The online version of this article (https://doi.org/10.1186/s13741-017-0071-6) contains supplementary material, which is available to authorized users.
Fluid resuscitation during cardiac surgery is common with significant variability in clinical practice. Our goal was to investigate current practice patterns of fluid volume expansion in patients undergoing cardiac surgeries in the USA.
We conducted a cross-sectional online survey of 124 cardiothoracic surgeons, cardiovascular anesthesiologists, and perfusionists. Survey questions were designed to assess clinical decision-making patterns of intravenous (IV) fluid utilization in cardiovascular surgery for five types of patients who need volume expansion: (1) patients undergoing cardiopulmonary bypass (CPB) without bleeding, (2) patients undergoing CPB with bleeding, (3) patients undergoing acute normovolemic hemodilution (ANH), (4) patients requiring extracorporeal membrane oxygenation (ECMO) or use of a ventricular assist device (VAD), and (5) patients undergoing either off-pump coronary artery bypass graft (OPCABG) surgery or transcatheter aortic valve replacement (TAVR). First-choice fluid used in fluid boluses for these five patient types was requested. Descriptive statistics were performed using Kruskal-Wallis test and follow-up tests, including t tests, to evaluate differences among respondent groups.
The most commonly preferred indicators of volume status were blood pressure, urine output, cardiac output, central venous pressure, and heart rate. The first choice of fluid for patients needing volume expansion during CPB without bleeding was crystalloids, whereas 5% albumin was the most preferred first choice of fluid for bleeding patients. For volume expansion during ECMO or VAD, the respondents were equally likely to prefer 5% albumin or crystalloids as a first choice of IV fluid, with 5% albumin being the most frequently used adjunct fluid to crystalloids. Surgeons, as a group, more often chose starches as an adjunct fluid to crystalloids for patients needing volume expansion during CPB without bleeding. Surgeons were also more likely to use 25% albumin as an adjunct fluid than were anesthesiologists. While most perfusionists reported using crystalloids to prime the CPB circuit, one third preferred a mixture of 25% albumin and crystalloids. Less interstitial edema and more sustained volume expansion were considered the most important colloid traits in volume expansion.
Fluid utilization practice patterns in the USA varied depending on patient characteristics and clinical specialties of health care professionals.
Additional file 1: Albumin Surgical Utilization Survey. (DOCX 415 kb)13741_2017_71_MOESM1_ESM.docx
Additional file 2: Figure S1. Frequency of adjunct fluid use for patients needing volume expansion during CPB when not experiencing significant blood loss when the first choice is crystalloidsa (scenario 1, n = 64). CPB, cardiopulmonary bypass; HES, hydroxyethyl starch. aResponses to the following question: How often do you use each of the following as an adjunct to your first choice in a patient not experiencing significant blood loss when volume expansion is indicated during cardiovascular surgery with CPB? (JPEG 168 kb)13741_2017_71_MOESM2_ESM.jpg
Additional file 3: Figure S2. Frequency of adjunct fluid use for patients needing volume expansion in the presence of blood loss during CPB when blood transfusion is not indicated (scenario 2) a when first fluid choice is 5% albumina (n = 52) and b when first fluid choice is crystalloidsb (n = 39). CPB cardiopulmonary bypass; Hb, hemoglobin; HES, hydroxyethyl starch. aResponses to the following question: How often do you use each of the following as an adjunct to your first choice in a patient not experiencing significant blood loss when volume expansion is indicated during cardiovascular surgery with CPB? bResponses to the following question: How often do you use each of the following as an adjunct to your first choice in a patient for volume expansion in the presence of blood loss when blood transfusion is not indicated (adequate Hb) during cardiovascular surgery with CPB? (ZIP 186 kb)13741_2017_71_MOESM3_ESM.zip
Additional file 4: Figure S3. Frequency of adjunct fluid use for patients needing volume maintenance during acute normovolemic hemodilution when first fluid choice is crystalloidsa (scenario 3, n = 78). HES, hydroxyethyl starch. aResponses to the following question: How often do you use the following as an adjunct to your first choice for a patient for volume maintenance during acute normovolemic hemodilution (autologous blood collection)? (JPEG 167 kb)13741_2017_71_MOESM4_ESM.jpg
Additional file 5: Figure S4. Frequency of adjunct fluid use for expansion during ECMO or VAD (scenario 4) a when first fluid choice is albumin 5%a (n = 33b) and b when first fluid choice is crystalloidsa (n = 31b). ECMO, extracorporeal membrane oxygenation; HES, hydroxyethyl starch; VAD, ventricular assist device. aResponses to the following question: How often do you use the following as an adjunct to your first choice for a patient who needs volume expansion during ECMO or VAD? bNo statistical tests were performed due to small sample size. (ZIP 169 kb)13741_2017_71_MOESM5_ESM.zip
Additional file 6: Figure S5. Frequency of adjunct fluid use for intraoperative volume expansion for OPCABG or TAVR when first fluid choice is crystalloidsa (scenario 5, n = 59). HES, hydroxyethyl starch; OPCAB, off-pump coronary artery bypass surgery; TAVR, transcatheter aortic valve replacement. aResponses to the following question: How often do you use the following as an adjunct to your first choice for a patient who needs intraoperative volume expansion for OPCAB or TAVR? (JPEG 167 kb)13741_2017_71_MOESM6_ESM.jpg
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- Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers
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