Restrictive Fluid Regimen Research Articles

Candidate Kidney Protective Strategies for Patients Undergoing Major Abdominal Surgery: A Secondary Analysis of the RELIEF Trial Cohort.

Acute kidney injury (AKI) is common after major abdominal surgery. Selection of candidate kidney protective strategies for testing in large trials should be based on robust preliminary evidence. A secondary analysis of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial was conducted in adult patients undergoing major abdominal surgery and randomly assigned to a restrictive or liberal perioperative fluid regimen. The primary outcome was maximum AKI stage before hospital discharge. Two multivariable ordinal regression models were developed to test the primary hypothesis that modifiable risk factors associated with increased maximum stage of postoperative AKI could be identified. Each model used a separate approach to variable selection to assess the sensitivity of the findings to modeling approach. For model 1, variable selection was informed by investigator opinion; for model 2, the Least Absolute Shrinkage and Selection Operator (LASSO) technique was used to develop a data-driven model from available variables. Of 2,444 patients analyzed, stage 1, 2, and 3 AKI occurred in 223 (9.1%), 59 (2.4%), and 36 (1.5%) patients, respectively. In multivariable modeling by model 1, administration of a nonsteroidal anti-inflammatory drug or cyclooxygenase-2 inhibitor, intraoperatively only (odds ratio, 1.77 [99% CI, 1.11 to 2.82]), and preoperative day-of-surgery administration of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker compared to no regular use (odds ratio, 1.84 [99% CI, 1.15 to 2.94]) were associated with increased odds for greater maximum stage AKI. These results were unchanged in model 2, with the additional finding of an inverse association between nadir hemoglobin concentration on postoperative day 1 and greater maximum stage AKI. Avoiding intraoperative nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors is a potential strategy to mitigate the risk for postoperative AKI. The findings strengthen the rationale for a clinical trial comprehensively testing the risk-benefit ratio of these drugs in the perioperative period.

Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice

The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.

Restrictive Versus Liberal Fluid Regimen in Refractory Sepsis and Septic Shock: A Systematic Review and Meta-Analysis.

The optimal fluid management strategy for patients with sepsis remains a topic of debate. This meta-analysis aims to evaluate the impact of restrictive versus liberal fluid regimens on mortality, adverse events, and other clinical outcomes in patients with sepsis. We systematically reviewed 11 randomized controlled trials published between 2008 and 2023, comprising a total of 4,121 participants. The studies assessed 90-day mortality, 30-day mortality, adverse events, hospital length of stay, ICU admission rate, mechanical ventilation, ventilator-free days, ICU-free days, and vasopressor-free days. Quality assessments indicated minimal bias across the studies. The meta-analysis showed no statistically significant difference in 90-day mortality between restrictive and liberal fluid regimens (OR, 0.93; 95% CI, 0.80 to 1.70; P=0.30). Similar results were observed for 30-day mortality (OR, 0.73; 95% CI, 0.30 to 1.80; P=0.50). Adverse events were comparable between the two groups (OR, 0.81; 95% CI, 0.55 to 1.19; P=0.28). Furthermore, there were no significant differences in hospital length of stay (OR, 0.47; 95% CI, -0.85 to 1.80; P=0.48) or ICU admission rate (OR, 1.09; 95% CI, 0.66 to 1.77; P=0.75) between the restrictive and liberal fluid regimens. Regarding mechanical ventilation and ventilator-free days, no significant distinctions were observed (OR, 0.87; 95% CI, 0.65 to 1.17; P=0.48; OR, 0.99; 95% CI, -0.17 to 2.15; P=0.09, respectively). ICU-free days and vasopressor-free days also showed no significant differences between the two groups (OR, 0.97; 95% CI, -0.28 to 2.21; P=0.13; OR, -0.38; 95% CI, -1.14 to 0.37; P=0.32, respectively). This comprehensive meta-analysis of clinical trials suggests that restrictive and liberal fluid management strategies have comparable outcomes in patients with sepsis, including mortality, adverse events, and various clinical parameters. However, most studies favored restrictive fluid regimen over liberal approach regarding the number of vasopressor-free days, need for mechanical ventilation, adverse events, 30-day mortality, and 90-day mortality in sepsis patients.

Fluid Resuscitation in Septic Patients.

Sepsis is a life-threatening organ failure caused by a dysregulated response to infection. Fluid resuscitation and vasopressors are used to maintain systolic blood pressure and organ perfusion. Fluid resuscitation can be done with liberal or restricted fluids as well as colloids or crystalloid fluids. This review analyses the evidence for the use of liberal or restrictive fluids and colloids or crystalloids for the management of sepsis. A methodical search was conducted across PubMed, Cochrane Library, and ScienceDirect, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines were followed for this study. Randomized controlled trials and retrospective observational studies were included in this study. Liberal and restrictive fluid strategies were found to be comparable in efficacy, but restrictive fluid regimens had the added benefit of a lower incidence of fluid overload. Balanced crystalloidswere safer and more effective when compared to normal saline. Albumin replacement was found to be safe and showed efficacy in reducing mortality in patients with sepsis and septic shock.

Restrictive Fluid Therapy for High-Complexity Advanced Ovarian Cancer Surgery: A Single-Center Retrospective Cohort Study

Background: Postoperative fluid management is vital for preventing perioperative morbidity and mortality in high-complexity advanced ovarian cancer surgery. We investigated the feasibility and benefits of restrictive fluid therapy on postoperative recovery. Methods: Patients with advanced ovarian cancer who underwent open radical surgery were randomized into the restrictive or liberal fluid group. The endpoints were the length of hospital stay post-surgery and the incidence of complications within 30 days. Results: The restrictive and liberal fluid regimen groups included 30 and 41 patients, respectively. The length of hospital stay was 16.5-days and 21.0-days for the restrictive and liberal group, respectively (p = 0.035). Multiple linear regression analysis showed that length of hospital stay was 2.971-days shorter in the restrictive group than in the liberal group (95% confidence interval (CI): –5.818~–0.124, p = 0.04). The incidence of complications at the end of 30 days was significantly lower in the restrictive group than in the liberal intravenous group (26.7% versus 51.2%; p = 0.032). Adjusted logistic regression demonstrated that restrictive group could significantly reduce the risk of postoperative complications by 68% (Odds Ratio 0.32, 95% CI: 0.11–0.91, p = 0.033). Conclusions: Restrictive fluid management after high-complexity advanced ovarian cancer surgery can significantly decrease the risk of major postoperative complications and facilitate postoperative recovery.

Evaluation of Intraoperative Fluid Management

Objective:Especially in large surgical procedures, it is recommended that the fluid treatment be performed according to the needs of the patient in the presence of hemodynamic monitoring during the operation. We aimed to review intraoperative fluid treatments and to increase awareness of intraoperative fluid management. Methods:The patients (393) who underwent general anesthesia were included in the study. According to the information of intraoperative fluid applications, the demographic characteristics of the patients and the amount and type of fluid that should be given according to the type of operation performed were determined. Results:In our study, the mean amount of fluid given to patients was found to be 2677.61 ml. The mean intraoperative fluid volume was higher in patients who were treated with IV vasopressors than in untreated patients (3477.27 ml). When compared with patients with ASA 1-2 group, the amount of fluid given to the patients in the ASA-3 group was high (2795 ml). Comparing the type of surgery and the amount of fluid given intraoperatively, we observed that the amount of intraoperative fluid was significantly higher in the high-risk surgical group (3601.65 ml). We can say that we are close to liberal practices as a liquid strategy. The use of balanced crystalloid with the closest content to plasma is the most preferred liquid type in our clinical practice. Conclusion:Due to the variability of the concepts of liberal and restrictive fluid regimen and the lack of standardized targeted clinical and physiological parameters, no specific evidence-based guideline or procedure specific fluid treatment could be demonstrated. In our study, we see that fluid replacement is performed under standard fluid treatment, which still can be considered liberal. We think that it can be useful to use hemodynamic monitoring methods more frequently in patients who need them, also in selected patient groups. Key Words: Fluid, Liberal, Restrictive, Perioperative, Crystalloid, Colloid

Restrictive versus Liberal Fluid Therapy in Patients Undergoing Pancreaticoduodenectomy

Introduction: Pancreaticoduodenectomy(PD) has significant morbidity (50%) and mortality (<5%) which may be influenced by perioperative fluid therapy. Traditional practice was the use of liberal fluid therapy. However, it is unclear what the ideal fluid therapy is for patients undergoing PD. This study was conducted to compare the postoperative complications between Restrictive fluid therapy (RES) and Liberal Fluid Therapy (LIB). Methods: Patients scheduled to undergo PD were consented for randomization to a perioperative Restrictive versus Liberal Fluid Therapy fluid regimen. Sample size was designed with 80% power to decrease Clavien Dindo Grade≥ IIIb complications from 60% to 30%. Sample size calculated was 40. Intraoperatively, RES patients received crystalloid 5ml/kg/hr and LIB patients received 10ml/kg/hr. Results: Between May 2020 and July 2021, 40 patients were included in the study. Patients were equally distributed for all demographic and intraoperative characteristics. Cumulative crystalloid given (median, IQR, ml) upto 24 hr of surgery was 3550 (1437.5) in RES group, 5325 (2525) in LIB group (p<0.001). Median operative time (median, IQR) for PD was 465(198) minutes for restrictive and 420(86) minutes for liberal fluid therapy (p=0.478). Grade ≥ IIIb complications occurred in 8 (40%) of RES and 3(15%) of LIB patients (p=0.08). Median length of hospital stay was 15.5 days and 16 days which was similar, in both study groups. The rate of complications like POPF, PPH and DGE were similar in both groups. Conclusion: The choice between restrictive or liberal fluid therapy did not affect overall major postoperative complications (Clavien Dindo Grade≥ IIIb) in pancreaticoduodenectomy.

Does fluid balance affect neurodevelopmental outcomes in hypoxic-ischaemic encephalopathy?

Hypoxic-ischaemic encephalopathy (HIE) is a major cause of morbidity and mortality in neonates worldwide.1 Neonates with HIE are treated with therapeutic hypothermia (TH) and other supportive measures. Restrictive fluid regimen, with attention to fluid balance, is advocated in the treatment of HIE to prevent exacerbation of cerebral oedema.2, 3 However, there is no evidence to support this practice or to provide insight into the effect of fluid balance on outcomes of neonates with HIE.4, 5 This study by Ottolini et al. aimed to determine any association between positive fluid balance and death or moderate to severe brain injury on post-rewarming magnetic resonance imaging (MRI) in neonates with HIE treated with TH. All neonates were initially administered fluids at a standard rate of 60 ml/kg/day. Infusion rates were adjusted subsequently as per clinical discretion to maintain target sodium and glucose levels. Retrospective analysis of data showed positive fluid balance during the first 24 h of TH conferred 3.4 times higher odds of death or moderate to severe brain injury in neonates. The odds of this primary adverse outcome increased to 5.8 times in neonates with positive fluid balance at 48–72 h of TH. Ottolini et al. propose acute kidney injury and syndrome of inappropriate secretion of anti-diuretic hormone (SIADH), as mechanisms underlying the higher incidence of free water retention and lower plasma sodium levels observed in neonates who died or had moderate-to-severe brain injury in this study.6-8 Accordingly, whilst it could be hypothesised that positive fluid balance itself contributes to the adverse neurodevelopmental outcome, the degree of positive fluid balance may concurrently indicate the severity of hypoxic injury in neonates with HIE. Therefore positive fluid balance may be used as an early prognostic marker of severity of brain injury. Previous randomised controlled trials (RCT) found fluid restriction precipitated hypoglycaemia and hyponatremia, potentially confounding the observed adverse outcomes.4, 7 Anticipation and correction of these electrolyte disturbances gives this study's results with greater validity. However, the lack of further details of fluid management makes it difficult to determine exact fluid volumes administered throughout the study period. Consequently, it is unclear whether positive fluid balance, as a result of hypoxic injury, was exacerbated by the fluid strategy undertaken in the study. Apart from a median of 9 days of life, and an interquartile range of 6–10 days of life, definitive details of timing of the post-rewarming MRI assessment of brain injury have not been provided. Furthermore, twenty neonatal deaths were recorded prior to MRI, and deaths beyond this point were not reported. A multicentre RCT comparing a standard versus restrictive fluid regimen with long-term neurodevelopmental surveillance may address the controversy around the ideal fluid strategy in HIE. Comparing levels of biomarkers that indicate the severity of HIE and SIADH in both groups may also provide information on prognostication. Despite the limitations discussed, the study illustrates a significant association between positive fluid balance and adverse outcomes, and further research is warranted on fluid therapy in HIE. None declared. URL to the full review on the EBNEO website.

Fluid and electrolyte therapy in childhood diabetic ketoacidosis management: A rationale for new national guideline.

Fluid and electrolyte therapy in childhood diabetic ketoacidosis (DKA) management has been controversial. Previous National Institute for Health and Care Excellence (NICE) 2015 guidance advocated a restricted fluid regimen while more recent guidelines have advocated a more liberal approach to fluid replacement in DKA. At the core of the debate is the need to avoid developing cerebral oedema as a complication. Although subtle asymptomatic cerebral oedema is common in children presenting in DKA, clinically apparent cerebral oedema is rare and has been reported in approximately 0.5%-1% of DKA cases in children. Recent research evidence has shown that there was no clear evidence of a difference in rates of clinically apparent cerebral injury in children in DKA managed with a range of fluid volumes and rates of rehydration. In view of this, NICE has updated its guideline. In this paper, we review literature evidence underpinning the current understanding of the pathophysiology of cerebral oedema in children and discuss the rationale for the new NICE guidance.

Effect of the Type of Intraoperative Restrictive Fluid Management on the Outcome of Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Background. The perioperative management of pancreaticoduodenectomy is complicated, and the significant morbidity and mortality may be influenced by the method of intraoperative fluid management. Whether intraoperative restrictive fluid therapy can affect the outcomes of pancreaticoduodenectomy or not is controversial. Methods. PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov were searched for prospective and retrospective studies comparing restrictive and liberal intraoperative fluids in patients undergoing pancreaticoduodenectomy. Following study identification, a systematic review and meta-analysis were performed. Results. Fourteen studies, including six prospective trials and eight retrospective studies, involving 2,596 patients, were included. Intraoperative restrictive fluid regimens had no effect on the mortality compared to liberal fluid regimens in the overall cohort (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 0.82–2.35, p = 0.773 ). Liberal fluid regimens could increase the risk of pulmonary adverse events (OR: 1.66; 95% CI: 1.10–2.50, p = 0.131 ) and prolong the length of hospital stay (SMD -0.10; 95% CI -0.19– -0.01, p = 0.375 ). There were no significant differences in the incidence of pancreatic fistulas. Conclusions. Restrictive fluid regimens have a slight effect on the outcomes of pancreaticoduodenectomy. The clinical relevance of this finding needs to be interpreted. The existing evidence may not be adequate; therefore, further studies are warranted.

Оценка безопасности интраоперационной инфузионной терапии при обширных абдоминальных операциях у пациентов с сопутствующей ишемической болезнью сердца

The study of intraoperative fluid therapy tactics has been of great interest over the past few years, especially in people with concomitant coronary heart disease, as they make up a significant proportion of all surgical patients. The purpose of our study was to assess the risk of intraoperative myocardial damage in patients with concomitant coronary heart disease depending on the fluid regimen used based on monitoring of hemodynamic parameters, electrocardiogram and biomarkers of myocardial damage. Material and methods. The study involved 89 patients, who were divided into two groups depending on the tactics of intraoperative fluid therapy – restrictive and liberal. In order to detect cardiac complications at different stages, we assessed biomarkers of myocardial damage Troponin I, NT-proBNP by solid-phase enzyme-linked immunosorbent assay (ELISA). Results and discussion. Analysis of the obtained data showed that MINS (myocardial injury in noncardiac surgery) incidents were diagnosed in 5 patients (11.1%) in the first group and in 6 patients (13.6%) in the second. In patients of both groups there was an increase in NT-proBNP in the dynamics at all stages, and in the 2nd group, with a liberal regimen of intraoperative fluid therapy, it was more pronounced. It should be noted that the obtained values of NT-proBNP in all patients did not differ significantly from those allowed for this age group; such dynamics of NT-proBNP may indicate a relative risk of complications of liberal fluid therapy in patients with baseline heart failure. One of the important points when choosing the mode of fluid therapy in patients with high cardiac risk is the assessment of the initial volemic status and careful monitoring of water balance in the perioperative period with the desire for "zero" balance. The obtained dynamics of laboratory markers of myocardial damage indicates that in patients with a significant reduction in cardiac reserves compensated for heart failure, a restrictive fluid regimen is preferable, which is also confirmed by slight changes in the concentration of biomarkers. Conclusion. Thus, the study demonstrated the relative safety of selected fluid regimens in patients with concomitant coronary heart disease without signs of congestive heart failure

Efficacy of goal-directed fluid therapy monitored by pulse-pressure variation using a continuous noninvasive arterial pressure monitoring system (the CNAPTM system) during parathyroidectomy in patients with end-stage renal failure – a randomised trial

IntroductionThere are no well-recognised guidelines for intraoperative fluid management in patients with end-stage renal failure (ESRF). Goal-directed fluid therapy (GDFT) is a concept of perioperative fluid management that improves patients’ prognosis. In this study, we assessed a GDFT protocol with monitoring of pulse pressure variation (PPV) in patients with ESRF undergoing parathyroidectomy.Material and methodsA total of 102 patients who underwent elective parathyroidectomy were randomised into a control group (restrictive group, n = 51), managed with a restricted fluid regimen, or a PPV group (GDFT group, n = 51), given a normal saline infusion, and they were monitored for changes in PPV. If PPV reached &gt; 13%, 250 ml of normal saline was administered over 15 min. Ephedrine was given to keep the mean arterial pressure &gt; 65 mm Hg. Haemodynamic variables in the perioperative period were recorded. The primary endpoint was the occurrence of postoperative hypotension.ResultsThe occurrence of postoperative hypotension (0 vs. 11.67%, p = 0.027) and complications (35.3% vs. 54.9%, p = 0.047) in the GDFT group was lower than in the restrictive group. The volume of saline infused during the operation was 364 (219–408) ml and 50 (50–50) ml, respectively (p = 0.001). Ephedrine was given to 16/51 (29.4%) patients of the GDFT group and 27/51 (52.9%) patients of the restrictive group (p = 0.027).ConclusionsThe use of GDFT with dynamic PPV monitoring in patients with ESRF undergoing parathyroidectomy could potentially be used to guide the administration of infused fluids, with the possibility of reducing the occurrence of postoperative hypotension.

Restrictive versus Liberal Fluid Therapy for Post-Cesarean Acute Kidney Injury in Severe Preeclampsia: a Pilot Randomized Clinical Trial

OBJECTIVES:The aim of this study was to determine whether a restrictive compared to a liberal fluid therapy will increase postoperative acute kidney injury (AKI) in patients with severe preeclampsia.METHODS:A total of 46 patients (mean age, 32 years; standard deviation, 6.8 years) with severe preeclampsia were randomized to liberal (1500 ml of lactated Ringer’s, n=23) or restrictive (250 ml of lactated Ringer’s, n=23) intravenous fluid regimen during cesarean section. The primary outcome was the development of a postoperative renal dysfunction defined by AKI Network stage ≥1. Serum cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) were evaluated at postoperative days 1 and 2. ClinicalTrials.gov: NCT02214186.RESULTS:The rate of postoperative AKI was 43.5% in the liberal fluid group and 43.5% in the restrictive fluid group (p=1.0). Intraoperative urine output was higher in the liberal (116 ml/h, IQR 69-191) than in the restrictive fluid group (80 ml/h, IQR 37-110, p<0.05). In both groups, serum cystatin C did not change from postoperative day 1 compared to the preoperative period and significantly decreased on postoperative day 2 compared to postoperative day 1 (p<0.05). In the restrictive fluid group, NGAL levels increased on postoperative day 1 compared to the preoperative period (p<0.05) and decreased on postoperative day 2 compared to postoperative day 1 (p<0.05).CONCLUSION:Among patients with severe preeclampsia, a restrictive fluid regimen during cesarean section was not associated with increased postoperative AKI.

Effect of Two Regimens of Fluid Administration on Airway Edema in Prone-Position Surgery.

Background:Surgeries in prone position expose a patient to multitude of complications including laryngeal edema which may be related to the volume of fluid administered. Administering larger volumes of fluid intraoperatively may contribute to significant tissue edema, leading many anesthesiologists to practice a restrictive fluid infusion strategy. Although previous studies have compared fluid infusion strategies, changes in airway dimensions leading to airway edema have not been extensively investigated. Here, we compared two fluid infusion regimens in patients undergoing spine surgery in the prone position, and assessed their association with airway edema by means of the cuff leak test (CLT).Aims:The aim of this study was to test the hypothesis whether a larger volume of crystalloid administration in spine surgeries performed in prone position would result in greater chances of airway edema, than would a restricted infusion policy, utilizing the CLT.Materials and Methods:After ethical committee approval, thirty patients, aged 21–60 years, American Society of Anesthesiologists Status I or II, scheduled for elective spine surgery in the prone position, were selected. Group 1 (restrictive group) received 3 mL.kg − 1.h − 1, whereas Group 2 (permissive group) received 5 mL.kg − 1.h − 1 of crystalloids plus urine output replacement. The airway edema was assessed by CLT which was performed soon after intubation (T1) and before extubation (T2). Cuff leak volume (CLV) was calculated from the difference in tidal volumes before (VTi) and after cuff deflation (VTe). Airway edema was evaluated by calculating the differences in the CLV at T1 and T2 (ΔCLV); the more the value of Δ CLV which means greater difference between these two points, the more the decrease in laryngeal lumen, signifying an increased risk of airway edema.Results:Decrease in laryngeal lumen was observed in patients who received permissive fluid regimen than that of the restrictive group, signifying more chances of airway edema in the former group. In addition, a poor correlation was found between the duration of anesthesia and development of airway edema in our study group.Conclusions:Because surgeries in the prone position are at risk of airway edema, restrictive fluid regimen strategy should be preferred over the liberal one as there are more chances of reduction in laryngeal lumen dimensions with permissive fluid infusions.

Effect of liberal versus restrictive fluid therapy on intraoperative lactate levels in robot- assisted colorectal surgery.

Background and Aims:Minimally invasive and robotic surgeries need lesser fluid replacement but the role of restricted fluids in robotic surgeries other than prostatic surgeries has not been clearly defined. Our primary aim was to evaluate the effects of a restrictive fluid regimen versus a liberal policy on intra-operative lactate in robotic colorectal surgery. Secondary outcomes were need for vasopressors, extubation on table, post-operative renal functions and length of ICU (LOICU) stay.Methods:American society of anaesthesiologists (ASA) physical status I–II patients scheduled for robot-assisted colorectal surgery were randomised into one of two groups, receiving either 2 mL/kg/h (Group R) or 4mL/kg/h, (group L). Fluid boluses of 250 ml were administered if mean arterial pressure (MAP) <65 mmHg or urine output <0.5 ml/kg/h. Norepinephrine was added for the blood pressure after 2 fluid boluses. Surgical field was assessed by modified Boezaart's scale and surgeon satisfaction by Likert scale.Results:Demographics and baseline renal functions were comparable. Adjusted intra-operative lactate at 2 h, 4 h, and 6 h and need for noradrenaline and post-operative creatinine were similar. One patient in the group L was ventilated due to hypothermia. The field was better at the 4 h in group R and comparable at other time points. The LOICU stay was longer in Group L.Conclusion:The use of restrictive fluid strategy of 2 mL/kg/h (group R) does not increase lactate levels or creatinine, improves surgical field at 4 h and shortens ICU stay in comparison to a liberal 4 mL/kg/h (group L) in robotic colorectal surgery.

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).

The role of fluid restriction in abdominal surgery.

Recently, Myles et al . (1) published a multi-center randomized controlled trial (RCT) concluding that compared to liberal fluid regimen, restricted fluid regimen did not improve clinical outcomes in patients after abdominal surgery. Perioperative fluid management plays an important role in postoperative care. As fluid accumulation was associated with poor outcomes in surgical patients (2), restricted fluid protocol was investigated to alleviate this situation.

Intraoperative Fluid Administration and Surgical Outcomes Following Pancreaticoduodenectomy: External Validation at a Tertiary Referral Center.

While intraoperative fluid overload is associated with higher complication rates following surgery, data for pancreaticoduodenectomy are scarce and heterogeneous. We evaluated multiple prior definitions of restrictive and liberal fluid regimens and analyzed whether these affected surgical outcomes at our tertiary referral center. Studies evaluating different intraoperative fluid regimens on outcomes after pancreatic resections were retrieved. After application of all prior definitions of restrictive and liberal fluid regimens to our patient cohort, relative risks of each outcome were calculated using all reported infusion regimens. Five hundred and seven pancreaticoduodenectomies were included. Nine different fluid regimens were evaluated. Two regimens utilized absolute volume cutoffs, and the remaining evaluated various infusion rates, ranging from 5 to 15mL/kg/h. Total volume administration of >5000mL and >6000mL was associated with increased complications (RR 1.25 and RR 1.17, respectively) and >6000mL with increased sepsis (RR 2.14). Conversely, a rate of <5mL/kg/h was associated with increased risk of postoperative pancreatic fistula (POPF, RR 3.16) and sepsis (RR 3.20), <6.8mL/kg/h with increased major morbidity (RR 1.64) and sepsis (RR 2.27), and <8.2mL/kg/h with increased POPF (RR 2.16). No effects were observed on pulmonary complications, surgical site infections, length of stay, or mortality. In an uncontrolled setting with no standard intraoperative or postoperative care map, the volume of intraoperative fluid administration appears to have limited impact on early postoperative outcomes following pancreaticoduodenectomy, with adverse outcomes only seen at extreme values.

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery

BackgroundGuidelines to promote the early recovery of patients undergoing major surgery recommend a restrictive intravenous-fluid strategy for abdominal surgery. However, the supporting evidence is limited, and there is concern about impaired organ perfusion.MethodsIn a pragmatic, international trial, we randomly assigned 3000 patients who had an increased risk of complications while undergoing major abdominal surgery to receive a restrictive or liberal intravenous-fluid regimen during and up to 24 hours after surgery. The primary outcome was disability-free survival at 1 year. Key secondary outcomes were acute kidney injury at 30 days, renal-replacement therapy at 90 days, and a composite of septic complications, surgical-site infection, or death.ResultsDuring and up to 24 hours after surgery, 1490 patients in the restrictive fluid group had a median intravenous-fluid intake of 3.7 liters (interquartile range, 2.9 to 4.9), as compared with 6.1 liters (interquartile range, 5.0 to 7.4) in 1493 patients in the liberal fluid group (P<0.001). The rate of disability-free survival at 1 year was 81.9% in the restrictive fluid group and 82.3% in the liberal fluid group (hazard ratio for death or disability, 1.05; 95% confidence interval, 0.88 to 1.24; P=0.61). The rate of acute kidney injury was 8.6% in the restrictive fluid group and 5.0% in the liberal fluid group (P<0.001). The rate of septic complications or death was 21.8% in the restrictive fluid group and 19.8% in the liberal fluid group (P=0.19); rates of surgical-site infection (16.5% vs. 13.6%, P=0.02) and renal-replacement therapy (0.9% vs. 0.3%, P=0.048) were higher in the restrictive fluid group, but the between-group difference was not significant after adjustment for multiple testing.ConclusionsAmong patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury. (Funded by the Australian National Health and Medical Research Council and others; RELIEF ClinicalTrials.gov number, NCT01424150.)

Effect of Restrictive Intraoperative Intravenous Fluids Combined with Prophylactic Noradrenaline on Postoperative Morbidity in Open Abdominal Procedures

AbstractBackground: Fluid regimens are variable and the choice of restrictive or liberal can have an impact on postoperative outcome especially during major procedures such as those of abdominal surgeries. The use of intraoperative noradrenaline infusion has been attributed to maintain perfusion alongside the restrictive regimen. The outcome is assessed both intra-and postoperatively using biomarkers and morbidity survey (Clavien Dindo classification).Aim of the Study: Our goal was to evaluate the effect of restrictive hydration while infusing noradrenaline followed by postoperative assessment of complications and hospital stay as opposed to liberal hydration in open abdominal pro-cedures.Patients and Methods: In this randomized double blinded study, 70 patients were split into two sections (restrictive and conventional hydration) scheduled for open abdominal pro-cedures namely radical cystectomy & hemi colectomy. They were then evaluated in the postoperative period for any morbidity or mortality.- Restrictive group (n=35): A primary infusion of Ringer's solution (1ml/kg/h) till the accomplishment of tumor resec-tion, followed by a different dose of 4ml/kg/h before post-operative transfer. The dose of the prophylactic noradren-aline infusion perioperatively was 0.08ug/kg/min.- Conventional group (n=35): An initial bolus of 5 ml/kg of Ringer's solution was infused intraoperatively in the early moments of surgery during anesthesia induction. It was then followed by the usual fluid administration in the form of maintenance, deficit and any other losses.The primary outcome we targeted was postoperative morbidity by the Clavien-Dindo classification and length of hospital stay. Secondary outcome included intra and postop-erative biomarkers and hemodynamics.Results: The restricted fluid regimen with prophylactic noradrenaline resulted in lower incidence of complications (whether medical or surgical) in contrast to liberal hydration.Conclusion: Restricting intravenous fluid therapy plus prophylactic noradrenaline infusion is a safe and effective method of intraoperative hydration with better postoperative outcome.