There is an ongoing debate amongst healthcare clinicians regarding the appropriate volume resuscitation necessary during major noncardiac surgery. Traditionally, the more volume you infuse, the better it is for the patient. Current research shows that a more restrictive or goal directed fluid balance produces better patient outcomes postoperatively. Considering the percentage of mortality and morbidity produced by hypervolemia, it is well worth the consideration of changing clinical practice to improve the lives of many. Two distinct practice guidelines may change the way we administer fluid therapy during surgery.
Keywords: Goal Directed Fluid Therapy, Restrictive Fluid Therapy, Fluid Management, Fluid Management in Non-cardiac Surgery, Fluid Administration Guideline
Fluid Management in the Operating Room
A 68-year-old patient presents to the operating room (OR) for a scheduled colon resection of a sigmoid colon mass. The patient was prepped and taken to the OR in usual fashion. The induction of anesthesia was smooth. Once the patient was asleep, an arterial line and sixteen-gauge peripheral intravenous (IV) line was started without complications. The patient was receiving Plasma-Lyte IV solution at the discretion of the Certified Registered Nurse Anesthetist (CRNA) based on a restrictive, zero balance fluid therapy guideline. The vital signs remained stable, no vasopressor support was required, and the urine output was adequate based on his weight of ninety kilograms.
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Three hours later, the surgeon would have a total blood loss of eight hundred milliliters. He looks at the IV fluid bag and asks, “is that bag number two or three?” It was explained that it was the first bag and the rationale behind doing so. The surgeon was furious and requested more IV fluids be administered. The patient was stable from an anesthesia standpoint, so fluid therapy continued as deemed appropriate. The surgeon later ordered the patient to receive an additional two liters of IV fluid after the patient left recovery. The rationale was that the patient had a negative fluid balance.
Intraoperative fluid therapy is a fundamental component of major surgical procedures, especially colorectal surgery. Traditionally, calculations to promote euvolemia resulted in an overestimation of fluid therapy. Wrzosek, et al. (2017) discussed how these fluid calculations were based on a 4‐2‐1 rule to calculate baseline fluid requirements (ml/h = 4 x first 10 kg + 2 x 10 kg + 1 x every kg bodyweight after), with additional fluid required for other types of fluid losses such as blood loss, vaporization, and the ‘third space’. Longer practicing surgeons still incorporate this as part of their perioperative care. Fluid overload, hypervolemia, has been shown to be an essential factor in postoperative complication rates. Previous research has reported up to 35% of complications rates with the traditional, older-style means of caring for patients during colorectal surgery (e.g., Nygren, et al., 2012; Varadhan, et al., 2010; Zhuang, Ye, Zhang, Chen, & Yu, 2013).
Fluid management is a critical component of surgical care and is currently one of the most frequently discussed issues of perioperative medicine. As reported by Wrzosek, et al. (2017), the goal of perioperative fluid therapy is to create and maintain a stable, physiological balance while patients are under anesthesia and to make sure there is adequate circulating volume to promote adequate tissue perfusion and oxygenation. Although this area of study has been extensively researched, there remains no definitive answer as to what the best fluid management therapy is for patients during the perioperative period. This article offers two recommendations for restriction of fluid administration during major noncardiac surgery. Goal‐directed fluid therapy (GDFT) is described as a perioperative approach of administering IV fluid based on constant hemodynamic measurements, such as cardiac output, stroke volume, stroke volume variation, and pulse pressure variation (Corcoran, Rhodes, Clarke, Myles, & Ho, 2012; Joosten, et al., 2015). An alternative to the GDFT is a restrictive fluid therapy (RFT) approach. The RFT approach has been hailed as being just as effective, if not more so than the GDFT guideline approach since it does not require specialty monitors or personnel. The RFT guideline was designed to reserve fluid replacement for losses occurred directly from surgery, in addition to the basal fluid requirements. Studies show that RFT was found to be more cost effective and practical in its use; and it required no additional acquisition of expensive equipment nor extensive training of staff for equipment use.
The participants included adults with ages of 18 years or more who were having major noncardiac surgery. Major surgery defined by Donati, et al. (2004) as Grade II or Grade III surgery based on the Johns Hopkins Appendix 1 grading criteria—which assigns a grade based on the surgical risk. The researchers noted that if there were inconsistency within a study, they would put together a survey to satisfy the criteria if at least 80% of the participants were eligible and met the requirements (Wrzosek, et al., 2017). There was no mention if the participants received compensation for their participation in the study. Studies were included for the use of randomized controlled trials (RCTs), while refraining from observational studies and quasi‐randomized trials (Wrzosek, et al., 2017).
For guideline development, Wrzosek, et al. (2017) defined the RFT guideline based on the study authors’ classification, that which being a near‐zero perioperative fluid balance or a zero‐balance approach, and no other hemodynamic monitoring used to guide fluid administration rates. In comparison, GDFT defined as continuous fluid infusions that are measured by hemodynamic monitoring factors used to maximize tissue perfusion and oxygen delivery; these assessments include monitoring of cardiac output, stroke volume, stroke volume variation, pulse pressure variation or other factors, measured by any device (Wrzosek, et al., 2017). Only studies that contained GDFT protocols were used if they included hemodynamic variables as previously described.
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The article showed validity about the case scenario. The authors calculated the risk ratio and the number that is required to produce for a more favorable outcome and explained extraordinary findings, with 95% confidence intervals (CIs) to create statistical modifications (Wrzosek, et al., 2017). The authors of the study calculated the number needed to treat beneficial outcomes as the give-and-take of absolute risk reduction (Wrzosek, et al., 2017). The absolute risk reduction refers to the difference between the control group that would not receive treatment and another group that may receive the designated treatment. In the meantime, they accommodate for undesirable factors, the number needed to treat those beneficial outcomes becomes the number required to manage for an additional harmful result (Wrzosek, et al., 2017). Hospital lengths of stay constitute constant measures, and the authors estimate average differences when means and standard deviations are accessible. The authors will show results with 95% confidence intervals, as well as consider P values equal to or less than 0.05 (two‐sided alpha) as statistically significant (Wrzosek, et al., 2017).
Hypervolemia has been shown to cause damage to the glycocalyx, which is a vascular component responsible for the lining of the endothelium. If there is damage to the endothelium lining, it may cause fluid to shift into the interstitial space; which may cause fluid to leak into that interstitial space where fluid could potentially accumulate.
The impact critique of this article focuses on the current fluid therapy in use in clinical practice for standards today and changes that should be made to accommodate for the newer guidelines. RFT shows promise in reducing hospital lengths of stay, infection rates, and reduced overall complications. The amount of fluid infused should cover basal fluid requirements and fluid losses associated directly with the surgery, mainly due to surgical bleeding. The reduction in overall fluid administration is the premise of the RFT guidelines. In studies discussed by Brandstrup, et al. (2003) and Jacob, Chappell, & Rehm (2009), fluid losses should be covered using a 1:1 ratio of blood and body fluid loss to volume administration so that there is no fluid accumulation. The ‘third space’ is not acknowledged as being a viable fluid retaining space, so proponents of RFT does not take that into account. As cited in Lamke, Nilsson, & Reithner (1977), insensible liquids and moisture lost from the skin is so minimal and has been shown to be 0.3 ml/kg/hour in an awake adult and during surgery. More importantly, perspiration from the abdominal cavity during major abdominal surgery is also very minimal, since it is estimated to vary between 2 and 32 g/hour depending on the incision size and time of possible bowel exteriorization (Lamke, Nilsson, & Reithner, 1977).
Applicability critique. The rationale for perioperative fluid therapy is based on an assumption of keeping normovolemic status and adequate peripheral tissue perfusion, with a reduction in the risks of fluid and electrolyte overdose. Fluid excess may lead to the shifting of intravascular volume into interstitial space and the cumulation of fluid in this area. Hypervolemia may be evident with a postoperative weight gain up to 10 kg, which directly relates with mortality (Wrzosek, et al., 2017). These findings may propose that an overestimation of the traditional fluid requirement calculations occurs in the OR.
These preclinical findings may suggest that a reduction in the dose of fluid may have beneficial effects in a clinical setting, and that the benefit of GDFT may be due to fluid dose reduction in comparison with standard abundant fluid therapy. Based on this assumption, fluid restriction may lead to the same benefit as with GDFT (Wrzosek, et al., 2017).
- Brandstrup, B., Tonnesen, H., Beier-Holgersen, R., Hjortso, E., Ording, H., Lindorff-Larsen, K., . . . Pott, F. (2006). Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Annals of Surgery, 238(5), 641-648. doi:10.1097/01.sla.0000094387.50865.23
- Corcoran, T., Rhodes, J. E., Clarke, S., Myles, P. S., & Ho, K. M. (2012). Perioperative Fluid Management Strategies in Major Surgery: A Stratified Meta-Analysis. Anesthesia & Analgesia, 114(3), 640-651. doi:10.1213/ANE.0b013e318240d6eb
- Donati, A., Ruzzi, M., Adrario, E., Pelaia, P., Coluzzi, F., Gabbanelli, V., & Pietropaoli, P. (2004). A new and feasible model for predicting operative risk. British Journal of Anesthesia, 93(3), 393-399. doi:10.1093/bja/aeh210
- Jacob, M., Chappell, D., & Rehm, M. (2009). The ‘third space’ – fact or fiction? Best Practice & Research Clinical Anaesthesiology, 23(2), 145-157. doi:10.1016/j.bpa.2009.05.001
- Joosten, A., Alexander, B., Delaporte, A., Lilot, M., Rinehart, J., & Cannesson, M. (2015). Perioperative goal directed therapy using automated closed-loop fluid management: the future? Anesthesiology Intensive Therapy, 47(5), 517-523. doi:10.5603/AIT.a2015.0069
- Nygren, J., Thacker, J., Carli, F., Fearon, K. C., Norderval, S., Lobo, D. N., . . . Ramirez, J. (2012). Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clinical Nutrition, 31(6), 801-816. doi:10.1016/j.clnu.2012.08.012
- Varadhan, K. K., Neal, K. R., Dejong, C. H., Fearon, K. C., Ljungqvist, O., & Lobo, D. N. (2010). The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clinical Nutrition, 29(4), 434-440. doi:10.1016/j.clnu.2010.01.004
- Wrzosek, A., Jakowicka‐Wordliczek, J., Zajaczkowska, R., Serednicki, W. T., Jankowski, M., Bala, M. M., . . . Wordliczek, J. (2017). Perioperative restrictive versus goal‐directed fluid therapy for adults undergoing major non‐cardiac surgery. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD012767
- Zhuang, C. L., Ye, X. Z., Zhang, X. D., Chen, B. C., & Yu, Z. (2013). Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Diseases of the Colon and Rectum, 56(5), 667-678. doi:10.1097/DCR.0b013e3182812842
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