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Original Clinical Investigation

Restrictive versus liberal intraoperative fluid delivery and outcome in surgical patients in a private tertiary care hospital in the Philippines for the year 2014

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | PDF (756 KB) |Back to Articles Page

Submitted: October 14, 2017 | Posted: March 18, 2018

AUTHORS:

Willmar Jayve M. Anoso, MD (1) and Danilo del Rosario, MD, FPCS, DPBCN (2)

  1. Resident, General Surgery, UERMMMC
  2. Consultant, General Surgery, UERMMMC
INSTITUTION WHERE RESEARCH WAS CONDUCTED:

Department of Surgery, University of the East Ramon Magsaysay Memorial Medical Center (UERMMMC), Metro-Manila, Philippines

ABSTRACT: | Back

Background: Recent reports on intraoperative fluid management have indicated a better outcome with restrictive fluid management compared to standard fluid management. (1) There is no restrictive fluid management practice in the country and there is a need to evaluate this practice.

Objective: To determine what is the protocol on restrictive fluid management and to evaluate its outcome in terms of complications and length of stay.

Methodology: A retrospective study based on surgical records collected for the year 2014 from the Surgery Department of UERMMMC was done. Based on the Brandstrup report (1) the restrictive group was arbitrarily assigned to those with intraoperative fluid delivery of 600 ml/hr or less and the liberal group at >600 ml/hr or more. The following data were collected: patient weight, intraoperative and postoperative fluid volume delivered for the day of surgery, type of fluid delivered, number of postoperative days.

Results: 47 records were retrieved with 25 in the restricted fluid group and 22 in the liberal fluid group. Significant differences were seen in the intraoperative fluid volume and fluid delivery rate; there were no differences in the mean weight of the patients, duration of surgery, mean days when initial bowel movement was noted or total post-operative days. For the restricted group: a) there were more crystalloids given alone, b) there were more colloids given alone; for the liberal group:  a) there were more crystalloids and colloids given together, d) there were more crystalloids, colloids and blood given together. There were lesser complications related to volume delivery in the restricted group: electrolyte imbalance, abdominal distention, sepsis and cardiac arrest episode (not significant). The Odds of developing complications with a liberal fluid delivery is 1.83x the usual.

Conclusion: Restricted fluid delivery in the intraoperative period (600 ml/hr or less) appears to have less complications compared to liberal fluid practice although the differences were not significant, but the odds of developing complications with liberal fluid delivery is 1.83.

KEYWORDS: Restricted, liberal, fluid delivery, intraoperative, complication, length of stay

INTRODUCTION | Back

Fluid and electrolyte management is key to the care and outcome of surgical patients. Changes in both fluid volume and electrolyte composition occur in the perioperative period in response to trauma (the surgery itself) and complications like sepsis with profound impact on the patient’s recovery. (2). Despite years of studies, research and training in the field of surgery the issue of appropriateness of fluid delivery still has to be clearly defined. As aptly pointed out by Navarro et al. currently taught and practiced methods of intraoperative fluid volume are not supported by known physiologic principles (3). This came out into the open with the report of Brandstrup et al (1) where the group showed more complications in the standard intraoperative fluid delivery protocol when compared to a “restricted intraoperative fluid delivery protocol”. They showed that the “restricted protocol” significantly reduced postoperative complications both by intention-to-treat (33% versus 51%, p=0.013) and per-protocol (30% versus 56%, p=0.003) analyses. The numbers of both cardiopulmonary (7% versus 24%, p=0.007) and tissue-healing complications (16% versus 31%, p=0.04) were significantly reduced and no patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, p=0.12).

These results have also raised questions on how to define “restricted” fluid delivery versus standard fluid delivery. As pointed out by Doherty et al. a restrictive regimen in once center may actually be liberal in another (4). Encouraged by the data on restrictive fluid delivery protocol and the question on how much is the volume rate, a study was designed in this institution (Department of Surgery, University of the East Ramon Magsaysay Memorial Medical Center, Metro-Manila, Philippines) to answer both questions. The objectives of this study are: a) To determine what is the volume that defines restrictive fluid management and b) To evaluate its outcome in terms of complications and length of stay.

METHODOLOGY | Back

The main reference for the intraoperative data which includes the type of fluid delivery, type of fluids, total volume of fluids delivered in the OR (operating room), and duration of surgery were based on the report of Brandstrup B. et al. (1)

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Records of major surgery patients from the Department of Surgery of UERMMC in the year 2014 were collected. Included were complete data records which were the following: height and weight, intraoperative fluid record, duration of surgery, complications (=infection) and length of stay.

With the Brandstrup study as reference, intraoperative liberal fluid delivery (L) was pegged at >600 ml/hr or more while intraoperative restrictive delivery (R) was pegged at < 600/hr or less.

These were the measured data:

  1. Preoperative: patient weight
  2. Intraoperative: intraoperative fluid volume, duration of surgery, type of fluid delivered (crystalloid, colloid or blood)
  3. Post-operative course: number of postoperative days, day of bowel movement and complications
  4. These are the complications noted: Nausea and vomiting, Tachycardia, Electrolyte imbalance, ileus, abdominal distention, anemia, fever, pneumonia/congestion and sepsis.
  5. Sepsis was defined as the presence of fever and leukocytosis.

For the statistical analysis, numerical data were presented as means and standard deviation and analyzed using T-Test for normally distributed data and non-parametric tests for non-normally distributed data. Categorical variables were analyzed using Chi-Square. Significance was set at P<0.05. The software used was the NCSS version 10. (5)

RESULTS | Back

Patient Profile:
47 records fulfilling all inclusion requirements were retrieved. Based on the cut-off criteria for restrictive vs. standard/liberal fluid delivery (600 ml/hr) 25 patients were included in the restrictive fluid delivery group while 22 were in the liberal/standard group. (See Table 2)

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Differences and Non-Differences:
The differences between the restricted and liberal group were seen in the protocol itself: intraoperative fluid volume and fluid delivery rate which were both significant. There were no differences in the mean weight of the patients, duration of surgery, mean days when initial bowel movement was noted or total post-operative days.

Fluid Delivery Profile:
The fluids delivered data showed the following: a) there were more crystalloids given alone in the restricted group, b) there were more colloids given alone in the restricted group, c) there were more crystalloids and colloids given together in the liberal group and d) there were more crystalloids, colloids and blood given together in the liberal group. The liberal group had the most fluid delivered either as crystalloid/colloid (45% v. 20%) or crystalloid/colloid/blood combinations (36% v. 20%).

The Complications:
The post-operative complications are listed below in Table 3 and arranged in early or late complications. Pulmonary congestion with or without the presence of pneumonia was the most common complication at 40% with more patients in the liberal intraoperative fluid group. There is no significant difference in comparison with the restricted group, but it is close (p=0.06).

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There were lesser complications related to volume delivery in the restricted group in the following data: electrolyte imbalance, abdominal distention, sepsis and cardiac arrest. Finally the odds of developing complications with a liberal fluid delivery is 1.83x the usual (Table 3).

DISCUSSION: | Back

The fluid regimen for the restricted group was now set at 600 ml/hr or less which was significantly different from that of the liberal group in terms of fluids delivered (2104 ml vs. 4066 ml, p=0.0003). The operative time was similar in both groups together with the postoperative period. The total fluid balances of the day for the rest of the postoperative course could have helped in the determination of fluid effect, but due to the nature of the study (=retrospective) this could not be done. New approaches to the conduct of surgery have been developed and on-going, all designed to put physiology back to the practice of surgery and it is hoped this could result to improvements of surgical patient care. These are the ERAS program (6) and the appropriate fluid for perioperative use especially saline (7). Hopefully the following observations related to increase fluid delivery can be changed in the future: weight increase of 3–6 kg (8.9), decreased muscular oxygen tension due to increased intravenous fluid especially crystalloids (10), delayed recovery of gastrointestinal function (8), and poor survival (11-13).

The study showed a trend towards better results with the restricted fluid group. These were mainly related to the lower volume of fluid delivered and the type of fluids delivered (Table 2). Crystalloids and colloids were mainly the fluids in the restrictive group compared to the liberal group which had all combinations from crystalloids to colloids to blood. Therefore, the complications related to volume were lower in the restrictive group which were the following: electrolyte imbalance (4 vs. 6), abdominal distention (2 vs. 3), and congestion/pneumonia (6 vs. 11). Infectious complication like sepsis was lower (1 vs. 4) and there was less cardiac arrest (1 vs. 2) in the restrictive group. Conversely, the odds of developing more complications is higher with the liberal fluid delivery group (=1.83) (Table 3).

The results echo and support the positive data of Brandstrup et al. (1) The inconclusive result, however, can be attributed to the following: a) small sample size (no power calculation was performed), b) retrospective nature of the study, c) no fluid balance record during the rest of the postoperative period which could have pinpointed the effect of fluid volume all throughout the postoperative phase. Therefore there is the need of a) doing a larger prospective study following calculations for an acceptable sample size and b) a strict fluid balance audit throughout the rest the postoperative period.

CONCLUSION: | Back

The “restrictive fluid regimen” in this institution, set at 600 ml/hr or less, has led to lesser number of complications specifically related to volume overload, although the differences were not statistically significant, but the odds of developing complications with liberal fluid delivery is 1.83.

 

REFERENCES: | Back

  1. Brandstrup B. et al. Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens: A Randomized Assessor-Blinded Multicenter Trial. Ann Surg 2003; 238: 641–8.
  2. Brunicardi FC, MD, Andersen DK, MD, Billiar TR, MD et al. Schwartz's Principles of Surgery, Ninth Edition. The McGraw-Hill Companies, Inc, 2010.
  3. Navarro LHC, Bloomstone J et al. Perioperative fluid therapy: A statement for the international Fluid Optimization Group. Perioperative Medicine2 015; 4:3
  4. Doherty M. Doherty and D.J. Buggy. Intraoperative fluids: how much is too much? British Journal of Anaesthesia 2012; 1-11.
  5. NCSS version 10. Available at: https://www.ncss.com/
  6. Early Recovery After Surgery. Available at: http://erassociety.org/
  7. Awad S and Lobo D. The history of 0.9% saline. Clin Nutr 2008; 27 (2): 179-88.
  8. Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 2002; 359: 1812–18.
  9. Perco MJ, Jarnvig I, Højgaard-Rasmussen N, et al. Electric impedance for evaluation of body fluid balance in cardiac surgical patients. J Cardiothorac Vasc Anesth 2001; 15: 44–8.
  10. Lang K, Boldt J, Suttner S, et al. Colloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery. Anesth Analg 2001; 93: 405–9.
  11. Lowell JA, Schifferdecker C, Driscoll DF, et al. Postoperative fluidoverload: not a benign problem. Crit Care Med 1990; 18: 728–33.
  12. Møller AM, Pedersen T, Svendsen P-E, et al. Perioperative risk factors in elective pneumonectomy: the impact of excess fluid balance. Eur J Anaesthesiol 2002;19: 57–62.
  13. Bennett-Guerrero E, Feierman DE, Barclay GR, et al. Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation. Arch Surg 2001; 136: 1177–1183.

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Articles Page