American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative  (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery

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Abstract

Background

Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery “bundles” because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain.

Methods

In the “Perioperative Quality Initiative (POQI) Fluids” workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP.

Discussion

We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.

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Most cited references 78

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Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.

Birgitte Brandstrup, Hanne Hjorth Tønnesen, Randi Beier-Holgersen … (2003)

To investigate the effect of a restricted intravenous fluid regimen versus a standard regimen on complications after colorectal resection. Current fluid administration in major surgery causes a weight increase of 3-6 kg. Complications after colorectal surgery are reported in up to 68% of patients. Associations between postoperative weight gain and poor survival as well as fluid overload and complications have been shown. We did a randomized observer-blinded multicenter trial. After informed consent was obtained, 172 patients were allocated to either a restricted or a standard intraoperative and postoperative intravenous fluid regimen. The restricted regimen aimed at maintaining preoperative body weight; the standard regimen resembled everyday practice. The primary outcome measures were complications; the secondary measures were death and adverse effects. The restricted intravenous fluid regimen 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. No patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, P = 0.12). No harmful adverse effects were observed. The restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduces complications after elective colorectal resection.

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Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.

Ludhmila Hajjar, Jean-Louis Vincent, Filomena R B G Galas … (2010)

Perioperative red blood cell transfusion is commonly used to address anemia, an independent risk factor for morbidity and mortality after cardiac operations; however, evidence regarding optimal blood transfusion practice in patients undergoing cardiac surgery is lacking. To define whether a restrictive perioperative red blood cell transfusion strategy is as safe as a liberal strategy in patients undergoing elective cardiac surgery. The Transfusion Requirements After Cardiac Surgery (TRACS) study, a prospective, randomized, controlled clinical noninferiority trial conducted between February 2009 and February 2010 in an intensive care unit at a university hospital cardiac surgery referral center in Brazil. Consecutive adult patients (n = 502) who underwent cardiac surgery with cardiopulmonary bypass were eligible; analysis was by intention-to-treat. Patients were randomly assigned to a liberal strategy of blood transfusion (to maintain a hematocrit ≥30%) or to a restrictive strategy (hematocrit ≥24%). Composite end point of 30-day all-cause mortality and severe morbidity (cardiogenic shock, acute respiratory distress syndrome, or acute renal injury requiring dialysis or hemofiltration) occurring during the hospital stay. The noninferiority margin was predefined at -8% (ie, 8% minimal clinically important increase in occurrence of the composite end point). Hemoglobin concentrations were maintained at a mean of 10.5 g/dL (95% confidence interval [CI], 10.4-10.6) in the liberal-strategy group and 9.1 g/dL (95% CI, 9.0-9.2) in the restrictive-strategy group (P < .001). A total of 198 of 253 patients (78%) in the liberal-strategy group and 118 of 249 (47%) in the restrictive-strategy group received a blood transfusion (P < .001). Occurrence of the primary end point was similar between groups (10% liberal vs 11% restrictive; between-group difference, 1% [95% CI, -6% to 4%]; P = .85). Independent of transfusion strategy, the number of transfused red blood cell units was an independent risk factor for clinical complications or death at 30 days (hazard ratio for each additional unit transfused, 1.2 [95% CI, 1.1-1.4]; P = .002). Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity. clinicaltrials.gov Identifier: NCT01021631.

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Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte.

Andrew Shaw, Sean Bagshaw, Stuart Goldstein … (2012)

To assess the association of 0.9% saline use versus a calcium-free physiologically balanced crystalloid solution with major morbidity and clinical resource use after abdominal surgery. 0.9% saline, which results in a hyperchloremic acidosis after infusion, is frequently used to replace volume losses after major surgery. An observational study using the Premier Perspective Comparative Database was performed to evaluate adult patients undergoing major open abdominal surgery who received either 0.9% saline (30,994 patients) or a balanced crystalloid solution (926 patients) on the day of surgery. The primary outcome was major morbidity and secondary outcomes included minor complications and acidosis-related interventions. Outcomes were evaluated using multivariable logistic regression and propensity scoring models. For the entire cohort, the in-hospital mortality was 5.6% in the saline group and 2.9% in the balanced group (P < 0.001). One or more major complications occurred in 33.7% of the saline group and 23% of the balanced group (P < 0.001). In the 3:1 propensity-matched sample, treatment with balanced fluid was associated with fewer complications (odds ratio 0.79; 95% confidence interval 0.66-0.97). Postoperative infection (P = 0.006), renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline. Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline.

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Author and article information

Contributors

Timothy E. Miller: timothy.miller2@duke.edu

Journal

Journal ID (nlm-ta): Perioper Med (Lond)

Journal ID (iso-abbrev): Perioper Med (Lond)

Title: Perioperative Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 2047-0525

Publication date (Electronic): 17 September 2016

Publication date PMC-release: 17 September 2016

Publication date Collection: 2016

Volume: 5

Electronic Location Identifier: 24

Affiliations

[1 ]Departments of Anesthesiology and Biomedical Engineering, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, UVA Enhanced Recovery after Surgery (ERAS) Program, University of Virginia School of Medicine, Charlottesville, VA USA

[2 ]Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA

[3 ]Duke University and Durham VA Medical Center, Durham, NC USA

[4 ]Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK

[5 ]Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, NW3 2QG UK

[6 ]Anaesthetic Department, Royal Free Perioperative Research Group, Royal Free Hospital, London, NW3 2QG UK

[7 ]Department of Surgery, University of Texas-Medical Branch at Galveston, Galveston, TX 77555 USA

[8 ]Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA USA

[9 ]Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, NY USA

[10 ]University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK

[11 ]Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN USA

[12 ]Division of General, Vascular and Transplant Anesthesia, American Society for Enhanced Recovery, Duke University Medical Center, Durham, NC 27710 USA

Article

Publisher ID: 49

DOI: 10.1186/s13741-016-0049-9

PMC ID: 5027098

PubMed ID: 27660701

SO-VID: 29ae2642-eae7-4874-adc4-73d8dd6d8b92

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 22 July 2016

Date accepted : 24 August 2016

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Keywords: enhanced recovery pathway,enhanced recovery,fluids,colorectal surgery,crystalloids,colloids,goal-directed fluid therapy,carbohydrate drink,hemodynamics

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Keywords: enhanced recovery pathway, enhanced recovery, fluids, colorectal surgery, crystalloids, colloids, goal-directed fluid therapy, carbohydrate drink, hemodynamics

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery

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Abstract

Background

Methods

Discussion

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SICOT-J (Orthopedic surgery and traumatology)

Most cited references 78

Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.

Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.

Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte.

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Article

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