The Operation Summary*
Judah Skolnick, MD, FCCP
* Judah Skolnick, MD, FCCP, was the moderator for this section of the conference, and the participants were Jay B. Brodsky, MD; Myer H. Rosenthal, MD; and Janice G. McFarland, MD.
Correspondence to: Judah L. Skolnick, MD, FCCP, 224 E Broadway, Louisville, KY 40202
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Overview
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A
multidisciplinary group reviewed intraoperative monitoring, fluid
management, and blood and blood component transfusions. The conclusions
took into account existing recommendations of the appropriate specialty
societies. Existing definitions of high, low, and intermediate risk of
the American Society of Anesthesiology (ASA) were used. A low operative
risk is a surgical procedure involving peripheral or superficial
surgery with no entrance into a body cavity. An intermediate-risk
procedure is a peripheral or superficial procedure with high risk of
blood loss, or an intra-abdominal or intrathoracic procedure with no
risk of physiologic impairment. A high-risk procedure is a major
intra-abdominal, intrathoracic, or intracranial procedure with high
risk of physiologic impairment.
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Intraoperative Monitoring
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For the low-risk patient, the recommendation for intraoperative
monitoring is to endorse existing ASA standards. The same
recommendation is made for intermediate- and high-risk patients with
the addition of appropriate invasive monitoring and laboratory studies
as indicated in each specific case.
Recommendations for Future Directions in Research
- Quantify risk based on patient physical status and type of
operation.
- Continued evaluation of old and new invasive monitoring
techniques to define indications.
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Intraoperative Fluid Management
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Intraoperative fluid management was considered. For low-risk
patients, the recommendation is to administer IV maintenance fluids in
amounts to maintain the patient euvolemic with fluids that would be
expected to maintain normal electrolyte status, at the discretion of
the provider. For intermediate- and high-risk patients, the same
recommendation as for low-risk patients is recommended with further
additions as follows:
Additional fluids should be administered to deal with blood loss
and fluid shifts. This should be based on an assessment of
intravascular volume and tissue perfusion and in response to laboratory
values. If the choice of fluids involves Hetastarch, established
guidelines should be followed that govern the amount to be used per
24-h period to avoid coagulopathy. Dextrose-containing fluids should
not be used routinely unless there is likelihood or evidence of
hypoglycemia, and appropriate laboratory studies are done.
Recommendation for Future Directions in Research
- The choice of fluid to be used: crystalloid vs colloid.
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Intraoperative Blood Component Therapy
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Intraoperative blood component therapy was considered next.
The recommendations are the same for low-, intermediate-, and high-risk
patients. There appears to be no standard minimum level of hemoglobin
or hematocrit required for surgery. Consideration should be given to
the patient’s cardiac and respiratory status and to oxygen demand. The
determinants may be cardiac output, oxygen saturation, and oxygen
demand.
Recommendation for Future Directions in Research
- Further research and assessment of substitutes for RBCs to
provide oxygen-carrying capacity.
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Intraoperative Use of Coagulation Factors
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Intraoperative use of coagulation factors was considered. The
recommendations are the same for low-, intermediate-, and high-risk
patients. There are guidelines by the American College of Pathology and
by the ASA. These should be endorsed. The only indication for fresh
frozen plasma, platelets, or cryoprecipitate is known or suspected
coagulopathy. Appropriate laboratory studies to assess coagulation
status should be initiated prior to administration.
Recommendations for Future Directions in Research
- Continued evaluation of what are safe levels of coagulation
factors.
- Continued assessment of risks and benefits of blood component
therapy.
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Overview
Intraoperative Monitoring
