As for the OP, conservative vs liberal fluid replacement strategies are inherently flawed. The goal is for the ideal replacement and not too much or too little. Give the right amount of fluid at the right time to help improve patient outcomes.
Ahhh, now you see where I'm getting at. What is your guide for what is too much or too little. Urine output, HR, BP? Until recently change in CVP and other pressure measurements were used to assess ones "volume status" and response to a "fluid challenge". Now there is literature on pulse pressure change or systolic pressure change up and down. Also, like mentioned, esophageal doppler.
How do you assess what part of the Starling curve you are on? I mean, that is what we are really asking.
In the end, our goal is to optimize O2 delivery. We shouldn't have to place a PAC to measure SV and CO in all our patients. I know there are less invasive devices to do this, PICCO but few have access to this. Also one that uses just an a-line, but not as much literature.
In simple cases and in healthy patients, I don't think plus or minus a couple liters matters that much. On the other hand, for a 6-8 hour whipple or a patient with end-stage organ disease I think fluid management can really alter patient outcome.
What are all you guys using for your big belly case, esophagectomy, big spine or maybe your pneumonectomy to guide your fluid management? Are you just guessing based of the response to BP, HR and Urine output. Is that good enough? I mean if you think about it, after inducing anesthesia and providing analgesia so our patients wake up comfortably, what do we do 90% of the time. We give IVF to "resuscitate" our patients.
At HSS in NY, for total hips, one attending uses an epidural to induce normovolemic hypotention to decrease blood loss. He keeps MAPS around 45-55. HE then augments CO with an epi gtts and uses this noninvasive device to follow hemodynamic variables(it uses a BP cuff that gathers several measurements that allows him to determine CO, SVR, ect..). He use to use a PAC before he used this new noninvasive device. He then places a nasal canula on the patient and gives sedation with a propofol gtts.
Besides decreasing blood loss (which in the end it might be an average of 500ml) and transfusion, he has been able to decrease overall morbidity and mortality. I believe it is because he is able to optimize in O2 delivery and fluid management. Not sure if the neuroaxial technique has something to do with it too. I'm sure it does.
I'm not saying this is this best way to provide anesthesia for a THR, but I'm trying to figure out what is the best way to guide and deliver fluids for our cases where it really can alter patient outcome.
