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The Perioperative Stress Response

Congratulations for being here – or should I say – say thanks to your ancestors who managed to survive long enough to pass their genes down to you despite no effective medical care until the mid 20th century. Doctors, nurses and other healthcare professionals don’t usually heal patients, they just create an environment in which the body can heal, assuming that it has sufficient physiological reserve to do so. Over hundreds of thousands of years we evolved systems to keep ourselves alive despite often horrific injuries sustained in trauma, conflict or accident. Most of the time that involved significant blood loss. The body evolved a series of defence mechanisms to keep itself alive: by shutting down systems that use up too much energy, and prioritizing blood flow to the heart and brain. It then accumulates a series of tools – that we call inflammation – to set about healing the injury. This process that EBBS and FLOWS is known as the STRESS RESPONSE. It is adaptive – which means that it is normal. The magnitude of the stress response is usually proportional to the degree of injury. Whether you are a doctor, a nurse or any kind of healthcare provider – you will encounter patients who are injured or have undergone surgery. To follow the remainder of this course you absolutely MUST understand the Stress Response – if you do not understand you may deliver inadequate or unnecessary treatment to patients or fail to recognize essential physical signs. Thanks, incidentally to my friend and mentor - Cliff Deutschman - who taught generations of trainees, including myself, at Hopkins, Penn and at Northwell Health, the fundamentals of Stress and Inflammation. @ccmtutorials www.ccmtutorials.org This video was re-edited in Jan 2024 0:00 Beginning 02:15 Contents 02:25 Clinical Scenario (postoperative patient high early warning score) 04:15 Components of the Stress Response 06:20 The Microcirculation at Rest and During Stress 07:35 Transcapillary Refill 08:45 The Inflammatory Stress Response 09:43 The Ebb Phase 11:30 The Flow Phase 14:00 Typical Fluid Balance during the Stress Response 15:12 Suggested Fluid Strategy during the Stress Response 18:10 Clinical Scenario Revisited 18:20 Conventional Approach to Perioperative Fluids 20:22 Why Hypotonic Fluid Boluses are Dangerous During the Acute Stress Response 21:35 Fluid Requirements and Fasting 23:06 Distribution of Intravenous Fluids 26:00 Conventional Approach to Intraoperative Fluid Requirements 28:00 My Suggestions for Postoperative Fluid Management 29:00 Review