Fluid Management in Cardiac Surgery: Results of a Survey in European Cardiac Anesthesia Departments

doi:10.1053/j.jvca.2017.04.017

Journal of Cardiothoracic and Vascular Anesthesia

Volume 31, Issue 5, October 2017, Pages 1624-1629

https://doi.org/10.1053/j.jvca.2017.04.017 Get rights and content

Objective

To evaluate the current practice of perioperative fluid management in cardiac surgery patients.

Design

Multiple choice survey with 26 questions about existing practice of perioperative fluid management in cardiac surgery patients.

Setting

Online survey.

Participants

Representatives of anesthesia departments in European cardiac surgical centers.

Intervention

None.

Measurements and Main Results

The study comprised 106 respondents from 18 European countries who mainly worked in teaching hospitals (66%). In 73% of institutions, patients were admitted to a cardiac surgery intensive care unit (ICU) postoperatively. Perfusionists were responsible for the cardiopulmonary bypass priming solution, whereas anesthesiologists were responsible for intraoperative and postoperative fluid management. For cardiopulmonary bypass priming, balanced crystalloids were used in 51.5% of the centers, whereas in 36%, a combination of crystalloid with either synthetic colloid or albumin was administered. Intraoperatively, balanced crystalloids were used by 74% of centers, followed by a combination of crystalloids with synthetic colloids (15%) and other combinations (11%). No colloids were used by 32% of respondents. When colloids were used, gelatin was preferred, compared with hydroxyethyl starches and albumin (60% v 24% v 16%, respectively). Seventy-three percent of respondents, also involved in ICU treatment, did not change their fluid strategy in the ICU compared with their intraoperative strategy. Thirty-two percent of those who changed their strategy either added (32%) or decreased (29%) synthetic colloids or added (32%) or decreased (7%) natural colloids.

Conclusions

Perioperative fluid management in cardiac surgery patients may have changed in the last few years in European centers. Balanced crystalloids now seem to be the preferred solutions, followed by synthetic colloids (mainly gelatins) and albumin.

Section snippets

Materials and Methods

The study was approved by the Ethics Committee, Faculty of Medicine at Leipzig University (reference number 075-16-14032016).

Results

The overall response rate was 28%, with 106 answers (101 complete, 5 incomplete) from 18 European countries (Fig 1).

Discussion

The results of the survey indicated a reduced use of colloids, especially HES, in cardiac surgery patients compared with the results from previous surveys in European countries conducted before the EMA warning.14, 15, 16, 17 One-third (32%) of all centers included in this study were not using colloids intraoperatively compared with only 12% of German centers in 2013.¹⁴ For CPB priming, colloids were not used in any of the 12 responding German centers; whereas in the survey by Sponholz et al,¹⁴

Conclusion

The results of this survey suggested that perioperative fluid management in cardiac surgery patients may have changed in the last few years in European centers. Balanced crystalloids seemed to be the preferred solutions, followed by synthetic colloids (mainly gelatins) and albumin.

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Cited by (37)

Intravenous albumin in cardiac and vascular surgery: a systematic review and meta-analysis
2024, British Journal of Anaesthesia
Intravenous albumin is commonly utilised in cardiovascular surgery for priming of the cardiopulmonary bypass circuit, volume replacement, or both, although the evidence to support this practice is uncertain. The aim was to compare i.v. albumin with synthetic colloids and crystalloids for paediatric and adult patients undergoing cardiovascular surgery for all-cause mortality and other perioperative outcomes.
A systematic review and meta-analysis of randomised controlled trials (RCTs) of i.v. albumin compared with synthetic colloids and crystalloids on the primary outcome of all-cause mortality was conducted. Secondary outcomes included renal failure, blood loss, duration of hospital or intensive care unit stay, cardiac index, and blood component use; subgroups were analysed by age, comparator fluid, and intended use (priming, volume, or both). We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CCRT) from 1946 to November 23, 2022.
Of 42 RCTs, mortality was assessed in 15 trials (2711 cardiac surgery patients) and the risk difference was 0.00, 95% confidence interval (CI) −0.01 to 0.01, I²=0%. Among secondary outcomes, i.v. albumin resulted in smaller fluid balance, mean difference −0.55 L, 95% CI −1.06 to −0.4, I²=90% (nine studies, 1975 patients) and higher albumin concentrations, mean difference 7.77 g L⁻¹, 95% CI 3.73–11.8, I²=95% (six studies, 325 patients).
Intravenous albumin use was not associated with a difference in morbidity and mortality in patients undergoing cardiovascular surgery, when compared with comparator fluids. The lack of improvement in important outcomes with albumin and its higher cost suggests it should be used restrictively.
PROSPERO; CRD42020171876.
Physiological changes after fluid bolus therapy in cardiac surgery patients: A propensity score matched case–control study
2024, Critical Care and Resuscitation
Fluid bolus therapy (FBT) is ubiquitous in intensive care units (ICUs) after cardiac surgery. However, its physiological effects remain unclear.
: We performed an electronic health record–based quasi-experimental ICU study after cardiac surgery. We applied propensity score matching and compared the physiological changes after FBT episodes to matched control episodes where despite equivalent physiology no fluid bolus was given.
The study was conducted in a multidisciplinary ICU of a tertiary-level academic hospital.
The study included 2,736 patients who underwent Coronary Artery Bypass Grafting and/or heart valve surgery.
Changes in cardiac output (CO) and mean arterial pressure (MAP) during the 60 minutes following FBT.
We analysed 3572 matched fluid bolus (FB) episodes. After FBT, but not in control episodes, CO increased within 10 min, with a maximum increase of 0.2 l/min (95%CI 0.1 to 0.2) or 4% above baseline at 40 min (p < 0.0001 vs. controls). CO increased by > 10% from baseline in 60.6% of FBT and 49.1% of control episodes (p < 0.0001). MAP increased by > 10% in 51.7% of FB episodes compared to 53.4% of controls. Finally, FBT was not associated with changes in acid-base status or oxygen delivery.
In this quasi-experimental comparative ICU study in cardiac surgery patients, FBT was associated with statistically significant but numerically small increases in CO. Nearly half of FBT failed to induce a positive CO or MAP response.
Perioperative Gelatin Use Is Associated With Increased Complication Rates and Does Not Prevent Postoperative Fluid Overload in Patients Undergoing Elective Cardiac Surgery
2023, Journal of Cardiothoracic and Vascular Anesthesia
The benefit of using gelatin solution in cardiac surgery is still controversial. Previous data suggested adverse interactions of gelatin infusion with acute kidney injury (AKI) or coagulopathy. The purpose of this study was to evaluate the association between perioperative gelatin use and fluid overload (FO), hemodynamic stability, and outcomes compared to crystalloid-based fluid management.
A retrospective study design.
At a single-center tertiary university setting.
Propensity score-matched cohort study of 191 pairs of patients scheduled for cardiac surgery.
Patients received either gelatin + crystalloid or pure crystalloid-based perioperative fluid management. The primary outcomes were the frequency of FO and hemodynamic stability defined by the vasoactive-inotropic score. Postoperative complications and 3-year survival were analyzed also.
Patients who received gelatin experienced more frequent postoperative FO than controls (11.0% v 3.1%, p = 0.006) despite comparable hemodynamic stability in both groups. Gelatin administration was linked with a higher rate of postoperative complications, including blood loss, AKI, and new-onset postoperative atrial fibrillation. Use of gelatin infusion resulted in an adjusted odds ratio of 1.982 (95% CI 1.051-3.736, p = 0.035) for developing early postoperative AKI. This study confirmed a dose-dependent relationship between gelatin infusion and AKI. Thirty-day mortality and 3-year survival were similar in the groups.
Gelatin administration versus crystalloid fluid management showed a significant association with a higher rate of FO and an increased risk for early postoperative AKI in a dose-dependent manner.
Intraoperative fluid balance and cardiac surgery-associated acute kidney injury: a multicenter prospective study
2022, Brazilian Journal of Anesthesiology (English Edition)
Recent data suggest the regime of fluid therapy intraoperatively in patients undergoing major surgeries may interfere in patient outcomes. The development of postoperative Acute Kidney Injury (AKI) has been associated with both Restrictive Fluid Balance (RFB) and Liberal Fluid Balance (LFB) during non-cardiac surgery. In patients undergoing cardiac surgery, this influence remains unclear. The study objective was to evaluate the relationship between intraoperative RFB vs. LFB and the incidence of Cardiac-Surgery-Associated AKI (CSA-AKI) and major postoperative outcomes in patients undergoing on-pump Coronary Artery Bypass Grafting (CABG).
This prospective, multicenter, observational cohort study was set at two high-complexity university hospitals in Brazil. Adult patients who required postoperative intensive care after undergoing elective on-pump CABG were allocated to two groups according to their intraoperative fluid strategy (RFB or LFB) with no intervention.
The primary endpoint was CSA-AKI. The secondary outcomes were in-hospital mortality, cardiovascular complications, ICU Length of Stay (ICU-LOS), and Hospital LOS (H-LOS). After propensity score matching, 180 patients remained in each group. There was no difference in risk of CSA-AKI between the two groups (RR = 1.15; 95% CI, 0.85-1.56, p = 0.36). The in-hospital mortality, H-LOS and cardiovascular complications were higher in the LFB group. ICU-LOS was not significantly different between the two groups. ROCcurve analysis determined a fluid balance above 2500 mL to accurately predict in-hospital mortality.
Patients undergoing on-pump CABG with LFB when compared with patients with RFB present similar CSA-AKI rates and ICU-LOS, but higher in-hospital mortality, cardiovascular complications, and H-LOS.
Early Albumin Exposure After Cardiac Surgery
2022, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
At time of publication, this trial had reached the recruitment target of 1,400 patients; however, it has yet to publish any results. It is important to note that Ringer's acetate is not used commonly as an initial resuscitation fluid after cardiac surgery internationally, so these results, once published, may not be generalizable to comparisons with other crystalloids.31-33 There still may be a requirement for a randomized evaluation of albumin compared with a more commonly used balanced crystalloid, such as Ringer's lactate or Plasma-Lyte 148.
To determine whether the early use of albumin after cardiac surgery in the first 24 hours in the intensive care unit (ICU) is associated with reduced mortality.
A single-center nonrandomized retrospective cohort study using the Medical Information Mart in Intensive Care IV database.
A single cardiothoracic ICU in the United States during a period between 2008 to 2019.
Patients undergoing valvular and/or cardiac bypass graft surgeries.
Albumin administered during the first 24 hours of the ICU admission.
A total of 8,136 patients were included in this study, of whom 4,444 (54.6%) received albumin at any stage during the first 24 hours of ICU admission, and 69 (1.6%) of those patients died. The patient population exposed to albumin had higher comorbidities and illness severity compared to the no-albumin group. Patients exposed to albumin during the first 24 hours of ICU admission had a statistically significant reduction in mortality (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.48-0.97, p < 0.05) after adjustment for age, the Oxford Acute Severity of Illness Score, and the Charlson comorbidity index. A sensitivity analysis of patients who received albumin at any stage during ICU admission showed increased mortality (OR, 1.93; 95% CI, 1.26-3.07, p < 0.01). Patients exposed to albumin had a significant increase in adjusted ICU length of stay (LOS) (geometric mean ratio 1.09; 95% CI, 1.05-1.10, p = < 0.001) and hospital LOS (geometric mean ratio 1.08; 95% CI, 1.05-1.10, p < 0.001).
Exposure to albumin in the first 24 hours after cardiac surgery is associated with a reduction in adjusted hospital mortality and an increase in both hospital and ICU lengths of stay.
Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Intravenous fluids for maintenance therapy and for correcting ongoing losses also can result in disturbances to serum Na+ concentration.58 The choice of fluid varies according to institutional practice, and the majority of centers in a survey of European units primarily use a crystalloid solution, in combination with colloid solutions, in the perioperative period.59 In view of these considerations, practitioners need to remain vigilant throughout the perioperative period and maintain close monitoring of serum Na+ concentrations.
Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.

View all citing articles on Scopus

: The development and analysis of the survey was supported by an unrestricted grant from Grifols S.A. to the European Association of Cardiothoracic Anaesthesiology. None of the authors has received any payment for his or her contribution.

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Original ArticleFluid Management in Cardiac Surgery: Results of a Survey in European Cardiac Anesthesia Departments

Objective

Design

Setting

Participants

Intervention

Measurements and Main Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Conclusion

J Cardiothorac Vasc Anesth

Anesthesiol Clin

J Cardiothorac Vasc Anesth

Br J Anaesth

Br J Anaesth

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

Aust N Z J Public Health

Cardiopulmonary bypass in cardiac surgery [in German]

Anaesthesist

On the absorption of fluids from the connective tissue spaces

J Physiol

Intensive insulin therapy and pentastarch resuscitation in severe sepsis

N Engl J Med

Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis

N Engl J Med

Hydroxyethyl starch or saline for fluid resuscitation in intensive care

N Engl J Med

Original Article
Fluid Management in Cardiac Surgery: Results of a Survey in European Cardiac Anesthesia Departments