Can Voluven Be Used in Hypotensive Patients with Obstructive Jaundice?
No, Voluven (hydroxyethyl starch) should not be used in hypotensive patients with obstructive jaundice; instead, use crystalloids (normal saline or balanced crystalloids) or albumin for volume replacement, as hydroxyethyl starches are contraindicated in critically ill patients and patients with obstructive jaundice have underlying cardiovascular instability that requires safer fluid choices.
Rationale for Avoiding Hydroxyethyl Starches
The 2016 Surviving Sepsis Campaign guidelines provide a strong recommendation against using hydroxyethyl starches for intravascular volume replacement in critically ill patients, with high-quality evidence supporting increased harm 1. While obstructive jaundice patients may not always meet sepsis criteria, they share similar pathophysiologic derangements including cardiovascular instability and renal vulnerability that make hydroxyethyl starches particularly dangerous.
Pathophysiology of Hypotension in Obstructive Jaundice
Patients with obstructive jaundice have unique cardiovascular vulnerabilities that make fluid choice critical:
- Cardiovascular instability is a major feature of obstructive jaundice, manifesting as systemic hypotension and defective vascular reactivity that sensitizes the kidney to prerenal failure 2
- Endocrine markers indicate functional hypovolemia, with elevated atrial natriuretic peptide (118 vs 40 pg/ml in controls) and aldosterone levels (156 vs 43 pg/ml) suggesting volume depletion despite potential fluid overload 3
- Acute renal failure occurs in 8-10% of surgical patients with obstructive jaundice and contributes to 70-80% mortality in those who develop it 2
Recommended Fluid Management Strategy
First-Line Fluid Choice
Use crystalloids (normal saline or balanced crystalloids) as the initial fluid of choice for volume replacement 1. The 2016 Surviving Sepsis guidelines recommend crystalloids with strong evidence for initial resuscitation in hemodynamically unstable patients 1.
When to Add Albumin
Consider adding albumin when patients require substantial amounts of crystalloids 1. The 2006 cirrhosis ascites guidelines specifically mention that colloids including albumin, gelofusine, or haemaccel can be used for volume expansion in patients with severe hyponatremia and elevated creatinine, though they note this will worsen salt retention 1.
Specific Considerations for Obstructive Jaundice
- Perioperative fluid therapy should focus on hemodynamic optimization with careful monitoring, as these patients have depressed cardiovascular function through complicated mechanisms 4
- Pulse pressure variation (PPV) >7.5% can predict fluid responsiveness (sensitivity 63.6%, specificity 71.4%) in mechanically ventilated patients with obstructive jaundice, though stroke volume variation and pleth variability index are unreliable in this population 5
- Volume expansion should be guided by dynamic hemodynamic monitoring rather than static parameters alone 5
Critical Pitfalls to Avoid
- Never use hydroxyethyl starches in any critically ill or hemodynamically unstable patient, as they increase mortality and renal dysfunction 1
- Do not assume normal volume status based on blood pressure alone, as obstructive jaundice patients have functional hypovolemia with activated volume-regulating hormones despite potential fluid overload 3
- Avoid aggressive fluid resuscitation without monitoring, as these patients are prone to both volume depletion and overload complications 4
- Do not overlook the need for biliary drainage, as decompression improves fluid homeostasis, decreases ANP (110 to 67 pg/ml) and aldosterone (182 to 85 pg/ml), and increases extracellular volume 3
Monitoring During Resuscitation
- Apply fluid challenge technique with continuous hemodynamic assessment, administering fluid as long as hemodynamic factors continue to improve 1
- Monitor for signs of renal dysfunction (creatinine clearance impairment occurs in approximately one-third of patients) 3
- Assess coagulation status preoperatively, as obstructive jaundice causes coagulopathies that should be reversed before procedures 4