How much fluid do we need for immediate post-operative management in

Tetralogy of Fallot?

J Figueira MD,I Machado MD, I Tolj MD, MA Arapé MD, Nakary Moreno RN BSN

Fundación De Todo Corazón Richard Gibson Hospital de Especialidades

Pediátricas

Background: Cardiopulmonary Bypass (CPB) produces a systemic

inflammatory response with consequences: endovascular lesion, alterated
vascular permeability, with increase of fluid pass from intravascular to interstitial
space.  This effect increases the total body water volume in the interstitial
space. Our aim is to show how in a homogenous group of patients, under CPB
and Aortic XClamp (AXC) stress, by monitorizing simple hemodynamic
parameters, we establish a fluid-management strategy that leads to a brief ICU
stay and avoid inotropes. Methods: From 231 patients submitted to cardiac
surgery, we retrospectively selected from January 2007 to August 2009, 34
cases (14.72%) diagnosed with Tetralogy of Fallot (TOF). In order to assess
intravascular space status and measure inflammatory response, we selected as
variables:  Blood Pressure (BP), Heart Rate (HR), Central Venous Pressure
(CVP), Urinary Output (UO) and Urinary Density (UD).  We related them to CPB
and AXC times, blood glucose (BG) and white-blood count (WBC) to admission
and discharge from our Intensive Care Unit (ICU).Results:  All 34 cases
underwent surgery on normothermia, with minicardioplegia. Infundibular patch
(18 cases), transanular patch (10 cases), infundibular and pulmonary patch (6
cases),. Management protocol includes: 2000cc/m²BSA base hydration with
saline 0.45% and dextrose 5%, NSAID (Ketoprofen 2 mg/Kg).  Aim was to
obtain normal UD, UO, HR, BP and CVP values. Our population (data
expressed: median (min-max).   Age: 2.1(0.9-9) years; Weight: 11.5(7.6-27.4)
Kg; Height: 82.5(63-132) cm; CPB time: 55.5(38-109) minutes; AXC time:
39(20-80)min;  Extubation time: 0(0-24) hours; ICU stay: 21.5(14-100)hours. 
UD (pre CPB): 1020(1006-1034), UD post CPB: 1021 (1006-1035), UD on ICU
admission: 1025 (1010-1036), 6 hours later 1030 (1015-1040).  BG on ICU
admission: 113 (103-238) mg/dl. BG on discharge: 110mg/dl (76-197) mg/dl,
p=0.46.  HR: 118(93-135) x´; Systolic BP: 97(63-127) mmHg; Diastolic: 58(48-
94) mmHg; CVP: 10(7-13) mmHg.  Total fluids in 6 hours: 1422(776-2379)
cc/m²BSA; Theoretical total fluids calculated per patient: 257(189-499)
cc/m²BSA; UO in 6 hours: 2.1(0.4-6.6) cc/kg/h; WBC on ICU admission:
15350(3600-32500)/mm3; WBC on discharge: 12975(3700-23800)/mm3
(p=0.117).   There is a 5.72 times-increase in the total fluid administration
during the first 6 postoperative hours compared to the theoretical-calculated
values (median=5.53, p<0.05). One patient died (1/34; 2.94%). Conclusion: On
selected patients, CPB and AXC time are no important variables to consider
regarding severity of the inflammatory response. It can be better observed
through clinical outcome, WBC and BG.  With normal renal function, UD is not
relevant as an isolated parameter, but together with all the before mentioned
variables, it permits to properly assess intravascular space.  Adequate values of
UD, UO, BP, HR and CVP, carried about a five-fold increase of total fluid
administration.  Early extubation, a friendly environment with parental presence
and adequate analgesia, led to a satisfactory final result: short ICU stay and
good clinical outcomes. The amount of suministrated fluids given as part of a
simplified cardiac surgery postoperative protocol is safe for our patients and
does not cause late complications. Reduced ICU stay was possible obtaining
final cost reduction, important aspect to be considered, especially in cost-
constrained environments.