Goal-Directed Therapy: There Is More Than “Fluid Balance” to Improve Postoperative Renal Function

Abstract

Perioperative management of fluid balance, particularly during cardiopulmonary bypass (CPB), is a matter of debate. Indeed, much has already been written, with theories on perfusion management often different and sometimes even conflicting. 1 Ranucci M. Johnson I. Willcox T. et al. Goal-directed perfusion to reduce acute kidney injury: a randomized trial. J Thorac Cardiovasc Surg. 2018; 156: 1918-1927 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar ,2 Chong M.A. Wang Y. Berbenetz N.M. McConachie I. Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes? A systematic review and meta-analysis. Eur J Anaesthesiol. 2018; 35: 469-483 Crossref PubMed Scopus (61) Google Scholar Within this debate, we read with interest the article by Smith and colleagues, 3 Smith B.B. Mauermann W.J. Yalamuri S.M. et al. Intraoperative fluid balance and perioperative outcomes after aortic valve surgery. Ann Thorac Surg. 2020; 110: 1286-1293 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar who evaluated the effect of intraoperative fluid balance on postoperative acute kidney injury (AKI) in 2327 heart surgery patients, concluding that positive intraoperative fluid balance is associated with a reduced risk of AKI and mortality. Given the retrospective nature of the study, however, a few observations should be made. Intraoperative Fluid Balance and Perioperative Outcomes After Aortic Valve SurgeryThe Annals of Thoracic SurgeryVol. 110Issue 4PreviewThe effect of intraoperative fluid balance on postoperative acute kidney injury (AKI) in cardiac surgical patients is poorly defined. Full-Text PDF Perioperative Goal-Directed Hemodynamic and Fluid Strategies: Still Much to Learn: ReplyThe Annals of Thoracic SurgeryVol. 110Issue 5PreviewWe read the insightful comments by Condello and Santarpino.1 We agree with the position that perioperative acute kidney injury (AKI) is multifactorial and that a goal-directed approach to optimize cellular oxygen delivery (DO2) is paramount. The purpose of our paper was to evaluate a practice that is variable (intraoperative fluid management) in a homogenous cardiac surgical cohort (primary sternotomy aortic valve replacement for aortic stenosis).2 A limitation to this study was the lack of retrospective data related to DO2 while on cardiopulmonary bypass (CPB); however, institutional protocol during the study period was to maintain a CPB cardiac index of 1.8 L•min•m2 to 2.4 L•min•m2. Full-Text PDF