Fluid Balance in an Enhanced Recovery Pathway Edwin Itenberg, DO, FACS, FASCRS St. Joseph Mercy Oakland MSQC/ASPIRE Meeting April 28, 2017
No Disclosures 2
Introduction The optimal intravenous fluid regimen for patients undergoing major abdominal surgery is unclear. Perioperative fluid management is controversial, with a large variability in daily practice Main goal of intraoperative fluid therapy is to maintain tissue perfusion by optimizing intravascular volume status and stroke volume 1. Chappell D, Jacob M, Hofmann-Kiefer K, et al. A rational approach to perioperative fluid management. Anesthesiology 2008; 109:723. 2. Lowell JA, Schifferdecker C, Driscoll DF, et al. Postoperative fluid overload: not a benign problem. Crit Care Med 1990; 18:728. 3
Enhanced Recovery After Surgery ERAS, also known as fast track programs, are evidence-based protocols designed to: reduce surgical trauma and postoperative stress minimizing pain reducing complications standardize medical care improve outcomes lower health care costs and LOS 4
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Enhanced Recovery After Surgery What is the most important component of the ERAS pathway? No prolonged fasting Carbohydrate loading Pain control Fluid administration Early feeding 6
Standard or liberal Restrictive Goal directed therapy Fluid Administration Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases 7
Fluid Administration Hypovolemia leads to low cardiac output and decreased tissue perfusion Hypervolemia associated with increases in morbidity, length of intensive care unit stay, and postoperative mortality 8
Effect on GI Tract In cardiac surgery patients, plasma volume expansion to achieve maximal ventricular stroke volume, assessed by oesophageal Doppler, led to significantly better perfusion of the gastrointestinal mucosa and a significant decrease in major postoperative complications In contrast, in 57 patients undergoing bowel surgery, no differences in postoperative ileus and hospital stay were found in the intervention group receiving goal-directed fluid therapy compared with standard fluid infusions 1. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 1995; 130: 423 9. 2. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia 2002; 57: 845 9 9
Hypovolemia Leads to decrease in tissue perfusion à 1. Acute kidney injury 2. Splanchnic vasoconstriction Chieveley-Williams S, Hamilton-Davies C. The role of the gut in major surgical postoperative morbidity. Int Anesthesiol Clin 1999; 37:81. 10
Acute Kidney Injury Major concern is that oliguria is a sign of developing renal failure As a result, surgeons and anesthesiologists strive to maintain UOP most commonly with boluses of intravenous fluid. Intraoperative UOP may not reflect fluid status or predict renal failure Within an ERAS protocol, postoperative hypotension and low UOP are common within the first 24 hr, whereas renal dysfunction is extremely rare 1. Kheterpal S, Tremper KK, Englesbe MJ, et al. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology 2007; 107: 892-902. 2. Hubner M, Lovely JK, Huebner M, Slettedahl SW, Jacob AK, Larson DW. Intrathecal analgesia and restrictive perioperative fluid management within enhanced recovery pathway: hemodynamic implications. J Am Coll Surg 2013; 216: 1124-34. 11
Hypervolemia Increased extracellular fluid in the bowel can lead sequentially to gastrointestinal edema, decreased gastrointestinal motility, and ileus In addition, for patients undergoing bowel surgery, intestinal edema can increase tension at bowel anastomoses and may contribute to anastomotic dehiscence 1. Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005; 103:25. 2. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002; 89:622. 12
Colon & Rectal Surgery Hypervolemia Increased duration of ileus, postoperative complications, and hospital stay after major abdominal surgery Delayed gastric emptying and ileus Difficulty of adequately assessing normovolemia 1. Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005; 103: 25 32. 2. 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 8 13
So, what should we do? 14
Many studies examined fluid administration, but few in the context of an ERAS pathway 100 patients total GDT mean of 2,115 ml Restrictive arm 1500 ml 15
Retrospective review of Premier database 84,722 colon, 22,178 rectal, and 548,526 primary hip or knee replacement surgical patients High fluid volume significantly associated with increased length of stay and total costs High fluid utilization associated with increased presence of post-op ileus Worse outcomes are seen in the extremes of fluid administration Protocoled approach toward optimal fluid management may improve outcomes 16
Clearance of fluids during general anesthesia is only a small fraction of that observed when awake Positive fluid balance has been shown to be associated with in increased incidence of acute kidney injury (AKI) after major surgery Laparoscopic surgery 1. Ewaldsson CA, Hahn RG. Kinetics and extravascular retention of lacetated Ringer s solution during isoflurane or propofol anesthesia for thyroid surgery. Anesthesiology 2005; 103: 460-9. 2. Alpert RA, Roizen MF, Hamilton WK, et al. Intraoperative urinary output does not predict postoperative renal function in patients undergoing abdominal aortic revascularization. Surgery 1984; 95: 707-11. 17
No literature comparing goal-directed therapy or restrictive to standard therapy in an enhanced recovery protocol When both the perioperative surgeon-driven elements and the intraoperative pain and fluid management anesthesia-driven elements are combined, the benefits of enhanced recovery are maximized 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. 18
Outcomes A multicenter randomized trial including 156 patients found that patients in the fast-track program had significantly decreased median LOS and fewer postoperative complications (5 versus 9 days, and 21 versus 49 percent, respectively). In one retrospective study, 541 consecutive procedures reviewed. Median LOS was 3 days, >25% discharged within 48 hrs. Factors associated with discharge in 48 hrs: Full compliance with ERAS pathway Low oral opiate intake High surgeon volume 1. Muller S, Zalunardo MP, Hubner M, et al. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009; 136:842. 2. Larson DW, et al. Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. BJS 2014;101:1023-30. 19
Thank You! 20
Questions? 21