Abstract
Objective: The purpose of this study was to test the hypothesis that extracellular fluid accumulation predicts fluid responsiveness after hydroxyethyl starch (HES) solution bolus infusion during major abdominal surgery. Methods: Twenty patients who underwent elective pancreaticoduodenectomy under general anesthesia were studied. Patients received 4 mL/kg boluses of Ringer’s acetate or 6% HES 70/0.5 solution over 15 min in random order when urine output decreased below 1.0 mL/kg/h. Stroke volume variation (SVV) and stroke volume index (SVI) were measured using the FloTracTM/VigileoTM system at pre-bolus, 15, 30, and 60 min after initiating bolus infusion. The percent change in pre-bolus extracellular fluid volume relative to that at the skin incision for arm (ΔVECF) was measured by bioelectrical impedance. Prediction of fluid responsiveness (an increase in SVI of ≥5%) by pre-bolus SVV or pre-bolus ΔVECF was tested by calculating the area under the receiver operating characteristic curve (AUC). Results: Fluid bolus infusions in this study consisted of 61 Ringer’s acetate infusions and 62 HES infusions. The best AUCs for identifying fluid responsiveness were seen with pre-bolus ΔVECF for HES at 30 min and 60 min (AUC = 0.74, P = 0.022; AUC = 0.74, P = 0.0054, respectively). Optimal threshold values of pre-bolus ΔVECF for predicting fluid responsiveness were 6.5% for 30 min (sensitivity: 78%, specificity: 58%) and 7.7% for 60 min (sensitivity: 56%, specificity: 76%). Conclusion: Extracellular fluid volume predicts fluid responsiveness after HES solution bolus infusion during major abdominal surgery. Substantial fluid responsiveness is observed upon increased accumulation of extracellular fluids.
Highlights
Volume replacement with hydroxyethyl starch (HES) solution according to goal-directed fluid therapy has been recommended in major abdominal surgery [1,2,3]
HES solution may leak into the interstitial space with time due to capillary leakage arising from surgical injury [6], thereby leading to interstitial edema and delaying postoperative recovery [7]
The major finding of the present study was that the responding fluid bolus for HES showed a larger pre-bolus ΔVECF compared to the non-responding fluid bolus
Summary
Volume replacement with hydroxyethyl starch (HES) solution according to goal-directed fluid therapy has been recommended in major abdominal surgery [1,2,3]. Given that HES induces volume expansion via a colloid osmotic effect, it is possible that, with increased extracellular fluid accumulation, HES extracts more fluid from the interstitial space to the intravascular space due to a larger gradient of colloid osmotic pressure across the capillary wall, thereby increasing fluid responsiveness. This information may help explore the most effective timing of HES infusion and prevent overdose of HES solution during major abdominal surgery
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