Perioperative Intravenous Fluid Research Articles

Fluids and body composition during anesthesia in children and adolescents: A pilot study

The purpose of this study is to evaluate the intracellular and extracellular volume before and after anesthesia in order to ascertain their variations and determine the potential utility of this information in optimizing intraoperative fluid administration practices. A bioimpedance spectroscopy device (body composition monitor, BCM) was used to measure total body fluid volume, extracellular volume, and intracellular volume. BCM measurements were performed before and after general anesthesia in unselected healthy children and adolescents visiting the Pediatric Institute of Southern Switzerland for low-risk surgical procedures hydrated with an isotonic solution. In 100 children and adolescents aged 7.0 (4.8–11) years (median and interquartile range), the average total body water increased perioperatively with a delta value of 182 (0–383) mL/m2 from pre- to postoperatively, as well as the extracellular water content, which had a similar increase with a delta value of 169 (19–307) mL/m2. The changes in total body water and extracellular water content significantly correlated with the amount of fluids administered. The intracellular water content did not significantly change. Conclusion: Intraoperative administration of isotonic solutions results in a significant fluid accumulation in low-risk schoolchildren during general anesthesia. The results suggest that children without major health problems undergoing short procedures do not need any perioperative intravenous fluid therapy, because they are allowed to take clear fluids up to 1 h prior anesthesia. In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy.What is Known:• Most children who undergo common surgical interventions or investigations requiring anesthesia are nowadays hydrated at a rate of 1700 mL/m2/day with an isotonic solution.• The use bioimpedance spectroscopy for the assessment of fluid status in healthy children has already been successfully validated.• The bioimpedance spectroscopy is already currently widely used in various nephrological settings to calculate fluid overload and determine patient’s optimal fluid status.What is New:• Routine intraoperative fluid administration results in a significant fluid accumulation during general anesthesia in low-risk surgical procedures.• This observation might be relevant for children and adolescents with conditions predisposing to fluid retention.• In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy.

A pragmatic, open-label, randomized controlled trial of Plasma-Lyte-148 versus standard intravenous fluids in children receiving kidney transplants (PLUTO)

Acute electrolyte and acid-base imbalance is experienced by many children following kidney transplant. This is partly because doctors give very large volumes of artificial fluids to keep the new kidney working. When severe, fluid imbalance can lead to seizures, cerebral edema and death. In this pragmatic, open-label, randomized controlled trial, we randomly assigned (1:1) pediatric kidney transplant recipients to Plasma-Lyte-148 or standard of care perioperative intravenous fluids (predominantly 0.45% sodium chloride and 0.9% sodium chloride solutions). We then compared clinically significant electrolyte and acid-base abnormalities in the first 72 hours post-transplant. The primary outcome, acute hyponatremia, was experienced by 53% of 68 participants in the Plasma-Lyte-148 group and 58% of 69 participants in the standard fluids group (odds ratio 0·77 (0·34 - 1·75)). Five of 16 secondary outcomes differed with Plasma-Lyte-148: hypernatremia was significantly more frequent (odds ratio 3·5 (1·1 – 10·8)), significantly fewer changes to fluid prescriptions were made (rate ratio 0·52 (0·40-0·67)), and significantly fewer participants experienced hyperchloremia (odds ratio 0·17 (0·07 – 0·40)), acidosis (odds ratio 0·09 (0·04 - 0·22)) and hypomagnesemia (odds ratio 0·21 (0·08 – 0·50)). No other secondary outcomes differed between groups. Serious adverse events were reported in 9% of participants randomized to Plasma-Lyte-148 and 7% of participants randomized to standard fluids. Thus, perioperative Plasma-Lyte-148 did not change the proportion of children who experienced acute hyponatremia compared to standard fluids. However fewer fluid prescription changes were made with Plasma-Lyte-148, while hyperchloremia and acidosis were less common.

Fluid Optimisation in Emergency Laparotomy (FLO-ELA) Trial: study protocol for a multi-centre randomised trial of cardiac output-guided fluid therapy compared to usual care in patients undergoing major emergency gastrointestinal surgery

IntroductionPostoperative morbidity and mortality in patients undergoing major emergency gastrointestinal surgery are a major burden on healthcare systems. Optimal management of perioperative intravenous fluids may reduce mortality rates and improve outcomes from surgery. Previous small trials of cardiac-output guided haemodynamic therapy algorithms in patients undergoing gastrointestinal surgery have suggested this intervention results in reduced complications and a modest reduction in mortality. However, this existing evidence is based mainly on elective (planned) surgery, with little evaluation in the emergency setting. There are fundamental clinical and pathophysiological differences between the planned and emergency surgical setting which may influence the effects of this intervention. A large definitive trial in emergency surgery is needed to confirm or refute the potential benefits observed in elective surgery and to inform widespread clinical practice.MethodsThe FLO-ELA trial is a multi-centre, parallel-group, open, randomised controlled trial. 3138 patients aged 50 and over undergoing major emergency gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intra-venous fluid, or usual care without cardiac output monitoring. The trial intervention will be carried out during surgery and for up to 6 h postoperatively. The trial is funded through an efficient design call by the National Institute for Health and Care Research Health Technology Assessment (NIHR HTA) programme and uses existing routinely collected datasets for the majority of data collection. The primary outcome is the number of days alive and out of hospital within 90 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation. Participant recruitment started in September 2017 with a 1-year internal pilot phase and is ongoing at the time of publication.DiscussionThis will be the largest contemporary randomised trial examining the effectiveness of perioperative cardiac output-guided haemodynamic therapy in patients undergoing major emergency gastrointestinal surgery. The multi-centre design and broad inclusion criteria support the external validity of the trial. Although the clinical teams delivering the trial interventions will not be blinded, significant trial outcome measures are objective and not subject to detection bias.Trial registrationISRCTN 14729158. Registered on 02 May 2017.

129 Compliance with The ERAS Protocol Amongst Colorectal Surgery Junior Doctors at Gloucester Royal Hospital

Abstract Background Enhanced recovery after surgery (ERAS) is an evidence-based protocol aiming to expedite recovery following elective surgical procedures. ERAS has shown to reduce the length of hospital stay, complications, readmissions, and costs. The junior doctor’s role in ERAS centres around admission, preoperative nutritional care, and ERAS compliance. This audit aimed to review prescribing of perioperative nutritional drinks (NutriciaPreop© and Fortisips) and intravenous fluids for patients undergoing elective colorectal surgery at Gloucester Royal Hospital. Method An 80% standard was set for this audit. A full audit cycle was completed. Drug and intravenous fluid charts were analysed for correct prescribing of NutriciaPreop© and intravenous fluids pre-operatively, and peri operative Fortisips. Improvement measures included ward posters and education to incoming junior doctors. Results Initial data collection showed that 70% of patients received a correct intravenous fluid prescription pre-operatively. 24% of patients were prescribed NutriciaPreop© and 18% were prescribed Fortisips. During re-auditing intravenous fluids were correctly prescribed in 80% of patients, NutriciaPreop© in 67% of patients and Fortisips in 60%. Conclusions This audit emphasises the importance of good quality inductions for junior doctors and how simple measures improve prescribing of essential peri-operative nutrition. Additionally, the value of multidisciplinary team involvement in junior doctor training has been highlighted.

Relation between liposuction volume and perioperative intravenous fluid

Balance in fluids as in any other surgical procedure, is obtained by having a balance between losses during surgery and fluids administered for replacement. The challenge in liposuction is to quantify bleeding with certainty, as well as the ingress and loss of transoperative fluid. Objective: To find relation between vacuum volume and fluid replenishment in the perioperative of liposuction surgery. Studio and design Observational, retrospective, longitudinal study. Material and methods: Patients undergoing lipodystrophy of the abdomen or back under general anesthesia who were underwent to liposuction with conventional liposupctor or VASER type during August 2013 to May 2016. Demographic data such as ; age, gender, body mass index (BMI), anesthetic risk estimation by ASA classification (American Society of Anesthesiologists),liposuction technique performed, liposuction volume, administered IV fluids and diuresis in the trans and postoperative were recorded. Statistical analysis: ni-varied descriptive analysis throughout the sample, the estimation of mean and standard deviation for numerical variables that follow a normal distribution and frequencies for qualitative variables. As well as a simple linear regression with Pearson correlation coefficient, perfect=1, to find a relation between lipoaspirated volume and intra and postoperative fluids IV, being considered significant with a p< 0.05. Results: 112, clinical records were included, mostly for women 97.3%,with a mean of 34.46 years and a body mass index (BMI) of 25.4, 75% were ASA I, There is no significant relationships between transoperative solutions IV and lipoaspired. A low correlation was obtained between liposuction volume and postoperative solutions IV (r.216; with p<.05) as well as the correlation of trans operative solutions IV and diuresis (r.224; p<.05). Conclusion: In this observational and retrospective study there was no direct and significant correlation between liposuction volume and the amount of trans operative fluids. Correlation with postoperative fluids IV was significant but low.

Effect of Intraoperative Fluid Administration on Post-operative Urinary Retention in Patients Undergoing Outpatient Anorectal Surgery

Post-operative urinary retention, POUR, is a common and potentially avoidable occurrence following surgery under anesthesia. We assessed whether the volume of intraoperative fluid administered is a causative factor of POUR in the setting of outpatient anorectal surgery. Anorectal operations at Hahnemann Hospital from January 2007 to February 2019 were reviewed. A total of 573 patients treated by two surgeons were studied. Data recorded consisted of the procedure date, discharge date, return date if applicable, age, sex, anesthetic type, and amount of perioperative intravenous fluid (IVF). Patients with a prior history of POUR were excluded. The chi-square test for homogeneity was used to assess the individual effects of age, sex, type of anesthetic, and amount of perioperative IVF on the rate of POUR. A p value of 0.05 was considered significant. Seventeen of the 573 patients in the study (3%) had urinary retention, 14 of the 442 males and 3 of the 131 females. POUR was seen in 5 of the 255 patients that had less than 500 mL of intravenous fluids, whereas 12 of 318 had 500 or more mL of fluids. We found that type of anesthesia and length of surgery were significant. No significance was found in amount of IVF used. Using more or less than 500 mL of intraoperative fluid did not have a significant impact on the rates of POUR in outpatient anorectal surgeries. Anesthesia type and surgery duration appear to decrease the occurrence of POUR in these patients.

Perioperative fluids and complications after pancreatoduodenectomy within an enhanced recovery pathway

Optimized fluid management is a key component of enhanced recovery (ERAS) pathways. Implementation is challenging for pancreatoduodenectomy (PD) and clear guidance is missing in the respective protocol. The aim of this retrospective study was to evaluate the influence of perioperative intravenous (IV) fluid administration on postoperative complications. 164 consecutive patients undergoing PD within ERAS between October 2012 and June 2017 were included. Perioperative IV fluid and morbidity (Clavien classification and comprehensive complication index (CCI)) were assessed. A threshold of more than 4400 ml IV fluid during the first 24 h could be identified to predict occurrence of complications (area under ROC curve 0.71), with a positive and negative predictive value of 93 and 23% respectively. More than 4400 ml intravenous fluids during the first 24 h was an independent predictor of overall postoperative complications (adjusted odds ratio 4.40, 95% CI 1.47–13.19; p value = 0.008). Patients receiving ≥ 4400 ml were associated with increased overall complications (94 vs 77%; p value < 0.001), especially pulmonary complications (31 vs 16%; p value = 0.037), as well as a higher median CCI (33.7 vs 26.2; p value 0.041). This threshold of 4400 ml intravenous fluid might be a useful indicator for the management following pancreatoduodenectomy.

Using automated pump-delivery devices to reduce the incidence of excessive fluid administration during pediatric dental surgery: a randomized-controlled trial.

The harms caused by excessive perioperative intravenous (IV) fluid administration are both well recognized and avoidable. The purpose of this study was to compare the incidence of excess intraoperative fluid administration in pediatric dental surgery patients when either an automated pump-delivery device or a manual gravity-drip device is used. We randomly assigned American Society of Anesthesiologists physical status I and II pediatric dental surgery patients to receive IV fluid via either a manual gravity-drip or automated pump-delivery device. Prior to each case, the attending anesthesiologist determined the target volume of maintenance IV fluid to be administered based on patient weight, estimated fluid deficits, and expected case length. The intraoperative IV fluid delivered was determined at the end of the case by the change in the IV bag weight. The primary outcome was the proportion of procedures that delivered ≥ 10% of the target IV fluid volume. We recruited 105 children aged two to 12 yr (n = 49 in the automated pump-delivery device; n = 53 in the manual gravity-drip device). The proportion of excessive fluid administration was 8/49 (16%) in the automated pump-delivery device group compared with 33/53 (62%) in the gravity-drip group (relative risk of excessive fluid administration, 0.26; 95% confidence interval, 0.13 to 0.51; P < 0.001). Intraoperative fluid administration using an automated pump-delivery device decreased the incidence of excessive IV fluid administration in pediatric dental surgery patients. www.clinicaltrials.gov (NCT03312452); registered 17 October 2017.

Effects of combined warmed preoperative forced-air and warmed perioperative intravenous fluids on maternal temperature during cesarean section: a prospective, randomized, controlled clinical trial

BackgroundPreventing the frequent perioperative hypothermia incidents that occur during elective caesarean deliveries would be beneficial. This trial aimed at evaluating the effect of preoperative forced-air warming alongside perioperative intravenous fluid warming in women undergoing cesarean sections under spinal anesthesia.MethodsWe randomly allocated 135 women undergoing elective cesarean deliveries to either the intervention group (preoperative forced-air and intravenous fluid warming, n = 69) or the control group (no active warming, n = 66). The primary outcome measure was the core temperature change between groups from baseline to the end of the surgical procedure. Secondary outcomes included thermal comfort scores, the incidences of shivering and hypothermia (< 36 °C), the core temperature on arrival at the post-anesthesia care unit, neonatal axillary temperature at birth, and Apgar scores.ResultsTwo-way repeated measures ANOVA revealed significantly different core temperature changes (from the pre-spinal temperature to that at the end of the procedure) between groups (F = 13.022, P < 0.001). The thermal comfort scores were also higher in the intervention group than in the control group (F = 9.847, P = 0.002). The overall incidence of perioperative hypothermia was significantly lower in the intervention group than in the control group (20.6% vs. 51.6%, P < 0.0001).ConclusionsWarming preoperative forced-air and perioperative intravenous fluids may prevent maternal hypothermia, reduce maternal shivering, and improve maternal thermal comfort for patients undergoing cesarean sections under spinal anesthesia.Trial registrationThe study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800019117) on October26, 2018.

Postoperative Anemia Predicts Length of Stay for Geriatric Patients Undergoing Minimally Invasive Lumbar Spine Fusion Surgery.

Introduction:We hypothesize that postoperative anemia will predict length of stay (LOS) for geriatric patients undergoing minimally invasive (MIS) lumbar spine fusions.Materials and Methods:Patients who underwent MIS lateral and transforaminal lumbar interbody fusion between January 2017 and March 2018 at an academic tertiary care referral center were selected. Eighty-one patients were included. The primary outcome variable was LOS, measured in days. The predictors studied were preoperative hemoglobin (Hgb), postoperative day 1 Hgb, postoperative nadir Hgb, intraoperative Hgb decrement (preoperative Hgb-postoperative day 1 Hgb), perioperative Hgb decrement (preoperative Hgb-postoperative nadir Hgb), age, American Society of Anesthesiologists–Physical Status (ASA-PS) score, volume of perioperative intravenous (IV) fluids (IVFs), and number of levels fused. Simple linear regression and analysis of variance were used for statistical analysis.Results:In the present study, preoperative anemia was not associated with longer LOS (P = .15). Postoperative anemia was associated with longer LOS as both postoperative day 1 Hgb (P = .05*) and postoperative nadir Hgb (P < .0001*) predicted longer LOS. Greater intraoperative Hgb decrement did not predict longer LOS (P = .36); however, greater perioperative Hgb decrement predicted longer LOS (P < .0001*). Older age (P = .01*) and greater number of levels fused (P = .03*) predicted longer LOS; however, a greater ASA-PS classification did not predict longer LOS. Greater IVF administration was associated with longer LOS (P < .0001*).Discussion:Postoperative nadir Hgb (P < .0001*) was more predictive of longer LOS than postoperative day 1 Hgb (P = .05*). There is a perioperative Hgb decrement associated with longer LOS (P < .0001*). Geriatric patients may be more susceptible to the potential contributors to Hgb decrement, including occult bleeding post-op and hemodilution from IVF administration.Conclusion:Postoperative anemia, perioperative decrement in Hgb, older age, greater number of levels fused, and greater total IVFs administered predict longer LOS. Understanding the impact of these factors on LOS is critical as these procedures increasingly move to the outpatient setting.

Fluid Abuse Following Minor to Intermediate Elective Surgeries

Background: The restriction to the guidelines for postoperative management (as omission of routine use of nasogastric tubes, early institution of oral feeding and mobilization and clarified indications of administration of intravenous fluids) has resulted in a decrease in perioperative intravenous fluid administration in fast-track surgical programs (in particular day case surgeries). In minor to intermediate surgeries, shifting of perioperative fluids are small and organ dysfunctions are minimum. Objective: To establish fluid abuse postoperatively following minor and intermediate surgeries. Patients and Methods: This is a prospective study done in Iraq-Diyala-Baquba teaching hospital over a period of one year from January 2018 – January 2019.The case sheets of 640 elective surgical cases had been reviewed for the intravenous fluid prescription after surgery. The types of surgeries reviewed were those which theoretically based, do not need postoperative intravenous fluid administration or shouldn’t be given for more than few hours; but should start early oral fluid. The emergency cases were excluded from this study. The data collected from the case sheets of different elective surgeries in the surgical ward. The 640 patients who underwent elective mild to intermediate surgeries. Results: Of those who underwent surgeries under general anesthesia, it has been found that 288 out of 390 patients (90%) were given intravenous fluid postoperatively for a period from 8- 24 hours. Of those who underwent surgeries under spinal anesthesia, it has been found that 134 out of 174 patients (77%) patients were given intravenous fluid postoperatively for a period from 8- 12 hours. Of those who underwent surgeries under local anesthesia, it has been found that 36 out of 76 patients (47%) were given intravenous fluid postoperatively for a period from 8- 12 hours. The volume of fluid prescribed ranged from 500ml to 2 liters. Conclusion: Routine prescription of intravenous fluids following minor to intermediate surgeries is theoretically unsupported and is unnecessary most of the time as far as the patient is maintained well hydrated intraoperatively.

PERioperative Fluid Management in Elective ColecTomy (PERFECT)—a national prospective cohort study

There is contradictory evidence regarding the merits of restricted versus liberal perioperative intravenous (IV) fluid administration in bowel surgery. This study sought to audit perioperative fluid management in elective colectomy in Ireland and to analyse the impact of such onoperative outcomes. A national surgical trainee collaborative audit of perioperative fluid management was performed. Data from each site was collected prospectively over a selected 3-week period within a pre-defined 2-month block. Collected variables included demographics, type of operation/anaesthethic, volume/type of fluid administration pre-, intra- and post-operatively, 30-day morbidity and mortality. Primary outcome was fluid balance 24-h post-operatively with further analysis to identify the impact of this on 30-day morbidity. ROC curves were generated to identify the critical volume at which fluid balance was associated with 30-day morbidity. Ninety-four patients were enrolled from 17 hospitals. Mean age was 64years. A total of 48.9% (N = 46) were managed by ERAS and 51.1% (N = 48) received bowel preparation. Almost 70% of cases (N = 63) were completed by minimally invasive techniques. Significant 30-day morbidity requiring hospital readmission was low [6.4% (n = 6)]. Median fluid balance at 24h was + 715ml (IQR 165-1486ml). On multivariate analysis, high BMI (p = 0.02), indication for surgery (p = 0.02) and critical care admission (p = 0.008) were significantly predictive of 30-day morbidity. Twenty-four hour fluid balance >+ 665ml was associated with increased risk of 30-day morbidity on univariate but not multivariate analysis, implying association but not causation. Overall, perioperative fluid management was within an acceptable range with minimal impact on 30-day morbidity following elective colorectal surgery.

Thresholds for optimal fluid administration and weight gain after laparoscopic colorectal surgery

BackgroundPerioperative fluid overload is an important modifiable risk factor for adverse outcomes after colorectal surgery. This study aimed to define critical thresholds for perioperative fluid management and postoperative weight gain for patients undergoing elective laparoscopic colorectal surgery.MethodsThis was an analysis of consecutive elective laparoscopic colorectal resections at Lausanne University Hospital from May 2011 to May 2017. Main outcomes were overall, major (Clavien–Dindo grade IIIb or above) and respiratory complications, and postoperative ileus. Thresholds regarding perioperative fluid management and postoperative weight gain were identified through receiver operating characteristic (ROC) analysis and clinical judgement. Independent risk factors for all four outcomes were assessed by multinominal logistic regression.ResultsOverall and major complications occurred in 210 (36·2 per cent) and 46 (7·9 per cent) of 580 patients respectively. Twenty‐three patients (4·0 per cent) had respiratory complications and 98 (16·9 per cent) had postoperative ileus. Median length of hospital stay was 5 (i.q.r. 3–9) days. Based on respiratory complications, thresholds for perioperative intravenous fluid administration (postoperative day (POD) 0) were set pragmatically at 3000 ml for colonic (calculated threshold 3120 ml (area under ROC curve (AUROC) 0·63)) and 4000 ml for rectal (AUROC 0·79) procedures. Postoperative weight gain of 2·5 kg at POD 2 was predictive of respiratory complications. Multivariable analysis retained perioperative intravenous fluid administration over the above thresholds as an independent risk factor for overall (odds ratio (OR) 2·25, 95 per cent c.i. 1·23 to 4·11), major (OR 2·49, 1·17 to 5·31) and respiratory (OR 4·71, 1·42 to 15·58) complications. Weight gain above 2·5 kg at POD 2 was identified as a risk factor for respiratory complications (OR 3·58, 1·10 to 11·70) and ileus (OR 1·82, 1·02 to 3·52).ConclusionPerioperative intravenous fluid and weight thresholds were associated with postoperative adverse outcomes. These thresholds need independent validation.

Nurses' Indications for Administration of Perioperative Intravenous Fluid Therapy—A Prospective, Descriptive, Single-Center Cohort Study

To examine whether nurse anesthetists and postanesthesia nurses' administration of intravenous (IV) fluid therapy during surgery and in the postanesthesia care unit is based on evidence. Secondarily to investigate if providing indications for IV fluid administration changed nursing practice. Prospective, descriptive, single-center study in Scandinavia comparing two cohorts. Descriptive, fluid volume, and type data were obtained in both cohorts. Cohort 1 (n=126) was used as baseline data. In cohort 2 (n=130), nurses recorded indications for type and volume of fluid therapy using a validated list. Analysis compared median volumes of crystalloid or colloid fluids of surgical types by cohort. Analysis compared frequency of given indication reasons for each IV fluid by surgical type. Basic static variables were chosen most frequently for indications of IV fluid needed for all surgeries except high-risk abdominal surgery where dynamic variables were more frequent. Signs and symptoms of inadequate tissue perfusion were only sparsely indicated. The volume of intraoperative crystalloid fluids was statistically different for patients with hip fracture surgery in cohort 2. Volumes of both colloid and crystalloid fluids were significantly higher for high-risk abdominal surgery in cohort2. Nurse anesthetists and nurses in the postanesthesia care unit rely more on basic static parameters than signs of inadequate tissue perfusion when they make decisions about fluid administration. The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines. This indicates the need of a stronger intervention to change practice to follow evidence-based clinical guidelines.

The effects of perioperative intravenous fluid administration strategy on renal outcomes in patients undergoing cardiovascular surgery: An observational study.

We assessed whether perioperative fluid management with balanced solutions and a limited volume of hydroxyethyl starch (renal-protective fluid management [RPF] strategy) could improve renal outcomes after cardiovascular surgery.For this retrospective observational study, we evaluated 2613 patients who underwent cardiovascular surgery from January 1, 2010 to December 31, 2013. The control group were given intravenous fluids with saline-based solutions and unlimited volumes of hydroxyethyl starch solutions and the RPF group were given intravenous fluids with RPF. The primary outcome was the incidence of acute kidney injury (AKI) and chronic dialysis within 12 months after cardiovascular surgery. Multivariable regression and propensity analyses were performed to evaluate the association between perioperative fluid management strategy and postoperative renal outcomes.Postoperative AKI and chronic dialysis occurred in 213 (21.2%) and 5 (0.5%) patients in the RPF group compared with 696 (43.2%) and 38 (2.4%) patients in the control group, respectively. After adjustment, the RPF group was linked to a decreased risk of postoperative AKI, severe AKI, persistent AKI, use of renal replacement therapy, chronic kidney disease, chronic dialysis, and a shorter postoperative extubation time and intensive care unit, and hospital stay duration.The perioperative fluid management strategy with balanced solutions and a limited volume of hydroxyethyl starch was related to improved acute and 1-year renal and clinical outcomes after cardiovascular surgery. These findings indicate the need for further definitive clinical trials on perioperative fluid management strategy.

Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial: study protocol for a multicentre international trial of cardiac output-guided fluid therapy with low-dose inotrope infusion compared with usual care in patients undergoing major elective gastrointestinal surgery

IntroductionPostoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and...

Impact of postoperative intravenous fluid administration on complications following elective hepato-pancreato-biliary surgery

BackgroundThe impact of perioperative intravenous fluid administration on surgical outcomes has been documented in literature, but not specifically studied in the context of hepato-pancreato-biliary (HPB) surgery. This study aimed to investigate the impact of postoperative intravenous fluid administration on intensive care unit (ICU), in this subgroup of patients. MethodsA single-center retrospective cohort of 241 HPB patients was assessed, focusing on intravenous fluid administration in ICU, during the first 24 h. Intravenous fluid variables were compared to hospital stay and postoperative complications. Data were assessed using Spearman's correlation test for bivariate correlations and logistic regression for multivariate analysis. ResultsThe median volume of intravenous fluid administered in the first 24 h postoperatively was 4380 mL, of which 2200 mL was crystalloid, 1500 mL colloid and 680 mL “other” fluid. Patients with one or more complications had a higher median total intravenous fluid input (4790 vs. 4300 mL), higher colloid volume (2000 vs. 1500 mL), lower urine output (1595 vs. 1900 mL) and greater overall fluid balance (+3040 vs.+2553 mL) than those without complications. There were correlations between total intravenous fluid volume administered (r = 0.278, P < 0.001), intravenous colloid input (r = 0.278, P < 0.001), urine output (r = -0.295, P < 0.001), positive fluid balance (r = 0.344, P < 0.001) and length of hospital stay. Logistic regression model was constructed to predict the occurrence of one or more complications; total intravenous fluid volume and overall fluid balance were both independent significant predictors (OR = 2.463, P = 0.007; OR = 1.001, P = 0.011; respectively). ConclusionsAdministration of high volumes of intravenous fluids in the first 24 hours post-HPB surgery, along with higher positive fluid balance is associated with a higher rate of complications and longer hospital stay. Moreover, lower urine output is associated with longer hospital stay. Whether these are the cause of complications or the result of them remains unclear.

Enhanced recovery after surgery (ERAS) versus conventional postoperative care in patients undergoing abdominal hysterectomies

In the present study, we aimed to compare the postoperative compliance and complications between ERAS and conventional postoperative care in patients undergoing abdominal hysterectomies. This is the prospective, randomized, controlled trial, which involved 62 patients, who underwent abdominal hysterectomy between December 2016 to February 2017. A total of 30 patients formed the ERAS group. A total of 32 patients who received conventional perioperative care and matched for age, body mass index (BMI) and American Society of Anesthesiologists score were assigned as a control group. Groups were compared in terms of patient characteristics [age, body mass index, ASA Score, parity, diagnosis, type of surgery, and perioperative intravenous fluids], postoperative compliance (postoperative intravenous fluids, time to first flatus, first defecation, ambulation, eating solid food, and postoperative hospital stay), and postoperative complications. Peri- and post-operative administrated intravenous fluids were significantly lower in the ERAS group (p < 0.001 for both). Time to first flatus (p = 0.001), time to first defecation (p < 0.001), and time to eating solid food (p < 0.001) were all significantly shorter in the ERAS group. Post-operative early mobilization on the first postoperative day was achieved in eight (26.7%) patients in the ERAS group. There were no significant differences in complications. One (3.3%) patient in the ERAS Group and 11 (34.4%) patients in the Conventional Group required hospital readmission after discharge (p = 0.002). The ERAS protocol seems to be a simple tool for reducing the incidence of postoperative complications and shortening hospitalization.

Risk factors for postoperative ileus following elective laparoscopic right colectomy: a retrospective multicentric study.

Postoperative ileus (POI) is associated with an elevated risk of other complications and increases the economic impact on healthcare services. The aim of this study was to identify pre-, intra- and postoperative risk factors associated with the development of POI following elective laparoscopic right colectomy. Between 2004 and 2016, 637 laparoscopic right colectomies were performed. Data were analysed retrospectively thanks to the CLIHMET database. Potential contributing factors were analysed by logistic regression. Patients with POI (n = 113, 17.7%) were compared to those without postoperative ileus (WPOI) (n = 524, 82.3%). In the POI group, there were more men (62 vs 49%; p = 0.012), more use of epidural anaesthesia (19 vs 9%; p = 0.004), more intraoperative blood transfusion requirements (7 vs 3%; p = 0.018) and greater perioperative intravenous fluid administration (2000 vs 1750mL; p < 0.001). POIs were more frequent when extracorporeal vascular section (20 vs 12%; p = 0.049) and transversal incision for extraction site (34 vs 23%; p = 0.044) were performed. Overall surgical complications in the POI group were significantly greater than in the control group WPOI (31.9 vs 12.0%; p < 0.0001). Multivariate analysis found the following independent POI risk factors: male gender (HR = 2.316, 1.102-4.866), epidural anaesthesia (HR = 2.958, 1.250-6.988) and postoperative blood transfusion requirement (HR = 6.994, 1.550-31.560). This study is one of the first to explore the CLIHMET database and the first to use it for investigating risk factors for POI development. Modifiable risk factors such as epidural anaesthesia and intraoperative blood transfusion should be used with caution in order to decrease POI rates.

Intravenous fluid and electrolyte administration in elective gastrointestinal surgery: mechanisms of excessive therapy.

INTRODUCTION While clinical guidelines stress the importance of the judicious perioperative intravenous fluid administration, data show that adherence to these protocols is poor. The reasons have not been identified. We therefore audited the magnitude and indications of fluid and electrolyte administration in a teaching hospital. We hypothesised that epidural analgesia is associated with excessive fluid therapy. MATERIALS AND METHODS Intravenous fluid and electrolyte administration during the day of surgery and the subsequent 2 days in consecutive patients undergoing elective gastrointestinal surgery between November 2013 and May 2014 were retrospectively audited. Timing, volumes and indications were recorded. RESULTS One hundred patients undergoing elective gastrointestinal resection were studied. Patients received 9030ml±2860ml (mean±standard deviation) intravenous fluids containing a total of 1180ml±420mmol sodium and resulting in a cumulative fluid balance of +5120ml±2510ml; 44%±14% of total volumes were given in theatre. Nearly all fluid was given for maintenance, 100% (96-100%, interquartile range), with 17 patients only receiving replacement or resuscitation. Independent predictors of increased volumes included open surgery, upper gastrointestinal surgery, increased duration and epidural analgesia but not body weight. Postoperative fluid volume was the only independent predictor of postoperative complication grade (P=0.0044). CONCLUSIONS Despite published guidelines, perioperative fluid and electrolyte administration were excessive and were associated with postoperative morbidity. Substantial volumes were administered in theatre. Nearly all administration was for maintenance, yet patients received approximately five times the amount of sodium required. Epidural analgesia was an independent predictor of fluid volumes but body weight was not.