Are postoperative intravenous fluids in patients undergoing elective laparoscopic cholecystectomy a necessity? A randomized clinical trial

Diuretic response to Ringer's solution is normal shortly after awakening from general anaesthesia: a retrospective kinetic analysis

Background

The elimination of Ringer's solution is severely depressed during general anaesthesia, but the degree to which this continues postoperatively is poorly established.

Methods

An intravenous infusion of Ringer's acetate solution 20 ml kg-1 was administered over 60 min in 12 patients undergoing laparoscopic cholecystectomy. Population kinetic analysis was performed based on repeated measurements of blood haemoglobin concentration and urinary excretion over 240 min regardless of when the operations were finished. The analysis contrasted the periods before and after awakening from general anaesthesia and compared them with data from 18 volunteers who received the same fluid at the same rate.

Results

Patients were monitored for approximately 2 h after awakening from general anaesthesia. The rate constant for redistribution of fluid from the extravascular space to the plasma (k21) and the rate constant for urinary excretion (k10) were significantly higher postoperatively than during the surgical period. Computer simulations indicated that urinary excretion after surgery was almost restored to the rate found in the volunteers. In contrast, the redistribution of fluid from the extravascular space to the plasma, which was almost nil during the surgery, showed only limited recovery during the postoperative phase, and was only approximately 10% of the flow rate found in the volunteers. The combination of nearly normalised urinary excretion and lack of adequate return of distributed fluid to the plasma promoted postoperative hypovolaemia.

Conclusion

The kinetic analysis indicates that plasma volume support should be given during the first 2 h after laparoscopic cholecystectomy.

ACERTO Project - 15 years changing perioperative care in Brazil

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Ultrasonography and Other Nutrition Assessment Methods to Monitor the Nutrition Status of Critically Ill Patients

BACKGROUND

This study aims to evaluate the use of ultrasonography (US) as an instrument to assess the quadriceps muscles in patients admitted to intensive care units (ICUs), comparing the evolution of US-assessed mass muscle to other nutrition methods.

METHODS

We conducted a prospective observational study of adult patients aged ≥18 years admitted to an ICU of the Hospital das Clínicas in Brazil. Quadriceps muscle measurements were performed by US, and adductor pollicis muscle thickness and arm, calf, and thigh circumferences were measured at admission and every 2 days within the first week. Nutrition status was assessed at baseline by using the Subjective Global Assessment and the Global Leadership Initiative on Malnutrition criteria. Mechanical ventilation time, length of hospital and ICU stay, and mortality were recorded.

RESULTS

Sixty patients were included. Reductions in quadriceps thickness and rectus femoris cross-sectional area were observed at landmarks two-thirds reduction of both measurements from days 1 and 3 to days 5 and 7 (P = .017 and P = .000, respectively). The mid arm circumference (MAC) was reduced. Malnourished patients had lower initial muscle mass. However, muscle mass loss was similar between nourished and malnourished individuals (P > .005). Clinical outcomes were not impacted by muscle loss.

CONCLUSIONS

US muscle mass assessment was able to detect short-term changes in critically ill patients but must be used with caution. MAC was also identified as a useful follow-up tool.

Uso da realimentação pós-operatória ultra precoce e seu impacto na redução de fluidos endovenosos

RESUMO Objetivo: investigar em uma série de casos de pacientes submetidos a operações de médio porte em cirurgia geral, o uso da conduta de realimentação pós-operatória “ultra precoce”(dieta oral líquida oferecida na recuperação pós-anestésica), avaliando-se o volume de fluidos endovenosos recebidos no pós-operatório por estes pacientes, assim como a ocorrência de complicações e o tempo de internação hospitalar. Métodos: estudo prospectivo, observacional. Avaliou-se a aderência à rotina de realimentação “ultra precoce”, abreviação do jejum pré-operatório, volume de hidratação venosa perioperatório, tempo de internação e morbidade operatória. Resultados: um total de 154 pacientes com média da idade de 46±15 anos, foram acompanhados. Realimentação “ultra precoce” foi realizada em 144 casos (93,5%). Pacientes que não receberam realimentação “ultra precoce” receberam volume significativamente maior de fluidos endovenosos no pós-operatório do que pacientes realimentados de maneira “ultra precoce” (500ml versus 200ml, p=0,018). O tempo de internação foi de 2,4±2,79 dias (realimentação convencional) versus 1,45±1,83 dias (realimentação “ultra precoce”), sem diferença estatística (p=0,133).Não houve diferença no percentual de complicações gerais (p=0,291), vômitos (p=0,696) ou infecção do sítio cirúrgico (p=0,534). Conclusão: a realimentação “ultra precoce” apresentou-se como uma conduta de elevada aderência em operações de médio porte em Cirurgia Geral nesta série de casos e, esteve relacionada a infusão de volume significativamente menor de fluidos endovenosos no pós-operatório, com índices baixos de complicações e sem impacto no tempo de internação.