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Perioperative fluid management for major abdominal surgery

Perioperative fluid management for major abdominal surgery. Anthony Ho, MD Department of Anaesthesia and Intensive Care. www.lib.mcg.edu/.../section7/7ch02/7ch02p09.htm. Ann Surg 2003;238: 641-648. Preop. No bowel prep mentioned (No bowel prep?). Postop:

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Perioperative fluid management for major abdominal surgery

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  1. Perioperative fluid management for major abdominal surgery Anthony Ho, MD Department of Anaesthesia and Intensive Care

  2. www.lib.mcg.edu/.../section7/7ch02/7ch02p09.htm

  3. Ann Surg 2003;238: 641-648

  4. Preop • No bowel prep mentioned (No bowel prep?)

  5. Postop: R group: 1 L of D5W ± K for the rest of the day of surgery, and loss through drains replaced with equal vol of HAES 6%; S group: 1-2 L of N/S per day, furosemide if wt gain>1 kg; All patients were encouraged to drink from 4 h postop

  6. Administered fluid and BW changes. R=restricted group; S=standard group. Fluids presented as summation of means. *P< 0.001. †P < 0.01. ‡“Other or unspecified” represents blood, albumin, &/or FFP on the day of surgery. Type of i.v. fluids not specified on postop days 1 to 6. Wt changes are compared with the wt the morning of surgery.

  7. Number of Patients With Complications (Per-Protocol Analysis). Median follow-up for 34 days.

  8. Requirements for Acceptance of Complications and Total Number of Complications Registered by Blinded Assessment

  9. Complication frequency related to intravenous fluid administration and body weight increase on the day of operation. P < 0.001 both for increasing intravenous fluid volume and increasing body weight ([chi]2 test for trend).

  10. Restricted group 12% Standard group 3% Urine output <0.5 mL/kg/h P = 0.008 Only on day of surgery Creatinine was higher on arrival to recovery room [86 M/L vs. 75.8 M/L (P=0.002)] but became equal subsequently. No renal dysfunction in either group.

  11. Restrictive group 28% Standard group 32% Postop hypotensive episodes Amount of vasopressors used not stated.

  12. Restricted group 0 Standard group 4 (4.7%) Pulmonary edoema (2) Pneumonia & septicaemia (1) Pulmonary embolus (1) Death P = 0.12

  13. Boldt J. EJA 2006 Day of surgery:Restricted group: mean HAES 2,740 mL and D5W (100-8,050 mL), 15% given more fluids than planned; Standard group: mean HAES 5,388 mL and NS (2700-11,083 mL), 24% given less fluids than planned. No information on hemodynamics, acid-base, and use of vasopressors

  14. Anesthesiology 2005; 103:25-32

  15. All patients had the same bowel prep (3 L of polyethylene glycol) • All patients received 1 L of D5W-0.45% NaCl over night before surgery • All patients received an epidural before anaesthesia started but neuraxial injection of local anaesthetic only commenced postop.

  16. Restricted group RL 4 mL/kg/h Blood loss replaced with RL in a 3:1 ratio Liberal group RL Before skin incision (10 mL/kg) Then RL 12 mL/kg/h Blood loss replaced with RL in a 3:1 ratio Fluid management Postop: D5W-0.45% NS at 1-1.5 mL/kg/h for 3 days

  17. 11 patients in the restrictive group required boluses; 0 patient in the liberal group required bolus No difference in vasopressor requirements If hemodynamically unstable and CVP<15 mmHg, HAES 6% or vasopressors, if CVP>15, consider furosemide

  18. Restrictive group Pass flatus [3(2-7) days] Pass feces [4(3-9) days] Hosp discharge [8(6-21) days] Liberal group Pass flatus [4(3-7) days] Pass feces [6(4-9) days] Hosp discharge [9(7-24) days] Other statistical significant complications

  19. What about postoperative i.v. fluid restriction?

  20. THE LANCET • Vol 359 • May 25, 2002 • www.thelancet.com 1812-18

  21. 10

  22. Restricted group Postop fluids managed by special team, details not specified Standard group Postop fluids managed in standard fashion, details not specified Method No bowel prep for right hemicolectomy Fluid intake up to 4 h preop Intraop entirely up to anaesthetists (not part of investigation and were not aware of the protocol or randomisation)

  23. Postop days 0 1 2 3 4

  24. Liquid and solid phase emptying • Measured on the 4th postop day using radioactively labeled water and a different radioactively labeled pancake

  25. These three patients happened to have had the highest Na intake

  26. British Journal of Surgery 2006; 93: 1469-1474

  27. Fluid management: Pre- & Intra-op • Preop: no bowel prep (phosphate enema the night before and on the morning of surgery for those having left-sided surgery), free fluids up to 4 h preop • Intraop: D4W-0.18% NS at 10 mL/kg/h plus 3 × the measured blood loss

  28. Restricted group 83 mL/h D4W-0.18% NS Liberal group 1 L NS + 2 L D5W per day until day 3 Fluid management: Post-op Oral fluids were encouraged immediately after operation in both groups, with protein drinks and normal food introduced on day 1 after surgery

  29. Conclusion • No difference in outcome • Fluid restriction postop is safe

  30. Doppler group Standard group CVP 12-15 torr Fluid management

  31. Volume of colloid given: standard (control) group 1500 mL vs. Doppler group 2000 mL

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