FluidBalanceinanEnhancedRecoveryPathway

EdwinItenberg,DO,FACS,FASCRSSt.JosephMercyOaklandMSQC/ASPIREMeetingApril28,2017

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NoDisclosures

Introduction

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• Theoptimalintravenousfluidregimenforpatientsundergoingmajorabdominalsurgeryisunclear.

• Perioperativefluidmanagementiscontroversial,withalargevariabilityindailypractice

• Maingoalofintraoperativefluidtherapyistomaintaintissueperfusionbyoptimizingintravascularvolumestatusandstrokevolume

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1.ChappellD,JacobM,Hofmann-KieferK,etal.Arationalapproachtoperioperativefluidmanagement.Anesthesiology2008;109:723.2.LowellJA,Schifferdecker C,DriscollDF,etal.Postoperativefluidoverload:notabenignproblem.Crit CareMed1990;18:728.

EnhancedRecoveryAfterSurgery

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• ERAS,alsoknownas“fasttrack”programs,areevidence-basedprotocolsdesignedto:– reducesurgicaltraumaandpostoperativestress– minimizingpain– reducingcomplications– standardizemedicalcare– improveoutcomes– lowerhealthcarecostsandLOS

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EnhancedRecoveryAfterSurgery

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• WhatisthemostimportantcomponentoftheERASpathway?– Noprolongedfasting– Carbohydrateloading– Paincontrol– Fluidadministration– Earlyfeeding

FluidAdministration

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• Standardor“liberal”• Restrictive• Goaldirectedtherapy

• FluidmanagementwithinERASshouldbeviewedasacontinuumthroughthepreoperative,intraoperative,andpostoperativephases

FluidAdministration

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• Hypovolemialeadstolowcardiacoutputanddecreasedtissueperfusion

• Hypervolemiaassociatedwithincreasesinmorbidity,lengthofintensivecareunitstay,andpostoperativemortality

EffectonGITract

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• Incardiacsurgerypatients,plasmavolumeexpansiontoachievemaximalventricularstrokevolume,assessedbyoesophageal Doppler,ledtosignificantlybetterperfusionofthegastrointestinalmucosaandasignificantdecreaseinmajorpostoperativecomplications

• Incontrast,in57patientsundergoingbowelsurgery,nodifferencesinpostoperativeileusandhospitalstaywerefoundintheinterventiongroupreceivinggoal-directedfluidtherapycomparedwithstandardfluidinfusions

1. MythenMG,WebbAR.Perioperativeplasmavolumeexpansionreducestheincidenceofgutmucosalhypoperfusion duringcardiacsurgery.ArchSurg 1995;130:423–9.

2. ConwayDH,Mayall R,Abdul-LatifMS,GilliganS,Tackaberry C.Randomised controlledtrialinvestigatingtheinfluenceofintravenousfluidtitrationusingoesophageal Dopplermonitoringduringbowelsurgery.Anaesthesia 2002;57:845–9

Hypovolemia

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• Leadstodecreaseintissueperfusionà1. Acutekidneyinjury2. Splanchnicvasoconstriction

Chieveley-WilliamsS,Hamilton-DaviesC.Theroleofthegutinmajorsurgicalpostoperativemorbidity.Int Anesthesiol Clin 1999;37:81.

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AcuteKidneyInjury

• Majorconcernisthatoliguriaisasignofdevelopingrenalfailure

• Asaresult,surgeonsandanesthesiologistsstrivetomaintainUOPmostcommonlywithbolusesofintravenousfluid.

• IntraoperativeUOPmaynotreflectfluidstatusorpredictrenalfailure

• WithinanERASprotocol,postoperativehypotensionandlowUOParecommonwithinthefirst24hr,whereasrenaldysfunctionisextremelyrare

1. Kheterpal S,Tremper KK,Englesbe MJ,etal.Predictorsofpostoperativeacuterenalfailureafternoncardiac surgeryinpatientswithpreviouslynormalrenalfunction.Anesthesiology2007;107:892-902.

2. Hubner M,LovelyJK,HuebnerM,Slettedahl SW,JacobAK,LarsonDW.Intrathecalanalgesiaandrestrictiveperioperativefluidmanagementwithinenhancedrecoverypathway:hemodynamicimplications.JAmColl Surg 2013;216:1124-34.

Hypervolemia

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• Increasedextracellularfluidinthebowelcanleadsequentiallytogastrointestinaledema,decreasedgastrointestinalmotility,andileus

• Inaddition,forpatientsundergoingbowelsurgery,intestinaledemacanincreasetensionatbowelanastomosesandmaycontributetoanastomoticdehiscence

1. Nisanevich V,Felsenstein I,Almogy G,etal.Effectofintraoperativefluidmanagementonoutcomeafterintraabdominalsurgery.Anesthesiology2005;103:25.2. Holte K,SharrockNE,Kehlet H.Pathophysiologyandclinicalimplicationsofperioperativefluidexcess.BrJAnaesth 2002;89:622.

Hypervolemia

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Colon&RectalSurgery• Increaseddurationofileus,postoperativecomplications,andhospitalstayaftermajorabdominalsurgery

• Delayedgastricemptyingandileus• Difficultyofadequatelyassessingnormovolemia

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1. Nisanevich V,Felsenstein I,Almogy G,etal.Effectofintraoperativefluidmanagementonoutcomeafterintraabdominalsurgery.Anesthesiology2005;103:25–32.2. LoboDN,BostockKA,NealKR,etal.Effectofsaltandwaterbalanceonrecoveryofgastrointestinalfunctionafterelectivecolonicresection:arandomised

controlledtrial.Lancet2002;359:1812–8

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So,whatshouldwedo?

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• Manystudiesexaminedfluidadministration,butfewinthecontextofanERASpathway

• 100patientstotal• GDTmeanof2,115mL• Restrictivearm1500mL

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• RetrospectivereviewofPremierdatabase• 84,722colon,22,178rectal,and548,526primaryhiporknee

replacementsurgicalpatients• Highfluidvolumesignificantlyassociatedwithincreasedlengthof

stayandtotalcosts• Highfluidutilizationassociatedwithincreasedpresenceofpost-op

ileus• Worseoutcomesareseenintheextremesoffluidadministration• Protocoledapproachtowardoptimalfluidmanagementmay

improveoutcomes

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• Clearanceoffluidsduringgeneralanesthesiaisonlyasmallfractionofthatobservedwhenawake

• Positivefluidbalancehasbeenshowntobeassociatedwithinincreasedincidenceofacutekidneyinjury(AKI)aftermajorsurgery

• Laparoscopicsurgery

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1. Ewaldsson CA,HahnRG.Kineticsandextravascularretentionoflacetated Ringer’ssolutionduringisofluraneorpropofol anesthesiaforthyroidsurgery.Anesthesiology2005;103:460-9.

2. AlpertRA,RoizenMF,HamiltonWK,etal.Intraoperativeurinaryoutputdoesnotpredictpostoperativerenalfunctioninpatientsundergoingabdominalaorticrevascularization.Surgery1984;95:707-11.

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• Noliteraturecomparinggoal-directedtherapyorrestrictivetostandardtherapyinanenhancedrecoveryprotocol

• Whenboththeperioperativesurgeon-drivenelementsandtheintraoperativepainandfluidmanagementanesthesia-drivenelementsarecombined,thebenefitsofenhancedrecoveryaremaximized

Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144:961–969.

Outcomes

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• Amulticenterrandomizedtrialincluding156patientsfoundthatpatientsinthefast-trackprogramhadsignificantlydecreasedmedianLOSandfewerpostoperativecomplications(5versus9days,and21versus49percent,respectively).

• Inoneretrospectivestudy,541consecutiveproceduresreviewed.MedianLOSwas3days,>25%dischargedwithin48hrs.

• Factorsassociatedwithdischargein48hrs:• FullcompliancewithERASpathway• Loworalopiateintake• Highsurgeonvolume

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1. MullerS,Zalunardo MP,Hubner M,etal.Afast-trackprogramreducescomplicationsandlengthofhospitalstayafteropencolonicsurgery.Gastroenterology2009;136:842.

2. LarsonDW,etal.Outcomesafterimplementationofamultimodalstandardcarepathwayforlaparoscopiccolorectalsurgery.BJS2014;101:1023-30.

ThankYou!

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Questions?

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