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: