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Bosboom JJ, Wijnberge M, Geerts BF, Kerstens M, Mythen MG, Vlaar APJ, Hollmann MW, Veelo DP. Restrictive versus conventional ward fluid therapy in non-cardiac surgery patients and the effect on postoperative complications: a meta-analysis. Perioper Med (Lond) 2023; 12:52. [PMID: 37735433 PMCID: PMC10514989 DOI: 10.1186/s13741-023-00337-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/10/2023] [Indexed: 09/23/2023] Open
Abstract
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.
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Affiliation(s)
- Joachim J Bosboom
- Department of Anesthesiology, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
- Department of Anesthesiology, Intensive Care, and Pain Medicine, Amphia Hospital, Breda, The Netherlands
| | - Marije Wijnberge
- Department of Anesthesiology, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
| | | | - Martijn Kerstens
- Department of Anesthesiology, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
| | - Michael G Mythen
- Departments of Anesthesia and Critical Care, University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
| | - Denise P Veelo
- Department of Anesthesiology, Amsterdam UMC, Amsterdam University, Amsterdam, the Netherlands
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2
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Yang TX, Tan AY, Leung WH, Chong D, Chow YF. Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review. Cureus 2023; 15:e38238. [PMID: 37261162 PMCID: PMC10226838 DOI: 10.7759/cureus.38238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.
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Affiliation(s)
- Timothy Xianyi Yang
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Adrian Y Tan
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Wesley H Leung
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - David Chong
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Yu Fat Chow
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
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3
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Park J, Han SS, Park SJ, Kang MJ, Park HM, Yu J, Kim SW. Effect of perioperative fluid volume restriction on the incidence of complications following pancreaticoduodenectomy. ANZ J Surg 2022; 92:1797-1802. [PMID: 35531886 DOI: 10.1111/ans.17751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 04/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. The purpose of this study was to compare the morbidity following pancreaticoduodenectomy (PD) between fluid restriction group and conventional management group. METHODS Seventy-two patients were enrolled for perioperative fluid restriction of PD. During the operation, main fluid was infused at a rate of less than 8 mL/kg/hr. Until POD#3, 10% dextrose and Hartmann's solution were administered at rates of 40 mL/h and {(1.5*body weight) - 42} mL/h, respectively. The historical control group consisted of 139 patients. We compared the rates of major complication (Clavien-Dindo grade III to V) and clinically relevant postoperative pancreatic fistula (CR-POPF), length of hospital stays (LOS), amount of urine output, and the rate of acute kidney injury (AKI). RESULTS The rates of major complication (19.0% versus 18.7%; p > 0.999), CR-POPF (15.5% versus 15.1%; p > 0.999), and LOS (19 days [range: 10-52] versus 19 days [range: 11-75]; p = 0.514) were comparable in the study and the control group, respectively. Amount of urine output during the operation and from POD#1 to POD#3 was more than minimal amount (0.5 mL/kg/hr) in the both groups. Incidence rate of AKI in the study group was not higher than the control group (Stage I: 1.7% versus 2.9%, p > 0.999; stage II: 0% versus 1.4%, p > 0.999). CONCLUSION There was no decrease in incidence of morbidity including POPF following PD with perioperative fluid restriction. Fluid restriction was feasible because it did not reduce urine output and did not increase incidence of AKI.
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Affiliation(s)
- Jangho Park
- Department of General Surgery, Osan Hankook Hospital, Osan, Republic of Korea.,Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Sung-Sik Han
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Sang-Jae Park
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Mee Joo Kang
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Hyeong Min Park
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Jihye Yu
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
| | - Sun-Whe Kim
- Center for Liver & Pancreato-Biliary Cancer, National Cancer Center, Goyang-si, Republic of Korea
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4
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Messina A, Robba C, Calabrò L, Zambelli D, Iannuzzi F, Molinari E, Scarano S, Battaglini D, Baggiani M, De Mattei G, Saderi L, Sotgiu G, Pelosi P, Cecconi M. Perioperative liberal versus restrictive fluid strategies and postoperative outcomes: a systematic review and metanalysis on randomised-controlled trials in major abdominal elective surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:205. [PMID: 34116707 PMCID: PMC8194047 DOI: 10.1186/s13054-021-03629-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/06/2021] [Indexed: 12/12/2022]
Abstract
Background Postoperative complications impact on early and long-term patients’ outcome. Appropriate perioperative fluid management is pivotal in this context; however, the most effective perioperative fluid management is still unclear. The enhanced recovery after surgery pathways recommend a perioperative zero-balance, whereas recent findings suggest a more liberal approach could be beneficial. We conducted this trial to address the impact of restrictive vs. liberal fluid approaches on overall postoperative complications and mortality. Methods Systematic review and meta-analysis, including randomised controlled trials (RCTs). We performed a systematic literature search using MEDLINE (via Ovid), EMBASE (via Ovid) and the Cochrane Controlled Clinical trials register databases, published from 1 January 2000 to 31 December 2019. We included RCTs enrolling adult patients undergoing elective abdominal surgery and comparing the use of restrictive/liberal approaches enrolling at least 15 patients in each subgroup. Studies involving cardiac, non-elective surgery, paediatric or obstetric surgeries were excluded. Results After full-text examination, the metanalysis finally included 18 studies and 5567 patients randomised to restrictive (2786 patients; 50.0%) or liberal approaches (2780 patients; 50.0%). We found no difference in the occurrence of severe postoperative complications between restrictive and liberal subgroups [risk difference (95% CI) = 0.009 (− 0.02; 0.04); p value = 0.62; I2 (95% CI) = 38.6% (0–66.9%)]. This result was confirmed also in the subgroup of five studies having a low overall risk of bias. The liberal approach was associated with lower overall renal major events, as compared to the restrictive [risk difference (95% CI) = 0.06 (0.02–0.09); p value = 0.001]. We found no difference in either early (p value = 0.33) or late (p value = 0.22) postoperative mortality between restrictive and liberal subgroups Conclusions In major abdominal elective surgery perioperative, the choice between liberal or restrictive approach did not affect overall major postoperative complications or mortality. In a subgroup analysis, a liberal as compared to a restrictive perioperative fluid policy was associated with lower overall complication renal major events, as compared to the restrictive. Trial Registration CRD42020218059; Registration: February 2020, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=218059. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03629-y.
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Affiliation(s)
- Antonio Messina
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
| | - Lorenzo Calabrò
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Daniel Zambelli
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Francesca Iannuzzi
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Edoardo Molinari
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Silvia Scarano
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
| | - Marta Baggiani
- Anesthesia and Intensive Care Medicine, Maggiore Della Carità University Hospital, Novara, Italy
| | - Giacomo De Mattei
- Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Integrata Udine, Udine, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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5
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2021; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
- Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Effect of the Type of Intraoperative Restrictive Fluid Management on the Outcome of Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2020. [DOI: 10.1155/2020/5658685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. The perioperative management of pancreaticoduodenectomy is complicated, and the significant morbidity and mortality may be influenced by the method of intraoperative fluid management. Whether intraoperative restrictive fluid therapy can affect the outcomes of pancreaticoduodenectomy or not is controversial. Methods. PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov were searched for prospective and retrospective studies comparing restrictive and liberal intraoperative fluids in patients undergoing pancreaticoduodenectomy. Following study identification, a systematic review and meta-analysis were performed. Results. Fourteen studies, including six prospective trials and eight retrospective studies, involving 2,596 patients, were included. Intraoperative restrictive fluid regimens had no effect on the mortality compared to liberal fluid regimens in the overall cohort (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 0.82–2.35,
). Liberal fluid regimens could increase the risk of pulmonary adverse events (OR: 1.66; 95% CI: 1.10–2.50,
) and prolong the length of hospital stay (SMD -0.10; 95% CI -0.19– -0.01,
). There were no significant differences in the incidence of pancreatic fistulas. Conclusions. Restrictive fluid regimens have a slight effect on the outcomes of pancreaticoduodenectomy. The clinical relevance of this finding needs to be interpreted. The existing evidence may not be adequate; therefore, further studies are warranted.
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7
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Optimal fluid management for patients undergoing pancreatoduodenectomy. Am J Surg 2020; 220:262-263. [DOI: 10.1016/j.amjsurg.2020.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/19/2020] [Indexed: 11/21/2022]
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8
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Mahmooth Z, Jajja MR, Maxwell D, Ferez-Pinzon A, Sarmiento JM. Ultrarestrictive intraoperative intravenous fluids during pancreatoduodenectomy is not associated with an increase in post-operative acute kidney injury. Am J Surg 2020; 220:264-269. [DOI: 10.1016/j.amjsurg.2020.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/08/2020] [Accepted: 03/19/2020] [Indexed: 01/01/2023]
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9
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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10
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Intraoperative Fluid Administration and Surgical Outcomes Following Pancreaticoduodenectomy: External Validation at a Tertiary Referral Center. World J Surg 2019; 43:929-936. [PMID: 30377724 DOI: 10.1007/s00268-018-4842-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND While intraoperative fluid overload is associated with higher complication rates following surgery, data for pancreaticoduodenectomy are scarce and heterogeneous. We evaluated multiple prior definitions of restrictive and liberal fluid regimens and analyzed whether these affected surgical outcomes at our tertiary referral center. METHODS Studies evaluating different intraoperative fluid regimens on outcomes after pancreatic resections were retrieved. After application of all prior definitions of restrictive and liberal fluid regimens to our patient cohort, relative risks of each outcome were calculated using all reported infusion regimens. RESULTS Five hundred and seven pancreaticoduodenectomies were included. Nine different fluid regimens were evaluated. Two regimens utilized absolute volume cutoffs, and the remaining evaluated various infusion rates, ranging from 5 to 15 mL/kg/h. Total volume administration of >5000 mL and >6000 mL was associated with increased complications (RR 1.25 and RR 1.17, respectively) and >6000 mL with increased sepsis (RR 2.14). Conversely, a rate of <5 mL/kg/h was associated with increased risk of postoperative pancreatic fistula (POPF, RR 3.16) and sepsis (RR 3.20), <6.8 mL/kg/h with increased major morbidity (RR 1.64) and sepsis (RR 2.27), and <8.2 mL/kg/h with increased POPF (RR 2.16). No effects were observed on pulmonary complications, surgical site infections, length of stay, or mortality. CONCLUSIONS In an uncontrolled setting with no standard intraoperative or postoperative care map, the volume of intraoperative fluid administration appears to have limited impact on early postoperative outcomes following pancreaticoduodenectomy, with adverse outcomes only seen at extreme values.
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11
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Restrictive Versus Liberal Fluid Regimens in Patients Undergoing Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2019; 23:1250-1265. [PMID: 30671798 DOI: 10.1007/s11605-018-04089-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 12/17/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy is associated with significant morbidity and mortality which may be influenced by perioperative fluid management. It remains unclear whether liberal and restrictive fluid regimens impact mortality and morbidity in patients undergoing pancreaticoduodenectomy. METHODS Medline, EMBASE, Cochrane Library and clinicaltrials.gov were searched for studies comparing restrictive and liberal perioperative fluids in patients undergoing pancreaticoduodenectomy. Both prospective and retrospective studies in those undergoing pancreaticoduodenectomy were eligible for inclusion where the patient outcomes were stratified to restrictive and liberal perioperative fluid management regimens, with mortality as the primary outcome. Following study identification, a systematic review and meta-analysis with trial sequential analysis was completed. RESULTS Thirteen studies including five prospective trials and eight retrospective analyses totalling 3062 patients were included. Restrictive fluid regimens were associated with a significant reduction in mortality compared to liberal fluid regimens for the overall cohort (odds ratio 0.54; 95% CI 0.31-0.94, p = 0.03). There were no significant differences in complication profile. Subgroup analysis revealed this result was contributed to significantly by retrospective studies. The results of the trial sequential analysis suggest this mortality benefit may be due to a type I statistical error and that further patient numbers are required for definitive conclusions. CONCLUSIONS Restrictive fluid regimens are associated with a reduction in mortality following pancreaticoduodenectomy. The clinical relevance of this finding needs to be interpreted pragmatically given the lack of association with significant causes of morbidity and in considering the results of the recently published RELIEF study.
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12
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Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial. Clin Nutr 2019; 38:174-181. [DOI: 10.1016/j.clnu.2018.01.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 12/21/2017] [Accepted: 01/02/2018] [Indexed: 12/18/2022]
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13
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Andrianello S, Marchegiani G, Bannone E, Masini G, Malleo G, Montemezzi GL, Polati E, Bassi C, Salvia R. Clinical Implications of Intraoperative Fluid Therapy in Pancreatic Surgery. J Gastrointest Surg 2018; 22:2072-2079. [PMID: 30066067 DOI: 10.1007/s11605-018-3887-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent studies have suggested that intraoperative fluid overload is associated with a worse outcome after major abdominal surgery. However, evidence in the field of pancreatic surgery is still not consistent. The aim of this study was to evaluate whether intraoperative fluid management could affect the outcome of a major pancreatic resection. METHODS Prospective analysis of 350 major pancreatic resections performed in 2016 at the Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust. Patients were dichotomized according to intraoperative fluid volume administration (near-zero vs. liberal fluid balance) and matched using propensity score. Intraoperative fluid administration was then correlated to the postoperative outcome. RESULTS Liberal fluid balance was associated with an increased rate of Clavien-Dindo ≥ IIIB both after pancreaticoduodenectomy (60.3 vs. 30.2%, p < 0.01) and distal pancreatectomy (50 vs. 27.1%, p = 0.03). In case of pancreaticoduodenectomy, liberal fluid balance was also associated with an increased rate of pancreatic fistula (33.3 vs. 19.9%, p = 0.05), but when considering patients with soft remnants, an increase rate of pancreatic fistula (52.8 vs. 23%, p = 0.03) was indeed associated with the near-zero fluid balance. CONCLUSION Considering all pancreatic resections, a liberal fluid balance is associated with an increased rate of postoperative morbidity. However, in the case of PD with a soft pancreas, an NZF balance could lead to pancreatic stump ischemia and anastomotic failure. Intraoperative fluid management should be managed according to patient's pancreas-specific risk factors.
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Affiliation(s)
- Stefano Andrianello
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Elisa Bannone
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Gaia Masini
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Gabriele L Montemezzi
- Intensive Care Unit - University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Enrico Polati
- Intensive Care Unit - University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy.
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Systematic Review and Meta-analysis of Restrictive Perioperative Fluid Management in Pancreaticoduodenectomy. World J Surg 2018; 42:2938-2950. [PMID: 29464346 DOI: 10.1007/s00268-018-4545-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is significant interest and controversy surrounding the effect of restrictive fluid management on outcomes in major gastrointestinal surgery. This has been most studied in colorectal surgery, although the literature relating to pancreaticoduodenectomy (PD) patients is growing. The aim of this paper was to generate a comprehensive review of the available evidence for restrictive perioperative fluid management strategies and outcomes in PD. METHODS MEDLINE/PubMed, Embase, and the Cochrane Library were searched from inception to April 2017. A review protocol was utilized and registered with PROSPERO. Primary citations that evaluated perioperative fluid management in PD, including those as part of a clinical pathway, were considered. The primary outcome was postoperative pancreatic fistula (POPF). Secondary outcomes included delayed gastric emptying (DGE), complication rate, length of stay (LOS), mortality, and readmission. RESULTS A total of six studies involving 846 patients were included (2009-2015), of which four were RCTs. Pooled analysis of RCTs and high-quality observational studies found no effect of restrictive intraoperative fluid management on POPF, DGE, complication rate, LOS, mortality, and readmission. Only one study assessed postoperative fluid management exclusively and found prolonged LOS in patients in the restricted fluid group. CONCLUSION Based on results of RCTs and high-quality observational studies, intraoperative fluid restriction in PD has not been shown to significantly affect postoperative outcomes. There are too few studies assessing postoperative fluid management to draw conclusions at this time.
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Abstract
Objectives: To determine whether perioperative fluid restrictive administration can reduce specific postoperative complications in adults undergoing major abdominal surgery. Methods: We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, Google scholar, and article reference lists (up to December 2015) for studies that assessed fluid therapy and morbidity or mortality in patients undergoing major abdominal surgeries. The quality of the trials was assessed using the Jadad scoring system, and a meta-analysis of the included randomized, controlled trials was conducted using Review Manager software, version 5.2. Results: Ten studies with a total of 1160 patients undergoing major abdominal surgeries were included. We found that perioperative restrictive fluid therapy could reduce the risk of postoperative infectious complications (odds ratio [OR]=0.54, 95% confidence interval [CI]:0.39-0.74, p=0.0001, I2=37%), pulmonary complications (OR=0.49, 95% CI: 0.26-0.93, p=0.03, I2=50%), and cardiac complications (OR=0.45, 95% CI: 0.29-0.69, p=0.0003, I2=48%), but had no effect on the risk of gastrointestinal complications (OR=0.87, 95% CI: 0.51-1.46, p=0.59, I2=0%), renal complications (OR=0.76, 95% CI: 0.43-1.34, p=0.35, I2=0%), and postoperative mortality (OR=0.62, 95% CI: 0.25-1.50, p=0.29, I2=0%). Conclusion: Perioperative restrictive fluid administration was superior to liberal fluid administration in reducing the infectious, pulmonary and cardiac complications after major abdominal surgeries.
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Affiliation(s)
- Qianyun Pang
- Department of Anesthesia, Chongqing Cancer Institute/ Hospital/Cancer Center, Chongqing, China. E-mail.
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16
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Impact of perioperative fluid administration on early outcomes after pancreatoduodenectomy: A meta-analysis. Pancreatology 2017; 17:334-341. [PMID: 28285959 DOI: 10.1016/j.pan.2017.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/13/2017] [Accepted: 02/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) remains a technically challenging surgical procedure with morbidity rates ranging between 30 and 50%. It is suggested that the liberal use of fluids is associated with a poor perioperative outcome. This review examines the impact of fluid administration on outcomes after PD. METHODS A literature search was conducted using the MEDLINE, EMBASE and PubMed database (June 1966-June 2016). Studies identified were appraised with standard selection criteria. Data points were extracted and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS Eleven studies, seven retrospective trials and four randomized control trials comprising 2842 patients were included. Seven studies were meta-analyzed. There was no difference in length of hospital stay (P = 0.25), pancreas specific complications (P = 0.20), pulmonary (P = 0.58), cardiovascular (P = 0.75), gastrointestinal (P = 0.49), hepatobiliary (P = 0.53), urogenital (P = 0.42), wound complication (P = 0.79), reoperation rate (P = 0.69), overall morbidity (P = 0.18), major morbidity (P = 0.91), 30-day mortality (P = 0.07) and 90-day mortality (P = 0.58) in low or high fluid groups. CONCLUSION The current available data fails to demonstrate an association between the amount of perioperative intravenous fluid administration and postoperative complications in patients undergoing PD.
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Enomoto LM, Blackham A, Woo Y, Yamamoto M, Pimiento J, Gusani NJ, Wong J. Ratio of intra-operative fluid to anesthesia time and its impact on short term perioperative outcomes following gastrectomy for cancer: A retrospective cohort study. Int J Surg 2016; 33 Pt A:13-7. [PMID: 27394407 DOI: 10.1016/j.ijsu.2016.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 06/17/2016] [Accepted: 07/05/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study evaluates the short-term impact of fluid administration during gastrectomy for cancer. METHODS A multi-institutional database of patients undergoing gastrectomy for cancer from three tertiary centers was reviewed. Logistic and linear regression analyses were performed. RESULTS 205 patients were included. The majority of patients (n = 116, 57%) underwent proximal or total gastrectomy. Median anesthesia time was 280 min (range 95-691 min). Median intraoperative crystalloid administration was 2901 ml (range 500-10,700 ml). Median colloid administration was 0 (range 0-3835 ml), although only 66 patients (32%) received colloid. On multivariate analysis, patients who received <10.0 ml total fluid per minute of anesthesia had a significantly higher risk of complications (OR 4.12, p = 0.010). Crystalloid and total fluid administration ratios did not significantly affect LOS or discharge disposition. CONCLUSIONS Restricting intra-operative fluid resuscitation to <10 ml total fluid per minute anesthesia is associated with an increased risk of complications in patients undergoing gastrectomy for cancer.
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Affiliation(s)
- Laura M Enomoto
- The Pennsylvania State University, College of Medicine, Department of Surgery, 500 University Drive, MC-H159, Hershey, PA 17033-0850, USA.
| | - Aaron Blackham
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
| | - Yanghee Woo
- Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA.
| | - Maki Yamamoto
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
| | - Jose Pimiento
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
| | - Niraj J Gusani
- Program for Liver, Pancreas, & Foregut Tumors, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA 17033, USA.
| | - Joyce Wong
- Program for Liver, Pancreas, & Foregut Tumors, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA 17033, USA.
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