Fluid Optimization in Liver Surgery

Abstract

Background: A previous study investigated the value of adding a dietitian to a geriatric discharge Liaison-Team. The scope of this study was to explore the possible economic savings of this. Methods: Patients, 70+ and at nutritional risk, were randomized to receive discharge Liaison-Team either with (intervention group, IG) or without a dietitian (control group, CG). The IG received three home visits by the dietitian during a 12-week period. Data included in the economic analysis was time spent by the dietitian, use of oral nutritional supplements (ONS) and number of hospitalization days. Results: Of the 71 included patients, 34 were in the IG, 30 patients received all three dietitian visits. Cumulated number of hospitalization days was 172 in the IG and 415 in the CG. Use of ONS was 48% in the IG and 17% in the CG (P=0.001). Estimated cost for the dietitian and ONS combined in the IG was €9,416 compared to €1,150 (ONS only) in the CG. For hospitalizations, estimated cost was €92,020 in the IG and €220,025 in the CG. Cost savings added up to €3,048 per patient in the IG. Conclusion: Adding a dietitian to a geriatric discharge Liaison-Team decreased health care costs. Study’s purposes: To reduce bleeding, hepatectomies are usually performed maintaining low central pressure (CVP) combined with extrahepatic control flow and this management can lead hemodynamic instability and reduction in oxygen delivery. This study analyzes hemodynamic changes and so the derived fluid management, in patients undergoing liver resection, through the Vigileo/FloTrac system. Basic procedures: Seventeen patients were included. Low CVP, below 4 mmHg, was reached by loop diuretics. Hemodynamic parameters were recorded and blood gas analysis was also performed. At the end of resection, fluid replacement was carried out with 500 ml of crystalloid solution in 20 minutes evaluating changes in CVP, Cardiac Index (CI) and Stroke Volume Variation (SVV). Main findings: During Pringle maneuver, Cardiac Index resulted stable through a modification in heart rate and vascular resistances (p<0.01). Only SVV significantly changed during Pringle maneuver (p=0.03) and not CVP (p=0.8). In all patients the oxygen delivery was maintained upper 600 ml/min/m2. Fluid optimization was performed with 1917 ml ± 1161 ml of crystalloid solution with a significant reduction in SVV (p<0.01) about 7% despite a CVP of 5 mmHg. Conclusions: We suppose that SVV can replace CVP in major hepatectomy management. Regarded results we can conclude that a good peripheral perfusion can be reached also with a fluid restrictive regimen avoiding overload and postoperative edema.