A close look at postoperative fluid management and electrolyte disorders after gastrointestinal surgery in a teaching hospital where patients are treated according to the ERAS protocol

Restrictive versus conventional ward fluid therapy in non-cardiac surgery patients and the effect on postoperative complications: a meta-analysis

BACKGROUND

Diligent fluid management is an instrumental part of Enhanced Recovery After Surgery. However, the effect of a ward regimen to limit intravenous fluid administration on outcome remains unclear. We performed a meta-analysis investigating the effect of a restrictive versus a conventional fluid regimen on complications in patients after non-cardiac surgery in the postoperative period on the clinical ward.

STUDY DESIGN

We performed a systematic search in MEDLINE, Embase, Cochrane Library, and CINAHL databases, from the start of indexing until June 2022, with constraints for English language and adult human study participants. Data were combined using classic methods of meta-analyses and were expressed as weighted pooled risk ratio (RR) or odds ratio (OR) with 95% confidence interval (CI). Quality assessment and risk of bias analyses was performed according to PRISMA guidelines.

RESULTS

Seven records, three randomized controlled trials, and four non-randomized studies were included with a total of 883 patients. A restrictive fluid regimen was associated with a reduction in overall complication rate in the RCTs (RR 0.46, 95% CI 0.23 to 0.95; P < .03; I2 = 35%). This reduction in overall complication rate was not consistent in the non-randomized studies (RR 0.74, 95% CI 0.53 to 1.03; P 0.07; I2 = 45%). No significant association was found for mortality using a restrictive fluid regimen (RCTs OR 0.51, 95% CI 0.05 to 4.90; P = 0.56; I2 = 0%, non-randomized studies OR 0.30, 95% CI 0.06 to 1.46; P = 0.14; I2 = 0%). A restrictive fluid regimen is significantly associated with a reduction in postoperative length of stay in the non-randomized studies (MD - 1.81 days, 95% CI - 3.27 to - 0.35; P = 0.01; I2 = 0%) but not in the RCTs (MD 0.60 days, 95% CI - 0.75 to 1.95; P = 0.38). Risk of bias was moderate to high. Methodological quality was very low to moderate.

CONCLUSION

This meta-analysis suggests restrictive fluid therapy on the ward may be associated with an effect on postoperative complication rate. However, the quality of evidence was moderate to low, the sample size was small, and the data came from both RCTs and non-randomized studies.

Risk factors for hypokalemia and its association with postoperative recovery in patients scheduled for radical gastrectomy: a retrospective study

BACKGROUND

Hypokalemia is common in patients of various operations, especially gastrointestinal surgery, which seriously affects the safety and enhanced recovery after surgery. Our study aims to explore the risk factors of preoperative hypokalemia of radical gastrectomy for gastric cancer and analyze its impact on postoperative recovery.

METHODS

A total of 122 patients scheduled for radical gastrectomy from September, 2022 to December, 2022 were retrospectively analyzed. According to the serum potassium level before skin incision, patients were divided into hypokalemia group (n = 64) and normokalemia group (n = 58). Factors including age, gender, BMI, ASA classification, glutamic pyruvic transaminase (ALT), glutamic oxaloacetic transaminase (AST), creatinine, blood urea nitrogen (BUN), albumin, hypertension history, whether taking calcium channel blockers, β-receptor blockers, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor antagonist (ARB), thiazide diuretics and other drugs, anemia history, diabetes mellitus history, inability to eat or intestinal obstruction, vomiting, diarrhea, hypokalemia on admission and whether under cooperation with clinical nurse specialist were compared between groups. Univariate logistic regression analysis was used to determine risk factors for hypokalemia with p < 0.2 included as a cutoff. Multivariate logistic regression was used to analyze the influencing factors of preoperative hypokalemia for the indicators with differences. A receiver operating characteristic (ROC) curve was used to evaluate the efficacy of the regression model. Primary exhaust time and defecation time after surgery were compared between the two groups.

RESULTS

The use of ACEI or ARB [OR 0.08, 95% CI (0.01 to 0.58), p = 0.012] and thiazide diuretics [OR 8.31, 95% CI (1.31 to 52.68), p = 0.025], inability to eat for more than 3 days or intestinal obstruction [OR 17.96, 95% CI (2.16 to 149.43), p = 0.008], diarrhea for more than 48 h [OR 6.21, 95% CI (1.18 to 32.61), p = 0.031] and hypokalemia on admission [OR 8.97, 95% CI (1.05 to 77.04), p = 0.046] were independent influencing factors of hypokalemia before skin incision. Primary postoperative exhaust time and defecation time was significantly longer in the hypokalemia group than in the normokalemia group, no matter after laparoscopic radical gastrectomy (p = 0.044, p = 0.045, respectively) or open radical gastrectomy (p = 0.033, p = 0.019, respectively).

CONCLUSION

Early attention and management of serum potassium in patients undergoing radical gastrectomy can better reduce perioperative adverse reactions and promote recovery of gastrointestinal function.

Effects of Preoperative Oral Carbohydrate Electrolyte Drinks on Preoperative Hypokalemia Incidence in Patients Scheduled for Laparoscopic Colorectal Resection: A Three-arm Randomized Clinical Trial

PURPOSE

In our previous study, hypokalemia incidence was high in patients scheduled for laparoscopic colorectal resection. This trial was conducted to verify the effects of preoperative carbohydrate drinks containing potassium in these patients.

DESIGN

A three-arm randomized controlled design was used.

METHODS

Patients were randomly assigned to control, placebo, and treatment groups. In the control group, patients fasted from midnight. In the placebo group, patients fasted from midnight and received carbohydrate drinks 2 to 3 hours before surgery. In the treatment group, patients fasted from midnight and received carbohydrate drinks containing potassium supplementation 2 to 3 hours before surgery. The primary outcome was the incidence and severity of preoperative hypokalemia. Other outcomes included postoperative gastrointestinal function, including the time to postoperative first flatus (FFL) and first feces (FFE), and other complications.

FINDINGS

The final analysis included 122 participants. The incidence of preoperative hypokalemia in the treatment group was significantly lower than that in the control and placebo groups (50% vs 88.1% vs 77.5%, P < .001). The severity of hypokalemia in the control and placebo groups was greater than that in the treatment group. No regurgitation or aspiration occurred in the three groups. No significant differences were observed among the three groups regarding time to FFL and FFE.

CONCLUSIONS

Preoperative carbohydrate drinks containing potassium significantly reduced the incidence of preoperative hypokalemia and improved preoperative thirst and hunger, but did not reduce the postoperative time to FFL and FFE or length of hospital stay. However, as part of the enhanced recovery after surgery protocol, preoperative carbohydrate drinks containing potassium should be considered, as early as first admittance to hospital.

Do the Fluids Consumed by Surgical Patients in the Postoperative Period Affect Their Gastrointestinal Motility?: A Correlational Study

PURPOSE

The aim of this study was to determine the relationship between gastrointestinal (GI) motility and oral fluid intake levels in the postoperative period.

DESIGN

This descriptive and correlational study was performed in an education and research hospital between June and September 2019.

METHODS

The sample in this study consisted of individuals aged 18 to 80 years who had undergone laparoscopic abdominal surgery. No sampling was performed, and all patients volunteering to take part were included.

FINDINGS

Patients were started on oral nutrition in a median of 6 hours (min: 6 max: 8) after surgery and received 500.00 mL (min: 100 max: 500) oral fluid on the first day after surgery, 600.00 mL (min: 200 max: 1200) on the second, and 725.00 mL (min: 652.47 max: 759.52) on the third. Median time to passage of flatus was 22.50 hours (min: 6 max: 36), and median time to stool production was 39.00 hours (min: 16 max: 70). A positive correlation was found between the amount of oral fluid consumption on the first day and time to passage of flatus, while a negative correlation was observed between the amount of fluid consumption on the second day and time to both flatus and stool production.

CONCLUSIONS

Time to flatus production increased in line with the amount of fluid consumed via the oral route on the first day postoperatively, while times to production of flatus and stool decreased as the amount of fluid consumed orally on the second day increased.

Early Prediction of Length of Stay After Pancreaticoduodenectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) is an evidence-based clinical pathway designed to standardize and optimize care. We studied the impact of ERAS and sought to identify the most important recommendations to predict shorter length of stay (LOS) after pancreaticoduodenectomy (PD).

METHODS

We retrospectively reviewed all patients undergoing PD at our institution between January 2014 and June 2018. We compared clinicopathologic outcomes for patients before and after ERAS implementation. We defined "A-recommendations" as those that were graded "strong" and had "moderate" or "high" levels of evidence. We then compared outcomes of the ERAS group with adherence to "A-recommendations" and performed a subset analysis of "A-recommendations" over the first 72 h after surgery, which we termed "early factors".

RESULTS

A total of 191 patients underwent PD during the study period. We excluded 87 patients who had minimally invasive PD (22), vascular reconstruction (53), or both (12). Of the 104 patients studied, 56 (54%) were pre-ERAS and 48 (46%) were ERAS. There were no differences in comorbidities or demographics between these groups, and morbidity, mortality, and readmission rates were also similar (P > 0.6). Median LOS was 3.5 d shorter in the ERAS group (7 versus 10.5 d, P < 0.001). Adherence to "A-recommendations" within ERAS was associated with a decreased LOS (r = -0.52 P = 0.0001). Patients with >5 "early factors" had a median LOS of 6 d, whereas patients with <5 "early factors" had a median LOS of 9 d (P = 0.008).

CONCLUSIONS

ERAS is an effective protocol that standardizes care and reduces LOS after PD. Implementation of ERAS resulted in a 3.5-day reduction in our LOS with no change in morbidity, mortality, or readmissions. Adherence to ERAS protocol "A-recommendations" and ≥5 "early factors" may be predictive of shortened LOS.

Electrolyte disorders are ERAS-associated in patients undergoing hepato-pancreato-biliary surgery

PURPOSE

Emerging evidences have raised concerns about electrolyte disorders caused by restrictive fluid management in the enhanced recovery after surgery (ERAS) protocol. This study aims to investigate the morbidity and treatment of electrolyte disorders associated with ERAS in patients undergoing hepato-pancreato-biliary (HPB) surgery.

METHODS

Clinical data from 157 patients under the ERAS program and 166 patients under the traditional (Non-ERAS) program after HPB surgery were retrospectively analyzed. Risk factors and predictive factors of postoperative electrolyte disorders were analyzed by logistic regression analysis and receiver operator characteristic (ROC) curve analysis, respectively.

RESULTS

The average of intravenous fluid, sodium, chloride, and potassium supplementation after surgery were significantly lower in the ERAS group. Hypokalemia was the most common type of electrolyte disorders in the ERAS group, whose incidence was substantially increased compared to that in the Non-ERAS group [28.77% vs. 8.97%, p < 0.001, on postoperative (POD) 5]. Logistic regression analysis identified the ERAS program and age as independent risk factors of hypokalemia. ROC curve analysis identified serum potassium levels below 3.76 mmol/L on POD 3 (area under curve 0.731, sensitivity 58.54%, specificity 82.69%) as a predictive factor for postoperative hypokalemia in ERAS patients. Oral supplementation at an average of 35.41 mmol potassium per day was effective in restoring the ERAS-associated hypokalemia.

CONCLUSIONS

ERAS procedures were particularly associated with a lower supplementation of potassium and a higher incidence of hypokalemia in patients after HPB surgery. Oral potassium supplementation could be an adopted ERAS program for the elderly undergoing HPB surgery.

Perioperative Pain Management Strategies in the Age of an Opioid Epidemic

According to the US Department of Health and Human Services 2016 and 2017 data, an estimated 130 people per day died from opioid-related drug overdoses; 42,249 people died from overdosing on opioids; and 2.1 million people had opioid-use disorder. Health care organizations such as the American Association of Nurse Anesthetists, the Association of periOperative Registered Nurses, the American Society of PeriAnesthesia Nurses, the American Society of Anesthesiologists, the American College of Surgeons, and the American Medical Association have information related to pain management and/or the opioid epidemic on their Web sites. It is imperative for health care providers to be cognizant of, and use low-dose opioid/opioid-free pain management therapies. This article reviews the pain process and outlines low-dose opioid/opioid-free pain management modalities.

Fluid Therapy in Patients Undergoing Abdominal Surgery: A Bumpy Road Towards Individualized Management

Prudent intraoperative fluid replacement therapy, inotropes, and vasoactive drugs should be guided by adequate hemodynamic monitoring. The study aimed to evaluate the single-centre practice on intraoperative fluid therapy in abdominal surgery (AS). The evaluation, based on a review of medical files, included 235 patients (103 men), aged 60 ± 15 years who underwent AS between September and November 2017. Fluid therapy was analyzed in terms of quality and quantity. There were 124 high-risk patients according to the American Society of Anaesthesiologists Classification (ASA Class 3+) and 89 high-risk procedures performed. The median duration of procedures was 175 (IQR 106-284) min. Eleven patients died post-operatively. The median fluids volume was 10.4 mL/kg/h of anaesthesia, including 9.1 mL/kg/h of crystalloids and 2.7 mL/kg/h of synthetic colloids. Patients undergoing longer than the median procedures received significantly fewer fluids than those who underwent shorter procedures. The volume of fluids in the longer procedures depended on the procedural risk classification and was significantly greater in high-risk patients undergoing high-risk surgery. Patients who died received significantly more fluids than survivors. In all patients, a non-invasive blood pressure monitoring was used and only six patients had therapy guided by metabolic equilibrium. The fluid therapy used was liberal but complied with the recommendations regarding the type of fluid and risk-adjusted dosing. Hemodynamic monitoring was suboptimal and requires modifications. In conclusion, the optimization of intraoperative fluid therapy requires a balanced and standardized approach consistent with treatment procedures.

Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway

Fluid management is an essential component of the Enhanced Recovery after Surgery (ERAS) pathway. Optimal management begins in the preoperative period and continues through the intraoperative and postoperative phases. In this review, we outline current evidence-based practices for fluid management through each phase of the perioperative period. Preoperatively, patients should be encouraged to hydrate until 2 hours prior to the induction of anesthesia with a carbohydrate-containing clear liquid. When mechanical bowel preparation is necessary, with modern isoosmotic solutions, fluid repletion is not necessary. Intraoperatively, fluid therapy should aim to maintain euvolemia with an individualized approach. While some patients may benefit from goal-directed fluid therapy, a restrictive, zero-balance approach to intraoperative fluid management may be reasonable. Postoperatively, early initiation of oral intake and cessation of intravenous therapy are recommended.

Prevalence and risk factors for hypokalemia in patients scheduled for laparoscopic colorectal resection and its association with post-operative recovery

Background

Perioperative serum potassium levels are closely associated with postoperative clinical outcomes after gastrointestinal surgery. The aim of our retrospective study was to identify the prevalence and risk factors for preoperative hypokalemia (before pneumoperitoneum) and to evaluate the influence of preoperative hypokalemia on the recovery of postoperative gastrointestinal function.

Methods

In this retrospective study, patients scheduled for laparoscopic colorectal resection from November 11 2014 to October 20 2016, were considered for inclusion. A blood potassium level between 3.5 and 5.5 mmol/L was defined as normal, with levels between 3.0 to 3.5 mmol/L, 2.5 to 3.0 mmol/L and < 2.5 mmol/L considered as slight, moderate, and severe level of hypokalemia. The factors including age, gender, ASA grade, BMI, hypertension, diabetes, anti-hypertension drugs, lactose oral soluble, oral cathartics, oral cathartics, cathartic enemas, and blood potassium level before gastrointestinal preparation which might be associated with blood potassium level before pneumoperitoneum were analysed. The time to postoperative first flatus (FFL) and first feces (FFE) was compared between patients with and without hypokalemia.

Results

The final analysis was based on the data of 108 patients. Hypokalemia was identified in 70.37% patients, with the following distribution of blood potassium levels before pneumoperitoneum: slight, 49 (45.37%) patients; moderate, 23 (21.30%); and severe, 4 (3.70%) patients. Hypokalemia was significantly associated with hypertension and the use of ≥2 types of oral cathartics for preoperative gastrointestinal preparation. With treatment, potassium levels recovered to normal levels in all patients within 48 h postoperatively. Hypokalemia was associated with a longer postoperative time to first feces, compared to patients with a normal potassium level before pneumoperitoneum.

Conclusions

Our findings underlie the importance of early monitoring and management of serum potassium levels in these patients.

Factors affecting the early post-operative prognosis in morbidly obese surgical patients after laparoscopic sleeve gastrectomy - a retrospective cohort study

Background

The number of morbidly obese patients who have undergone bariatric surgery has been gradually increasing in Japan. These obese patients are often complicated with metabolic, cardiac, respiratory, and other diseases. The aim of this study was to analyze the perioperative clinical course in a retrospective cohort with respect to the utility of anesthesia management in order to prevent longer hospital stays after surgery.

Findings

Sixty-seven morbidly obese patients who had undergone sleeve gastrectomy were divided into two groups, based upon the duration of postoperative hospital stay; group S was comprised of the patients who were discharged within 5 days after surgery (n = 57) and group L was comprised of those who were discharged after 6 days or more (n = 10). The mean duration of the hospital stay was 4.8 ± 0.4 days and 7.8 ± 1.4 days in groups S and L, respectively. Multivariate logistic regression analysis showed that prolonged anesthesia was a predictor of a longer postoperative hospital stay (p < 0.05). While the difference in BMI was not significantly different, the percentage of patients with BMI ≥ 50 was 12 and 30% in groups S and L, respectively.

Conclusions

Longer duration of anesthesia affected the duration of postoperative hospital stay in morbidly obese patients undergoing sleeve gastrectomy. In addition, patients with BMI ≥ 50 might be at risk of longer hospitalization after surgery.

Intravenous fluid and electrolyte administration in elective gastrointestinal surgery: mechanisms of excessive therapy

INTRODUCTION While clinical guidelines stress the importance of the judicious perioperative intravenous fluid administration, data show that adherence to these protocols is poor. The reasons have not been identified. We therefore audited the magnitude and indications of fluid and electrolyte administration in a teaching hospital. We hypothesised that epidural analgesia is associated with excessive fluid therapy. MATERIALS AND METHODS Intravenous fluid and electrolyte administration during the day of surgery and the subsequent 2 days in consecutive patients undergoing elective gastrointestinal surgery between November 2013 and May 2014 were retrospectively audited. Timing, volumes and indications were recorded. RESULTS One hundred patients undergoing elective gastrointestinal resection were studied. Patients received 9030 ml ± 2860 ml (mean ± standard deviation) intravenous fluids containing a total of 1180 ml ± 420 mmol sodium and resulting in a cumulative fluid balance of +5120 ml ± 2510 ml; 44% ± 14% of total volumes were given in theatre. Nearly all fluid was given for maintenance, 100% (96-100%, interquartile range), with 17 patients only receiving replacement or resuscitation. Independent predictors of increased volumes included open surgery, upper gastrointestinal surgery, increased duration and epidural analgesia but not body weight. Postoperative fluid volume was the only independent predictor of postoperative complication grade (P = 0.0044). CONCLUSIONS Despite published guidelines, perioperative fluid and electrolyte administration were excessive and were associated with postoperative morbidity. Substantial volumes were administered in theatre. Nearly all administration was for maintenance, yet patients received approximately five times the amount of sodium required. Epidural analgesia was an independent predictor of fluid volumes but body weight was not.

Enhanced Recovery After Surgery: It's Time to Change Practice!

Perioperative surgical care is undergoing a paradigm shift. Traditional practices such as prolonged preoperative fasting (nil by mouth from midnight), bowel cleaning, and reintroduction of oral nutrition 3-5 days after surgery are being shunned. These and other similar changes have been formulated into a protocol called Enhanced Recovery After Surgery (ERAS) pathway. It is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early mobilization. The recent literature is heavily influenced by colorectal surgery, but the principles are now being applied to a wide range of disciplines. As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes.

Recovery of gastric ileus following laparoscopic ventral rectopexy within an enhanced recovery protocol

PURPOSE

The enhanced recovery after surgery (ERAS) protocol has had limited adoption in laparoscopic ventral rectopexy (LVR), and the extent of gastric ileus shortly after LVR remains unknown. This study was designed to assess the degree of gastric emptying shortly after LVR within an ERAS protocol.

METHODS

From August 2012 to June 2014, 40 patients diagnosed with external or internal rectal prolapse were recruited. All patients underwent LVR within an ERAS protocol. Carbohydrate solution (CS) was administered before and 5 h after surgery on the same day. The pyloric area (PA) was measured using ultrasonography before and after each CS intake.

RESULTS

The PA was measured in 34 patients. The PA measured prior to CS intake, before surgery, was not significantly different from that after surgery. The rate of increase in the PA, which was calculated by the PA measured 1 h after CS intake divided by the PA measured prior to CS intake before surgery, was not significantly different from that after surgery. The postoperative hospital stay was 1 (1-2) day, and 36 patients (90 %) were discharged on the first postoperative afternoon.

CONCLUSION

Postoperative gastric ileus was resolved in most cases within 5 h after LVR under an ERAS protocol.