The Société Francais d’Anesthésie et de Réanimation (SFAR) have recently released a set of guidelines entitled ‘Stratégie du remplissage vasculaire périopératoire’ (Guidelines for perioperative hemodynamic optimization), which are SFAR Board approved. The objective is to ‘highlight perioperative vascular filling practices (VF) as a benefit for patients, for use in daily practice’. The first three recommendations relate directly to EDM+ and Fluid Management and received the highest possible rating of GRADE1+.
The guidelines state that during ‘high-risk surgery it is recommended to guide this filling, following the response obtained from the patient’s heart during surgery, in a continuous measurement’.
The guidelines are divided into 15 recommendations regarding fluid management. The first three recommendations are directly relevant to the use of EDM+ and Fluid Management.
Each recommendation made within the document is graded in a binary system:
High: You must do or not do (GRADE1+ or GRADE1-)
Low: It is possible to do or not do (GRADE2+ or GRADE2-)
All three recommendations relating directly to EDM+ fluid management received a GRADE1+ rating. This means that they must all be carried out in the case of high-risk patients, as the evidence level is high. It has been assessed by the SFAR that future evidence is unlikely to change any conclusions drawn from current evidence.
Q1: Filling guided by the measurement of the systolic ejection volume of (SV) reduces post-operative morbidity and duration of stay.
A1: Fluid titration for high-risk surgical patients should be guided by stroke volume to reduce post-operative morbidity, get earlier return to oral feeding and reduce length of stay. GRADE1+
High-risk surgical patients have an increased risk of post-operative complications due to the patient’s condition and/or the surgical procedure being carried out. Various evidence is supplied to support the grading of this recommendation, based primarily on the EDM+ evidence base. SFAR make the vital point that an increase in the Stroke Volume in response to filling confirms that guiding and managing SV was relevant and should be continued. SFAR also state that fluid challenges should be in volumes of 200ml ±50ml.
Q2: Should we interrupt the filling in the absence of the SV increase?
A2: It is recommended to discontinue filling if SV does not increase. GRADE1+
The recommendation is describing the requirement of the clinician to prevent overfilling, which can be just as concerning as the underfilling of a patient.
Q3: Should we regularly reassess the SV?
A3: Reassess SV regularly and the SV response to a fluid challenge, especially during periods of hemodynamic instability. GRADE1+
This recommendation is largely based on studies involving fluid monitoring by EDM+. Within the appendix, there is an algorithm which is very similar to that of the EDM+ 10% fluid management algorithm. It does state that, in order to improve the prognosis of the patient, the method of fluid challenges and monitoring the SV response is beneficial when compared to the traditional method of fluid administration, which can sometimes lead to insufficient or excessive fluid volumes.