Goal-Directed Fluid Therapy Using Stroke Volume Variation Does Not Result in Pulmonary Fluid Overload in Thoracic Surgery Requiring One-Lung Ventilation

Abstract

<jats:p><jats:italic>Background</jats:italic>. Goal-directed fluid therapy (GDT) guided by functional parameters of preload, such as stroke volume variation (SVV), seems to optimize hemodynamics and possibly improves clinical outcome. However, this strategy is believed to be rather fluid aggressive, and, furthermore, during surgery requiring thoracotomy, the ability of SVV to predict volume responsiveness has raised some controversy. So far it is not known whether GDT is associated with pulmonary fluid overload and a deleterious reduction in pulmonary function in thoracic surgery requiring one-lung-ventilation (OLV). Therefore, we assessed the perioperative course of extravascular lung water index (EVLWI) and -ratio during and after thoracic surgery requiring lateral thoracotomy and OLV to evaluate the hypothesis that fluid therapy guided by SVV results in pulmonary fluid overload.<jats:italic>Methods</jats:italic>. A total of 27 patients (group T) were enrolled in this prospective study with 11 patients undergoing lung surgery (group L) and 16 patients undergoing esophagectomy (group E). Goal-directed fluid management was guided by SVV (SVV &lt; 10%). Measurements were performed directly after induction of anesthesia (baseline—BL), 15 minutes after implementation OLV (OLVimpl15), and 15 minutes after termination of OLV (OLVterm15). In addition, postoperative measurements were performed at 6 (6postop), 12 (12postop), and 24 (24postop) hours after surgery. EVLWI was measured at all predefined steps. The -ratio was determined at each point during mechanical ventilation (group L: BL-OLVterm15; group E: BL-24postop).<jats:italic>Results</jats:italic>. In all patients (group T), there was no significant change in EVLWI during the observation period (BL: 7.8 ± 2.5, 24postop: 8.1 ± 2.4 mL/kg). A subgroup analysis for group L and group E also did not reveal significant changes of EVLWI. The -ratio decreased significantly during the observation period (group L: BL: 462 ± 140, OLVterm15: 338 ± 112 mmHg; group E: BL: 389 ± 101, 24postop: 303 ± 74 mmHg) but remained &gt;300 mmHg except during OLV.<jats:italic>Conclusions</jats:italic>. SVV-guided fluid management in thoracic surgery requiring lateral thoracotomy and one-lung ventilation does not result in pulmonary fluid overload. Although oxygenation was reduced, pulmonary function remained within a clinically acceptable range.</jats:p>

Anaesthesia during oesophagectomy

“…Minimally invasive technologies currently available to guide goal-directed fluid therapy include oesophageal Doppler, arterial waveform analysis, photoplethysmography, and bioimpedance. Some experiences in thoracic surgery have been made using arterial waveform analysis targeting dynamic markers of preload responsiveness such as stroke volume variation (SVV), pulse pressure variation (PPV) and stroke volume index (SVI) (49)(50)(51). The accuracy of SVV and PVV are influenced by the tidal volume given and chest compliance, which is affected during open chest surgery.…”

“…EVLW has been used as a predictor for the development of acute lung injury in patients after thoracotomy. Recently, Haas et al showed that a GDFT algorithm using SVV did not increase extravascular lung water (EVLW) in patients undergoing thoracotomy for lung resection and oesophagectomy suggesting the safety of use of such protocols (49). Unfortunately no large prospective outcome studies have been done as yet and especially the utility of these markers with surgery by means of thoracoscopy is unknown.…”

Volume Management and Resuscitation in Thoracic Surgery

“…Another potential limitation in the thoracic surgical setting is the influence of distribution of lung perfusion by position and lung collapse: a spurious increase in measured EVLW has been noted due to regional alterations of pulmonary blood flow [95]. A study assessing a goal-directed approach to fluid management for thoracic surgery requiring lateral thoracotomy and OLV found that their strategy, fluid management guided by SVV, did not result in pulmonary fluid overload as assessed by PiCCO EVLWI [96].…”

Anesthesia for Thoracic Surgical Procedures

“…One study has shown that GDT is at least not deleterious or does not result in pulmonary fluid overload when used for thoracic surgery requiring lateral thoracotomy and OLV [52]. While changing from the supine to the reverse Trendelenburg or prone positions significantly alters SV and thus SVV, 30° left or right recumbent and supine positions do not appear to affect SV or SVV measurements [53].…”