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• W2114480030 abstract "In the Sceptic's Medical Dictionary,1O'Donnell M A Sceptic s Medical Dictionary. BMJ Publishing Group, London1997Google Scholar an iconoclastic book we highly recommend, Michael O'Donnell defines clinical experience as ‘Making the same mistakes with increasing confidence over an impressive number of years'. Although provocative, this statement is sometimes not so far from reality when considering intra- and postoperative fluid management. For decades, the decision to give fluid was based on clinical examination, heart rate, and arterial pressure, for example, a high heart rate and low arterial pressure often triggering a fluid bolus, when not simply based on the gut feeling of the good doctor. Unfortunately, tachycardia and hypotension are not specific and sensitive markers of hypovolaemia. Many studies have also demonstrated the limited value of cardiac filling pressures to predict fluid responsiveness. If the heart is sensitive to cyclical changes in preload induced by mechanical ventilation, it should also be sensitive to changes in preload induced by a fluid load.2Michard F Changes in arterial pressure during mechanical ventilation.Anesthesiology. 2005; 103: 419-428doi:10.1097/00000542-200508000-00026Crossref PubMed Scopus (507) Google Scholar Using this very simple hypothesis as a foundation, many clinical studies have demonstrated that the arterial pulse pressure variation (PPV) and the stroke volume variation (SVV) are accurate predictors of fluid responsiveness.2Michard F Changes in arterial pressure during mechanical ventilation.Anesthesiology. 2005; 103: 419-428doi:10.1097/00000542-200508000-00026Crossref PubMed Scopus (507) Google Scholar 3Marik P Cavallazzi R Vasu T et al.Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature.Crit Care Med. 2009; 37: 2642-2647doi:10.1097/CCM.0b013e3181a590daCrossref PubMed Scopus (876) Google Scholar A recent meta-analysis3Marik P Cavallazzi R Vasu T et al.Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature.Crit Care Med. 2009; 37: 2642-2647doi:10.1097/CCM.0b013e3181a590daCrossref PubMed Scopus (876) Google Scholar showed that the average sensitivity and specificity of these two parameters is 85%, which is indeed not perfect, but quite impressive when compared with all other clinical indicators. As a result, dynamic parameters are today available on almost all bedside and haemodynamic monitors and have dramatically changed the way clinicians think and give fluid. However, these dynamic parameters have limitations precluding their use in several clinical situations.4Michard F Volume management using dynamic parameters: the good, the bad, and the ugly.Chest. 2005; 128: 1902-1903doi:10.1378/chest.128.4.1902Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar In this issue of the British Journal of Anaesthesia, Lansdorp and colleagues5Lansdorp B Lemson J van Putten MJAM et al.Dynamic indices do not predict volume responsiveness in routine clinical practice.Br J Anaesth. 2012; 108: 395-401Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar have studied the clinical applicability of dynamic indices in the postoperative period of cardiac surgery and conclude that they do not predict volume responsiveness in daily clinical practice. The main limitations to the use of dynamic parameters in surgical patients have been recently summarized as ‘SOS'.6Michard F Stroke volume variation: from applied physiology to improved outcomes.Crit Care Med. 2011; 39: 402-403doi:10.1097/CCM.0b013e318205c0a6Crossref PubMed Scopus (35) Google Scholar The first ‘S' stands for small tidal volume and spontaneous breathing activity; the ‘O' stands for open chest. In these conditions, changes in intrathoracic pressure are usually too small to induce significant changes in venous return. As a result, a false-negative may be observed, that is a small PPV or SVV in fluid responders. Several clinical studies have confirmed that the predictive value of PPV and SVV is decreased when patients are breathing spontaneously, when they are mechanically ventilated with a tidal volume <7–8 ml kg−1, or when the pericardium and the chest are open. The second ‘S' stands for sustained cardiac arrhythmias. In this setting, PPV and SVV reflect altered cardiac filling times rather than the effects of mechanical ventilation and then cannot be used to predict fluid responsiveness. Other limitations, such as right ventricular failure and a high respiratory rate, do exist but are less frequently encountered. Finally, questions remain regarding the usefulness of dynamic parameters in other clinical situations such as laparoscopic procedures, where they may still be valuable but with different cut-off values. In their clinical study, Lansdorp and colleagues5Lansdorp B Lemson J van Putten MJAM et al.Dynamic indices do not predict volume responsiveness in routine clinical practice.Br J Anaesth. 2012; 108: 395-401Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar have focused on two main limitations: low tidal volume and cardiac arrhythmia. Not surprisingly, they have confirmed that when these limitations are not taken into account, PPV and SVV are less accurate at predicting fluid responsiveness, so that their clinical applicability is limited. While not disputing the results reported by Lansdorp and colleagues,5Lansdorp B Lemson J van Putten MJAM et al.Dynamic indices do not predict volume responsiveness in routine clinical practice.Br J Anaesth. 2012; 108: 395-401Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar their small study population (28 patients) renders any generalization hazardous. A recent and larger study7Maguire S Rinehart J Vakharia S et al.Respiratory variation in pulse pressure and plethysmographic waveforms: intraoperative applicability in a north American academic center.Anesth Analg. 2011; 112: 94-96Crossref PubMed Scopus (82) Google Scholar based on the analysis of more than 12 000 patients showed that dynamic parameters are usable in 39% of all surgical patients, and in 53% of patients with an arterial line. The latter being a common scenario for high-risk procedures where optimal fluid management is key. When dynamic parameters are usable, several studies have demonstrated that their intraoperative measurement and optimization was useful in improving postoperative outcome.8Lopes MR Oliveira MA Pereira VO et al.Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial.Crit Care. 2007; 11: R100doi:10.1186/cc6117Crossref PubMed Scopus (332) Google Scholar 9Benes J Chytra I Altmann P et al.Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study.Crit Care. 2010; 14: R118doi:10.1186/cc9070Crossref PubMed Scopus (333) Google Scholar First, clinicians have to be trained in order to understand the limitations of dynamic parameters. There is no magic parameter and when their limitations are not duly recognized, dynamic parameters cannot provide the expected information. In this respect, the study by Lansdorp and colleagues is a useful reminder. Secondly, some of the limitations could be bypassed in the near future by technological and software improvements. Several systems are already able to detect cardiac arrhythmia in order to inform clinicians that dynamic parameters should not be used.10Cannesson M Slieker J Desebbe O et al.The ability of a novel algorithm for automatic estimation of the respiratory variations in arterial pulse pressure to monitor fluid responsiveness in the operating room.Anesth Analg. 2008; 106: 1195-1200doi:10.1213/01.ane.0000297291.01615.5cCrossref PubMed Scopus (98) Google Scholar Other systems use filters either to attenuate the influence of ectopic heart beats11Auler JO Galas F Hajjar L et al.Online monitoring of pulse pressure variation to guide fluid therapy after cardiac surgery.Anesth Analg. 2008; 106: 1201-1206doi:10.1213/01.ane.0000287664.03547.c6Crossref PubMed Scopus (96) Google Scholar or to discard abnormal heart beats, restore the respiratory oscillations of the arterial pressure waveform and in fine the predictive value of SVV.12Cannesson M Tran NP Cho M et al.Predicting fluid responsiveness with stroke volume variation despite multiple extrasystoles.Crit Care Med. 2012; 40: 193-198Crossref PubMed Scopus (31) Google Scholar Thirdly, when dynamic parameters cannot be used, alternatives do exist. The simplest one consists of administering a fluid bolus of 200–250 ml and quantifying the effect on stroke volume. If stroke volume does increase in response to the bolus, the patient is obviously fluid responsive (SVV and PPV values would be high, if they were usable). In the UK, this approach is now recommended by the National Institute for Clinical Excellence (NICE) to guide fluid therapy in high-risk surgical patients.13Pearse RM Holt JE Grocott MPW Managing perioperative risk in patients undergoing elective non-cardiac surgery.Br Med J. 2011; 343: d5759doi:10.1136/bmj.d5759Crossref PubMed Scopus (94) Google Scholar Similar recommendations were made in October 2011 by the French Society of Anaesthesiology (SFAR) and we can reasonably assume that other scientific societies will follow. These recommendations are based on multiple single-centre randomized controlled trials and on several meta-analyses.13Pearse RM Holt JE Grocott MPW Managing perioperative risk in patients undergoing elective non-cardiac surgery.Br Med J. 2011; 343: d5759doi:10.1136/bmj.d5759Crossref PubMed Scopus (94) Google Scholar 14Hamilton MA Cecconi M Rhodes A A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients.Anesth Analg. 2011; 112: 1392-1402doi:10.1213/ANE.0b013e3181eeaae5Crossref PubMed Scopus (621) Google Scholar Of note, the most recent of these meta-analyses14Hamilton MA Cecconi M Rhodes A A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients.Anesth Analg. 2011; 112: 1392-1402doi:10.1213/ANE.0b013e3181eeaae5Crossref PubMed Scopus (621) Google Scholar has shown that rational fluid management based on objective haemodynamic measurements is associated with a very significant decrease in postoperative morbidity and mortality. If such a rational approach was to be adopted worldwide, it may be possible to prevent every year almost 3 million postoperative complications and to save more than 800 000 lives.15Michard F The burden of high-risk surgery and the potential benefit of goal-directed strategies.Crit Care. 2011; 15: 447doi:10.1186/cc10473Crossref PubMed Scopus (12) Google Scholar Whether clinicians will quickly adopt perioperative fluid optimization strategies is another story. The availability of new and less invasive technologies facilitating stroke volume monitoring, such as oesophageal Doppler and pulse contour methods, should help but may not be sufficient (Fig. 1). Indeed, despite the existing body of scientific evidence, uncertainty remains for some clinicians. Large-scale clinical studies16McDonald N Pearse RM Peri-operative hemodynamic therapy: only large clinical trials can resolve our uncertainty.Crit Care. 2011; 15: 122doi:10.1186/cc10011Crossref PubMed Scopus (6) Google Scholar and quality-improvement programmes17Michard F Cannesson M Vallet B Peri-operative hemodynamic therapy: quality improvement programs should help to resolve our uncertainty.Crit Care. 2011; 15: 445doi:10.1186/cc10336Crossref PubMed Scopus (7) Google Scholar confirming the benefits of such strategies may help to resolve their uncertainty (Fig. 1). Another challenge will be the adherence to treatment protocols in a very busy environment where priority is given to anaesthesia and analgesia (Fig. 1). Teaching and training will play a major role and the use of (paper or electronic) checklists may further help.18Gawande A The Checklist Manifesto. How to Get Things Right. Profile Books Ltd, London2010Google Scholar Ultimately, the development of closed-loop systems may unload anaesthesiologists from this task and ensure an optimal compliance to fluid optimization treatment protocols.19Rinehart J Alexander B Le Manach Y et al.Evaluation of a novel closed-loop fluid administration system based on dynamic predictors of fluid responsiveness: an in-silico simulation study.Crit Care. 2011; 15: R278doi:10.1186/cc10562Crossref PubMed Scopus (61) Google Scholar In conclusion, Lansdorp and colleagues5Lansdorp B Lemson J van Putten MJAM et al.Dynamic indices do not predict volume responsiveness in routine clinical practice.Br J Anaesth. 2012; 108: 395-401Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar bring additional evidence that limitations to the use of dynamic parameters are not exceptions. However, their study should not discourage clinicians to use dynamic parameters when they can, and alternative solutions when necessary. Indeed, rational and individualized perioperative fluid strategies are key to decrease the human and economic burden of postoperative complications.15Michard F The burden of high-risk surgery and the potential benefit of goal-directed strategies.Crit Care. 2011; 15: 447doi:10.1186/cc10473Crossref PubMed Scopus (12) Google Scholar 20Cannesson M Vallet B Michard F Pulse pressure variation and stroke volume variation: from flying blind to flying right?.Br J Anaesth. 2009; 103: 896-904doi:10.1093/bja/aep321Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar F.M. is a Vice-President, Global Medical Strategy, at Edwards Lifesciences. The above statements do not support the use of any specific medical device." @default.
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• W2114480030 title "Rational fluid management: dissecting facts from fiction" @default.
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