Perioperative Fluid Restriction Research Articles

Effect of perioperative fluid volume restriction on the incidence of complications following pancreaticoduodenectomy.

Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. The purpose of this study was to compare the morbidity following pancreaticoduodenectomy (PD) between fluid restriction group and conventional management group. Seventy-two patients were enrolled for perioperative fluid restriction of PD. During the operation, main fluid was infused at a rate of less than 8mL/kg/hr. Until POD#3, 10% dextrose and Hartmann's solution were administered at rates of 40 mL/h and {(1.5*body weight) - 42} mL/h, respectively. The historical control group consisted of 139 patients. We compared the rates of major complication (Clavien-Dindo grade III to V) and clinically relevant postoperative pancreatic fistula (CR-POPF), length of hospital stays (LOS), amount of urine output, and the rate of acute kidney injury (AKI). The rates of major complication (19.0% versus 18.7%; p > 0.999), CR-POPF (15.5% versus 15.1%; p > 0.999), and LOS (19 days [range: 10-52] versus 19 days [range: 11-75]; p=0.514) were comparable in the study and the control group, respectively. Amount of urine output during the operation and from POD#1 to POD#3 was more than minimal amount (0.5mL/kg/hr) in the both groups. Incidence rate of AKI in the study group was not higher than the control group (Stage I: 1.7% versus 2.9%, p > 0.999; stage II: 0% versus 1.4%, p > 0.999). There was no decrease in incidence of morbidity including POPF following PD with perioperative fluid restriction. Fluid restriction was feasible because it did not reduce urine output and did not increase incidence of AKI.

The Effect of Perioperative Fluid Volume Restriction in Postoperative Complication of Pancreaticoduodenectomy

Background: Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. The purpose of this study was to compare the morbidity following pancreaticoduodenectomy (PD) between fluid restriction group and conventional management group.

Carbohydrate loading and fluid management within enhanced recovery

Enhanced recovery pathways (ERP) are focused on improving perioperative patient care to reduce postoperative complications and improve outcomes. ERP includes elements of preoperative preparation, fluid management, anesthesia and analgesia, and perioperative nutrition and mobilization. Significant evidence suggests that traditional non-evidence-based perioperative nutritional and fluid management dogmas that prolong fasting and promote fluid overload should be abandoned. Carbohydrate loading has been shown to be safe in non-diabetic patients while also reducing postoperative insulin resistance. Evidence suggest that perioperative fluid overload and restriction should be avoided, and near-zero homeostasis should be the goal of perioperative fluid management. Goal-directed fluid therapy (GDFT) has shown to be safe in most patients and could be beneficial in high-risk patients.

The effect of perioperative fluid volume restriction in postoperative complication of pancreaticoduodenectomy

Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. However, there are few studies regarding fluid restriction of pancreato-biliary surgery. The purpose of this study was to compare the morbidity following PD between the fluid restriction group and conventional management group. Between September 2017 and October 2020, 72 patients were enrolled for perioperative fluid restriction of PD. During the operation, main fluid was injected at a rate of 6-8 mL/kg*hr. From the operation day to the day 3 postoperatively, 10% dextrose and Hartmann's solution were infused at a rate of 40 mL/hr and {(1.5*bwt)-42} mL/hr, respectively. Of 72 patients, 57 patients were finally analyzed in this study. The control group consisted of 139 patients who underwent PD from March 2013 to March 2016 and they were conventionally managed after the operation. We compared the postoperative morbidity, transfusion rate, length of hospital stays, amount of input and output, and serum creatinine level between the 2 groups. The rate of major morbidity defined as any complication from grade III to V on the Clavien-Dindo scale in the study group was not significantly higher than that in the control group (19.3% vs. 18.7%; p = 1.0). There were no differences in the rate of clinically relevant postoperative pancreatic fistula (CR-POPF) between both groups (15.8% vs. 12.9%; p = 0.65). No significant differences were also present in transfusion rate, operation time and length of hospital stay. Perioperative fluid restriction did not affect incidence of major morbidity, especially CR-POPF following PD.

The effect of perioperative fluid volume restriction in postoperative complication of pancreaticoduodenectomy

Background: Complications following pancreaticoduodenectomy are reported to be still high. Pancreatic fistula has been the most common complication after the surgery. Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. However, there are few studies regarding fluid restriction of pancreatobiliary surgery. The purpose of this study was to compare the morbidity following pancreaticoduodenectomy between fluid restriction group and conventional management group.

Perioperative Fluid Restriction in Abdominal Surgery: A Systematic Review and Meta-analysis.

Perioperative fluid management is a critical component in patients undergoing abdominal surgery. However, the benefit of restricted fluid regimen remains inconclusive. This systematic review aimed to explore potential factors causing these inconsistent findings. The literature searches were performed in three databases including PubMed, Embase, and the Cochrane library until August 30, 2018. Only randomized, controlled trials comparing the effect of restricted versus liberal regimen in abdominal surgery were included. The primary outcome was total postoperative complications. Subgroup analysis was performed according to between-group weight increase difference (≥ 2kg and < 2kg) and fluid intake ratio (≥ 1.8 and < 1.8). Sixteen studies were finally included in this meta-analysis. The benefit of the restricted regimen in reducing postoperative complication was only significant in the subgroup with high weight increase difference (≥ 2kg) (RR 0.67, 95% CI 0.57-0.79) and the subgroup with high fluid intake ratio (≥ 1.8) (RR 0.72, 95% CI 0.62-0.82). In the subgroup with low weight increase difference (< 2kg) or low fluid intake ratio (< 1.8), the effect of the restricted regimen was not significant (RR 0.88, 95% CI 0.51-1.50, and RR 1.18, 95% CI 0.91-1.53, respectively). The benefit of the restricted regimen was only significant in the subgroup with high weight increase difference (≥ 2kg) or high fluid intake ratio (≥ 1.8).

Comparison of Accuracy of Different Methods for Detection of Postoperative Renal Impairment in Colorectal Surgery with Restrictive Fluid Strategy

Objective: Perioperative fluid restriction in major abdominal surgeries carries a potential risk of organ dysfunction such as acute kidney injury. Profound fluid restriction should be applied cautiously. The aim of this study is to compare the accuracy of (serum creatnine, urine output and KDIGO compared to NGAL for detection of postoperative AKI after colorectal surgery.Methods: Restrictive fluid strategy was applied to all patients with 5 mL/kg/h of lactated ringer (LR) and was administered intraoperatively starting from the induction of general anesthesia till the end of surgery and patient extubation. Data collected included incidence of AKI with three screening tools in addition to intra and postoperative complications.Results: None of the above tested AKI based criteria has satisfactory both sensitivity and specificity. The sensitivity of urine output for detection of AKI was 72.7 [39.0-94.0] while its specificity was 79.8 [69.9-87.6], for creatinine above 0.3 mg/dl; the sensitivity was 63.6 [30.8-89.1] and specificity was 98.9 [93.9-99.9], and for KDIGO the sensitivity was 81.8 % [95% CI 48.2-97.7] and specificity was 74.2% [95% CI 63.8-82.9].Conclusion: Despite use CVP for detection of hypovolemia, there is still high incidence of AKI. Creatinine based criteria, urine based criteria or combination of both are inaccurate when volume restriction is applied.

Fluids in abdominal surgery: what is the goal?

In the early 2000s, the approach to perioperative fluid management in major abdominal surgery underwent a paradigm change in favor of restrictive, rather than standard or liberal, fluid regimens. The basis for this shift in philosophy was a result of randomized controlled trials such as one by Brandstrup et al ., which demonstrated improved morbidity and outcomes with perioperative fluid restriction (1). With similar results reported across a variety of other prospective trials, the practice of perioperative fluid restriction garnered more support and acceptance (2,3).

1034 - The Efficacy of Perioperative Fluid Restriction for Postoperative Complications after Pancreatoduodenectomy

1034 - The Efficacy of Perioperative Fluid Restriction for Postoperative Complications after Pancreatoduodenectomy

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery.

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

Targeting oliguria reversal in perioperative restrictive fluid management does not influence the occurrence of renal dysfunction: A systematic review and meta-analysis.

Interest in perioperative fluid restriction has increased, but it could lead to hypovolaemia. Urine output is viewed as a surrogate for renal perfusion and is frequently used to guide perioperative fluid therapy. However, the rationale behind targeting oliguria reversal - achieving and maintaining urine output above a previously defined threshold by additional fluid boluses - is often questioned. We assessed whether restrictive fluid management had an effect on oliguria, acute renal failure (ARF) and fluid intake. We also investigated whether targeting oliguria reversal affected these parameters. Systematic review of randomised controlled trials with meta-analyses. We used the definitions of restrictive and conventional fluid management as provided by the individual studies. We searched MEDLINE (1966 to present), EMBASE (1980 to present), and relevant reviews and articles. We included randomised controlled trials with adult patients undergoing surgery comparing restrictive fluid management with a conventional fluid management protocol and also reporting the occurrence of postoperative ARF. We included 15 studies with a total of 1594 patients. There was insufficient evidence to associate restrictive fluid management with an increase in oliguria [restrictive 83/186 vs. conventional 68/230; odds ratio (OR) 2.07; 95% confidence interval (CI), 0.97 to 4.44; P = 0.06; I = 23.7%; Nstudies = 5]. The frequency of ARF in restrictive and conventional fluid management was 20/795 and 20/799, respectively (OR 1.07; 95% CI, 0.60 to 1.92; P = 0.8; I = 17.5%; Nstudies = 15). There was no statistically significant difference in ARF occurrence between studies targeting oliguria reversal and not targeting oliguria reversal (OR 0.31; 95% CI, 0.08 to 1.22; P = 0.088). Intraoperative fluid intake was 1.89 l lower in restrictive than in conventional fluid management when not targeting oliguria reversal (95% CI, -2.59 to -1.20 l; P < 0.001; I = 96.6%; Nstudies = 7), and 1.63 l lower when targeting oliguria reversal (95% CI, -2.52 to -0.74 l; P < 0.001; I = 96.6%; Nstudies = 6). Our data suggest that, even though event numbers are small, perioperative restrictive fluid management does not increase oliguria or postoperative ARF while decreasing intraoperative fluid intake, irrespective of targeting reversal of oliguria or not.

Goal directed fluid therapy reduces major complications in elective surgery for abdominal aortic aneurysm: liberal versus restrictive strategies

BackgroundOptimal fluid management is crucial for patients undergoing surgical repair of abdominal aortic aneurysm (AAA). Persistent hypovolemia is associated with complications but fluid overload is also harmful.AimThis study evaluates that perioperative fluid restriction would reduce complications and improve outcome through goal-directed strategies in patients undergoing AAA.MethodsFifty patients, aged from 60 to 75 years undergoing elective surgical repair of AAA were included in this randomized study. Patients were divided into two groups, 25 for each: liberal group (L) receives 12 ml/kg/h and restrictive group (R) receives 4 ml/kg/h. Goal-directed-therapy approach was concerning assessment of tissue oxygenation. Dobutamine and fluid challenges were used to maintain adequate tissue perfusion during surgery.ResultsThe patients of the (L) group received a significant greater amount of Lactated Ringer’s solution (3586.76 ± 473.21) than the (R) group (1219 ± 140.6). The (R) group had 50% lower rate of major postoperative complications than the (L) group (24% vs 48%) and less hospital stay.ConclusionA restrictive strategy of fluid maintenance during optimization of oxygen delivery with early treatment directed to maintain oxygen extraction ratio estimate (O2ERe) at <27% reduces major complications and hospital stay of surgical patients undergo abdominal aortic aneurysm.

Perioperative fluid restriction therapy in major hepatectomy

Perioperative fluid restriction therapy in major hepatectomy

Intraoperative Fluid Restriction in Pancreatic Surgery: A Double Blinded Randomised Controlled Trial.

BackgroundPerioperative fluid restriction in a variety of operations has shown improvement of: complications, recovery of gastrointestinal function and length of stay (LOS). We investigated effects of crystalloid fluid restriction in pancreatic surgery. Our hypothesis: enhanced recovery of gastrointestinal function.MethodsIn this double-blinded randomized trial, patients scheduled to undergo pancreatoduodenectomy (PD) were randomized: standard (S:10ml/kg/hr) or restricted (R:5ml/kg/hr) fluid protocols. Primary endpoint: gastric emptying scintigraphically assessed on postoperative day 7.ResultsIn 66 randomized patients, complications and 6-year survival were analyzed. 54 patients were analyzed in intention to treat: 24 S-group and 30 R-group. 32 patients actually underwent a PD and 16 patients had a palliative gastrojejunostomy bypass operation in the full protocol analysis. The median gastric emptying time (T½) was 104 minutes (S-group, 95% confidence interval: 74–369) versus 159 minutes (R-group, 95% confidence interval: 61–204) (P = 0.893, NS). Delayed gastric emptying occurred in 10 patients in the S-group and in 13 patients in the R-group (45% and 50%, P = 0.779, NS). The primary outcome parameter, gastric emptying time, did not show a statistically significant difference between groups.ConclusionA fluid regimen of 10ml/kg/hr or 5ml/kg/hr during pancreatic surgery did not lead to statistically significant differences in gastric emptying. A larger study would be needed to draw definite conclusions about fluid restriction in pancreatic surgery.Trial registration ISRCTN62621488

Perioperative Fluid Restriction in Major Abdominal Surgery: Systematic Review and Meta‐analysis of Randomized, Clinical Trials

Fluid management is a fundamental component of surgical care. Recently, there has been considerable interest in perioperative fluid restriction as a method of facilitating recovery following elective major surgery. A number of randomized trials have addressed the issue in various surgical specialities, and a recent meta-analysis proposed uniform definitions regarding fluid amount as well as examining fluid restriction in patients undergoing colonic resection. Medline, Embase, trial registries, conference proceedings, and article reference lists were searched to identify randomized, controlled trials of perioperative fluid restriction versus "standard" perioperative fluid management, as per definitions formulated previously. All of the studies involved patients undergoing colonic resection. The primary outcome measure was postoperative morbidity. Secondary endpoints included mortality, renal failure, time to first flatus, and length of hospital stay. A random effects model was applied. Seven randomized, controlled trials with a total of 856 patients investigating standard versus restrictive fluid regimes, as denoted by the definitions, were included. Perioperative fluid restriction had no effect on the risk of postoperative complications (OR 0.49 (95 % confidence interval (CI) 0.2-1.18; P = 0.101). There was no detectable effect on death and fluid restriction did not reduce hospital stay (Pooled weighted mean difference -0.25; 95 % CI 0.72-0.21; P = 0.29). Perioperative fluid restriction does not significantly reduce the risk of complications following major abdominal surgery. Furthermore, it does not appear to reduce length of hospital stay.

Restricted intravenous fluid regimen reduces the rate of postoperative complications and alters immunological activity of elderly patients operated for abdominal cancer: a randomized prospective clinical trail.

Perioperative fluid restriction can lead to better clinical outcomes and reduced complications. However, whether perioperative fluid restriction can alter the patient's postoperative cellular immunity is unknown. Therefore, a randomized, prospective clinical study was designed to determine whether fluid restriction improves immunological outcome in elderly patients who undergo gastrointestinal surgery for cancer removal. A total of 179 patients aged 65 years or older were recruited for the study and were randomly assigned to receive the restricted fluid regimen (R group) or the standard fluid regimen (S group). Postoperative T-lymphocyte subpopulations (CD3(+), CD4(+), and CD8(+)) frequencies and monocyte HLA-DR expression was investigated. Perioperative complications and cellular immunity changes were analyzed comparatively between the two groups. The restricted intravenous fluid regimen was associated with significantly less postoperative complications (1.5 complications/patient vs. S group: 2.2 complications/patient), especially for infection complications (15% vs. S group: 27%, p = 0.04). Circulating CD3(+) T-cells were suppressed after surgery in both treatment groups, but the cell frequency (cell/μL) was higher in the R group (746 vs. S group: 480 at postoperative day (POD) 2, p = 0.022; 878 vs. 502 at POD 3, p = 0.005; 892 vs. 674 at POD 5, p = 0.042). Similarly, the HLA-DR expression (% of all T cells) in monocytes were decreased in both groups, but the expression remained higher in the R group (66.20 vs. S group: 51.97 at POD 1, p = 0.029; 68.19 vs. 51.26 at POD 2, p = 0.039; 72.19 vs. 57.45 at POD 3, p = 0.014; 73.92 vs. 60.46 at POD 5, p = 0.036). Multivariate analysis suggested that perioperative CD3(+) T cell changes were associated with the development of postoperative complications [odds ratio (OR) = 1.963; 95% confidence interval (CI) 1.019-3.782; p = 0.044] and postoperative infections (OR = 3.106; 95% CI 1.302-7.406; p = 0.011). In elderly gastrointestinal cancer patients, cellular immunity is better preserved by the perioperative fluid restriction regimen. The better preserved cellular immunological function is correlated with a reduced perioperative complications rate.

Preliminary Results of a Prospective Randomized Trial of Restrictive Versus Standard Fluid Regime in Elective Open Abdominal Aortic Aneurysm Repair

Open abdominal aortic aneurysm (AAA) repair is associated with a significant morbidity (primarily respiratory and cardiac complications) and an overall mortality rate of 4% to 10%. We tested the hypothesis that perioperative fluid restriction would reduce complications and improve outcome after elective open AAA repair. In a prospective randomized control trial, patients undergoing elective open infra-renal AAA repair were randomized to a "standard" or "restricted" perioperative fluid administration group. Primary outcome measure was rate of major complications (MC) after AAA repair and secondary outcome measures included: Sequential Organ Failure Assessment Score; FiO2/PO2 ratio; Urinary Albumin/Creatinine Ratio; Length-of-stay in, intensive care unit, high dependency unit, in-hospital. This prospective Randomized Controlled Trial was registered in a publicly accessible database and has the following ID number ISRCTN27753612. Overall 22 patients were randomized, 1 was excluded on a priori criteria, leaving standard group (11) and restricted group (10) for analysis. No significant difference was noted between groups in respect to age, gender, American Society Anesthesiology class, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity scores, operation time, and operation blood loss. There were no in-hospital deaths and no 30-day mortality. The cumulative fluid balance on day 5 postoperative was for standard group, 8242 +/- 714 mL, compared with restricted group, 2570 +/- 977 mL, P < 0.01. MC were significantly reduced in the restricted group (n = 10), 1 MC, compared with standard group (n = 11), 14 MC, P < 0.024. Total and postoperative length-of-stay in-hospital was significantly reduced in the restricted group, 9 +/- 1 and 8 +/- 1 days, compared with standard group, 18 +/- 5 and 16 +/- 5 days, P < 0.01 and P < 0.025, respectively. Serious complications are common after elective open AAA repair, and we have shown for the first time that a restricted perioperative fluid regimen can prevent MC and significantly reduce overall hospital stay.

The Volume of Lactated Ringer's Solution Required to Maintain Preload and Cardiac Index During Open and Laparoscopic Surgery

Recent studies have emphasized the importance of perioperative fluid restriction. However, fluid restriction regimens may increase the likelihood of insufficient perioperative fluid administration or may result in excess intravascular crystalloid replacement. We postulate that the use of transesophageal echocardiography may reduce the amount of crystalloid administered during open and laparoscopic colorectal surgery. Fifteen ASA I and II patients scheduled for open colorectal surgery, and 15 patients scheduled for laparoscopic surgery were studied. Lactated Ringer's solution was infused during the procedures. Left ventricular end diastolic volume index (LVEDVI) and cardiac index were assessed throughout surgery and used to guide the rate of lactated Ringer's solution administration. Statistical analysis was performed with Student's t-test for unpaired samples. The rate of crystalloid administration required to maintain baseline LVEDVI and cardiac index was 5.9 +/- 2 mL x kg(-1) x h(-1) for open surgery and 3.4 +/- 0.8 mL x kg(-1) x h(-1) for laparoscopic surgery (P < 0.01). This slower rate for laparoscopic surgery was offset by the longer surgical duration. The rate of crystalloid solution to maintain baseline LVEDVI and cardiac index was greater in open surgery than laparoscopic surgery, and lower than commonly recommended for colorectal surgery.

Perioperative fluid restriction reduces complications after major gastrointestinal surgery

The physiologic response to surgical trauma promotes sodium and water retention AND weight gain owing to perioperative fluid loading increases morbidity SO perioperative fluid restriction should reduce postoperative complications after gastrointestinal surgery.

Selective continuous vascular occlusion and perioperative fluid restriction in partial hepatectomy. Outcomes in 101 consecutive patients

Background This study documents patient outcomes with one department's approach to performing partial hepatectomy. Methods 101 consecutive patients underwent: preoperative dehydration; intraoperative CVP <5 cm H 2O and selective continuous vascular occlusion. Outcome variables: pathology; type of hepatic resection; intraoperative blood loss and transfusion rate; 30 day morbidity and mortality; disease free and long term survival. Perioperative liver function was assessed by serial blood sampling. Results Of 101 resections: 90% malignant disease; 59% major resections and 35% synchronous procedures. Median estimated blood loss was 400 mL (mean 512 mL, range 50–3000 mL) with postoperative transfusions in 4%. Thirty day morbidity was 20% with no deaths. Median time to local recurrence after colorectal liver metastases resection was 17.1 months with 3 year survival of 51%. Distinct perioperative changes in hepatic function were seen. Conclusion Selective continuous vascular occlusion and perioperative fluid restriction result in minimal blood loss, low morbidity and zero mortality in patients undergoing partial hepatectomy.