Estimation of the Safety of Intraoperative Fluid Therapy during Great Abdominal Surgery in Patients with Coronary Heart Disease

The study of intraoperative fluid therapy tactics has been of great interest over the past few years, especially in people with concomitant coronary heart disease, as they make up a significant proportion of all surgical patients. The purpose of our study was to assess the risk of intraoperative myocardial damage in patients with concomitant coronary heart disease depending on the fluid regimen used based on monitoring of hemodynamic parameters, electrocardiogram and biomarkers of myocardial damage. Material and methods. The study involved 89 patients, who were divided into two groups depending on the tactics of intraoperative fluid therapy – restrictive and liberal. In order to detect cardiac complications at different stages, we assessed biomarkers of myocardial damage Troponin I, NT-proBNP by solid-phase enzyme-linked immunosorbent assay (ELISA). Results and discussion. Analysis of the obtained data showed that MINS (myocardial injury in noncardiac surgery) incidents were diagnosed in 5 patients (11.1%) in the first group and in 6 patients (13.6%) in the second. In patients of both groups there was an increase in NT-proBNP in the dynamics at all stages, and in the 2nd group, with a liberal regimen of intraoperative fluid therapy, it was more pronounced. It should be noted that the obtained values of NT-proBNP in all patients did not differ significantly from those allowed for this age group; such dynamics of NT-proBNP may indicate a relative risk of complications of liberal fluid therapy in patients with baseline heart failure. One of the important points when choosing the mode of fluid therapy in patients with high cardiac risk is the assessment of the initial volemic status and careful monitoring of water balance in the perioperative period with the desire for "zero" balance. The obtained dynamics of laboratory markers of myocardial damage indicates that in patients with a significant reduction in cardiac reserves compensated for heart failure, a restrictive fluid regimen is preferable, which is also confirmed by slight changes in the concentration of biomarkers. Conclusion. Thus, the study demonstrated the relative safety of selected fluid regimens in patients with concomitant coronary heart disease without signs of congestive heart failure

Intraoperative Fluid Restriction is Associated with Functional Delayed Graft Function in Living Donor Kidney Transplantation: A Retrospective Cohort Analysis

Background: In 2016 we observed a marked increase in functional delayed graft function (fDGF) in our living donor kidney transplantation (LDKT) recipients from 8.5% in 2014 and 8.8% in 2015 to 23.0% in 2016. This increase coincided with the introduction of a goal-directed fluid therapy (GDFT) protocol in our kidney transplant recipients. Hereupon, we changed our intraoperative fluid regimen to a fixed amount of 50 mL/kg body weight (BW) and questioned whether the intraoperative fluid regimen was related to this increase in fDGF. Methods: a retrospective cohort analysis of all donors and recipients in our LDKT program between January 2014–February 2017 (n = 275 pairs). Results: Univariate analysis detected various risk factors for fDGF. Dialysis dependent recipients were more likely to develop fDGF compared to pre-emptively transplanted patients (p < 0.001). Recipients developing fDGF received less intraoperative fluid (36 (25.9–50.0) mL/kg BW vs. 47 (37.3–55.6) mL/kg BW (p = 0.007)). The GDFT protocol resulted in a reduction of intraoperative fluid administration on average by 850 mL in total volume and 21% in mL/kg BW compared to our old protocol (p < 0.001). In the unadjusted analysis, a higher intraoperative fluid volume in mL/kg BW was associated with a lower risk for the developing fDGF (OR 0.967, CI (0.941–0.993)). After adjustment for the confounders, prior dialysis and the use of intraoperative noradrenaline, the relationship of fDGF with fluid volume was still apparent (OR 0.970, CI (0.943–0.998)). Conclusion: Implementation of a GDFT protocol led to reduced intraoperative fluid administration in the LDKT recipients. This intraoperative fluid restriction was associated with the development of fDGF.

Restrictive versus liberal fluid therapy in geriatric patients undergoing major abdominal surgery: a randomized controlled trial

BACKGROUND: The optimal fluid therapy in elderly patients undergoing major abdominal surgery remains unclear. Although some trials have reported a restrictive fluid therapy may lead to better outcomes, there is no evidence whether it is suitable for elderly patients. METHODS: In a double-blinded pragmatic trial, 107 elderly patients undergoing major abdominal surgery were randomized to receive either a liberal (L group) or restrictive intravenous-fluid therapy (R group) . The postoperative fluid therapy was similar in the two groups. The primary outcome was vital organ injury included Myocardial injury after noncardiac surgery (MINS) and acute kidney injury（AKI）, the secondary outcomes included hypotension needed intervention intraoperatively, length of stay (LOS) , death and other complications defined up to 30 days. Analysis was performed by intention-to-treat. RESULT: 50 patients in the L group had an average intravenous fluid of 1943ml, as compared to 1295.61ml in 57 patients in the R group (P<0.001). The baseline Characteristics and operative details were similar between the groups. Patients in the L group had a lower rate of AKI (10% vs 35.1%, P=0.002) and surgical-site infection (0 vs 10.5%, P=0.029) than in the R group；MINS (20% vs 20.8%, P=0.724) and the other postoperative complications showed no differences between two groups. One patient died in the R group. No significant difference was found for the length of hospital stay[median(range) L: 15(8-49) vs R: 17(8-80); P=0.27]. The follow-up was 30 days. CONCLUSION: In geriatric patients undergoing major abdominal surgery, a liberal fluid regimen was associated with a lower rate of AKI and postoperative infection than restrictive fluid regimen and did not increase the risk of postoperative complications. Trial registration: ChiCTR1800019022. Registered 21 October 2018

Perioperative Fluid Therapy for Major Surgery

A moderately liberal IV fluid regimen, using a balanced crystalloid, and consideration of the use of an advanced hemodynamic monitor in a setting of an enhanced recovery pathway are recommended for major surgery. Supplemental Digital Content is available in the text.

Effects of Intravenous Fluid Restriction on Postoperative Complications

This case focuses on the effects of limiting intravenous fluids on postoperative complications by asking the question: What are the effects of a restricted intravenous fluid regimen targeting an unchanged body weight vs. a standard regimen on complications after elective colorectal surgery? Patients receiving combined thoracic epidural and general anesthesia were randomized to two groups: the restricted fluid regimen and the standard fluid regimen. A total of 141 patients completed the trial: 69 in the restricted group and 72 in the standard group. This randomized, observer-blinded clinical trial demonstrated that a restricted intravenous fluid regimen aimed at unchanged body weight reduced complications after elective colorectal surgery.