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Anesth Analg 2001;92:1146-1151
© 2001 International Anesthesia Research Society

CARDIOVASCULAR ANESTHESIA

Can Initial Distribution Volume of Glucose Predict Hypovolemic Hypotension After Radical Surgery for Esophageal Cancer?

Akiko Suzuki, MD, Hironori Ishihara, MD, Hirobumi Okawa, MD, Toshihito Tsubo, MD, and Akitomo Matsuki, MD

Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki, Japan

Address correspondence and reprint requests to H. Ishihara, MD, Department of Anesthesiology, University of Hirosaki, School of Medicine, 5-Zaifu-Cho, Hirosaki-Shi, 036-8562, Japan. Address e-mail to ishihara{at}cc.hirosaki-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
We recently reported that the initial distribution volume of glucose (IDVG) reliably measures the central extracellular fluid volume in the presence or absence of fluid gain or loss. We examined which variables, including IDVG, can predict subsequent hypovolemic hypotension produced by the continuous shift of the extracellular fluid from the central to the peripheral compartment early after radical surgery for esophageal cancer. IDVG and plasma volume were calculated after measuring cardiac index (CI), central venous pressure, and pulmonary artery wedge pressure immediately after admission to the intensive care unit. Intraoperative fluid balance and urine volume were also recorded. Postoperative hypovolemic hypotension was clinically defined as systolic blood pressure < 80 mm Hg responsive to IV fluid administration. Either IDVG < 105 mL/kg or CI < 3.4 L · min-1 · m-2 was associated with subsequent hypovolemic hypotension (P = 0.002 for the former and P = 0.00 03 for the latter), while remaining variables were not. IDVG and CI were well correlated (r = 0.8 7, n = 25, P = 0.0001). Our results suggest that IDVG can help predict the subsequent hypovolemic hypotension early after radical surgery for esophageal cancer.

Implications: Routine cardiovascular variables immediately after major surgery cannot predict the subsequent hypovolemic hypotension produced by the shift of the extracellular fluid. Glucose dilution using glucose 5 g and a one-compartment model can predict it simply and rapidly.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Major surgery induces a shift of the extracellular fluid (ECF) from the central to the peripheral compartment that occurs intraoperatively and lasts postoperatively (1). The central ECF consists of the interstitial fluid (ISF) in highly perfused organs such as heart, lungs, kidneys, and liver as well as plasma, and the peripheral one consists of the ISF in less perfused organs such as muscle, fat, and subcutaneous tissues. Hypovolemic hypotension is often observed in the early postoperative period of major surgery such as esophagectomy. According to our experience, more than 60% of patients who underwent radical surgery for esophageal cancer developed hypovolemic hypotension postoperatively on the operative day, even though operative hemorrhage and/or postoperative bloody drainage were minimal and cardiovascular states immediately after surgery were stable. Presumably, the postoperative hypovolemic hypotension would be mainly associated with a further reduction in the central ECF volume, unless apparent hemorrhage develops postoperatively.

Routine hemodynamic variables such as cardiac output (CO), central venous pressure (CVP), and pulmonary artery wedge pressure are commonly used to evaluate the intravascular volume or cardiac preload. Intraoperative fluid balance study, including urine volume, is also used for the assessment of the intravascular volume immediately after surgery. However, none of these measures indicates the intravascular volume status or cardiac preload adequately (2,3). Thus, an alternative simple and rapid measure is required to assess the intravascular volume or cardiac preload.

Glucose, administered IV, distributes throughout the ECF compartment, and radioisotopic studies demonstrated that insulin affects neither the size nor the exchanging rates of rapidly exchanging glucose pools (4,5). We have reported that the initial distribution volume of glucose (IDVG) indicates fluid volume status of the central ECF in various pathological conditions without a significant modification of glucose metabolism (6–11). Our previous studies also demonstrated that IDVG, rather than plasma volume determined by the indocyanine green (ICG) dilution method (PV-ICG), had a better correlation with CO in critically ill patients (6,7,12). Assuming that IDVG rather than routine cardiovascular variables consistently mirrors the central ECF volume state or cardiac preload, IDVG has the potential of being an alternative indicator of fluid management, because IDVG can be approximated simply and rapidly even in critically ill patients (13,14).

In this study, we examined which variables immediately after surgery, including IDVG, can predict subsequent hypovolemic hypotension through the first 15 hours after radical surgery for esophageal cancer.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
The study was approved by our IRB, and each patient or authorized relative gave written, informed consent. Twenty-five consecutive patients who were admitted to our intensive care unit (ICU) immediately after radical surgery for esophageal cancer were studied. Each patient had a pulmonary artery catheter inserted for measurement of continuous thermodilution CO preoperatively. Intraoperative fluid management was determined by each anesthesiologist who did not know the contents of this study. All patients postoperatively received mechanical ventilatory support by 10 cm H2O of pressure support without positive end-expiratory pressure under continuous infusions with midazolam and morphine for at least 15 h after surgery. Vasoactive drugs such as dopamine and dobutamine were not given during the study. A 4.3% glucose solution with electrolytes was infused at a constant rate of 2 mL · kg-1 · h-1 throughout the first postoperative day. All patients preoperatively had normal cardiovascular function and a stable general condition in the absence of apparent dehydration. Patients who were at risk of central nervous system ischemia were excluded from the study.

Intraoperative fluid balance was calculated as a simple sum of infused crystalloids and colloids minus urine and estimated blood loss. Immediately after admission to the ICU, after measurement of hematocrit (Hct) and hemodynamic variables including arterial blood pressure (ABP), heart rate (HR), CO, CVP and pulmonary artery wedge pressure, both 25 mL of 20% glucose (5 g) and 10 mL of ICG (25 mg) were infused for 30 s through the central venous line. Serial blood samples were obtained through an indwelling artery catheter at the following times: immediately before and 1, 2, 3, 4, 5, 7, 9, and 11 min after the completion of glucose and ICG infusion. Each 2-mL blood sample was collected in a heparinized syringe, and plasma was separated immediately for measurements of concentrations of glucose and ICG. Electrocardiogram, ABP, oxygen saturation, and end-tidal carbon dioxide concentrations were monitored during the course of the study procedure, and all variables were maintained constant.

Plasma glucose concentrations were measured by using the glucose oxidase method (Glucose analyzer GA-1150; Kyoto Daiichi Kagaku Co. Ltd, Kyoto, Japan), and plasma ICG concentrations were measured using a spectrophotometric technique (U3200 Spectrophotometer; Hitachi Co. Ltd, Tokyo, Japan). Each value was measured in duplicate and averaged. Coefficient of variation for repeated measurements were 2% or less for plasma glucose (range: 50–300 mg/100 mL) and plasma ICG (range: 0.01–1.5 mg/100 mL), respectively.

IDVG and PV-ICG were calculated by using a one-compartment model from the increased plasma value between 3 and 7 min after the infusion for the former and between 3 and 11 min after the infusion for the latter. A microcomputer-based least-squares program (15,16) was used to analyze plasma glucose and ICG values, and Akaike’s Information Criterion (17) were examined to evaluate the exponential term of the pharmacokinetic model as described previously (11,12).

During the first 15 h postoperatively, hypovolemic hypotension was diagnosed as follows: systolic ABP either 70–80 mm Hg lasting longer than 30 min or <70 mm Hg at anytime accompanied by either tachycardia (HR more rapid than 120 bpm) or oliguria (urine volume < 10 mL/h), and responsive to IV fluid administration (lactated Ringer’s solution 500–1000 mL or colloid 250–500 mL). Hct and PV-ICG were measured again 15 h later as performed previously, to compare values including the circulating blood volume (=PV-ICG/(1-Hct/100)) with those on admission to the ICU. Postoperative drainage volumes were also measured.

Calculated values are presented on the basis of the reported basal body weight before surgery. They are also indexed to body surface area when compared with CO. Unless otherwise stated, data are presented as median (range). Regression analysis, Fisher’s exact probability test, Wilcoxon’s signed rank test, and Mann-Whitney U-test were performed as needed. P < 0.05 was considered statistically significant.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Demographic and clinical data for each patient are shown in Table 1. The patients developed no adverse cardiovascular events during the surgical procedure. Systolic ABP and HR on arrival in the ICU were 129 (92–180) mm Hg (mean ABP 87 [73–121] mm Hg), and 93 (65–112) bpm, respectively. Apparent hypotension was not observed. Hypertension and tachycardia were observed in some patients during recovery from general anesthesia. However, they improved after the infusion of morphine and midazolam immediately after admission to the ICU. Intraoperatively, eight patients underwent hemodilutional autologous blood transfusion of 350–860 mL and six patients were given plasma protein fraction of 250–1000 mL. Packed red cells were not given intraoperatively or during the first 15 h postoperatively.


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  		Table 1. Characteristics of Patients
 
The median Akaike’s Information Criterion (17) value of IDVG and PV-ICG were –24.0 (–16.0 to –34.3) for the former, –42.9 (–24.1 to –52.0) for the latter, assuming convergence. The plasma glucose concentration before glucose infusion was 149 (102–221) mg/100 mL, and insulin was not used in any of patients. IDVG and PV-ICG on admission to the ICU were 104 (74–159) mL/kg for the former and 47 (30–62) mL/kg for the latter. No correlation was observed between the plasma glucose concentration before its infusion and IDVG (r = 0.26), while a close inverse correlation was observed between the increased glucose concentration at 3 min and IDVG (r = 0.97, n = 25, P = 0.0001, y = –0.098x + 12.7). Calculated overestimation of IDVG and PV-ICG caused by duration of the infusion of glucose and ICG by using the formula proposed by Loo and Riegelman (18) was 2.1% (1.3%–2.7%) and 5.7% (1.9%–9.6%), respectively.

A significant relationship was observed between IDVG and PV-ICG (r = 0.65, n = 25, P = 0.0005) ( Fig. 1). IDVG correlated well with cardiac index (CI) (r = 0.87, n = 25, P = 0.0001) ( Fig. 2). Although PV-ICG also had a linear correlation with CI (r = 0.55, n = 25, P = 0.005), the correlation was less than that of IDVG and CI (P < 0.001).



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  		Figure 1. The relationship between IDVG and PV-ICG immediately after admission to the intensive care unit. IDVG = initial distribution volume of glucose, PV-ICG = plasma volume determined by the indocyanine green dilution method. The solid line is a regression line between the IDVG and the PV-ICG: y = 0.23x + 22.1, r = 0.65, P = 0.0005.

 


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  		Figure 2. The relationship between the IDVG and cardiac index immediately after admission to the intensive care unit. IDVG = initial distribution volume of glucose. The solid line is a regression line between the IDVG and cardiac index: y = 1.1 x -1.0, r = 0.87, P = 0.0001.

 
Although no patient had any episodes of systolic ABP less than 75 mm Hg, 11 patients met the criteria of subsequent hypovolemic hypotension. Furthermore, 5 patients developed hypotension at least twice after initial treatment that required more IV fluid administration to normalize their pressure. Either lactated Ringer’s solution 500–1000 mL or plasma protein fraction 250–500 mL was administered as needed. Ten of the 14 patients whose IDVG was <105 mL/kg and 11 of the 15 patients whose CI was <3.4 L · min-1 · m-2 required additional IV fluids to overcome hypovolemic hypotension (P = 0.002 for the former, P = 0.0003 for the latter) ( Fig. 3). None of the other measures correlated with clinical hypovolemia (Fig. 3). Plasma glucose decay curves after its infusion in each patient in the two groups with or without hypovolemic hypotension are shown in Figure 4. The 95% confidence limits of IDVG with or without hypovolemic hypotension ranged from 87 to 102 mL/kg for the former or from 105 to 133 mL/kg for the latter. When the cutoff of IDVG for prediction of hypovolemic hypotension was set at 105 mL/kg, the sensitivity of prediction was 71% and its specificity was 91%.



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  		Figure 3. Comparison between each clinical variable and hypovolemic hypotension. IDVG = initial distribution volume of glucose, PV-ICG = plasma volume determined by the indocyanine green dilution method, CI = thermodilution cardiac index, CVP = central venous pressure, and PAWP = pulmonary artery wedge pressure, measured respectively on admission to the intensive care unit. Balance = simple sum of intraoperative fluid balance study, Urine = intraoperative urine volume. Open circles indicate each patient who did not develop subsequent hypovolemic hypotension through the first 15 h postoperatively. Closed circles indicate each patient associated with subsequent hypovolemic hypotension. Dashed lines in the IDVG and CI columns are dividing lines with or without hypovolemic hypotension (105 mL/kg, [P = 0.002] for the former, 3.4 L · min-1 · m-2 [P = 0.0003] for the latter).

 


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  		Figure 4. The plasma glucose decay curves after IV infusion in each patient in the two groups with or without subsequent hypovolemic hypotension. Hypo(-) = the patients who did not develop subsequent hypovolemic hypotension through the first 15 h postoperatively, Hypo(+) = the patients associated with subsequent hypovolemic hypotension.

 
Hct immediately after surgery was 36.2% (29.1%–42.4%) in the patients with hypovolemic hypotension and 32.6% (25.5%–44.4%) without hypotension, and these values remained unchanged after 15 h (34.2% [24.9%–39.3%] for the former, 32.9% [25.9%–43.0%] for the latter). There was no significant difference in Hct with or without hypovolemic hypotension. Circulating blood volume immediately after admission to the ICU was 68 (48–90) mL/kg with hypovolemic hypotension and 76 (49–84) mL/kg without it, and remained unchanged after 15 h (61 [54–83] mL/kg and 68 [57–86] mL/kg, respectively). There was also no significant difference between the two groups. Postoperative drainage volumes during the first 15 h were similar in both groups (303 [105–450] mL with hypotension, 244 [131–705] mL without hypotension).


   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
When hypotension occurs in the early postoperative period, postoperative hemorrhage should be initially considered, even though many other factors may be responsible. However, we believe apparent postoperative hemorrhage did not account for the hypotension in this study, because Hct and calculated circulating blood volumes remained unchanged during the study period and postoperative drainage volumes were similar in both groups. Also, intraoperative fluid administration and urine output seemed adequate. Furthermore, postoperative acute cardiac failure was unlikely because each hypotensive episode was responsive to IV fluid administration. Considering these observations, the ECF shift from the central to the peripheral compartment seems to be the major causative factor of hypotension in this study.

The median IDVG in the present study was 104 mL/kg, and the critical volume for hypovolemic hypotension was 105 mL/kg. In our earlier experimental canine study, the normovolemic IDVG was 117–124 mL/kg (8,9). This value is also calculated as 105–142 mL/kg from the reported normal PV-ICG of 40–50 mL/kg in humans (19) and PV-ICG/IDVG ratio of 0.35–0.38 in our previous study (11). Thus, the normal IDVG ranged approximately from 110 to 130 mL/kg. During surgery, in addition to the ECF shift, evaporated water from operated fields, lymph tissues, and intraoperative hemorrhage also play a significant role in decreasing the ECF volume. This decrease may initially be unaccompanied by hypotension or tachycardia because of the normal vasoconstrictive response. However, the ECF shift from the central to the peripheral compartment may continue progressively during the early postoperative period (1). We have shown in this study that hypovolemic hypotension is likely to develop in patients whose IDVG decreases to <105 mL/kg immediately after arrival in the ICU, even though we were not able to perform IDVG measurements during the subsequent hypotension, which occurred mostly during the night after surgery.

Although either IDVG or CO could predict subsequent hypotension in this study, PV-ICG could not predict it, and correlated less with CO as observed previously (6,7,12). This can be explained partly by the fact that circulating blood volume does not consistently play a key role in determining intrathoracic blood volume or cardiac preload, because of redistribution of blood between the central and peripheral compartment. In fact, the application of positive end-expiratory pressure (20) or an infusion of phentolamine (21) does not produce any changes in measured circulating blood volume. In contrast, IDVG rather than PV-ICG correlated better with CO in various underlying pathological conditions (6,7,12) as observed in this study, suggesting that IDVG has more potential of being an indicator of cardiac preload.

Potential inaccuracy of PV-ICG estimation can occur when systemic capillary protein leakage is present, as ICG binds to plasma proteins (22). We previously reported that the PV-ICG/IDVG ratio could detect the presence of systemic capillary protein leakage in dogs (8,10). The larger the ratio, the more protein leakage would occur (8). A ratio larger than 0.45 would indicate protein leakage and overestimation of PV-ICG in critically ill patients (6,7,11,12). In this study, 11 of 25 patients had a ratio more than 0.45, indicating that their PV-ICG was potentially overestimated immediately after radical surgery for esophageal cancer.

In this study, all data collection began at three minutes after the infusion of glucose and ICG to ensure complete mixing within the initial distribution volume (19,23). Although this could not consistently be achieved at three minutes after the infusion in a low CO state (19), underestimation of PV-ICG by using measurements beginning at three minutes after the infusion (when CI was <2.5 L · min-1 · m-2) is clinically negligible (11). As there were only three patients whose CI were <2.5 L · min-1 · m-2, underestimation can be ignored in this study. This is supported by the fact that underestimation of PV-ICG in each patient was only 0.7, 1.5, and 3.1 mL/kg, as compared with the volume when using measurements beginning at five minutes after the infusion.

Potential inaccuracies can also occur from a one-compartment model applied in this study, because the model of glucose distribution kinetics has at least two glucose pools (23). The "fast" pool consists of the central ECF compartment including plasma, and it is not insulin-dependent. The IV administered glucose equilibrates rapidly into this space. The "slow" pool consists of the less perfused peripheral compartment, where glucose is slowly metabolized and insulin-dependent. As the amount of administered glucose is smaller compared with the conventional IV glucose tolerance test, the plasma glucose concentration failed to show a consistent decrease 9 minutes after the infusion (Fig. 4), nor did it show that administered glucose had been almost cleared from the plasma within 15 minutes after the infusion (8,9). Consequently, we applied a one-compartment model using data beginning at 3 minutes for determining IDVG, instead of a more complex pharmacokinetic model. A one-compartment model tended to produce values 0.57 L more than a two-compartment model (12).

A 30-second infusion of glucose and ICG instead of a bolus injection was performed in this study. The duration of the infusion may alter the results of the distribution volumes. The more rapid the disappearance rate of the indicator from plasma, the more overestimation of the distribution volumes would be induced, because the administered indicator begins to be cleared from the plasma during infusion (18). However, noncorrected data were used for analysis because the calculated overestimation was negligible (2.1% for IDVG and 5.7% for PV-ICG), as reported previously in humans (11).

Although severe hypovolemia can be detected by routine cardiovascular variables, smaller volume depletion or overload cannot consistently be detected even when a flow-directed pulmonary artery catheter is used, as was observed in this study and previous studies as well (2,3). Accordingly, inadequate blood flow in several important organs, such as the gastrointestinal tract, can occur despite these variables being normal. Fluid therapy based solely on these variables may also lead to inadequate pharmacological support of the circulation instead of fluid administration or restriction. Consequently, a further reduction of oxygen supply to these important organs can develop, resulting in a significant increase in morbidity and mortality as well as length of hospital stay in critically ill patients (24,25). In addition, the magnitude of perioperative fluid shifts would vary widely between patients, even if the surgical procedure were standardized. In contrast, the present results support that IDVG can be more useful as an indicator of the central ECF volume status or cardiac preload as a guide for early postoperative fluid management. By using the formula we reported (13,14), IDVG can be approximated from an increased plasma glucose level at three minutes after the infusion. Assuming that basal body weight is 60 kg, an increase in the plasma glucose level more than 67 mg/100 mL at three minutes after the infusion would indicate IDVG <105 mL/kg (13), meaning that subsequent hypovolemic hypotension is likely to develop. The 95% confidence limits of increased plasma glucose level at three minutes after the infusion with or without hypovolemic hypotension ranged from 69–78 mg/100 mL for the former or 50–67 mg/100 mL for the latter.

In conclusion, the results of this study demonstrate that IDVG closely correlates with CI, and suggests that IDVG < 105 mL/kg immediately after surgery can help predict the development of subsequent hypovolemic hypotension after radical surgery for esophageal cancer.


   Acknowledgments
 
The authors thank Dr. Pall Hollister (Misawa, Japan) and Dr. Ed Major (Swansea, UK) for their valuable comments.


   References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

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Accepted for publication January 8, 2001.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press