2011-a modern approach to perioperative fluid management-beverly morningstar

7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar

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Goal Directed Fluid Therapy:Goal Directed Fluid Therapy:A Modern Approach toA Modern Approach toPerioperativePerioperativeFluidFluidManagementManagementBeverly Morningstar, MD, FRCP (C)Beverly Morningstar, MD, FRCP (C)

Department of AnesthesiologyDepartment of Anesthesiology

Sunnybrook Health Sciences CentreSunnybrook Health Sciences CentreToronto ONToronto ON


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DisclosureDisclosure

FreseniusFreseniusKabiKabi::SpeakerSpeakers honorarias honoraria


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1999 UK Confidential Enquiry into1999 UK Confidential Enquiry into

PerioperativePerioperativeDeathsDeaths

Errors in fluid management (usuallyErrors in fluid management (usuallyfluid excess): most common cause offluid excess): most common cause of

perioperativeperioperativemorbidity, mortalitymorbidity, mortality

Lobo DN. BestLobo DN. Best PractPractResResClinClinAnaesthAnaesth2006;20(3):4392006;20(3):439


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Why do we give so much fluid?Why do we give so much fluid?preoppreopfastingfastingsurgical blood losssurgical blood loss

evaporationevaporation

urinary excretionurinary excretion

vasodilationvasodilationcaused by anesthesia,caused by anesthesia,epiduralepidural

transfer totransfer to third spacethird space

transcapillarytranscapillary leak of albumin causedleak of albumin causedby inflammatory mediatorsby inflammatory mediators

Many liters ofMany liters of

fluid during afluid during astandardstandard

operationoperation

Hahn RG.Hahn RG.AnesthAnesthAnalgAnalg2007;105:3042007;105:304


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StandardStandardmanagement grosslymanagement grosslyoverestimates iv fluidoverestimates iv fluidrequirementsrequirements

Maintenance:Maintenance:4:2:1 rule4:2:1 rule

Deficit:Deficit:Maintenance x hr fastingMaintenance x hr fasting3rd space losses:3rd space losses:1010--1515 mLmL/kg/hr/kg/hrBlood loss:Blood loss:3:1 replacement with3:1 replacement with

crystalloidcrystalloid


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StandardStandardfluid managementfluid management90 kg male, APR,90 kg male, APR,

NPO x 8 hr, 6 hrNPO x 8 hr, 6 hr

surgery, EBL 1500surgery, EBL 1500 mLmL

Using standard formulaUsing standard formula

this patient should getthis patient should get12 L crystalloid12 L crystalloidintraopintraop


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How much harm doesHow much harm does

excess fluid really cause?excess fluid really cause?


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Aggressive fluidAggressive fluid

strategiesstrategies

adversely affectadversely affecteveryevery systemsystem

and organand organ

ProwleJR et al. Nat Rev Nephrol2010;6:107


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Why are patients sensitive toWhy are patients sensitive to

large volumes of crystalloid?large volumes of crystalloid?

clearance of crystalloid during anesthesia and surgeryclearance of crystalloid during anesthesia and surgery

isis 1010--20%20%of that in awake volunteersof that in awake volunteerscrystalloid leaves the plasma space, equilibrates withcrystalloid leaves the plasma space, equilibrates with

interstitial space after 20interstitial space after 20--30 min30 min

Hahn RG.Hahn RG.AnesthAnesthAnalgAnalg2007;105:3042007;105:304


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Minerals, protein,glycogen, fat

40%

Minerals, protein,Minerals, protein,glycogen, fatglycogen, fat

40%40%

CapillaryCapillarymembranemembrane

CellCellmembranemembrane

PlasmaPlasma

volume(4.3%)volume(4.3%)InterstitialInterstitial

fluid (15.7%)fluid (15.7%)

ColloidsColloids

Crystalloid:Crystalloid:7575--80% leaves vasculature after 20 minutes80% leaves vasculature after 20 minutes

5% Dextrose5% Dextrose

Body water componentsBody water components

ICFICF

40%40%ECFECF

20%20%


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Preoperative measured blood volumePreoperative measured blood volume

PerioperativePerioperative

inputinput}}{{

PerioperativePerioperativeoutputoutput

TotalTotal perioperativeperioperativefluid balancefluid balance

..

Standard infusion 12Standard infusion 12 mL/kg/hmL/kg/hcrystalloid; blood loss replaced 1:1 with colloid.crystalloid; blood loss replaced 1:1 with colloid.

CrystalloidsCrystalloids

ColloidsColloids

PostopPostopmeasured blood vol.measured blood vol.750mL750mL

1,7001,700 mLmL

2,0002,000 mLmL

3,8003,800 mLmL

PreopPreopmeasured blood vol.measured blood vol.

3,8333,833 mLmLmissingmissing

Blood lossBlood loss

UrineUrine

Chappell D et al. Anesthesiology 2008;109:723Chappell D et al. Anesthesiology 2008;109:723

What happens to all thatWhat happens to all that

crystalloid?crystalloid?


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Can a healthy person die ofCan a healthy person die of

pulmonary edema?pulmonary edema?

13 patients, death13 patients, deathfrom pulmonaryfrom pulmonaryedema within 36 hredema within 36 hr

postoppostopaverageaverage 7 L +7 L +vevefluidfluidbalancebalance in first 24 hrin first 24 hr

10/13:10/13: ASA IASA I

average age:average age: 38 yr38 yr

ArieffAI. Chest 1999;115:1371-1377


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CurrentCurrent perioperativeperioperativefluidfluidtherapytherapy

anesthesiologists haveanesthesiologists havebecome desensitized tobecome desensitized to

administration of high fluidadministration of high fluid

volumes (5volumes (5--6 liters for6 liters formajor surgical procedures)major surgical procedures)

patients typically gain 5 kgpatients typically gain 5 kgof body weight after majorof body weight after major

surgical proceduressurgical procedures

Chappell D et al. Anesthesiology 2008;109:723Chappell D et al. Anesthesiology 2008;109:723


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PerioperativePerioperativeweight gain andweight gain andmortalitymortality

Overallm

ortality(%)

Weight gain (%)

More +vefluid balance = worse outcomesLowell JA etal. CritCare Med 1990;18:728


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For major surgery, all expertsFor major surgery, all experts

agree...agree...

11--22 mLmL/kg/hr/kg/hrmaximummaximumcrystalloid duringcrystalloid during

OROR

average 100average 100 mLmL/hr/hr


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What happens when youWhat happens when you

restrictrestrict perioperativeperioperativefluids?fluids?


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Fluid restriction andFluid restriction and postoppostopcomplicationscomplications

Restricted Regimen Standard Regimen

Preloading No preloading 500 mLcolloidThird spaceloss

No replacementNS 7 mL/kg h first hr; 5 mL/kg2nd + 3rd hr, then 3 mL/kg/hr= 1350 mLNS

Fluid loss forfast

500 mLD5W, minus pointake during fast 500 mLN/SBlood loss 500 mLcolloid 1500 mLN/STotal in 1000 mL 3850 mL

141 patients for elective colorectal resectionBased on 90 kg person, 500 ml blood loss:

BrandstrupBrandstrupB et al. AnnB et al. Ann SurgSurg2003;238:6412003;238:641


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Com

plicationfreq

uency%

Com

plicationfreq

uency%

Complications related to IV fluid,Complications related to IV fluid,

weight gain on day of operationweight gain on day of operation

BrandstrupBrandstrupB et al. AnnB et al. Ann SurgSurg2003;238:6412003;238:641

PP


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RingerRingers lactate onlys lactate only

liberal: av. 3900liberal: av. 3900 mLmL

restrictive: av. 1400restrictive: av. 1400 mLmL

blood loss both groupsblood loss both groupsreplaced 3:1replaced 3:1

NisanevichNisanevichV et al. Anesthesiology 2005;103:25V et al. Anesthesiology 2005;103:25

LiberalLiberal vsvsrestricted:restricted:IntraabdominalIntraabdominal

surgerysurgery


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LiberalLiberal vsvsrestricted:restricted:IntraabdominalIntraabdominal

surgerysurgery

RingerRingers lactate onlys lactate only

liberal: av. 3900liberal: av. 3900 mLmL

restrictive: av. 1400restrictive: av. 1400 mLmL

blood loss both groupsblood loss both groupsreplaced 3:1replaced 3:1

NisanevichNisanevichV et al. Anesthesiology 2005;103:25V et al. Anesthesiology 2005;103:25


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Even cutting down on IV fluidsEven cutting down on IV fluids

postoppostopspeeds GI recovery!speeds GI recovery!colon resection,colon resection, postoppostopIV fluid 2/3IV fluid 2/3--1/31/3standardstandardatat 125125 mLmL/hr/hrvsvsrestrictedrestrictedatat 8585 mLmL/hr/hrstandard group had:standard group had:

3 kg weight gain3 kg weight gain

more complicationsmore complications

3 day longer hospital stay3 day longer hospital stay

Lobo DN at al. Lancet 2002;359:1812


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So too much crystalloid isSo too much crystalloid is

harmful in major surgery...whatharmful in major surgery...whatabout too little?about too little?

GI li ti th


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GI complications are theGI complications are the

leading cause of delayedleading cause of delayeddischargedischarge

BennettBennett--Guerrero E et al.Guerrero E et al.AnesthAnesthAnalgAnalg1999;89:5141999;89:514

Percentage

Percentage


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GI complicationsGI complications

Major:Major:hemorrhagehemorrhageabscessabscess

gastric/bowelgastric/bowelobstructionobstruction

infectioninfection

fistulafistula

anastomoticanastomotic leakleakGI infarctionGI infarctionanything requiringanything requiringreoperationreoperation

Minor:Minor:severe nausea andsevere nausea andvomiting requiringvomiting requiring

rescuerescue antiemeticantiemeticileusileus

diarrheadiarrhea

abdominal distensionabdominal distensionpancreatitispancreatitis

GiglioGiglioMT et al. Br JMT et al. Br JAnaesthAnaesth2009;103(5):6372009;103(5):637


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Why are GI complications soWhy are GI complications so

common?common?healthy patients: 25healthy patients: 25--30%30%

loss of blood volume withloss of blood volume withno change in BP or HRno change in BP or HR

splanchnicsplanchnicperfusion fallsperfusion fallswith only 10with only 10--15%15%decrease in blood volumedecrease in blood volume

gutgut hypoperfusionhypoperfusionoftenoftenoutlastsoutlasts hypovolemiahypovolemiano simple clinicalno simple clinical

monitormonitor

GiglioGiglioMT et al. Br JMT et al. Br JAnaesthAnaesth2009;103:6372009;103:637


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The trouble with blood volumeThe trouble with blood volume

assessmentassessment

no direct beside measurementno direct beside measurement

clinical surrogates used:clinical surrogates used:

VS (BP, HR), examination (chest)VS (BP, HR), examination (chest)U/OU/O

lab: Hg, serum and urinary Nalab: Hg, serum and urinary Na++

ongoing losses (EBL, NG, etc.)ongoing losses (EBL, NG, etc.)fluid balance chartsfluid balance chartsCXR (pulmonary congestion)CXR (pulmonary congestion)


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surrogate measures:surrogate measures: accurate prediction of volumeaccurate prediction of volume

status


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PAOP and CVP fail to predictPAOP and CVP fail to predictventricular filling volume,ventricular filling volume,

cardiac performance, or thecardiac performance, or theresponse to volume infusion inresponse to volume infusion in

normal subjectsnormal subjects

Kumar A et al.Kumar A et al.

Critical Care Medicine 2004;32:691Critical Care Medicine 2004;32:691--699699


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Kumar A et al.Kumar A et al. CritCritCare Med 2004;32:691Care Med 2004;32:691


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Cardiac fillingCardiac filling

pressures arepressures arepoor measurespoor measures

of preload andof preload andvolumevolume

responsivenessresponsiveness

Kumar A et al.Kumar A et al. CritCritCare Med 2004;32:691Care Med 2004;32:691


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...very poor relationship between CVP and blood volume as...very poor relationship between CVP and blood volume aswell as the inability of CVP/well as the inability of CVP/CVP to predict theCVP to predict thehemodynamichemodynamic response to a fluid challenge ...response to a fluid challenge ...

CVP should not be used to make clinical decisions regardingCVP should not be used to make clinical decisions regardingfluid management...fluid management...

...Based on the results of our systematic review, we believe...Based on the results of our systematic review, we believethat CVP should no longer be routinely measured in the ICU,that CVP should no longer be routinely measured in the ICU,

operating room or emergency department.operating room or emergency department.

MarikMarikPE et al. Chest 2008; 134:172PE et al. Chest 2008; 134:172


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MarikMarikPE et al. Chest 2008; 134:172PE et al. Chest 2008; 134:172


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All great truthsAll great truthsbegin asbegin as

blasphemiesblasphemies

George Bernard ShawGeorge Bernard Shaw18561856 --19501950


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Bowel edemaBowel edemaBowel ischemiaBowel ischemia

Too much, too little or just right?Too much, too little or just right?

BundgaardBundgaard--NeilsenNeilsenM et al.M et al.ActaActaAnaesthesiolAnaesthesiolScandScand2009 53:8432009 53:843


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The answer:The answer:

GoalGoal--Directed Therapy (GDT)Directed Therapy (GDT)

The gold standard forThe gold standard forperioperativeperioperativefluidfluidmanagement in critical illness, or duringmanagement in critical illness, or duringmajor surgery with significant fluid shiftsmajor surgery with significant fluid shifts

and blood lossand blood loss


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intensive monitoring and aggressive management ofintensive monitoring and aggressive management of

perioperativeperioperativehemodynamicshemodynamics in high risk patients toin high risk patients tooptimize oxygen deliveryoptimize oxygen deliveryearly reports in the literature first appeared aroundearly reports in the literature first appeared around

20002000

standard of care:standard of care:

most majormost majorcentrescentresin USin USNICE* guidelines in UK for surgical patientsNICE* guidelines in UK for surgical patientsalmost all currentalmost all current periopperiopfluid literaturefluid literature


*NICE: National Institute for Health and Clinical Excellence*NICE: National Institute for Health and Clinical Excellence


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Target specific values for cardiac index,Target specific values for cardiac index,OO22 delivery, Odelivery, O22 consumptionconsumption

Use fluids andUse fluids and inotropesinotropes

mortality and morbiditymortality and morbidity++==

Shoemaker WC et al. Chest 1988;94:1176Shoemaker WC et al. Chest 1988;94:1176--8686



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GoalGoal--directed therapy (GDT):directed therapy (GDT):What goals can we target?What goals can we target?

stroke volume (SV)*stroke volume (SV)*

cardiac index (CI)cardiac index (CI)

stroke volume variation (SVV)stroke volume variation (SVV)oxygen delivery or consumption**oxygen delivery or consumption**

mixed venous oxygen saturation (SvO2)mixed venous oxygen saturation (SvO2)

gastric mucosal pHgastric mucosal pHstroke distance (esophagealstroke distance (esophageal dopplerdoppler))

*most commonly used goal*most commonly used goal**ideal goal**ideal goal


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expected blood loss >500expected blood loss >500 mLmL

examples:examples: major abdominalmajor abdominal----gengensurgsurg,, gyngyn, urologic, urologic orthopedic: major spine, hip (orthopedic: major spine, hip (espesprevision)revision) major head and neck oncologymajor head and neck oncology cardiac, thoraciccardiac, thoracic

traumatrauma

patients at high risk of complications (poor LV)patients at high risk of complications (poor LV) uncertain preoperative volume statusuncertain preoperative volume status ICU: sepsis, burns, etc.ICU: sepsis, burns, etc.

GoalGoal--directed therapy (GDT):directed therapy (GDT):What operations? Which patients?What operations? Which patients?


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FrankFrank--Starling curve of ventricular functionStarling curve of ventricular function

ItIts all about oxygen delivery!s all about oxygen delivery!


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42Funk AnesthAnalg2009;108(3)887


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GDT technologies:GDT technologies:EsophagealEsophageal dopplerdoppler


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GDT technologies:GDT technologies:OesophagealOesophagealdopplerdoppler


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Screenshot from esophagealScreenshot from esophagealdopplerdoppler


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GDT technologies:GDT technologies:Fluid administration algorithmFluid administration algorithm


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DopplerDoppler--optimized fluid therapyoptimized fluid therapy

RCT, elective colorectalRCT, elective colorectalsurgerysurgery

standard fluid therapystandard fluid therapy vsvsesophagealesophageal dopplerdopplermonitoringmonitoring

postoppostopcare similar in bothcare similar in bothgroupsgroups

NoblettNoblettSE et al. Br JSE et al. Br J SurgSurg2006;93:10692006;93:1069


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DopplerDoppler--optimized fluid therapyoptimized fluid therapyResults: GDT group had decreasedResults: GDT group had decreased

time to tolerate diettime to tolerate diet(median 3(median 3 vsvs4 days,4 days,pp=0.003)=0.003)

incidence of unplanned ICU admissionincidence of unplanned ICU admission(0(0 vsvs12%,12%, pp=0.012)=0.012)major complicationsmajor complications(0(0 vsvs12%) and12%) and overalloverallcomplicationscomplications(25%(25% vsvs45%,45%, pp=0.07)=0.07)time to fitness for dischargetime to fitness for discharge(median 7(median 7 vsvs9 days,9 days,pp=0.005)=0.005)

NoblettNoblettSE et al. Br JSE et al. Br J SurgSurg2006;93:10692006;93:1069


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DopplerDoppler--optimized fluid therapyoptimized fluid therapy

no difference inno difference in intraopintraopcolloid use or crystalloidcolloid use or crystalloid

use between groupsuse between groups

most of the volume inmost of the volume in

the study group wasthe study group was

administered in the firstadministered in the first

quarter of the operatingquarter of the operating

timetime(i.e., first 40 min)(i.e., first 40 min)NoblettNoblettSE et al. Br JSE et al. Br J SurgSurg2006;93:10692006;93:1069

Functional intravascularFunctional intravascular


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Functional intravascularFunctional intravascular

volume deficit in patientsvolume deficit in patientsbefore surgerybefore surgery

Volume of colloid to establish maximal cardiac stroke volumeVolume of colloid to establish maximal cardiac stroke volume

Patients(n

)

Patients(n

)

BundgaardBundgaard--Nielsen M et al.Nielsen M et al.ActaActaAnaesthesiolAnaesthesiolScand 2010;54:464Scand 2010;54:464


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GoalGoal--directed fluid therapy:directed fluid therapy:The right fluid, for the rightThe right fluid, for the right

patient, at the right timepatient, at the right time


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Goal directed fluid technologies:Goal directed fluid technologies:Pulse contour analysisPulse contour analysis

requires highrequires high--fidelity arterialfidelity arterial

lineline

simple, no manualsimple, no manual

calibrationcalibration

monitor SV, SVI, CO, CI,monitor SV, SVI, CO, CI,SVVSVV

when used with CVP giveswhen used with CVP givesScvOScvO22

updates every 20 sec: realupdates every 20 sec: real

time cardiac outputtime cardiac output


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FloTracFloTrac: Stroke Volume: Stroke Volume

Variation (SVV)Variation (SVV)

requires mechanicalrequires mechanicalventilation Vventilation VTT 8mL/kg8mL/kg

affected by PEEPaffected by PEEP

not valid duringnot valid duringarrhythmias (arrhythmias (egeg. a. a

fib)fib)

normal value


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Fluid management algorithm usingFluid management algorithm usingFloTracFloTrac--VigileoVigileomonitormonitor


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PhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935


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Decreased length of stayDecreased length of staywith GDTwith GDT

Decreased time to resume full dietDecreased time to resume full diet with GDTwith GDTPhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935


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Decreased morbidityDecreased morbiditywith GDTwith GDTPhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935


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Average increased volume colloid 700Average increased volume colloid 700 mLmL

supports the hypothesis thatsupports the hypothesis that sublinicalsublinicalhypovolemiahypovolemiacausescausespostoperative bowel dysfunctionpostoperative bowel dysfunction

preventable by using GDTpreventable by using GDT

PhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935


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Why is GDT not used routinely?Why is GDT not used routinely?

Fears about uncontrolled implementation?Fears about uncontrolled implementation?

(cost of PA catheter,(cost of PA catheter, cordiscordis/central line kit, CXR?)/central line kit, CXR?)

$250 disposable$250 disposable $210 disposable$210 disposable


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NiceNice

AnesthestistAnesthestist ORORManagementManagement

OncologyOncologyFundingFunding

Ministry ofMinistry ofHealthHealth

IIM LOOKINGM LOOKING

FOR FUNDING FORFOR FUNDING FOR

GDT MONITORINGGDT MONITORING

ItIt s fors for

the OR notthe OR not

the floorthe floor

It helpsIt helps

the floorthe floor

not the ORnot the OR

Show me the money !Show me the money !


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lack of immediate results (notlack of immediate results (not intraopintraopor earlyor early postoppostop))lack of userlack of user--friendly equipment, lack offriendly equipment, lack oftraining/knowledgetraining/knowledge

no largeno large--scalescale RCTsRCTs, only systematic reviews, only systematic reviews

skepticism about clinical effectivenessskepticism about clinical effectivenessAnesthAnesthAnalgAnalg2011;112:12742011;112:1274

S f l i l t ti fS f l i l t ti f


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Successful implementation ofSuccessful implementation of

GDTGDTconcern aboutconcern about postoppostopcomplications related to fluidcomplications related to fluidcampaign to adopt GDT (campaign to adopt GDT (esophesoph.. dopplerdoppler) in 3 large) in 3 large

hospitals in Englandhospitals in England

consultantconsultant anaesthetistanaesthetist, divisional manager, audit, divisional manager, auditfacilitator at each sitefacilitator at each site

business case prepared with support from NHSbusiness case prepared with support from NHS

Technology Adoption Centre to overcome unequalTechnology Adoption Centre to overcome unequalspread of costs vs. benefitsspread of costs vs. benefits

clinician and manufacturer training support forclinician and manufacturer training support for

anaesthestistsanaesthestistsKuperKuperM et al. BMJ 2011;342:d3016M et al. BMJ 2011;342:d3016

S f l i l t ti fS f l i l t ti f


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compared patient outcomescompared patient outcomes~~650 matched pairs 12 months650 matched pairs 12 months

before and after implementationbefore and after implementation

use of GDTuse of GDT from 11% to 65%from 11% to 65%of eligible operationsof eligible operations

LOS reduced 3.7 daysLOS reduced 3.7 days

1 complication (pulmonary edema)1 complication (pulmonary edema)

www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidewww.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativedIntraoperative

KuperKuperM et al. BMJ 2011;342:d3016M et al. BMJ 2011;342:d3016

Successful implementation ofSuccessful implementation of

GDTGDT
http://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperative


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GDTGDT vsvsrestrictive fluid balancerestrictive fluid balance150 pts elective colorectal surgery (laparoscopic and150 pts elective colorectal surgery (laparoscopic and

open)open)

randomized to (A) GDT to max SV, orrandomized to (A) GDT to max SV, or

(B) zero fluid balance, normal body wt(B) zero fluid balance, normal body wtno difference in complications:no difference in complications:

majormajor

minorminorcardiopulmonarycardiopulmonarytissuetissue--healinghealing

BrandstrupBrandstrupB et al.B et al. EurEurJJAnaesthAnaesth2010;27:42010;27:4


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SummarySummaryhypovolemiahypovolemia is common, unrecognized andis common, unrecognized andpotentially avoidablepotentially avoidable

standard monitoring methods of fluid managementstandard monitoring methods of fluid managementhave failed ushave failed us

crystalloid excess is not the answercrystalloid excess is not the answer

GDT improves patient outcomesGDT improves patient outcomes

fluids must be individualizedfluids must be individualized

the right fluid, for the right patient, at the right timethe right fluid, for the right patient, at the right time

our nursing colleagues must be champions for GDT!our nursing colleagues must be champions for GDT!

2011-a modern approach to perioperative fluid management-beverly morningstar

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