No patients who received fluid therapy from a student registered nurse anaesthestist were included, on the basis that only one of the two institutions had them. In the UK, intraoperative cardiac output monitoring to guide stroke volume optimization during many elective major surgeries is recommended by the National Institute for Health and Care Excellence NICE 6 and advocated as a means to achieve bespoke fluid therapy for the individual, but this has gained little traction in America as yet.
The authors of this paper specifically mention that goal-directed fluid therapy was not practised. Also omitted is information about perioperative vasoactive drug use. But there are broad similarities between the health-care models in the two continents. Is the variability unique to the two institutions in this study?
Registry data for a period of 5 yr from more than half a million patients having colonic or arthroplasty surgery confined to nine ICD-9 procedure codes across US hospitals shows that fluid usage complies to a U-shaped curve, with a median of around 3 litres crystalloid per procedure; however, the interquartile range of intraoperative fluid administration ranges from 1. This is certainly apparent in UK perioperative fluid therapy studies. It seems unlikely that both ends of this spectrum of current common clinical practice are correct Fig.
Hourly water and solute load of two i. The more elements achieved, the better the outcome. For elective abdominal surgery, of around 20 elements, avoidance of fluid overload is one of the key two the other is provision of preoperative carbohydrate drinks. This theme is echoed in the UK ER literature. Deviation from an ER pathway is associated with an increase in length of stay; continued i.
But it is likely that also included in the delayed discharge group are many patients who receive excess i. Is consistency achievable across a multitude of clinicians? It is interesting that in the paper by Lilot and colleagues, 5 the mean fluid administration rate for ASA I patients was 9. Is this indicative of closer attention being paid to patients who are perceived as sicker? This means bringing patients to theatre in a euvolaemic state, then paying meticulous attention to detail in fluid administration.
Does it take something unique or special to reduce inter and intraprovider variability in this manner? Experienced anaesthetists claim that there is no substitute for their clinical judgement. There is some evidence for this. Two recent large multicentre effectiveness randomized controlled trials of early goal-directed therapy for patients admitted to the emergency department with severe sepsis have returned the same result; that strictly protocolized management targeted at defined haemodynamic milestones is no better than judicious sustained care delivered by experienced clinicians.
Additional information provided by minimally invasive advanced haemodynamic monitors could be a useful adjunct to assist understanding of the volaemic status of individual patients, effectively allowing inexperienced staff to emulate the artistry of the masters through painting by numbers. British Consensus Guidelines for Intravenous Fluid Therapy in Adult Surgical Patients 20 recommend that whenever we give fluid and salt for correction of a volume deficit during major surgery it should be directed towards a particular goal.
Goals may or may not be a nominal cardiac stroke volume or related index of blood flow.
Goal Directed Therapy reduces postoperative complications and improves outcome
The consensus statement from the Department of Health's Enhanced Recovery Partnership Programs ERPP on perioperative fluid therapy makes a similar recommendation regarding goal-directed therapy. An underappreciated facet of perioperative care is that much of the i.
- Article Tools.
- Goal Directed Therapy.
- Perioperative fluid management: Consensus statement from the enhanced recovery partnership.
- Perioperative fluid management: Progress despite lingering controversies.
In contrast to the intraoperative setting, many hospitals leave delivery of this to nurses and surgical juniors. NICE are thus broadly intended for non-expert first responders, such as trainee doctors on call out of hours. That should not mean we, as perioperative physicians, can ignore them. We need to be accountable for this territory. As self-proclaimed experts in perioperative care, it is our responsibility to prescribe an appropriate fluid in an appropriate volume for postoperative care and to participate in consistent education of those entrusted with front-line delivery of this.
In the modern multidisciplinary era, much postoperative care is directly delivered by nursing staff, who are very capable of following algorithms to achieve good clinical outcomes. Best-practice algorithms are elusive. Many UK hospitals have declined involvement on the basis that they consider the question resolved in favour of restrictive and consider themselves to practice this already. But do you really know how much fluid you give? It is not clear that all these hospitals collect data on their fluid practice.
The perpetual cycle of quality improvement relies on embedded collection and continuous feedback of reliable data. This allows services to know how they are really performing rather than how they think they are. Definitions are difficult, there being considerable overlap between the four phases of fluid therapy relevant to acute patients as mentioned above.
Clinical application may be even more difficult because we do not know what the best end points and algorithms are. Resuscitation is restoration of circulating volume to above a critical perfusion threshold 27 and is achieved with isotonic colloid, crystalloid, or where appropriate, blood and blood products. Replacement is likewise targeted, bespoke, and difficult. We believe that careful measurement and replacement of losses with fluid of a similar composition makes biological sense.
Advanced haemodynamic monitoring may assist in achieving this aim. However, we wish to conclude this commentary by focusing on maintenance fluid therapy, particularly after surgery. Consider our model of electrolyte and fluid homeostasis in the human organism after a physiological stress, such as major surgery. The body is avidly holding on to salt and water. Lactated Ringer solution and normal saline are not maintenance solutions, because their sodium content is much too high for this purpose.
A single litre bag of Hartmann's solution contains around twice the recommended daily intake of sodium chloride. Accordingly, three bags of this stuff hung as daily maintenance creates a large salt load. Can we as a clinical community agree? We have been researching perioperative fluid therapy for a very long time, yet because of inconsistent trial design we are no closer to the truth.
In the absence of clearer evidence, in our view fluid management according to the standard practice group in the OPTIMISE trial is a reasonable approach to adopt for current best practice. An acceptable alternative is that hospitals produce their own local perioperative fluid guidelines based on reliable local audit. But continued apathy is not the answer. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
Fluid Management Practices After Surgery for Congenital Hear : Pediatric Critical Care Medicine
Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Upon the arrival of the patients in the operating room, the left side of the cubital vein was catheterized in all of the patients. An A-line was established via a G catheter that was inserted in the radial artery for invasive arterial pressure measurement.
All of the monitoring transducers were positioned and zeroed at the midaxillary level. The data registration was excluded when a fast flush test indicated an unacceptable pressure recording. The induction of anesthesia was conducted with intravenous IV midazolam 0. A volume-controlled mode with zero end-expiratory pressure was used to ventilate the lungs in all of the patients Drager Julian, Philips Healthcare, Tilburg, The Netherlands.
The ventilator settings were unchanged during the study. Patients whose peak airway pressures exceeded 40 mmHg were excluded from the study. Anesthesia was maintained with a 2. Immediately after induction, all of the patients received 2. All of the surgeries in this study were performed by the same surgical team. Pulse pressure variation measurement. The mean value of the three determinations was used for the analysis. As a reference for fluid administration in the goal-directed therapy groups, the PPV values were measured every 15 minutes during the operation. Grouping and fluid therapy protocol.
Baseline measurements were instituted after induction and hemodynamic stabilization. Next, the patients were randomly assigned to one of three groups according to the intraoperative fluid protocol using a random number generator in sealed envelopes. Anesthesia was discontinued when the operation was completed. A total of 80 mg of parecoxib and 5 mg of morphine was injected intravenously for analgesia 30 minutes before the end of the surgery. Patients were extubated in the operating room when they fulfilled the standard clinical criteria adequate protective reflexes, adequate oxygenation, and stable hemodynamics.
Once the patients were sent to the ward, follow-up was conducted by an independent researcher Zhiyong He who was unaware of the randomization of the patient until the patient was discharged from the hospital. The same surgical team was in charge of the postoperative care of the patients, including fluid infusion a baseline crystalloid infusion of 1.
To treat postoperative nausea and vomiting, 10 mg of metoclopramide was administered intravenously. The discharge criteria adopted the standard protocol that was predefined by the Department of General Surgery at our hospital. In this study, the primary endpoint was the postoperative length of hospital stay, and the secondary endpoints were the time to bowel flatus and postoperative complications. Additionally, the preoperative and postoperative biochemical and hemodynamic variables; the type and volume of the intraoperative fluid infusions; the estimation of blood loss; the urine output; and the medications were recorded.
To calculate the sample size, we used the retrospective data that were available for the same surgical population at our hospital. A one-day reduction in the postoperative length of hospital stay was considered to be clinically relevant, which required approximately 20 patients with a type I error of 0.
The patient characteristics and the perioperative data were analyzed using a one-way analysis of variance ANOVA , and the differences between the individual treatment groups were determined using the Student- Newman-Keuls test. The differences between the treatment groups according to the incidence of adverse events were determined using the two-tailed Fisher's exact test. The statistical analysis was performed using the SPSS A total of 60 patients with gastrointestinal cancer who were undergoing laparotomy were enrolled.
No patients were excluded or dropped out of the study. There were no significant differences between the groups regarding the demographic characteristics and preoperative diseases Table 1. The perioperative data are shown in Table 2. No differences were observed between the types of surgery, operation duration, intraoperative blood loss, and analgesic consumption fentanyl. However, the urine output in the. GD-RL group The amount of the intraoperative fluid infusion in the GD-RL group Specifically, the GD-RL group No patient required a blood transfusion according to the hematocrit measurements during the operation.
The baseline hematocrit, biochemical parameters albumin and creatine levels and hemodynamic variables CVP and PPV were comparable among the three groups Table 2. No anastomotic leaks or intra-abdominal bleeding occurred, and all of the patients survived during the study period.
The time to first passage of flatu s was The length of postoperative hospital stay was 9. Perioperative fluid replacement is a challenging issue in surgical care, especially in a procedure-specific model.
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Recently, goal-directed fluid therapy has been introduced into clinical practice as part of perioperative management. To our knowledge, this study is the first to directly compare the effects of an intraoperative restrictive protocol with a PPV-directed protocol on the outcomes of patients undergoing gastrointestinal surgery. Our results suggest that PPV-directed therapy with HES solution results in a shorter postoperative hospital stay and faster bowel function recovery than an infusion with either restricted or PPV directed lactated Ringer's solution.
However, the incidence of postoperative complications was similar among the patients who were treated with the three fluid strategies. The accuracy and early recognition of the intravascular volume status is essential to prevent both hypoperfusion due to volume depletion and fluid overload due to an unnecessary infusion.
Therefore, appropriate hemodynamic monitoring is necessary for intraoperative fluid management. A simple, affordable and reliable method to achieve this goal would be appropriate for routine intraoperative application. PPV measurement with a multiparameter monitor that is commonly used in clinical practice has been described and successfully used for intraoperative fluid therapy 9, This type of PPV monitoring is not associated.
PPV monitoring has been recommended to guide volume expansion in surgical patients. Lopes et al. Many studies have investigated the effects of the amount of intraoperative fluid administration on perioperative outcomes. A meta-analysis demonstrated that a restrictive intraoperative 3,12,13 and postoperative 14 fluid protocol in major abdominal surgery reduces the incidence of perioperative complications, such as cardiopulmonary events and disturbances in bowel motility; improves wound and anastomotic healing; and reduces the length of the hospital stay.
In addition, several studies examined the effects of intraoperative fluid therapy that is guided by various hemodynamic targets, such as conventional hemodynamic parameter-guided and functional hemodynamic paramet er-directed fluid therapy, on perioperative outcomes. Studies demonstrated that patient outcomes improved after functional hemodynamic parameter PPV or SVV -directed fluid therapy in major surgery Therefore, two optimal intraoperative strategies have been proposed: restrictive and goal-directed fluid therapy.
However, patients who are treated using a goal-directed protocol receive greater amounts of fluid than patients who are treated with a restrictive protocol. Several studies have questioned the positive effects of goal-directed fluid therapy. Senagore et al. Lahner et al. PPV is considered to be more reliable than SVV and can be used to recognize volume contraction earlier than other indicators 21,22 ; however, amplified PPV does not represent the hypovolemic status, such as anesthesia or inflammation-induced vasodilation Therefore, restrictive fluid infusion with vasopressor administration during abdominal surgery has been advocated to prevent fluid retention after the anesthetic effects have subsided.
However, recent randomized trials did not confirm the potential benefits of fluid restriction on recovery after elective surgery 3, Intraoperative fluid restriction was associated with frequent episodes of intraoperative hypovolemia 23 , which is a major determinant of postoperative organ dysfunction 11 and an independent predictor of postoperative complications, such as an anastomotic leak and postoperative sepsis 5.
Whether goal-directed therapy is superior to a restrictive fluid strategy in major abdominal surgery remains uncertain. Therefore, we designed a prospective, randomized study to compare the effects of restrictive and goal-directed fluid therapy on perioperative outcomes in patients who were undergoing open gastrointestinal surgery. The goal-directed therapy group was further divided into two subgroups, a GD- RL group and a GD-C group, to compare the role of fluid type in intraoperative fluid therapy.
In this study, a total fluid volume of ml in the GD-C group was sufficient for organ perfusion in open abdominal surgery over a 3-hour period; however, a greater volume ml in the GD-RL group or reduced volume ml in the R-RL group was less effective. Another factor that may influence the outcomes of patients who undergo major abdominal surgery is the type of fluid. In the setting of moderate hypovolemia, an infusion of colloids increases blood volume and cardiac output more effectively than the same volume of crystalloids, even when the crystalloid infusion is rapidly administered over min 2 5.
Crystalloids enter the extravascular space more rapidly and in greater quantities than colloid; therefore, third-space fluid accumulation and altered capillary permeability may occur Large amounts of intravenous crystalloid solutions can lead to an interstitial volume load, the development of interstitial edema and the impairment of the diffusion of O 2 in gut tissues 27 , which may prolong the period of ileus and increase postoperative complications and thus undermine the healing process The large amounts of crystalloids that were administered in the GD-RL group may have offset the beneficial effects of the goal-directed therapy during the surgery.
Subsequently, the elimination of flatus and the postoperative discharge times were delayed in the goal-directed crystalloid therapy group compared with the restrictive regimen group Two studies have compared the outcomes between intraoperative restrictive and goal-directed fluid management strategies in animal experiments. Kimberger et al. In contrast to the mucosal tissue, the microcirculatory blood flow in the perianastomotic muscularis tissue was significantly higher in the GD-C group compared with the GD-RL group.
These results suggest that goal-directed therapy with colloids during gastrointestinal surgery can lead to more stable intraoperative hemodynamics, faster bowel function recovery and a shorter postoperative discharge time compared with the goal-directed therapy with crystalloids in this study. However, several authors have questioned the beneficial role of goal-directed fluid therapy and indicated that the better outcomes in the goal-directed groups can be solely attributed to the larger amounts of colloids that are used in these groups compared with the control groups A restrictive colloid group was not included in our fluid protocols; therefore, we cannot completely rule out the possibility that additional colloids may have contributed to our findings.
However, in another experimental study with a small bowel anastomosis rat model, Marjanovic et al. However, the colloid restriction group had only comparable, but not better, results than the colloid overload and crystalloid restriction groups. There are several limitations to this study. The first limitation is that an accelerated surgical recovery program was not adopted. The morphine administration for postoperative rescue analgesia may have affected the results because this treatment can delay bowel function recovery and cause PONV.
Moreover, nasogastric tubes are routinely applied during gastrointestinal surgery at our hospital. However, the three groups in our series were similar with respect to the surgeons the same surgical team , clinical characteristics and postoperative quality of care conventional but standardized.
Second, we did not establish a restrictive colloid group; therefore, the improvement in the outcomes could be due to the fluid type rather than the fluid therapy strategy. However, colloid replacement alone is not recommended in the textbooks and guidelines on intravenous fluid therapy in surgical patients.