Liberal Fluid Administration Research Articles

The effect of high-volume intraoperative fluid administration on outcomes among pediatric patients undergoing living donor liver transplantation

BackgroundPediatric patients undergoing liver transplantation are particularly susceptible to complications arising from intraoperative fluid management strategies. Conventional liberal fluid administration has been challenged due to its association with increased perioperative morbidity. This study aimed to assess the impact of intraoperative high-volume fluid therapy on pediatric patients who are undergoing living donor liver transplantation (LDLT).MethodsConducted at the Children’s Hospital of Chongqing Medical University from March 2018 to April 2021, this retrospective study involved 90 pediatric patients divided into high-volume and non-high-volume fluid administration groups based on the 80th percentile of fluid administered. We collected the perioperative parameters and postoperative information of two groups. Multivariable logistic regression was utilized to assess the association between estimated blood loss (EBL) and high-volume FA. Kaplan-Meier survival analysis was used to compare patient survival after pediatric LDLT.ResultsPatients in the high-volume FA group received a higher EBL and longer length of stay than that in the non-high-volume FA group. Multivariate logistic regression analysis indicated that hours of maintenance fluids and fresh frozen plasma were significantly associated risk factors for the occurrence of EBL during pediatric LDLT. In addition, survival analysis showed no significant differences in one-year mortality between the groups.ConclusionsHigh-volume fluid administration during LDLT is linked with poorer intraoperative and postoperative outcomes among pediatric patients. These findings underscore the need for more conservative fluid management strategies in pediatric liver transplantations to enhance recovery and reduce complications.

The effect of restrictive compared to liberal intravenous fluid volume on hypotension in adults undergoing major abdominal surgery

In a cardiac output (CO) sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial, it was shown that restrictive fluid management was associated with lower cardiac index at the end of surgery. However, the association of the fluid protocol with intraoperative blood pressure was less clear. This paper primarily compares rates of hypotension between the two fluid regimens. The haemodynamic effects of these protocols may increase our understanding of perioperative fluid prescription. Using a data set of arterial pressure and cardiac output measurements, this observational cohort study primarily compares intraoperative hypotension rates defined by a mean arterial pressure < 65 mmHg between liberal and restrictive fluid protocols. Secondary analyses explore predictors of invasive mean arterial pressure and doppler-derived cardiac output, including fluid volume regimens and surgical duration. 105 patients had a combined total of 835 haemodynamic data capture events from the beginning to the end of the surgery. Here we report that a restrictive regimen is not associated with a greater proportion of participants who experience at least one episode of hypotension than the liberal regimen 64.1% vs. 61.5% (mean difference 2.6%, 95% CI − 15.9% to 21%, p = 0.78). Duration of surgery was associated with an increased risk of hypotension (OR 1.05, 1 to 1.1, p = 0.038). A fluid restriction protocol compared to liberal fluid administration is not associated with lower blood pressure.

Intraoperative Fluid Management Correlates with Intraoperative Complications in Cesarean Section: A Prospective Clinical Trial

Background: This study focused on perioperative fluid administration in pregnant women undergoing a caesarean section (CS) by comparing liberal and non-liberal fluid administration in a multicentre setting across various Hospitals in the Bali province and its surrounding areas.&#x0D; Methods: Sampling was conducted using a total sampling method. All patients meeting the inclusion criteria were included in this study. A total of 310 samples of pregnant patients undergoing CS surgery in various operating rooms across hospitals in the Bali province and surrounding areas were obtained during the period of January to December 2022. The fluid administration strategy was divided into two types: liberal and non-liberal. Data analysis was performed using the Chi-square test with the correlation test of the contingency coefficient.&#x0D; Results: The results showed that liberal fluid administration significantly increased complications in the operating room for pregnant patients undergoing cesarean section (p&lt;0.001; r=0.305; OR 6.22) but not in the recovery room or postoperative hospital ward.&#x0D; Conclusion: Liberal fluid administration could significantly increase complications in the operating room for pregnant patients undergoing cesarean section but not in the postoperative period.

Comparative Study between Restrictive versus Liberal Intravenous Fluid Administration in Severe Sepsis and Septic Shock; A Randomized Clinical Trial

Abstract Background Sepsis is an inflammatory response to severe infection characterized by hypovolemia and vasodilation and treated with early antibiotics and fluid resuscitation. In-hospital mortality rates have decreased from 80% in the early years of intensive care to 20-30% in the modern era through improved surveillance, early treatment of underlying infection, and advances in support for failing organs. Despite the central role intravenous (IV) fluid administration has played in sepsis management for the last 15 years, fundamental questions regarding “which fluid” and “in what amount” remain unanswered. Objective To compare between the outcomes of fluid administration strategies in the form of restricted or usual fluid administration in patient with severe sepsis and septic shock, and to detect the optimal strategy of fluid administration which decreases morbidity and mortality. Patients and Methods This was a Prospective controlled; randomized, comparative study was conducted in the intensive care units at Ain-Shams University Hospitals and Gamal Abdelnaser Hospital. This study was conducted on 80 adult patients divided into two groups: Group A: 40 adult patients taking the Usual Care, and Group B: 40 adult patients taking the Restrictive Care. Results The restrictive fluid group received significantly less resuscitative IV fluid than the usual care group prior to randomization, over 24 hours, over 48 hours, over 72 hours and total, Moreover; the restrictive fluid group also received a lower fraction of non-resuscitative IV fluid than the usual care group. In addition, the restrictive fluid group also received less amount of total forms IV fluid than the usual care group. There were no statistically significant differences between the two groups in adjunct resuscitative measures administered including albumin, blood transfusion, or stress dose steroids. By day 30, 9 participants (22.5%) in the restrictive fluid group and 7 participants (17.5%) in the usual care had died with no statistical significant difference between the both groups (p = 0.29). Conclusion A restrictive resuscitation strategy that significantly limited the amount of IV fluid administered to patients with severe sepsis and septic shock show slight improvement as regard mean arterial blood pressure, urine output and lactate level. at the same time did not appear to increase mortality, organ dysfunction, or adverse events. Our data contribute to the current state of clinical equipoise surrounding the use of IV fluids in sepsis, support a larger multicenter trial addressing this topic, and inform future study design. This study demonstrates that a restrictive resuscitation strategy can successfully reduce the amount of IV fluid administered to patients with severe sepsis and septic shock compared with usual care. Although limited by the sample size, we observed no increase in mortality, organ failure, or adverse events.

Protocol for a systematic review and meta-analysis assessing conservative versus liberal intravenous fluid administration in patients with sepsis or septic shock at risk of fluid overload

IntroductionIntravenous crystalloid fluid resuscitation forms a crucial part of the early intervention bundle for sepsis and septic shock, with the Surviving Sepsis Campaign guidelines recommending a 30 mL/kg fluid bolus...

Comparison of P6 Acupoint Stimulation, Ondansetron and Dexamethasone for Prevention of Postoperative Nausea and Vomiting after Laparoscopic Surgeries: A Randomised Clinical Study

Introduction: Non pharmacological techniques have an established role in treatment of chronic pain and related conditions. A few non pharmacological techniques have been employed to avoid the adverse effects of drugs. They have also proven to be cost-effective. Liberal fluid administration is the most common non pharmacological methodology used for the prevention of PONV. However, the associated volume overload can be detrimental. Aim: To compare the efficacy of P6 acupoint stimulation, ondansetron and dexamethasone in the prevention of PONV in laparoscopic surgeries. Materials and Methods: This was a randomised clinical study, conducted in the Department of Anaesthesiology at a Tertiary Care Medical College and Hospital, India. The duration of the study was five months, from June 2022 to October 2022. A total of 120 patients posted for laparoscopic surgeries were divided randomly into three groups, group A, group O and group D. Patients were allocated by computer-generated randomisation. Patients in group A received capsicum plaster at P6 point. Patients in group O received 4 mg of ondansetron and patients of group D received 8 mg of dexamethasone. They were given 30 minutes before induction. Postoperatively, patients were extubated and shifted to postanaesthesia care unit for further monitoring. The demographic data, baseline vitals, surgical procedure, duration of surgery and duration of Carbon Dioxide (CO2 ) insufflation were noted intraoperatively. Additional fentanyl requirement, total analgesic requirement, postoperative heart rate, Mean Arterial Pressure (MAP), the incidence of PONV, nausea and vomiting score, number of episodes the requirement of rescue antiemetic, postoperative complication, adverse reactions and patient satisfaction score were all recorded postoperatively and was compared between the three groups using one-way Analysis of Variance (ANOVA). The data was analysed using Statistical Package for Social Sciences (SPSS) version 21.0. Results: The mean age of the study participants for group A was 40.42±11.05 years, group O was 40.92±10.49 years and group D was 40.30±10.01 years, respectively. The three groups were comparable with respect to the demographics, baseline vitals, surgical procedure, duration of surgery, duration of CO2 insufflation, additional fentanyl requirement, total analgesic requirement, postoperative heart rate, and MAP. The incidence of PONV was insignificant between the groups with p-value=0.866. The p-value of nausea and vomiting scores were insignificant. The number of episodes of nausea and vomiting was also comparable between the groups p-value=0.880 and 0.375, respectively. The requirement of rescue antiemetic vomiting was insignificant with p-value=0.810. Conclusion: Ondansetron, dexamethasone and P6 acupoint stimulation are equally effective as prophylaxis for the management of PONV. It can be concluded that, P6 acustimulation can be used as an alternative to pharmacological agents for the management of PONV.

Goal-directed fluid therapy guided by Plethysmographic Variability Index (PVI) versus conventional liberal fluid administration in children during elective abdominal surgery: A randomized controlled trial

BackgroundPVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery. Methods42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either ‘conventional liberal intraoperative fluids’ (liberal group) or ‘goal-directed intraoperative fluids’ (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes. ResultsThe mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001). ConclusionIntraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy.Type of study: Randomized Clinical Trial.Level of evidence: Treatment Study (LEVEL 1).

Liberal versus conservative intravenous fluid administration in pediatric diabetic ketoacidosis.

Liberal versus conservative intravenous fluid administration in pediatric diabetic ketoacidosis.

Fluid restriction versus conventional fluid administration in acute lung injury patients (Comparative study between different strategies of fluid administration in acute lung injury patients)

Abstract Background Acute lung injury and ARDS are major causes of morbidity and mortality all over the world. Major steps of understanding the pathophysiology, causes, diagnosis and treatment of this syndrome were taken in last twenty year. Diagnosis of this condition remains underestimated by physicians particularly mild form of this syndrome specially in developing world in which presence of investigations and well trained physicians is not adequate. Objective To compare between the outcomes of fluid administration strategies in the form of restricted or conventional fluid administration that affect oxygenation, weaning of mechanical ventilation and free days of icu admission in acute lung injury patients and its severe form ARDS. To detect the optimal strategy of fluid administration which decrease morbidity and mortality. Patients and Methods Type of Study: Prospective study. Study Setting: The study will be conducted in the ICU units at Ain-Shams University Hospitals and Ahmed Maher Teaching Hospital. Study Period: Four months from date of approval of the protocol. 90 adult patients- divided into three groups each group include 30 patients- (fulfilling inclusion criteria) admitted in the ICU units at Ain Shams University Hospitals and Ahmed Maher Teaching Hospital were included. Results Based on more than one point of view; underlying cause of ARDS palys major role in predicting these unpredictable results of this study in haemodynamically unstable patients. There are many factors, rather than hypoxemia, that affect organ outcomes (including respiratory system itself) in haemodynamically unstable patients which may caused by septic shock and other types of shock. Conclusion This small trial evoked new questions more than answering traditional ones about fluid management of acute lung injury and ARDS. Firstly; the accurate method to assess and guide fluid therapy in ARDS should be on top of searching priorities. Although using central venous pressure to guide fluid therapy could theoretically results in outcome improvement, but according to its many limitations and poor relation to volume status, its using in that issue is questionable. Secondly; establishing one fluid management strategy to all patients with ARDS seems to be not accurate. Unpredictable results on outcomes in ARDS patients receiving fluids particularly in those were haemodynamically unstable drive us to seek for new classification of ARDS patients based on underlying cause, haemodynamic stability and other elements that responsible for organ failure rather than volume status. However; this small trial suggests conservative fluid strategy in acute lung injury patients which are haemodynamically stable. And using of both conservative and liberal fluid administration strategies wisely in those patients which are haemodynamically unstable to reach the optimal intravascular volume– pressure with the best risk–benefit ratio.

Restrictive Intraoperative Fluid Rate is Associated with Improved Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Management of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) has historically favored liberal fluid administration owing to lengthy duration of surgery and hyperthermia. This practice has been challenged in recent years with studies demonstrating improved outcomes with restrictive fluid administration. Patients who underwent CS/HIPEC between March 2010 and September 2018 were included for analysis. Patients who received an above-median fluid rate (high-IVF) versus below-median fluid rate (low-IVF) were compared, and multivariate analyses were performed for length of stay, 90-day unplanned readmissions, and major complications. The 167 patients had a mean age of 56.7 ± 11.4years and body mass index of 29.5 ± 6.9kg/m2. The median rate of total intraoperative crystalloid and colloid was 7.4mL/kg/h. The low-IVF group had less blood loss (183 vs. 330 mL, p = 0.002), were less likely to need intraoperative vasopressor drip (2.4% vs. 11.9%, p = 0.018), and experienced fewer cardiac complications (2.4% vs. 10.7%, p = 0.031), pneumonias (0% vs. 6.0%, p = 0.024), and Clavien-Dindo grade 3-5 complications (14.5% vs. 33.3%, p = 0.004). Multivariate analyses identified bowel resection (HR 4.65, p = 0.0008) as a risk factor for 90-day unplanned readmission, while bowel resection, intraoperative fluid rate, and estimated blood loss were associated with increased length of stay. Higher intraoperative fluid intake was associated with multiple postoperative complications and increased length of stay, and represents a potentially avoidable risk factor for morbidity in CS/HIPEC.

Crossing the rubicon: Exploring different peri – Operative fluid resuscitation strategies in traumatic extremity free tissue transfer- a retrospective case control study

Free tissue transfer has added to the plastic surgeon's armamentarium and has afforded patients more chances towards limb salvage in recent decades following severe trauma. Venous congestion is a common occurrence, can be the result of several reasons and has devastating results in patients' outcomes. Recent studies have highlighted the importance of restrictive fluid administration. We hypothesized that a restrictive fluid administration in the intra – operative period would be associated with a lower incidence of venous congestion in patients undergoing free flap reconstruction of traumatic defects of the extremities. All patients undergoing a perforator free flap soft tissue reconstruction of traumatic defects of the extremities, from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities and technical aspects of the operation were extracted. The study population was divided in two groups based on the amount of fluids administered (restrictive: < 6 ml/kg/hr; liberal: ≥ 6 ml/kg/hr). Multivariate analyses were performed to identify the impact of fluid strategy on the development of clinically significant venous congestion. A total of 75 patients were identified. Out of these, 24 patients had clinically significant venous congestion. Fluid administration strategy [AOR (95% CI): 1.53 (1.22, 1.92)], use of the superficial venous system [0.03 (0.01, 0.26)], operative time [1.98 (1.97, 1.99)] and age>50 [5.60 (1.10, 28.52)]. A cut – off analysis identified 6 ml/kg/hr as the cut off point for fluid administration. Liberal fluid administration (≥6 ml/kg/hr) was independently associated with a higher incidence of venous congestion and return to the OR for flap debridement, both overall and after exclusion of anastomotic revisions. Venous congestion in free flap reconstruction following traumatic defects of the extremities remains high. Several factors are associated with congestion. Liberal fluid administration ≥6 ml/kg/hr is independently associated with this complications and should be avoided when possible. • Free Fasciocutaneous tissue transfer in lower extremity trauma is challenging. • Venous congestion can result in complete or partial flap loss. • Peri – operative fluid administration has been shown to increase the complication rate infree flaps. • Fluid administration intra – operative of more than 6 ml/kg/hr resulted in a higher incidence of venous congestion. • Judicious fluid administration may be warranted.

Goal-directed Therapy and Postcystectomy Ileus: Comment.

We read the article by Arslan-Carlon et al.1 with great interest. The authors are to be congratulated for their research on the impact of fluid therapy on postoperative ileus. In this recent randomized, controlled trial including 283 patients, they found no difference in the incidence of postoperative ileus between patients treated with a goal-directed therapy compared with a standard procedure in a homogenous open radical cystectomy patient cohort from a high caseload center.The pathogenesis of postoperative ileus is clearly multifactorial (fluid overload, opioids, neurohormonal dysregulation, gastrointestinal stretch, inflammatory response).2,3 In the era of enhanced recovery protocols including multiple preoperative, intraoperative, and postoperative optimization steps, it is not surprising to find that intraoperative goal-directed therapy alone has no impact on the return of bowel function compared with a moderate liberal fluid standard fluid administration. Furthermore, it remains questionable whether postoperative fluid substitution should be uniformly managed in patients who received either an intraoperative goal-directed therapy or a restrictive or relatively liberal fluid administration. Indeed, in this study net fluid during the hospitalization was higher in the standard group (−1,986 ml vs. −1,296 ml) but resulted in similar maximum body weight changes (2.7 kg vs. 3.0 kg) and could be interpreted as the consequence of a more aggressive diuretic therapy in the standard group postoperatively. This is of importance because postoperative submucosal edema has been postulated as a risk factor for a delayed return of gastrointestinal function.3 Unfortunately, the authors did not give any information on the postoperative administration of diuretics.The problem of adequate terminology is another ongoing issue. We were surprised by the authors’ comment in the discussion that the term constipation was not adequately described in the article by Wuethrich et al., as both the term constipation as well as the term ileus were defined in the appendix. Constipation was defined as no passage of stool without signs of ileus by postoperative day 5 and could be considered similar to what was considered a primary postoperative ileus in the article by Arslan-Carlon et al. This definition was based on the nomenclature resulting from a well-performed case series analysis aiming to standardize complications after cystectomy from the Department of Urology at the Sloan-Kettering Cancer Center (New York, New York).5 Perhaps the authors could specify why they did not apply their own above-mentioned definition in the present study. We recognize that the publication by Shabsigh et al. is more than 10 yr old, but the goal of a good standardized reporting methodology should be its continued long-term applicability. The Clavien Dindo classification remains the best example hereof.4,6 In the context of prevention of postoperative ileus, it would also be interesting to know which opioid antagonist was administered subcutaneously perioperatively.Finally, no data are presented about the systemic administration of opioids, a known risk factor for delayed return of bowel function. We only learn that patients received an epidural analgesia with a mixture containing a very low dose of bupivacaine (0.05%) and a relatively high dosage of opioid (8 μg/ml hydromorphone).In conclusion, the saying “one size does not fit all” can also be applied to fluid therapy. This study is of importance because it shows no benefit of goal-directed therapy in terms of reducing gastrointestinal-related complication rates. A more selective and differentiated approach in fluid management is needed. In some cases, restrictive fluid therapy may be beneficial, and in other cases, a modestly liberal fluid administration resulting in a postoperative weight gain of approximately 2 to 3 kg would make no difference in outcome. Fluid management is only part of a complex battery of interventions affecting outcome after open radical cystectomy.The authors declare no competing interests.

Higher Fluid Balance is Associated With Worse Outcome in Critically Ill Traumatic Brain Injury Patients

Background: Fluid therapy is a ubiquitous part of management of critically ill patients with traumatic brain injury (TBI) and may impact on outcome. Our aim was to quantify variability in current fluid therapy in patients with TBI admitted at European and Australian Intensive Care Units (ICUs) and to study the association between fluid therapy and outcome after TBI. Methods: We analyzed data from patients admitted to the ICU with TBI and aged 16 and older included in the observational European CENTER-TBI and Australian OzENTER-TBI studies. The association of net daily fluid balance and -input with outcome (ICU mortality and functional outcome at 6 months) was analyzed at patient level with mixed effects logistic and ordinal regression with a random intercept for centre and adjustment for patient characteristics, and at centre level with centre as instrumental variable. Findings: In total, 2125 patients were included (1005 patients with isolated TBI). Mean daily fluid input ranged from 1·5 to 4·2L per centre. More positive daily mean fluid balance and fluid input were associated with worse outcome in patient-level analyses (fluid balance: ORs per 0·1L increase 1·10 [95%CI:1·07–1·13] and 1·03 [95%CI:1·02–1·05] for ICU mortality and functional outcome respectively; fluid input: ORs 1·05 [95%CI:1·03–1·06] and 1·03 [95%CI:1·02–1·04]). Centre-level analysis showed similar associations for fluid balance (ORs 1·15 [95%CI:1·02-1·29]; and 1·07 [95%CI:1·01-1·12], but not for fluid input (ORs: 0·95 [95%CI: 0·90-1·00]; and 1·01 [95%CI:0·99–1·03]). Interpretation: In critically ill patients with TBI, there is significant variability in fluid management with more positive fluid balances being associated with worse outcomes. Further research is needed to establish whether mitigation of positive fluid balance by less liberal fluid administration contributes to improved outcome. Funding: This research was funded by the European Commission 7th Framework program (602150) and the Australian Health and Medical Research Council (NHMRC 1074181). Declaration of Interests: DJC is an Australian NHMRC Practitioner Fellow and reports grants from the NHMRC and consulting fees to Monash University from PresSura Neuro. AIM declares consulting fees from PresSura Neuro, Integra Life Sciences, and NeuroTrauma Sciences. DKM reports grants from the UK National Institute for Health Research, during the conduct of the study; grants, personal fees, and non-financial support from GlaxoSmithKline; personal fees from Neurotrauma Sciences, Lantmaanen AB, Pressura, and Pfizer, outside of the submitted work. ES reports personal fees from Springer, during the conduct of the study. All other authors declare no competing interests. Ethics Approval Statement: In each recruiting site ethical approval was given.

Pulmonary Complications in Esophagectomy Based on Intraoperative Fluid Rate: A Single-Center Study

Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy. Retrospective cohort study (level 3 evidence). Tertiary care referral center. Patients who underwent esophagectomy from 2007 to 2017. The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h). Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use. A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified. Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

Role of Fluid Management on Renal Failure in Hospitalized COVID-19 Patients

Introduction: The reported incidence of AKI with COVID-19 varies from 0.5% to 22%. Several mechanisms were postulated as a cause of AKI in patients infected with COVID-19. The appropriate management of AKI in patients with COVID-19 remains unclear at this time. One point of absolute importance, is the consideration of volume status. Given the paucity of knowledge with regards to the role of different strategies for fluid management during an episode of AKI in patients with COVID-19, this retrospective study aims to compare renal outcome and overall prognosis in patients who received conservative versus liberal fluid management. Methods: This is a single-center retrospective observational cohort study at a community hospital in Westchester County, NY. All adult patients who tested positive for the COVID-19 infection by PCR testing of a nasopharyngeal swab and were hospitalized from March 22, 2020 to May 25, 2020 are eligible. Among those identified with AKI, patients were divided into two groups: conservative fluid administration versus liberal fluid administration. Results: Of the 136 patients, 84 (61.76%) were admitted to the ICU, with 60% of patients under the conservative fluid strategy and 40% receiving liberal fluid management. On the other hand, 52 (38.23%) patients were admitted on the medical floors, with more patients (67.31%) receiving liberal fluid management. Discussion: In our cohort of 136 patients with COVID-19 respiratory illness and AKI, there was a significant difference in renal outcome, in terms of improvement of renal function in patients receiving liberal fluid management (55.07%) versus conservative fluid management (16.41%, p ≤ 0.001), with more patients in the liberal group having lower peak creatinine before levels improved. This, as well, was associated with improvement in oxygenation, characterized by improvement in respiratory status, facilitating weaning of oxygen supplementation (p < 0.001). On the other hand, there was no significant difference between the conservative and liberal groups in terms of undergoing renal replacement therapy. Twenty-one of the 136 patients with AKI required RRT and 19 (90%) of them were admitted to the ICU and mechanically ventilated. On the other hand, there was no statistical difference in mortality rate of patients who underwent renal replacement therapy, regardless of whether they were in the conservative or liberal strategy group. Conclusion: Our data report that liberal fluid management in COVID-19 patients with AKI, had better outcomes, in terms of renal function, oxygenation and mortality rate, as compared to patients in the conservative fluid management group. Once patients are started on renal replacement therapy, however, renal and lung outcomes and mortality rate become insignificant between the two groups.

S0128 Clinically Significant Ileus in Patients With Acute Pancreatitis Is Associated With Severity of Pancreatitis, Not Volume of Fluid Resuscitation

INTRODUCTION: Aggressive fluid resuscitation has been the standard of care for acute pancreatitis but a tailored approach appears to have best outcomes. Liberal perioperative fluid administration is an independent risk factor for the development of ileus and delayed recovery of gastrointestinal functions after abdominal surgeries. The recovery of gastrointestinal functions is an important determinant of course of acute pancreatitis and the timing of hospital discharge. Here, we evaluated association between fluid resuscitation volume and clinically significant ileus development in patients with acute pancreatitis. METHODS: Consecutive adults admitted with acute pancreatitis between Jan 2014 and Dec 2019 to our academic and two community hospital were included. The Bedside Index for Severe Acute Pancreatitis (BISAP) and systemic inflammatory response syndrome (SIRS) were used to predict severity of pancreatitis based on their readily availability and ease in use. Severity of pancreatitis was determined based on the Revised Atlanta classification. Fluid resuscitation volume was collected as administered in time 0 to 24 hours, 0 to 48 hours and 0 to 72 hours. Clinically significant ileus was determined based on treating physician’s assessment with radiological diagnosis. RESULTS: A total of 441 unique patients were included in the study. Among them, 49 (11%) patients developed clinically significant ileus. Demographics of patients with or without ileus are summarized in Table 1 and were similar between the two groups. On univariate analysis, the presence of SIRS syndrome (<0.001), and higher BISAP scores (P < 0.001) were associated with ileus but pancreatitis etiology and fluid resuscitation volume were not (see table 2). However, Ileus development was associated with increased length of hospital stay and admission to intensive care unit. CONCLUSION: Our data showed that ileus development is associated with severity of acute pancreatitis, not with fluid resuscitation volume or patient demographic.Table 1.: Demographic characteristics.Table 2.: Clinical and laboratory characteristics.

Effect of intraoperative vasopressor use on free flap outcome following major head-and-neck reconstructive surgeries

Introduction: Major head-and-neck surgeries involving wide excision of the tumor usually necessitate reconstruction with free flaps for tissue cover. Even with meticulous fluid management with crystalloids, colloids, albumin, blood, and blood products, many patients become hemodynamically unstable and require the use of vasopressors perioperatively. Objectives: The purpose of this analysis was to assess the safety, role, and present-day trends of the use of vasopressor agents in free flap surgeries and to find any relation of graft rejection or failure of flap surgeries or postoperative complications with perioperative use of such agents. Methods: Reviewing the literature regarding the usage of vasopressors in head-and-neck free flap surgeries, percentage of flap survival, thrombosis of the artery, venous edema, and need for revision surgery were analyzed. Most of the published data had shown that optimizing hemodynamic stability with vasopressors had a more beneficial effect on overall flap perfusion and minimized the complications of iatrogenic fluid overload. The common conclusion was that perioperative vasopressor administration was not detrimental to free flap survival. Conclusion: Based on available data, it is concluded that perioperative use of vasopressors does not adversely affect free flap outcome in patients undergoing head-and-neck reconstructive surgeries and could even be beneficial considering the avoidance of complications of liberal intravenous fluid administration.

Fluidoterapia perioperatoria y complicaciones post pancreatectomía distal videolaparoscópica

Despite mortality in pancreatic surgery has decreased over the last decade, morbidity remains high. One of the most important causes is pancreatic fistula. Recent studies have demonstrated the importance of fluid therapy management during the perioperative period in major abdominal surgeries. This finding was observed first in colonic surgery, demonstrating that overload of fluids increases postoperative complications. Objective. To evaluate the impact of fluid management on postoperative complications after laparoscopic distal pancreatectomy. Material and methods. Descriptive, retrospective study of a prospective database of patients whom underwent laparoscopic distal pancreatectomy from November 2011 to September 2018. Thirty patients were evaluated and divided in two groups depending on the fluid management (restrictive, or liberal). The data were collected from the anesthesia protocols and nursery reports (until 3rd postoperative day). Demographics, length of stay, kind of fluid management and complications were analyzed. For statistical analysis SPSS®v.21 was used (p &lt; 0.05 was considered significant). Results. Out of 30 patients, 17% were male, mean age was 55 ± 18 years (r 19-82); 17 patients (57%) were included in the liberal group and 13 (43%) in the restrictive group. Twenty-three patients developed complications; 16 (53%) belonged to liberal group whereas 7 (23%) to restrictive group. (p = 0.01). Fourteen patients of liberal group vs. 6 patients of restrictive group had postoperative pancreatic fistula (p = 0.04). There were 7 patients (23%) in liberal group. and 4 (13%) patients in restrictive group with clinically relevant pancreatic fistula (13%, p = NS). Ninety day-mortality was 3.3, with no differences between groups. Conclusion. After laparoscopic distal pancreatectomy, liberal fluid administration at the perioperative period is associated with an increase in the incidence of complication, specially favoring the development of pancreatic fistula.

Perioperative fluid managment and postoperative complications after laparoscopic distal pancreatectomy

Presenter: Pablo Barros | Hospital Universitario Fundación Favaloro Background: Despite mortality in pancreatic surgery has decreased over the last decade, morbidity still remains high. One of the most important causes for this is the occu pancreatic fistula. Recent studies have demonstrated the importance of fluid management during the post-operative period in major abdominal surgeries. This finding was observed in colonic surgery as well, demonstrating that the overcharge of fluids increases post-operative complications. We aime to evaluate the impact of fluid management on post-operative complications after videolaparoscopic distal pancreatectomy (VDP). Methods: Descriptive, retrospective study of a prospective database of patients who underwent VDP from November 2011 to September 2018. Thirty patients were evaluated and divided into two different groups according to the fluid management protocol used (restrictive or liberal). The data were collected from the anesthesia`s protocols and nursery reports (until 3rd post-operative day). Demographics, length of stay, kind of fluid management and complications were analyzed. For statistical analysis SPSS®v.21 was used (p= < 0.05 was considered significant) Results: Out of 30 patients, 17 (%) were male, mean age was 55 years(r 19-82); 17 patients (57%) were included in liberal group (LG) and 13 (43%) in restrictive group (RG). Twenty-three patients developed complications;16 (53 %) belonged to LG whereas7 (23 %) to RG(p=0,01). Fourteen patients of LG vs. 6 patients of RG had post-operative pancreatic fistula (p=0.04). There were 7 patients (23 %) in LG and 4 (13 %) patients in RG with POPF-CS (13 %, p=ns). 90-day-mortality was 3.3 % Conclusion: After videolaparoscopic distal pancreatectomy, liberal fluid administration at the perioperative period is associated with an increase in the incidence of complication, specially the development of POPF.

Cardiac output-guided hemodynamic therapy for adult living donor kidney transplantation in children under 20kg: A pilot study.

BackgroundA living‐donor (adult) kidney transplantation in young children requires an increased cardiac output to maintain adequate perfusion of the relatively large kidney. To achieve this, protocols commonly advise liberal fluid administration guided by high target central venous pressure. Such therapy may lead to good renal outcomes, but the risk of tissue edema is substantial.AimsWe aimed to evaluate the safety and feasibility of the transpulmonary thermodilution technique to measure cardiac output in pediatric recipients. The second aim was to evaluate whether a cardiac output‐guided hemodynamic therapy algorithm could induce less liberal fluid administration, while preserving good renal results and achieving increased target cardiac output and blood pressure.MethodsIn twelve consecutive recipients, cardiac output was measured with transpulmonary thermodilution (PiCCO device, Pulsion). The algorithm steered administration of fluids, norepinephrine and dobutamine. Hemodynamic values were obtained before, during and after transplantation. Results are given as mean (SD) [minimum‐maximum].ResultsAge and weight of recipients was 3.2 (0.97) [1.6‐4.9] yr and 14.1 (2.4) [10.4‐18] kg, respectively. No complications related to cardiac output monitoring occurred. After transplantation, cardiac index increased with 31% (95% CI = 15%‐48%). Extravascular lung water and central venous pressure did not change. Fluids given decreased from 158 [124‐191] mL kg−1 in the first 2 patients to 80 (18) [44‐106] mL kg−1 in the last 10 patients. The latter amount was 23 mL kg−1 less (95% CI = 6‐40 mL kg−1) than in one recent study, but similar to that in another. After reperfusion, all patients received norepinephrine (maximum dose 0.45 (0.3) [0.1‐0.9] mcg kg−1 min−1). Patient and graft survivals were 100% with excellent kidney function at 6 months post‐transplantation.ConclusionTranspulmonary thermodilution‐cardiac output monitoring appeared to be safe and feasible. Using the cardiac output‐guided algorithm led to excellent renal results with a trend toward less fluids in favor of norepinephrine.