Restrictive Fluid Therapy Research Articles

Intraoperative fluid management and kidney transplantation outcomes: A retrospective cohort study.

Patients undergoing kidney transplantation traditionally receive liberal amounts of fluid during surgery. However, excessive fluids can lead to fluid overload and ileus. In this retrospective cohort study, we compared the effect of restrictive versus liberal fluid therapy on kidney transplantation outcomes. Patients who underwent deceased-donor kidney transplantation at Mayo Clinic from January 2014 to March 2019 were included. Those who received <3 L of intravenous fluids intraoperatively were categorized as "restrictive;" those who received ≥3 L were categorized as "liberal." The primary outcome was incidence of delayed graft function (DGF). Secondary outcomes included length of stay, readmission within 30 days, time to return of bowel function, and incidence of postoperative complications. Of the 1171 patients included, 557 were in the restrictive group and 614 in the liberal group. The mean (SD) fluid intake was 2.17 (.54)L in the restrictive group and 3.67 (.68)L in the liberal group (P<.001). There was no difference in DGF (relative risk, 1.03; P= .56), length of stay (P= .34), readmission (P= .80), return of bowel function (P= .71), or other postoperative complications. Intraoperative restrictive fluid therapy during kidney transplantation was not associated with DGF or worse outcomes when compared with liberal fluid therapy.

Клиническое значение влияния инфузионной терапии по рестриктивному типу на восстановление моторики желудочно-кишечного тракта после панкреатодуоденальной резекции

Актуальность. Современные достижения в хирургических и анестезиологических технологиях позволили снизить уровень летальности после панкреатодуоденальной резекции (ПДР) до 3 %, однако послеоперационные осложнения при данной патологии достигают 29,5–70 %. Поэтому вопрос поиска и избежания факторов, вызывающих возникновение осложнений после ПДР, является одним из важнейших в развитии современной хирургической панкреатологии. Материалы и методы. Для оценки эффективности схем периоперационного лечения было проведено проспективно-ретроспективное исследование результатов ПДР 78 больных с доброкачественной и злокачественной патологией билиопанкреатодуоденальной зоны за период с 2003 по 2017 г. С 2015 года при выполнении операции начато применение программы ускоренного восстановления (ПУВ). С целью сравнительного анализа больные были разделены на две группы: в I группу (основная) включено 39 пациентов за период с января 2015 по декабрь 2017 г., периоперационное ведение которых проводили в соответствии с ПУВ, во II группу (группа сравнения) ретроспективно отобраны 39 пациентов за период с января 2003 по октябрь 2014 г., периоперационное лечение которых проводилось по традиционному методу. Изучали объем интраоперационной инфузионной терапии, сроки восстановления моторики желудочно-кишечного тракта (ЖКТ) и частоту развития гастростаза. Результаты. Объем применяемых растворов при интраоперационной инфузионной терапии был значительно ниже в первой группе (2100 мл, 95% CI: [1988; 2300] против 3300 мл, 95% CI: [3100; 3500]; p &lt; 0,001). Пациенты I группы вернулись к обычной диете быстрее, чем пациенты ІІ группы (1,00, 95% CI: [1,00; 1,00] против 6,00, 95% CI: [6,00; 7,00]; p &lt; 0,001). При статистическом анализе по данным ROC-кривой была выявлена взаимосвязь между объемом интраоперационной инфузионной терапии и сроком удаления назогастрального зонда и восстановлением перорального питания в послеоперационном периоде. Выводы. Применение рестриктивного типа инфузионной терапии в концепции ПУВ достоверно сокращает сроки восстановления моторики ЖКТ, уменьшая частоту гастростаза у пациентов после ПДР. Обнаружилось, что статистически достоверным фактором влияния на возможность проведения раннего перорального питания является объем интраоперационной инфузии у пациентов после ПДР.

Effect of Goal-directed Fluid Therapy on the Shedding of the Glycocalyx Layer in Retroperitoneal Tumour Resection.

To evaluate the effects of different stroke volume variation (SVV) targets on endothelial glycocalyx (EG) shedding. Randomised controlled trial. Department of Anaesthesiology, Peking University International Hospital, Beijing, China, from February to June 2018. Patients undergoing elective retroperitoneal tumour resection were assigned to one of two groups. SVV 9% group (n=40), who received a more traditional (liberal) fluid therapy with SVV ≤9%; and the SVV 14% group (n=40), received restrictive fluid therapy with SVV ≤14%. Patients' serum concentrations of syndecan-1 (SDC-1), interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) were measured at the time that patients entered the operating theatre; at 1- and 4-hours following initiation of the surgery; and at 24- and 72-hours post-surgery. Postoperative complications, and one-year survival rates were also noted. Perioperative serum SDC-1, IL-6 and TNF-α concentrations were significantly elevated in both groups, which were more pronounced in SVV 9% (p = 0.028, <0.001, and <0.001 respectively). A positive correlation was observed between SDC-1 and TNF-α, L-6, and infusion volume, respectively. Postoperative complications, including fever and blood transfusion, were more aggravated in SVV 9% than those in SVV 14% (80% vs. 59%, and 45% vs. 23.1%, both p <0.05). However, no significant difference in the one-year survival rate was observed. Using SVV 14% as a target for guiding fluid therapy in elective retroperitoneal tumour resection was associated with reduced perioperative glycocalyx shedding, ameliorated inflammatory response, and reduced postoperative complications. Key Words: Randomised controlled trial, Retroperitoneal neoplasms, Glycocalyx, Tumour necrosis factor-alpha, Interleukin-6, Fluid therapy, Stroke volume.

Fluid administration in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: neither too much nor too little

IntroductionIntraoperative fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy plays an important role in postoperative morbidity. Studies have found an association between overload fluid therapy and increased postoperative complications, advising restrictive intraoperative fluid therapy. Our objective in this study was to compare the morbidity associated with restrictive versus non-restrictive intraoperative fluid therapy. MethodsRetrospective analysis of a database collected prospectively in the Anesthesiology Service of Virgen del Roc.ío Hospital, from December 2016 to April 2019. One hundred and six patients who underwent complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were divided into two cohorts according to Fluid Therapy received 1. Restrictive.ß..±.ß9.ßmL.kg-1.h-1 (34 patients), 2. Non-restrictive .ß.ß....ß9.ßmL.kg-1.h-1 (72 patients). Percentage of major complications (Clavien-Dindo grade III...IV) and length hospital stay were the main outcomes variables. ResultsOf the 106 enrolled patients, 68.9% were women; 46.2% had ovarian cancer, 35.84% colorectal cancer, and 7.5% peritoneal cancer. The average fluid administration rate was 11.ß...ß3.58.ßmL.kg-1.h-1. The restrictive group suffered a significantly higher percentage of Clavien-Dindo grade III...IV complications (35.29%) compared with the non-restrictive group (15.27%) (p.ß=.ß0.02). The relative risk associated with restrictive therapy was 1.968 (95% confidence interval: 1.158...3.346). We also found a significant difference for hospital length of stay, 20.91 days in the restrictive group vs 16.19 days in the non-restrictive group (p.ß=.ß0.038). ConclusionsIntraoperative fluid therapy restriction below 9.ßmL.kg-1.h-1 in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was associated with a higher percentage of major postoperative complications.

Urine the Right Direction: The Consensus Statement From the Committee on Transplant Anesthesia of the American Society of Anesthesiologists on Fluid Management During Kidney Transplantation.

Urine the Right Direction: The Consensus Statement From the Committee on Transplant Anesthesia of the American Society of Anesthesiologists on Fluid Management During Kidney Transplantation.

High Dose Ascorbic Acid During Acute Resuscitation in Critically Burn Patients.

Ascorbic acid (AA) is a potent oxygen-free radical scavenger. We hypothesized that treating severe burn patients with high doses of AA (HDAA) can reduce fluid resuscitation requirements and prevent organ dysfunction. We performed a unicentric, retrospective case-control study of 75 burn patients: 25 patients admitted from 2018 to 2019 with more than 30% Total Surface Body Surface Area (TSBA) burned who received HDAA (66 mg/kg/h as soon as possible after admission until 36 h after injury), and 50 patients admitted from 2014 to 2017 with similar Abbreviated Burn Severity Index (ABSI)/Baux scores who were treated with the same protocol but did not receive HDAA. During the first 24 hours of burn resuscitation the HDAA group required less fluids than the control group (3.06 ± 0.87 ml/kg/%TBSA vs 4.32 ± 1.51 P < .05), but the overall reduction of fluid requirements during the first 72 hours was not significant. There were no significant differences in Sequential Organ Failure Assessment (SOFA), other hemodynamic parameters, complications, or mortality. We also did not find an increase acute kidney injury in patients who received HDAA even though the mean urine oxalate/creatinine ratio was 0.61 (0.02-0.96). We conclude that in severe burn patients treated with a restrictive fluid therapy protocol, administration of HDAA can decrease only the initial fluid requirements but not total fluid intakes. We did not find differences in severity score after resuscitation or in mortality. Nor did we find an increase in renal failure in patients administered with HDAA.

Transthoracic Echocardiography A Predictor of Complications in Patients with Severe Preeclampsia

Background: Severe preeclampsia (PE) and eclampsia are a hypertensive disease of pregnancy associated with significant morbidity and mortality and require special monitoring. Lung ultrasonography and transthoracic echocardiography are a novel monitoring and diagnostic tools in intensive care and are widely used nowadays. Objective: To detect the role and value of transthoracic echocardiography (TTE) in postoperative monitoring in patients with severe PE. Patients and Methods: This was a cross sectional study of 55 patients with severe preeclampsia, 35 patients with eclampsia and 60 healthy controls. Transthoracic echocardiography was done to evaluate diastolic function using E/A ratio with continuous wave Doppler, ejection fraction using M mode in long axis parasternal view and inferior vena cava (IVC) diameter in subcostal view. All measurements were done postoperatively. Results: There was significant difference between the 3 groups regarding diastolic function (p value 0.0001). Abnormal diastolic function in severe PE, eclampsia and controls was 81.2%, 94.3% and 5% respectively. There was no difference between the 3 groups of the study as regard IVC diameter. There was significant difference between the 3 groups as regards EF (P=0.007), the mean of EF in severe PE, eclampsia and controls was 66.89 ± 5.54, 63.029 ± 8.45 and 66.43 ± 4.16 respectively. Conclusions: The use of transthoracic echocardiography is mandatory in postoperative monitoring in patients with severe PE and eclampsia as they can adjust management and detect complications. Restricted fluid therapy policy is indicated with the higher grades of diastolic dysfunction and lower ejection fraction (EF).

STRATEGIES FOR PERIOPERATIVE FLUID THERAPY: GOAL-DIRECTED VS LIBERAL AND RESTRICTIVE (literature review)

The review highlights the analysis of modern literature data from randomized multicenter controlled trials conducted in the world in order to determine the optimal strategy for perioperative fluid therapy in both planned and urgent interventions. To date, despite a large number of studies on the effect of perioperative infusion therapy volumes on treatment outcome in abdominal operations, conflicting data have been obtained. There is no convincing evidence about the benefits of restrictive, liberal regimes or goal-directed fluid therapy, although from both theoretical and practical points of view, none of the researchers doubts the fact that maintaining an optimal balance requires an individual approach, which could reduce many postoperative complications. Recently, researchers have pointed out the advantages of goal-directed infusion therapy as one of the components of the ERAS protocol, the strategy which based on the regulation of cardiac output (SV) and stroke volume (UO) and achieving intraoperative zero fluid balance, especially in high-risk patients with concomitant diseases of cardio-vascular system. Recent multicenter studies such as RELIEF compared the restrictive and liberal regimes of fluid therapy and concluded that perioperative fluid management in extensive operations should be achieved using a “conditionally liberal regimen” with positive water balance of one to two liters by the end of the operation. Researchers are revising the concept of fluid loss in the “third space” and the need for its compensation. The role of endothelial glycocalyx in maintaining the integrity of the endothelium, as well as the reaction of atrial natriuretic peptide (ANP) to volumetric fluid overload, which provokes platelet aggregation, increases vascular permeability and, as a result, manifests tissue edema, is shown. Large-scale RELIEF and OPTIMISE studies are continuing in this direction in order to offer the optimal regimen of perioperative fluid therapy for various surgical interventions.

Effect of fluid strategy on stroke volume, cardiac output, and fluid responsiveness in adult patients undergoing major abdominal surgery: a sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial

BackgroundWe designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes. MethodsStroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness. ResultsAnalysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6–48.8) vs liberal 44.0 (34.9–61.9) ml m−2; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32–4.05) vs 2.42 (1.94–3.26) L min−1 m−2; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant). ConclusionsThe liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups. Clinical trial registrationACTRN12615000125527.

Fluid restriction in the management of transient tachypnea of the newborn.

Transient tachypnea of the newborn (TTN) is caused by delayed clearance of lung fluid at birth. TTN typically appears within the first two hours of life in term and late preterm neonates and is characterized by tachypnea and signs of respiratory distress. Although it is usually a self-limited condition, admission to a neonatal unit is frequently required for monitoring and providing respiratory support. Restricting intake of fluids administered to these infants in the first days of life might improve clearance of lung liquid, thus reducing the effort required to breathe, improving respiratory distress, and potentially reducing the duration of tachypnea. To evaluate the efficacy and safety of restricted fluid therapy as compared to standard fluid therapy in decreasing the duration of oxygen administration and the need for noninvasive or invasive ventilation among neonates with TTN. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 12), in the Cochrane Library; Ovid MEDLINE and electronic ahead of print publications, in-process & other non-indexed citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on December 6, 2019. We also searched clinical trial databases and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. We included randomized controlled trials (RCTs), quasi-RCTs, and cluster trials on fluid restriction in term and preterm neonates with the diagnosis of TTN or delayed adaptation during the first week after birth. For each of the included trials, two review authors independently extracted data (e.g. number of participants, birth weight, gestational age, duration of oxygen therapy, need for continuous positive airway pressure [CPAP], need for mechanical ventilation, duration of mechanical ventilation) and assessed the risk of bias (e.g. adequacy of randomization, blinding, completeness of follow-up). The primary outcome considered in this review was the duration of supplemental oxygen therapy in hours or days. We used the GRADE approach to assess the certainty of evidence. Four trials enrolling 317 infants met the inclusion criteria. Three trials enrolled late preterm and term infants with TTN, and the fourth trial enrolled only term infants with TTN. Infants were on various methods of respiratory support at the time of enrollment including room air, oxygen, or nasal CPAP. Infants in the fluid-restricted group received 15 to 20 mL/kg/d less fluid than those in the control group for varying durations after enrollment. Two studies had high risk of selection bias, and three out of four had high risk of performance bias. Only one study had low risk of detection bias, with two at high risk and one at unclear risk. The certainty of evidence for all outcomes was very low due to imprecision of estimates and unclear risk of bias.Twotrialsreported the primary duration of supplemental oxygen therapy. We are uncertain whether fluid restriction decreases or increases the duration of supplemental oxygen therapy (mean difference [MD] -12.95hours, 95% confidence interval [CI]-32.82to 6.92;I² = 98%; 172 infants).Similarly, there is uncertainty for various secondary outcomes including incidenceof hypernatremia (serum sodium > 145 mEq/L, risk ratio [RR] 4.0, 95% CI 0.46 to 34.54; test of heterogeneitynot applicable;1 trial, 100 infants), hypoglycemia(blood glucose < 40 mg/dL, RR 1.0, 95% CI 0.15 to 6.82; test of heterogeneity not applicable;2 trials, 164 infants), endotracheal ventilation (RR0.73, 95% CI 0.24 to 2.23; I² = 0%; 3 trials, 242infants), need for noninvasiveventilation (RR 0.40, 95% CI 0.14 to 1.17; test of heterogeneity not applicable; 2 trials, 150 infants), length of hospital stay (MD -0.92 days, 95% CI -1.53 to -0.31; test of heterogeneity not applicable; 1 trial, 80 infants), and cumulative weight loss at 72 hours of age (%) (MD 0.24, 95% CI -1.60to 2.08; I² = 89%; 2 trials, 156 infants).We did not identify any ongoing trials; however, one trial is awaiting classification. We found limited evidence to establish the benefits and harms of fluid restriction in the management of TTN. Given the very low certainty of available evidence, it is impossible to determine whether fluid restriction is safe or effective for management of TTN. However, given the simplicity of the intervention, a well-designed trial is justified.

Goal-directed Therapy and Postcystectomy Ileus: Comment.

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

Effects of controlled hypotension with restrictive transfusion on intraoperative blood loss and systemic oxygen metabolism in elderly patients who underwent lumbar fusion

BackgroundThe effects of restrictive fluid therapy combined with controlled hypotension in the elderly on systemic oxygen metabolism and renal function are clinical concerns. The aim of this study was to evaluate blood loss, oxygen metabolism, and renal function in different levels of controlled hypotension induced by intravenous nitroglycerin, in combination with limited infusion, in elderly patients undergoing posterior lumbar fusion.MethodsA total of 40 patients, aged 60–75 with ASA grade II or III, who were planned for posterior lumbar fusion were randomly allocated into two groups: experimental group [target mean arterial pressure 65 mmHg (MAP 65) or control group (MAP 75)]. Indicators for blood loss, hemodynamic, systemic oxygen metabolism, and renal function evaluation index were recorded before operation (T0), 1 h after induced hypotension (T1), 2 h after hypotension (T2), and in recovery (T3). We compared changes in these parameters between groups to evaluate the combined effects of controlled hypotension with restrictive infusion.ResultsCI, DO2I, and VO2I were lower in both groups at T1–T3 compared with T0 (p < 0.05). DO2I and VO2I in the MAP 65 group were lower than the MAP 75 group after operation. In both groups, SCysC increased at T1, T2, and T3 (p < 0.05) compared with T0.ConclusionsRestrictive transfusion and control MAP at 65 mmHg can slightly change in renal function and reduce the risk of insufficient oxygen supply and importantly have no significant effect on blood loss and postoperative complications.Trial registrationChiCTR-INR-16008153. Registered on 25 March 2016.

Understanding Restrictive Versus Liberal Fluid Therapy for Major Abdominal Surgery Trial Results: Did Liberal Fluids Associate With Increased Endothelial Injury Markers?

The restrictive versus liberal fluid therapy for major abdominal surgery trial was an international, randomized, assessor-blinded trial comparing restrictive with liberal IV fluid regimens that represented traditional care in patients undergoing major abdominal surgery. Cohort of restrictive versus liberal fluid therapy for major abdominal surgery bloods was collected at a single major site (161 patients) prior to, day 1 and day 3 after surgery. Bloods were blindly and randomly batch analyzed for plasma markers of endothelial/glycocalyx injury-angiopoietin-1, angiopoietin-2, soluble tyrosine-protein kinase-2 receptor, soluble intracellular adhesion molecule-1, syndecan, and tumor necrosis factor-α. Data were examined as restrictive versus liberal enrollment groups and high versus low (± 5,000 mL) fluid groups. Differences were examined by linear mixed modeling. There were no significant differences in any biomarkers between the restrictive (n = 75) and liberal (n = 86) groups. When examined as low (n = 81) and high (n = 79) fluid groups, plasma angiopoietin-2 (p = 0.009) and soluble intracellular adhesion molecule-1 (p = 0.01) were elevated in the high fluid group. There were no differences in other biomarkers. Although these results are consistent with previous findings of vascular injury following liberal fluid therapy, they suggest alternative mechanisms underlie the clinical outcomes from restrictive versus liberal fluid therapy for major abdominal surgery study. NCT01424150.

Effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy combined with enhanced recovery after surgery protocol on complications after thoracoscopic lobectomy in high-risk patients: study protocol for a prospective randomized controlled trial

BackgroundAcute kidney injury (AKI) is a common complication after thoracoscopic lobectomy in high-risk patients due to insufficient intraoperative infusion. Goal-directed fluid therapy (GDFT) is an individualized fluid infusion strategy; the fluid infusion strategy is adjusted according to the patient’s fluid response. GDFT during operation can reduce the incidence of AKI after major surgery. Enhanced recovery after surgery (ERAS) protocol optimizes perioperative interventions to decrease the postoperative complications after surgery. In ERAS protocol of lobectomy, intraoperative restrictive fluid therapy is recommended. In this study, we will compare the effects of intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients.Methods/designThis is a prospective single-center single-blind randomized controlled trial. Two hundred seventy-six patients scheduled for thoracoscopic lobectomy are randomly allocated to receive either GDFT or restrictive fluid therapy combined with an ERAS protocol at a 1:1 ratio. The primary outcome is the incidence of AKI after operation. The secondary outcomes include (1) the incidence of renal replacement therapy, (2) the length of intensive care unit stay after operation, (3) the length of hospital stay after operation, and (4) the incidence of other complications including infection, acute lung injury, pneumonia, arrhythmia, heart failure, myocardial injury after noncardiac surgery, and cardiac infarction.DiscussionThis is the first study to compare intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients. The hypothesis is that the restrictive fluid therapy is noninferior to GDFT in reducing the incidence of AKI, but restrictive fluid therapy is simpler to apply than GDFT.Trial registrationClinicalTrials.govNCT04302467. Registered on 26 February 2020

Hipertermik İntraperitoneal Kemoterapi Yapılan Hastalarda İntraoperatif Restriktif Sıvı Tedavisinin Postoperatif Sonuçlar Üzerine Etkisi

INTRODUCTION: Hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRC) are effective multimodal treatment options in patients with peritoneal carcinomatosis. Procedures are long-lasting operations with excessive blood and fluid loss. Intraoperative fluid management is very important because of major hemodynamic, respiratory and metabolic changes. This study aims to investigate the effect of intraoperative restrictive fluid therapy on postoperative outcome in patients undergoing HIPEC and SRS. METHODS: Patients who underwent HIPEC and SRS in our clinic between 2014-2018 were included in the study. The demographic, intraoperative and postoperative data of all patients were retrospectively analyzed. The patients who underwent restrictive fluid replacement were named Group R, and the group with liberal fluid replacement was named Group L. RESULTS: It was observed that the mean age was 54.6 ± 11.4 years, the female gender was 60.5% and the malignancy originating from the gastrointestinal system was 76.3%. There was no effect of liberal and restrictive fluid treatments on postoperative minor and major complications, length of stay in hospital and intensive care, and mortality. DISCUSSION AND CONCLUSION: We concluded that intraoperative restrictive fluid therapy did not affect postoperative complications and mortality in HIPEC and SRS surgeries.

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.

Effects of Liberal Versus Restrictive Fluid Therapy on Renal Function Indices in Laparoscopic Bariatric Surgery.

BackgroundEarlier studies have suggested the liberal administration of fluids in favor of reducing the risk of rhabdomyolysis in obese patients, but the results are conflicting.ObjectivesThe present study aimed at comparing the effects of liberal and restrictive fluid therapy on renal indices in laparoscopic gastric bypass surgery.MethodsIn a double-blinded randomized clinical trial, 72 candidates of bariatric surgery were randomly assigned into two groups of restrictive and liberal fluid therapy. Indices, including BUN, creatinine, creatine kinase, GFR, and urine output were measured before and 24 hours after the surgery. The clinical trial was registered at IRCT.ir under code IRCT20170109031852N3.ResultsThere was no significant difference in BUN, creatinine, creatinine kinase, and GFR indices between the two groups of liberal and restrictive fluid therapy both before and 24 hours after surgery (P > 0.05). Intragroup comparisons before and after surgery revealed that BUN decreased in both groups after the surgery (P < 0.05). Also, creatinine and GFR values improved in patients who received a liberal fluid regimen, whereas these indices remained statistically unchanged in the restrictive group before and 24 hours after the surgery (P > 0.05).ConclusionsTwo methods of liberal and restrictive fluid therapy have comparable effects on traditional renal functional indices in laparoscopic bariatric surgery. The clinical significance of observed differences in outcomes should be investigated in further studies. The use of early biomarkers of acute kidney injury is warranted.

English

BACKGROUND Restriction of fluid is widely adopted as a strategic non-pharmacological therapy for patients with heart failure (HF). However, insufficient fluid leads to intravascular volume contraction further causing hypoperfusion of vital organs. Renal dysfunction and cardiac ischemia caused by hypoperfusion can further aggravate heart failure. Therefore, the authors decided to study the effect of fluid intake on various functional and cardiac parameters of patients of HF. METHODS 50 patients with a diagnosis of heart failure with reduced ejection fraction who had been discharged from the hospital since last 6 months and who were on restricted fluid therapy were included in the study. Patients were advised to visit the OPD once every 4 weeks and provide a record of their fluid intake. All patients irrespective of functional class were advised a fluid intake of 30 mL / day / Kg body weight. Functional status, biochemical parameters and clinical parameters were measured regularly until the end of 12 weeks. RESULTS There was marked improvement in the functional status of patients and statistically significant number was shifted from NYHA III and IV to NYHA I and II. PFI (Prescribed Fluid Intake) was associated with improvement of exercise tolerance in all NYHA Classes. Creatinine levels declined in all NYHA Classes with very high drop from 2.32 to 1.0 in NYHA Class IV. CONCLUSIONS Compensated HF patients should be prescribed physiologically correct dietary fluid intake based on body weight. This improves their functional capacity, biochemical parameters and left ventricular ejection fraction. KEYWORDS Heart Failure, Diet, Sodium-Restricted, Diuretics, Exercise Tolerance

The Impact of Suprarenal Cross-Clamping on Kidney Function in Patients Undergoing Retroperitoneal Abdominal Aortic Aneurysm Repair following an Enhanced Recovery Protocol

The retroperitoneal approach (RP) is a well-established procedure for juxtarenal and infrarenal (IR) abdominal aortic aneurysm (AAA) repair when an endovascular option is not available. The aim of this study is to compare the effect of suprarenal (SR) and IR aortic clamping on postoperative renal function following an Enhanced Recovery Protocol (ERP). Since there are no defined guidelines within aortic surgery, we focused our attention on the role of fluid and vasopressor administration in the development of postoperative acute kidney injury (AKI). This is a single-center retrospective cohort study on 140 RP aortic aneurysm repair patients operated between 2009 and 2019. Patients were divided in 2 groups: 24 had SR clamping and 116 IR clamping. Since 2009, at our institution all patients have followed an Enchanced Recovery Program which has been implemented as standard care for patients undergoing open AAA repair. The 2 groups were well matched for baseline characteristics, preoperative renal function, and comorbidity. There was an increased need for intraoperative fluids (P=0.015), and vasopressors (P=0.002) in the SR group compared to the IR group. Patients in the SR group showed a higher trend of postoperative AKI as opposed to the control group (37.5% vs. 19.8%), although this event was not statistically significant (P=0.106). Acute Kidney Injury Network stage III requiring temporary dialysis occurred in only 3 patients who all belonged to the IR group. Conversely, stage I and II with a 2- or 3-fold increase in postoperative creatinine were more frequent in the SR group. However, these normalized before discharge in all cases. To the best of our knowledge, none of the above required permanent dialysis. The results from this study show that SR clamping during RP juxtarenal aortic aneurysm repair does not have an adverse effect on postoperative renal function in the short term. However, patients undergoing SR clamping require greater fluid and vasopressor usage, in contrast with the restrictive fluid therapy established by traditional protocols. This could be an important benchmark for future implementation of ERPs in vascular surgery, especially in open procedures requiring visceral clamping.

Minimal Clinically Important Difference, Maximum Impact.

Minimal Clinically Important Difference, Maximum Impact.