be in these cases but I think that there is value in maintaining relative hemoconcentration to prevent dilution of clotting factors. There is good evidence for anti-fibrinolytics significantly reducing blood loss in posterior fusions for scoliosis in children.

Anecdotally, it seems that SVV is exagerrated in prone positioning, but I think it's still the simplest means of ascertaining fluid-responsive hypotension.

 

[1flyndo]

Consider some trans AA for the case.

 

[Idiopathic]

25% albumin and blood on top of a maintenance NS infusion

 

[caligas]

When they bleed blood, give 'em blood. Right?

 

[Idiopathic]

When they bleed blood, give 'em blood. Right?

sometimes.

 

[dhb]

My eyes are bleeding: albumin? CVP? wtf are we back in the 90's 😱

 

[proman]

I have to admit, I rarely need the aid of the Flotrack... but in certain cases I find them valuable.

This is one of those cases: COPD + potentially lots of fluids in a big spine case.

Props to Smallz and WhollattaGame for suggesting the Flotrack. 👍

We got into some bleeding intraop that was a bit more than the typical ooze one sees with these cases.

It's really nice to see how quickly the Flotrack picked it up compared to the CVP.
On the second pic, you can see where the CO and SV started to drop off and you can also see the response to prbc’s and colloids. Like WholattaGame, I also like SVV (stroke volume variance) but also like to monitor ScvO2. I’m not sure which one is more helpful. I must say I have a slight preference to SVV. In the heart room I like SvO2.

That's not really surprising that CVP, value or trend, is pretty much worthless.

I don't think these patients automatically have to be edematous. Obviously prone will cause some but it's amazing how not-puffy pts look when they don't get a ton of crystalloid.

 

[TrojanGopher]

With regards to minimizing blood loss and thus reducing fluid administration, I've had a couple cases where we ran an amicar infusion, which definitely seemed to help and the surgeons absolutely loved. I couldn't quote you any papers without doing some research first, but just another thought to throw out there.

This is actually the standard where I train, either EACA or tranexamic acid for spines. Though to be fair, one of the two attending anesthesiologists who refuses to use them was a Hematologist prior to switching to anesthesia. So...

 

[sevoflurane]

That's not really surprising that CVP, value or trend, is pretty much worthless.

Although I agree with you on the futility of using CVP alone for fluid management, I would say it is not a worthless number. If my starting CVP is 20 and I'm now running at 12, I would be a bit more concerned. Of course, by that time, I would already have picked it up on other patient data such as surgical bleeding in the field, cell saver, BPs, U/O, need for vasopressors, color of the skin, TEE and one of my favorites... finger on the pulse. A CVP of 12 from 20 is just another color in the overall picture. I wouldn't consider it worthless, but others might.

The above 2 pics does show a decrease in both CVP and CO/SV.... but obviously CO/SV are more meaningful. I was just making a comment on observation. I wasn't implying that I use CVP to guide my fluid management. That would be very short minded. Just an observation.

I don't think these patients automatically have to be edematous. Obviously prone will cause some but it's amazing how not-puffy pts look when they don't get a ton of crystalloid.

I 100% agree with you in that patients don't have to wake up edematous. 90% of my patients don't, but I always keep my crystalloids to a minimum and use @ least 500ccs of albumin (usually 1000ccs) and use prbcs when appropriate. This was an 11 hour case with a HUGE incision that had at least 1600 of surgical bleeding despite an amicar infusion (I don't do permissive hypotension in 77 y/o patients with DM as I'm more concerned about hypoperfusion of brain, kidneys, eyeballs, etc).

25% albumin and blood on top of a maintenance NS infusion

I've never thought of 25% albumin for these cases... It is an interesting thought though. We give 250cc's of 25% albumin for our cardiac cases as we try and limit our crystalloids for these cases as well. We find it beneficial when we start wrapping once the aortic cannula is in, then wrap again once the venous line is in... we also use whole blood cardioplegia (also nice to dial in your K+). This cuts down on our hemodilution significantly.

For the spine case, the patient got 1500 of albumin, 4U of prbcs, 1 of platelets, 2.5 of crystalloids, 500 of cell saver + the amicar that was infused. U/O was 700 for the case.
Minimal swealling... eyelids and a little around the lips. Extubated in the pacu after 30 minutes of 45 degress. Good airlieak and following commands.

She had a mild mixed acidosis at the end of the case. Since she was going to be extubated, I didn't want to give bicarb. I gave THAM instead and dropped her off in the ICU with a PH of 7.29.

PACU hgb was 12. The following morning it was 10. POD #2 it was 9.2.

Sounds like there isn't a consensus for colloids here. Albumin vs Voluven isn't quite sorted out, but with the bogus studies for starches, I've been sticking to albumin.

Here we are getting albumin @ $50 per 500cc
HES is $10... but that is dirty.
I don't remember off the top of my head how much Voluven costs..

Addendum:

Just double checked:

Albumin $70
Vouven $50
Hes $10

 

[dhb]

Albumin $70
Vouven $50
Hes $10

😱
Here Albumin is around 100$
Voluven 10€
HES non existant
Gelatin 6€ :

 

[Idiopathic]

100cc of 25% albumin is essentially the equivalent of a liter of normal saline, should stay intravascularly for the duration of the case. If you dont ALSO flood them with crystal, they should really not be too puffy. im sure its expensive, so i wouldnt do it for simple spines just ones i was really concerned about afterward

 

[urge]

100cc of 25% albumin is essentially the equivalent of a liter of normal saline, should stay intravascularly for the duration of the case. If you dont ALSO flood them with crystal, they should really not be too puffy. im sure its expensive, so i wouldnt do it for simple spines just ones i was really concerned about afterward

I played with 25% albumin for a while in the heart room. Was giving 200 ml at end of case to prevent the pt from becoming hypovolemic in the ICU after dropping him off (always happens, ICU people just crank up the levo and wonder why the lactate goes up post op...).

I wasn't convinced it worked.

 

[deleted9493]

I played with 25% albumin for a while in the heart room. Was giving 200 ml at end of case to prevent the pt from becoming hypovolemic in the ICU after dropping him off (always happens, ICU people just crank up the levo and wonder why the lactate goes up post op...).

I wasn't convinced it worked.

Do you suspect a drop in SVR from dilution? I can't imagine that your patients didn't have the interstitial water necessary to make the 25% effective (post-bypass).

 

[proman]

I played with 25% albumin for a while in the heart room. Was giving 200 ml at end of case to prevent the pt from becoming hypovolemic in the ICU after dropping him off (always happens, ICU people just crank up the levo and wonder why the lactate goes up post op...).

I wasn't convinced it worked.

I think 500cc-1 liter of 5% albumin is more worth it. I try to limit crystalloid to <500 cc before bypass and give as little as possible post.

 

[Idiopathic]

For the spine case, the patient got 1500 of albumin, 4U of prbcs, 1 of platelets, 2.5 of crystalloids, 500 of cell saver + the amicar that was infused. U/O was 700 for the case.
Minimal swealling... eyelids and a little around the lips. Extubated in the pacu after 30 minutes of 45 degress. Good airlieak and following commands.

She had a mild mixed acidosis at the end of the case. Since she was going to be extubated, I didn't want to give bicarb. I gave THAM instead and dropped her off in the ICU with a PH of 7.29.

you gave a >$1000 drug for a mild metabolic acidosis? why give anything?

 

[sevoflurane]

I really hope you guys aren't paying > $1000 for THAM. That is insane. 😱
It should be 1/2-1/3rd of that once you get through negotiations with the hospira rep.

Ph was 7.23 before THAM. Although she had a chronic respiratory acidosis @ baseline from her COPD, her bicarb was down and her PCO2 was up from baseline but not enough to account for the PH drop. She had a mixed acidosis picture.

We don't call in our ICU docs for soft call admissions. A hospitalist does the ICU admission. I really didn't feel comfortable letting it ride or giving bicarb as I don't trust all of our hospitalists (some are excellent, some not so much). I dropped her off in the ICU after I finished managing her acid base status in the pacu.

If I had chosen bicarb I would have had to put her on BIPAP to ensure she would blow off the increased CO2 produced by bicarb administration... and even then my care would have continued as I have a habit to call the ICU several times a night when things aren't tight in my mind. It was 730pm and I was ready to go home... so I took care of the problem.

This case is easily going to be billed in excess of 150K. $300-500 (I actually think it's in the $200 dollar range... but not sure) extra is just a drop in the bucket and I thought she was a perfect candidate for it.

If it was a simple 2-3 level fusion, I probably wouldn't have used it.

 

[TrustMe]

I played with 25% albumin for a while in the heart room. Was giving 200 ml at end of case to prevent the pt from becoming hypovolemic in the ICU after dropping him off (always happens, ICU people just crank up the levo and wonder why the lactate goes up post op...).

I wasn't convinced it worked.

Maybe you and/or your surgeons need to discuss things with the ICU folks. Nearly all of the cardiac pt's dropped off to me get volume within the first hour (or less). They come out dry (which is expected and understood/appreciated) and we resuscitate them when they get there. 500-1,000 of 5% Albumin and they are often off the levo with fairly smooth hemodynamics.

As for the OP's discussion, I like the idea of amicar for big back whacks. Where I trained, our adult guys very rarely did more than 4 or 5 levels so it wasn't an issue, but our peds guys always ran amicar throughout the case.

 

[proman]

Maybe you and/or your surgeons need to discuss things with the ICU folks. Nearly all of the cardiac pt's dropped off to me get volume within the first hour (or less). They come out dry (which is expected and understood/appreciated) and we resuscitate them when they get there. 500-1,000 of 5% Albumin and they are often off the levo with fairly smooth hemodynamics.

As for the OP's discussion, I like the idea of amicar for big back whacks. Where I trained, our adult guys very rarely did more than 4 or 5 levels so it wasn't an issue, but our peds guys always ran amicar throughout the case.

I'm not sure post CPB patients come out "dry". That implies that they are hypovolemic and underresuscitated. Don't forget the CPB prime is about 800-1500 cc depending how the perfusionist sets up the circuit. Even with RAP, there's going to be a significant crystalloid bolus. Plus, at the end the perfusionist will chase the reservoir with more crystalloid to retransfuse. Even with appropriate anticoagulation, CPB produces an intense activation of the inflammatory system, vascular leak and associated vasodilation. I think that's the main reason why they become fluid responsive. Complicating things, many patients requiring CPB have diastolic dysfunction and need higher filling pressures to optimize their Starling curves.

 

[Jay K]

Nice teaching case, Sevo.