Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance

Greg S Martin¹, David A Kaufman², Paul E Marik³, Nathan I Shapiro⁴, Denny Z H Levett^{5

6}, John Whittle⁷, David B MacLeod⁷, Desiree Chappell^{8

9}, Jonathan Lacey¹⁰, Tom Woodcock¹¹, Kay Mitchell¹², Manu L N G Malbrain¹³, Tom M Woodcock¹⁴, Daniel Martin¹⁵, Chris H E Imray¹⁶, Michael W Manning⁷, Henry Howe⁸, Michael P W Grocott^{5

6}, Monty G Mythen¹⁷, Tong J Gan¹⁸, Timothy E Miller⁷

Affiliations

¹ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory Critical Care Center, Emory University School of Medicine, Grady Health System, Atlanta, GA USA.
² 2Division of Pulmonary, Critical Care, and Sleep Medicine, NYU School of Medicine, New York, NY USA.
³ 3Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA USA.
⁴ 4Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA.
⁵ 5Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.
⁶ 17Department of Anesthesiology and Critical Care, Stony Brook University, Stony Brook, New York, USA.
⁷ 6Department of Anesthesiology, Division of General, Vascular and Transplant Anesthesia, Duke University School of Medicine, Duke University Medical Center, Durham, NC USA.
⁸ TopMedTalk, London, UK.
⁹ Private address: Louisville, Kentucky, USA.
¹⁰ 8Institute of Sport Exercise & Health, University College London, London, UK.
¹¹ 9University Hospitals Southampton, Southampton, UK.
¹² 10Respiratory Biomedical Research Unit, University of Southampton, Southampton, England.
¹³ 11Department of Intensive Care, University Hospital Brussels, Jette, Belgium and Facultyof Medicine and Pharmacy, Vrije Universiteit Brussels, Brussels, Belgium.
¹⁴ Elsevier R&D Solutions, 1600 JFK Blvd, Philadelphia, PA 19103 USA.
¹⁵ 13Intensive Care Unit and Division of Surgery and Interventional Science, Royal Free Hospital, London, UK.
¹⁶ Vascular and Renal Tranplant Surgeon, National Institute of Health Research Clinical Research Facility, Coventry, UK.
¹⁷ 15UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK.
¹⁸ 16Department of Anesthesiology, Stony Brook University, Stony Brook, NY USA.

PMID: 32337020
PMCID: PMC7171743
DOI: 10.1186/s13741-020-00142-8

Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance

Greg S Martin et al. Perioper Med (Lond). 2020.

. 2020 Apr 21:9:12.

doi: 10.1186/s13741-020-00142-8. eCollection 2020.

Authors

Affiliations

¹ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory Critical Care Center, Emory University School of Medicine, Grady Health System, Atlanta, GA USA.
² 2Division of Pulmonary, Critical Care, and Sleep Medicine, NYU School of Medicine, New York, NY USA.
³ 3Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA USA.
⁴ 4Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA.
⁵ 5Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.
⁶ 17Department of Anesthesiology and Critical Care, Stony Brook University, Stony Brook, New York, USA.
⁷ 6Department of Anesthesiology, Division of General, Vascular and Transplant Anesthesia, Duke University School of Medicine, Duke University Medical Center, Durham, NC USA.
⁸ TopMedTalk, London, UK.
⁹ Private address: Louisville, Kentucky, USA.
¹⁰ 8Institute of Sport Exercise & Health, University College London, London, UK.
¹¹ 9University Hospitals Southampton, Southampton, UK.
¹² 10Respiratory Biomedical Research Unit, University of Southampton, Southampton, England.
¹³ 11Department of Intensive Care, University Hospital Brussels, Jette, Belgium and Facultyof Medicine and Pharmacy, Vrije Universiteit Brussels, Brussels, Belgium.
¹⁴ Elsevier R&D Solutions, 1600 JFK Blvd, Philadelphia, PA 19103 USA.
¹⁵ 13Intensive Care Unit and Division of Surgery and Interventional Science, Royal Free Hospital, London, UK.
¹⁶ Vascular and Renal Tranplant Surgeon, National Institute of Health Research Clinical Research Facility, Coventry, UK.
¹⁷ 15UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK.
¹⁸ 16Department of Anesthesiology, Stony Brook University, Stony Brook, NY USA.

PMID: 32337020
PMCID: PMC7171743
DOI: 10.1186/s13741-020-00142-8

Abstract

Background: Optimal fluid therapy in the perioperative and critical care settings depends on understanding the underlying cardiovascular physiology and individualizing assessment of the dynamic patient state.

Methods: The Perioperative Quality Initiative (POQI-5) consensus conference brought together an international team of multidisciplinary experts to survey and evaluate the literature on the physiology of volume responsiveness and perioperative fluid management. The group used a modified Delphi method to develop consensus statements applicable to the physiologically based management of intravenous fluid therapy in the perioperative setting.

Discussion: We discussed the clinical and physiological evidence underlying fluid responsiveness and venous capacitance as relevant factors in fluid management and developed consensus statements with clinical implications for a broad group of clinicians involved in intravenous fluid therapy. Two key concepts emerged as follows: (1) The ultimate goal of fluid therapy and hemodynamic management is to support the conditions that enable normal cellular metabolic function in order to produce optimal patient outcomes, and (2) optimal fluid and hemodynamic management is dependent on an understanding of the relationship between pressure, volume, and flow in a dynamic system which is distensible with variable elastance and capacitance properties.

Keywords: Fluid responsiveness; Goal-directed fluid therapy; Perioperative fluid management; Physiology; Venous capacitance.

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Conflict of interest statement

Competing interestsGSM - none; DAK - grant funding and travel reimbursement for Cheetah Medical, Advisory Board and speaker honoraria for Pulsion Medical Systems; PEM - advisory board and research funding from Baxter; NS - none ; DL - none; JW – none; DBM – none; DC - Speakers Bureau for Edwards Lifesciences, Medtronic; JL – none; TW – none; KM – none; MLNGM – xxx; TMW – none; DM – consultant for Edwards Lifesciences and Siemens Healthineers; CHEI – none; MWM – none; HH – none; MPWG – research funding from Sphere Medical Ltd (UK) and Pharmacosmos Ltd (UK), advisory board of Sphere Medical Ltd.; MGM - University Chair Sponsor at UCL by Smiths Medical, Director Evidence Based Perioperative Medicine (EBPOM) Community Interest Company (CiC), Director Medinspire Ltd (Patent holder “QUENCH”), Paid consultant for Edwards Lifesciences and Baxter; TJG - Consultant for Acacia, Edwards Lifesciences, Mallinckrodt, Medtronic and Merck; TEM – research funding and consultant for Edwards Lifesciences.

Figures

**Fig. 1**
The macrocirculation, microcirculation, and the cellular level relevant for fluid therapy. Figure reused with the permission of the Perioperative Quality Initiative (POQI). For permission requests, contact info@poqi.org

**Fig. 2**
Fluid compartments in adult humans. Figure reused with the permission of the Perioperative Quality Initiative (POQI). For permission requests, contact info@poqi.org

**Fig. 3**
Pressure and volume in the venous system. Figure reused with the permission of the Perioperative Quality Initiative (POQI). For permission requests, contact info@poqi.org.

**Fig. 4**
Depiction that differentiates stressed and unstressed volumes in the venous circulation. Figure reused with the permission of the Perioperative Quality Initiative (POQI). For permission requests, contact info@poqi.org

**Fig. 5**
Effects of fluid and vasoactive agents on cardiovascular performance and the venous system. Figure reused with the permission of the Perioperative Quality Initiative (POQI). For permission requests, contact info@poqi.org. I Effect of volume loading on mean systemic filling pressure (Pmsf) and (un)stressed volume. Administration of a fluid bolus increases Pmsf (from Pmsf1 to Pmsf2, indicated respectively by position A (red dot) to B (green dot) on the pressure/volume curve). Unstressed volume remains constant while stressed volume increases. Total volume = unstressed + stressed increases, carrying a risk for fluid overload. See text for explanation. II Effect of venoconstriction and venodilation on mean systemic filling pressure (Pmsf) and (un)stressed volume. Venoconstriction increases Pmsf (from Pmsf1 to Pmsf2, indicated respectively by position A (red dot) to B (green dot) on the pressure/volume curve). Unstressed volume decreases while stressed volume increases. Total volume = unstressed + stressed remains constant, resulting in an auto-transfusion effect. Venodilation as seen in sepsis (vasoplegia) decreases Pmsf (from Pmsf1 to Pmsf3, indicated respectively by position A (red dot) to C (blue dot) on the pressure/volume curve). Unstressed volume increases while stressed volume decreases. Total volume = unstressed + stressed remains constant, resulting in an intravascular underfilling effect

**Fig. 6**
Stylized depiction of the passive leg raise (PLR) maneuver. Figure reused with the permission of the Perioperative Quality Initiative (POQI). For permission requests, contact info@poqi.org

See this image and copyright information in PMC

References

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Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance

Affiliations

Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources