Fluid administration in laparoscopic cholecystectomy
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Transcript of Fluid administration in laparoscopic cholecystectomy
high vs. low fluid administration to improve recovery after laparoscopic
cholecystectomy
Holte K, Klarskov B, Christensen DS, Lund C, Grubbe Nielsen K, Bie P, Kehlet H
Dpt of Surgical Gastroenterology and Dpt of Anesthesiology, Hvidovre University Hospital, Denmark,
Dpt Physiology and Pharmacology, University of Southern Denmark, Denmark
perioperative fluid therapy
compensation fordehydration/preop
optimisation
improved outcome Holte & Kehlet
Acta Anaesth Scand 2002; 46: 1084
”large” volumes
morbidity (cardio. pulm, ileus, thrombo-embolic)
Brandstrup et al., Ann Surg 2003; 641 Holte,
Sharrock & KehletBr J Anaesth 2002;89:622
optimal regimen?
methods• 48 ASA I-II patients• lap. cholecystectomy• randomize to:
– 15 ml/kg Ringer´s lactate intraop. (~1 liter)
– 40 ml/kg Ringer´s lactate intraop. (~3 liters)
• double-blinded• 175 ml water preop• only morning sessions• standardized
perioperative management
primary outcome assessments
• hormonal responses (pre,0-2h)– aldosterone, ADH, renin, AT-II, ANP
• pulmonary function (pre, 0-4h, 24h)• exercise capacity (pre, 4h, 24h)• balance function (pre, 4h, 24h)• weight (pre, 4h, 24h)• pain, PONV, dizziness
– (early (0-4h) and late (1-3 days postop))• discharge (PADDS > 9, actual discharge)
patient demograpics and anesthesia data
• sex, age, BMI, ASA class – no difference between groups
15 ml kg-1 RL 40 ml kg-1 RL p value
998 (722-1455) 2928 (1950-3920) <0,01
62 (28-144) 74 (40-215) 0,04
95 (63-191) 121 (63-253) 0,06
591 (222-1223) 708 (358-1821) 0,04
duration of surgery (min)
duration of anesthesia (min)
propofol (mg)
fluid infused (ml)
weight
*
*
0,5
1
1,5
2
2,5
4 24time (hours postoperatively)
wei
ght d
iffer
ence
(kg) low fluid
high fluid
* p<0,05 between groups
hormonal responses – aldosterone
* p<0,05 increase# p<0,05 decrease
* p<0,05 vs. preop
*
*
0
20
40
60
80
100
baseline 0 1 2
time (hours postoperatively)
aldo
ster
one
(pg/
ml)
low fluidhigh fluid
* p<0,05 vs. preop
hormonal responses - ADH
* p<0,05 increase# p<0,05 decrease
**
0
0,5
1
1,5
baseline 0 1 2
time (hours postoperatively)
ADH
(pg/
ml)
low fluidhigh fluid
* p<0,05 vs. preop
hormonal responses - ANP
* p<0,05**
**
40
80
120
baseline 0 1 2
time (hours postoperatively)
ANP
(pg/
ml)
low fluidhigh fluid
* p<0,05 vs. preop
pulmonary function - FEV1
**
2,2
2,4
2,6
2,8
3
pre 1 2 4 24
time (hours postoperatively)
FEV
(l se
c-1)
low fluidhigh fluid
* p<0,05 between groups
exercise capacity
*
0
20
40
60
80
100
pre 4 24
time (hours postoperatively)
wor
kloa
d (w
att)
low fluidhigh fluid
* p<0,05 between groups
balance functionstatic and dynamic tests on force plates(BalanceMaster®)
results:•better balance function in high vs. low fluid
group 4h postop (p<0,05)•no difference 24 h postop
subjective parameters
nausea dizziness thirst drowsiness wellbeing
effects of high vs. low fluid administration 0-4 hours postop:
p<0,05
in high fluid group:
15 ml/kg Ringer
40 ml/kg Ringer p value
fulfilling discharge data (PADDS> 9) at day of surgery 67% 96% 0,01
discharge at day of surgery 65% 95% 0,02
discharge data
• decreased vasoactive surgical stress response
• improved perioperative physiology (pulmonary function, exercise capacity, balance function)
• enhanced recovery (nausea, thirst, drowsiness, dizziness, well-being)
• shortened hospital stay
conclusions~3 liters compared to ~1 liter fluid in laparoscopic cholecystectomy lead to: