Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers

Abstract

Background: Fluid resuscitation during cardiac surgery is common with significant variability in clinical practice. Our goal was to investigate current practice patterns of fluid volume expansion in patients undergoing cardiac surgeries in the USA.

Methods: We conducted a cross-sectional online survey of 124 cardiothoracic surgeons, cardiovascular anesthesiologists, and perfusionists. Survey questions were designed to assess clinical decision-making patterns of intravenous (IV) fluid utilization in cardiovascular surgery for five types of patients who need volume expansion: (1) patients undergoing cardiopulmonary bypass (CPB) without bleeding, (2) patients undergoing CPB with bleeding, (3) patients undergoing acute normovolemic hemodilution (ANH), (4) patients requiring extracorporeal membrane oxygenation (ECMO) or use of a ventricular assist device (VAD), and (5) patients undergoing either off-pump coronary artery bypass graft (OPCABG) surgery or transcatheter aortic valve replacement (TAVR). First-choice fluid used in fluid boluses for these five patient types was requested. Descriptive statistics were performed using Kruskal-Wallis test and follow-up tests, including t tests, to evaluate differences among respondent groups.

Results: The most commonly preferred indicators of volume status were blood pressure, urine output, cardiac output, central venous pressure, and heart rate. The first choice of fluid for patients needing volume expansion during CPB without bleeding was crystalloids, whereas 5% albumin was the most preferred first choice of fluid for bleeding patients. For volume expansion during ECMO or VAD, the respondents were equally likely to prefer 5% albumin or crystalloids as a first choice of IV fluid, with 5% albumin being the most frequently used adjunct fluid to crystalloids. Surgeons, as a group, more often chose starches as an adjunct fluid to crystalloids for patients needing volume expansion during CPB without bleeding. Surgeons were also more likely to use 25% albumin as an adjunct fluid than were anesthesiologists. While most perfusionists reported using crystalloids to prime the CPB circuit, one third preferred a mixture of 25% albumin and crystalloids. Less interstitial edema and more sustained volume expansion were considered the most important colloid traits in volume expansion.

Conclusions: Fluid utilization practice patterns in the USA varied depending on patient characteristics and clinical specialties of health care professionals.

Keywords: Albumin; Cardiopulmonary bypass; Cardiovascular surgery; Colloids; Crystalloids; Fluid resuscitation; Intraoperative volume expansion; Survey.

Conflict of interest statement

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

SA has received an honorarium as a medical advisor from Grifols. MB is an employee of Grifols, a manufacturer of albumin. PN has no competing interests relevant to this manuscript.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1

Use of volume status indicators/diagnostic tools in assessing fluid needsa (n = 124b). aResponses to the following question: Which of the following indicators (diagnostic tools) of volume status and the need for volume expansion do you use? (Please select all that apply.) bSample included 52 anesthesiologists, 47 surgeons, and 25 perfusionists

Fig. 2

First choice of intravenous fluid for patients needing volume expansion during CPB when not experiencing significant blood lossa (scenario 1, n = 124). CPB, cardiopulmonary bypass; HES, hydroxyethyl starch. Superscript S denotes the difference between specialties that are statistically significant at P  <  .05. aResponses to the following question: Which of the following is your first choice for a patient who needs volume expansion during cardiovascular surgery with CPB who is not experiencing significant blood loss?

Fig. 3

First choice of IV fluid for patients needing volume expansion in the presence of blood loss during CPB when blood transfusion is not indicated (adequate Hb)a (scenario 2, n = 124). CPB, cardiopulmonary bypass; Hb, hemoglobin; HES, hydroxyethyl starch; IV, intravenous. Superscript A denotes the difference between specialties that are statistically significant at P < .05. aResponses to the following question: Which of the following is your first choice for a patient who needs volume expansion in the presence of blood loss when blood transfusion is not indicated (adequate Hb) during cardiovascular surgery with CPB?

Fig. 4

First choice of IV fluid for maintenance during ANH (autologous blood collection)a (scenario 3, n = 119b). ANH, acute normovolemic hemodilution; HES, hydroxyethyl starch; IV, intravenous; n/a, not available. Superscript A and S denote differences between specialties that are statistically significant at P <  .05. aResponses to the following question: Which of the following is your first choice for a patient for volume replacement maintenance during ANH (autologous blood collection)? bA total of 119 HCPs responded to this question; five respondents (two anesthesiologists, one surgeon, two perfusionists) indicated the patient type was “not applicable” to their practice

Fig. 5

First choice of IV fluid for volume expansion during ECMO or VADa (scenario 4, n = 124). ECMO, extracorporeal membrane oxygenation; HES, hydroxyethyl starch; IV, intravenous; VAD, ventricular assist device. aResponses to the following question: Which of the following is your first choice for a patient who needs volume expansion during ECMO or VAD? bResponse was only available to perfusionists

Fig. 6

First choice of IV fluid for intraoperative volume expansion for OPCABG or TAVRa (scenario 5, n = 124). HES, hydroxyethyl starch; IV, intravenous; OPCAB, off-pump coronary artery bypass surgery; TAVR, transcatheter aortic valve replacement. aResponses to the following question: Which of the following is your first choice for a patient who needs intraoperative volume expansion for OPCAB or TAVR? bResponse was only available to perfusionists

Fig. 7

Importance of colloid traits when colloids were used for volume expansiona (n = 124). Superscripts A–E on y-axis labels represent the respective trait for statistical comments. Letters following values represent the traits from which the trait’s percentage differs significantly. aResponses to the following question: Using the scale below, please indicate how important each of the following is in terms of your reasons for using colloids for volume expansion (5-point scale: not important, somewhat important, important, very important, absolutely essential). Data presented in this graph are the proportions of respondents indicating colloid trait is “very important” or “absolutely essential” when used for volume expansion

Fig. 8

First choice of solutions for priming the CPB circuit among perfusionistsa (n = 25). CPB, cardiopulmonary bypass; HES, hydroxyethyl starch. aResponses to the following question: Which of the following solutions is your first choice for priming the CPB circuit?