Goal-directed fluid therapy in urgent GAstrointestinal Surgery-study protocol for A Randomised multicentre Trial: The GAS-ART trial

Use of colloids and crystalloids for perioperative clinical infusion management in cardiac surgery patients and postoperative outcomes: a meta-analysis

BACKGROUND

The optimal fluid management strategy for patients undergoing cardiac surgery was controversial regarding fluid volume and intraoperative fluid types. This study aimed to assess the correlation between colloids and crystalloids used for perioperative fluid therapy in cardiac surgery patients and postoperative prognosis.

METHODS

The Ovid MEDLINE(R) ALL, Embase, and Cochrane Central Register of Controlled Trials databases were searched for eligible studies on fluid management strategies using colloids and crystalloids for cardiac surgery patients published before August 25th, 2023.

RESULTS

Ten randomized controlled trials met the eligibility criteria. Compared to the use of crystalloids, the use of colloids, including hydroxyethyl starch (HES), albumin, and gelatine, did not show any differences in mortality, transfusion, acute kidney injury, and atrial fibrillation rates, postoperative blood loss, the length of hospital stay, or the length of intensive care unit (ICU) stay. The results of this meta-analysis showed that the crystalloid group had significantly reduced postoperative chest tube output compared to the colloid group. In the subgroup analysis, the amount of fresh frozen plasma (FFP) infused was significantly lower when using fluid management in the ICU and when using isotonic crystalloids compared to the colloids. In addition, when using fluid management in the ICU, patients in the colloid group had a significant increase in urine volume 24 h after surgery. However, other related factors, including the type of crystalloid solution, type of colloidal solution, and timing of liquid management, did not affect most outcomes.

CONCLUSION

Both colloids and crystalloids could be used as alternatives for perioperative fluid management after cardiac surgery. The use of crystalloids significantly reduced the postoperative chest tube output, and the need for FFP infusion decreased significantly with the use of isotonic crystalloids or fluid management during the ICU stay. ICU patients in the colloid group had higher urine output 24 h after surgery. In addition, although the infusion method was not related to most outcomes, the rates of red blood cell and FFP transfusion and postoperative blood loss in the crystalloid group seemed to be lower, which needed to be further studied in high-quality and large-sample RCTs.

TRIAL REGISTRATION

PROSPERO, CRD42023415234.

The association of the perioperative fluid balance and cardiopulmonary complications in emergency gastrointestinal surgery: exploration of a randomized trial

BACKGROUND

The association between perioperative fluid administration and risk of complications following emergency surgery is poorly studied. We tested the association between the perioperative fluid balance and postoperative complications following emergency surgery for gastrointestinal obstruction or perforation.

METHODS

We performed a re-assessment of data from the Goal-directed Fluid Therapy in Urgent Gastrointestinal Surgery Trial (GAS-ART) studying intra-operative stroke volume optimization and postoperative zero-balance fluid therapy versus standard fluid therapy. The cohort was divided into three groups at a perioperative fluid balance (FB) of low < 0 L, moderate 0-2 L, or high > 2 L. We used a propensity adjusted logistic regression to analyse the association with cardiopulmonary (primary outcome), renal, infectious, and wound healing complications. Further, the risk of complications was explored on a continuous scale of the FB.

RESULTS

We included 303 patients: 44 patients belonged to the low-FB group, 108 to the moderate-FB group, and 151 to the high-FB group. The median [interquartile range] perioperative FB was -0.9 L [-1.4, -0.6], 0.9 L [0.5, 1.3], and 3.8 L [2.7, 5.3]. The risk of cardiopulmonary complications was significantly higher in the High-FB group 3.4 (1.5-7.6), p = 0.002 (odds ratio (95% confidence interval). On a continuous scale of the fluid balance, the risk of cardiopulmonary complications was minimal at -1 L to 1 L.

CONCLUSION

Following emergency surgery for gastrointestinal obstruction or perforation, a fluid balance < 2.0 L was associated with decreased risk of cardiopulmonary complications without increasing renal complications.

Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial

BACKGROUND

More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group).

METHODS

In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications.

RESULTS

In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found.

CONCLUSION

Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay.

CLINICAL TRIAL REGISTRATION

EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).

Application value of goal-directed fluid therapy with ERAS in patients undergoing radical lung cancer surgery

OBJECTIVE

To explore the application value of goal-directed fluid therapy (GDFT) in the enhanced recovery after surgery (ERAS) of patients undergoing radical lung cancer surgery (RLCS).

METHODS

A total of 74 patients undergoing elective RLCS based on the enhance recovery after surgery (ERAS) concept in the HanDan Central Hospital between December 2016 and December 2019 were enrolled and assigned to a group treated by regular conventional liquids (regular group, n=34) and a group treated by goal-directed fluid (GDFT group, n=40) according to the fluid infusion scheme. The two groups were compared in intraoperative fluid inflow and outflow, hemodynamic indexes at 30 min (T0) before operation, 4 h (T1) and 24 h (T2) after operation, postoperative complications, postoperative recovery, inflammatory factors at 1 day (d 0) before operation, and at 1 day (d 1) and 7 days (d 3) after operation, as well as for postoperative life quality.

RESULTS

Crystalloid fluid input, fluid infusion, and urine output of the GDFT group were all significantly less than those of the regular group (all P<0.05), and the GDFT group showed significantly lower fluctuations of MAP, cardiac index, and stroke volume (SV) than the regular group (all P<0.05). Additionally, the GDFT group showed a significantly lower overall complication rate and experienced notably earlier time to flatus and getting out-of-bed time and notably shorter hospitalization time than the regular group (all P<0.05). Moreover, the GDFT group presented with less fluctuation of IL-10, IL-6, and TNF-α levels and experienced notably higher life quality scores than the regular group.

CONCLUSION

GDFT is beneficial to the rapid recovery of patients after RLCS, because it can exert a positive effect on maintaining the stability of hemodynamic indexes and reducing inflammation and postoperative complications.