Current Urology Reports

, 16:17 | Cite as

New Perioperative Fluid and Pharmacologic Management Protocol Results in Reduced Blood Loss, Faster Return of Bowel Function, and Overall Recovery

  • Patrick Y. WuethrichEmail author
  • Fiona C. Burkhard
Urothelial Cancer (A Sagalowsky, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Urothelial Cancer


Cystectomy and urinary diversion have high morbidity, and strategies to reduce complications are of utmost importance. Epidural analgesia and optimized fluid management are considered key factors contributing to successful enhanced recovery after surgery. In colorectal surgery, there is strong evidence that an intraoperative fluid management aiming for a postoperative zero fluid balance results in lower morbidity including a faster return of bowel function. Recently, a randomized clinical trial focusing on radical cystectomy demonstrated that a restrictive intraoperative hydration combined with a concomitant administration of norepinephrine reduced intraoperative blood loss, the need for blood transfusion and morbidity. The purpose of this review is to highlight specific anesthesiological aspects which have been shown to improve outcome after RC with urinary diversion.

Key points

• Thoracic epidural analgesia (TEA) enhances the return of gastrointestinal function, decreases postoperative morbidity, accelerates postoperative recovery and allows less or no systemic opioid administration.

• Administer a preemptive norepinephrine infusion with a starting dose of 2 μg/kg/h to counteract the vasodilative side-effects of anesthetics/analgesics, thus averting any detrimental effect of impaired tissue oxygenation due to a restrictive fluid regimen.

• Perioperative intravenous fluid should replace the minor physiological losses (0.5–1 ml/kg/h) and the blood loss. Fluid loss to a third space is negligible.

• Avoid postoperative weight gain which is a reliable marker of fluid overload. Fluid overload results in alterations in the endothelial glycocalyx resulting in fluid shift toward the interstitium, causing increased postoperative morbidity.

• Decreased urinary output is physiological during major surgery and not a surrogate parameter for hypovolemia alone or renal dysfunction.

• Avoid the use of colloids because they diminish coagulation function, increase intraoperative blood loss, and may be nephrotoxic.


Fluid therapy Norepinephrine Epidural analgesia Postoperative outcome Cystectomy Urinary diversion 


Compliance with Ethics Guidelines

Conflict of Interest

Each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009;55:164–74.CrossRefPubMedGoogle Scholar
  2. 2.
    Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology. 2005;103:1079–88. quiz 109-10.CrossRefPubMedGoogle Scholar
  3. 3.
    Ballantyne JC, Carr DB, De Ferranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg. 1998;86:598–612.PubMedGoogle Scholar
  4. 4.
    Svircevic V, Nierich AP, Moons KG, et al. Thoracic epidural anesthesia for cardiac surgery: a randomized trial. Anesthesiology. 2011;114:262–70.CrossRefPubMedGoogle Scholar
  5. 5.
    Svircevic V, van Dijk D, Nierich AP, et al. Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery. Anesthesiology. 2011;114:271–82.CrossRefPubMedGoogle Scholar
  6. 6.
    Holte K, Kehlet H. Epidural anaesthesia and analgesia—effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr. 2002;21:199–206.CrossRefPubMedGoogle Scholar
  7. 7.
    Lattermann R, Carli F, Wykes L, Schricker T. Epidural blockade modifies perioperative glucose production without affecting protein catabolism. Anesthesiology. 2002;97:374–81.CrossRefPubMedGoogle Scholar
  8. 8.
    Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology. 2002;97:540–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Carli F, Kehlet H, Baldini G, et al. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med. 2011;36:63–72.CrossRefPubMedGoogle Scholar
  10. 10.
    Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS((R))) society recommendations. Clin Nutr. 2013;32:879–87.CrossRefPubMedGoogle Scholar
  11. 11.
    Karl A, Buchner A, Becker A, et al. A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study. J Urol. 2014;191:335–40.CrossRefPubMedGoogle Scholar
  12. 12.
    Jouve P, Bazin JE, Petit A, et al. Epidural versus continuous preperitoneal analgesia during fast-track open colorectal surgery: a randomized controlled trial. Anesthesiology. 2013;118:622–30.CrossRefPubMedGoogle Scholar
  13. 13.
    Lee CT, Chang SS, Kamat AM, et al. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur Urol. 2014.Google Scholar
  14. 14.
    Brandstrup B, Svendsen PE, Rasmussen M, et al. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth. 2012;109:191–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens. Ann Surg. 2003;238:641.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Futier E, Constantin JM, Petit A, et al. Conservative vs restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial. Arch Surg. 2010;145:1193–200.CrossRefPubMedGoogle Scholar
  17. 17.
    Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A rational approach to perioperative fluid management. Anesthesiology. 2008;109:723–40.CrossRefPubMedGoogle Scholar
  18. 18.
    Shires T, Williams J, Brown F. Acute change in extracellular fluids associated with major surgical procedures. Ann Surg. 1961;154:803–10.CrossRefPubMedCentralPubMedGoogle Scholar
  19. 19.
    Lamke LO, Nilsson GE, Reithner HL. Water loss by evaporation from the abdominal cavity during surgery. Acta Chir Scand. 1977;143:279–84.PubMedGoogle Scholar
  20. 20.
    Reithner L, Johansson H, Strouth L. Insensible perspiration during anaesthesia and surgery. Acta Anaesthesiol Scand. 1980;24:362–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Jacob M, Chappell D, Conzen P, Finsterer U, Rehm M. Blood volume is normal after pre-operative overnight fasting. Acta Anaesthesiol Scand. 2008;52:522–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Jacob M, Chappell D, Rehm M. The 'third space'—fact or fiction? Best Pract Res Clin Anaesthesiol. 2009;23:145–57.CrossRefPubMedGoogle Scholar
  23. 23.
    Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359:1812–8.CrossRefPubMedGoogle Scholar
  24. 24.•
    Wuethrich PY, Burkhard FC, Thalmann GN, Stueber F, Studer UE. Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial. Anesthesiology. 2014;120:365–77. RCT demonstrating in patients undergoing radical cystectomy that a restrictive fluid management supported by vasopressors reduced postoperative morbidity. CrossRefPubMedGoogle Scholar
  25. 25.
    Gao T, Li N, Zhang JJ, et al. Restricted intravenous fluid regimen reduces the rate of postoperative complications and alters immunological activity of elderly patients operated for abdominal cancer: a randomized prospective clinical trial. World J Surg. 2012;36:993–1002.CrossRefPubMedGoogle Scholar
  26. 26.
    Lobo DN, Stanga Z, Aloysius MM, et al. Effect of volume loading with 1 liter intravenous infusions of 0.9 % saline, 4 % succinylated gelatine (Gelofusine) and 6 % hydroxyethyl starch (Voluven) on blood volume and endocrine responses: a randomized, three-way crossover study in healthy volunteers. Crit Care Med. 2010;38:464–70.CrossRefPubMedGoogle Scholar
  27. 27.
    de Aguilar-Nascimento JE, Diniz BN, Do Carmo AV, Silveira EA, Silva RM. World J Surg. 2009;33:925–30.CrossRefPubMedGoogle Scholar
  28. 28.
    Marjanovic G, Villain C, Juettner E, et al. Impact of different crystalloid volume regimes on intestinal anastomotic stability. Ann Surg. 2009;249:181–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Schnuriger B, Inaba K, Wu T, Eberle BM, Belzberg H, Demetriades D. Crystalloids after primary colon resection and anastomosis at initial trauma laparotomy: excessive volumes are associated with anastomotic leakage. J Trauma. 2011;70:603–10.CrossRefPubMedGoogle Scholar
  30. 30.
    Uray KS, Shah SK, Radhakrishnan RS, et al. Sodium hydrogen exchanger as a mediator of hydrostatic edema-induced intestinal contractile dysfunction. Surgery. 2011;149:114–25.CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Shah SK, Uray KS, Stewart RH, Laine GA, Cox Jr CS. Resuscitation-induced intestinal edema and related dysfunction: state of the science. J Surg Res. 2011;166:120–30.CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Chowdhury AH, Lobo DN. Fluids and gastrointestinal function. Curr Opin Clin Nutr Metab Care. 2011;14:469–76.CrossRefPubMedGoogle Scholar
  33. 33.
    Myburgh JA, Higgins A, Jovanovska A, Lipman J, Ramakrishnan N, Santamaria J. A comparison of epinephrine and norepinephrine in critically ill patients. Intensive Care Med. 2008;34:2226–34.CrossRefPubMedGoogle Scholar
  34. 34.
    De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362:779–89.CrossRefPubMedGoogle Scholar
  35. 35.
    Hiltebrand LB, Koepfli E, Kimberger O, Sigurdsson GH, Brandt S. Hypotension during fluid-restricted abdominal surgery: effects of norepinephrine treatment on regional and microcirculatory blood flow in the intestinal tract. Anesthesiology. 2011;114:557–64.CrossRefPubMedGoogle Scholar
  36. 36.
    Di Giantomasso D, Morimatsu H, May CN, Bellomo R. Increasing renal blood flow: low-dose dopamine or medium-dose norepinephrine. Chest. 2004;125:2260–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Chiarandini P, Pompei L, Costa MG, et al. Effects of catecholamines on microcirculation during general inhalation anesthesia. J Cardiothorac Vasc Anesth. 2013;27:1239–45.CrossRefPubMedGoogle Scholar
  38. 38.
    Wuethrich PY, Studer UE, Thalmann GN, Burkhard FC. Intraoperative continuous norepinephrine infusion combined with restrictive deferred hydration significantly reduces the need for blood transfusion in patients undergoing open radical cystectomy: results of a prospective randomised trial. Eur Urol. 2014;66:352–60.CrossRefPubMedGoogle Scholar
  39. 39.•
    Varadhan KK, Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. ProcNutr Soc. 2010;69:488–98. Meta-analysis emphasizing the importance of minimizing the postoperative weight gain. Google Scholar
  40. 40.
    Burkhard FC, Studer UE, Wuethrich PY. Superior functional outcome after radical cystectomy with orthotopic bladder substitution with restrictive intraoperative fluid management: a followup study of a randomized clinical trial. J Urol. 2015;193:173–8.Google Scholar
  41. 41.
    Nekhendzy V, Lemmens HJ, Vaughan WC, et al. The effect of deliberate hypercapnia and hypocapnia on intraoperative blood loss and quality of surgical field during functional endoscopic sinus surgery. Anesth Analg. 2007;105:1404–9. table of contents.CrossRefPubMedGoogle Scholar
  42. 42.
    Gelman S, Mushlin PS. Catecholamine-induced changes in the splanchnic circulation affecting systemic hemodynamics. Anesthesiology. 2004;100:434–9.CrossRefPubMedGoogle Scholar
  43. 43.•
    Matot I, Dery E, Bulgov Y, Cohen B, Paz J, Nesher N. Fluid management during video-assisted thoracoscopic surgery for lung resection: a randomized, controlled trial of effects on urinary output and postoperative renal function. J Thorac Cardiovasc Surg. 2013;146:461–6. RCT showing that the intraoperative fluid administration has no impact on intraoperative urinary output. CrossRefPubMedGoogle Scholar
  44. 44.
    Prowle JR, Liu YL, Licari E, et al. Oliguria as predictive biomarker of acute kidney injury in critically ill patients. Crit Care. 2011;15:R172.CrossRefPubMedCentralPubMedGoogle Scholar
  45. 45.••
    Md Ralib A, Pickering JW, Shaw GM, Endre ZH. The urine output definition of acute kidney injury is too liberal. Crit Care. 2013;17:R112. This study challenges the recommended urinary output threshold of 0.5 ml/kg/h for 6 h as a predictor for the development of AKI. CrossRefPubMedCentralPubMedGoogle Scholar
  46. 46.
    Pickering JW, Endre ZH. The definition and detection of acute kidney injury. J Ren Inj Prev. 2014;3:21–5.PubMedCentralPubMedGoogle Scholar
  47. 47.
    Hahn RG. Why are crystalloid and colloid fluid requirements similar during surgery and intensive care? Eur J Anaesthesiol. 2013;30:515–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Hahn RG. Volume kinetics for infusion fluids. Anesthesiology. 2010;113:470–81.CrossRefPubMedGoogle Scholar
  49. 49.
    Stewart RM, Park PK, Hunt JP, et al. Less is more: improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring. J Am Coll Surg. 2009;208:725–35. discussion 35-7.CrossRefPubMedGoogle Scholar
  50. 50.••
    Wilcox CS. Regulation of renal blood flow by plasma chloride. J Clin Invest. 1983;71:726–35. Evidence from an observational study for the deleterious effect of 0.9% saline solution compared to balanced crystalloid solution. CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    Shaw AD, Bagshaw SM, Goldstein SL, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9 % saline compared to Plasma-Lyte. Ann Surg. 2012;255:821–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Hadimioglu N, Saadawy I, Saglam T, Ertug Z, Dinckan A. The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation. Anesth Analg. 2008;107:264–9.CrossRefPubMedGoogle Scholar
  53. 53.
    O'Malley CM, Frumento RJ, Hardy MA, et al. A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation. Anesth Analg. 2005;100:1518–24. table of contents.CrossRefPubMedGoogle Scholar
  54. 54.
    Li Y, Zhu S, Hahn RG. The kinetics of Ringer's solution in young and elderly patients during induction of general anesthesia with propofol and epidural anesthesia with ropivacaine. Acta Anaesthesiol Scand. 2007;51:880–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Hahn RG. Fluid therapy in uncontrolled hemorrhage—what experimental models have taught us. Acta Anaesthesiol Scand. 2013;57:16–28.CrossRefPubMedGoogle Scholar
  56. 56.
    Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999;27:200–10.CrossRefPubMedGoogle Scholar
  57. 57.
    Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;2:CD000567.PubMedGoogle Scholar
  58. 58.
    Woodcock TE, Woodcock TM. Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Br J Anaesth. 2012;108:384–94.CrossRefPubMedGoogle Scholar
  59. 59.
    Jacob M, Chappell D, Rehm M. Clinical update: perioperative fluid management. Lancet. 2007;369:1984–6.CrossRefPubMedGoogle Scholar
  60. 60.•
    Rasmussen KC, Johansson PI, Hojskov M, et al. Hydroxyethyl starch reduces coagulation competence and increases blood loss during major surgery: results from a randomized controlled trial. Ann Surg. 2014;259:249–54. RCT showing that colloid in patients undergoing radical cystectomy results in impaired coagulation with more bleeding and increases the need for blood transfusion compared to the use of crystalloid alone. CrossRefPubMedGoogle Scholar
  61. 61.
    Kind SL, Spahn-Nett GH, Emmert MY, et al. Is dilutional coagulopathy induced by different colloids reversible by replacement of fibrinogen and factor XIII concentrates? Anesth Analg. 2013;117:1063–71.CrossRefPubMedGoogle Scholar
  62. 62.
    Donati A, Loggi S, Preiser JC, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132:1817–24.CrossRefPubMedGoogle Scholar
  63. 63.
    Wenkui Y, Ning L, Jianfeng G, et al. Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy. Surgery. 2010;147:542–52.CrossRefPubMedGoogle Scholar
  64. 64.
    Morgan TM, Barocas DA, Chang SS, et al. The relationship between perioperative blood transfusion and overall mortality in patients undergoing radical cystectomy for bladder cancer. Urol Oncol. 2011.Google Scholar
  65. 65.
    Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006;105:198-208.Google Scholar
  66. 66.
    Pillai P, McEleavy I, Gaughan M, et al. A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol. 2011;186:2201–6.CrossRefPubMedGoogle Scholar
  67. 67.
    Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–6.CrossRefPubMedGoogle Scholar
  68. 68.
    Pearse RM, Harrison DA, MacDonald N, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. Jama. 2014;311:2181–90.CrossRefPubMedGoogle Scholar
  69. 69.
    Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia. 2008;63:44–51.CrossRefPubMedGoogle Scholar
  70. 70.
    Walsh SR, Tang T, Bass S, Gaunt ME. Doppler-guided intra-operative fluid management during major abdominal surgery: systematic review and meta-analysis. Int J Clin Pract. 2008;62:466–70.CrossRefPubMedGoogle Scholar
  71. 71.
    Solus-Biguenet H, Fleyfel M, Tavernier B, et al. Non-invasive prediction of fluid responsiveness during major hepatic surgery. Br J Anaesth. 2006;97:808–16.CrossRefPubMedGoogle Scholar
  72. 72.
    Phan TD, D'Souza B, Rattray MJ, Johnston MJ, Cowie BS. A randomised controlled trial of fluid restriction compared to oesophageal Doppler-guided goal-directed fluid therapy in elective major colorectal surgery within an Enhanced Recovery After Surgery program. Anaesth Intensive Care. 2014;42:752–60.PubMedGoogle Scholar
  73. 73.•
    Srinivasa S, Taylor MH, Singh PP, Yu TC, Soop M, Hill AG. Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy. Br J Surg. 2013;100:66–74. Systematic review showing that GDT fluid management is not superior to restrictive fluid management in patients undergoing colorectal surgery. CrossRefPubMedGoogle Scholar
  74. 74.
    Challand C, Struthers R, Sneyd JR, et al. Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth. 2012;108:53–62.CrossRefPubMedGoogle Scholar
  75. 75.
    Srinivasa S, Lemanu DP, Singh PP, Taylor MH, Hill AG. Systematic review and meta-analysis of oesophageal Doppler-guided fluid management in colorectal surgery. Br J Surg. 2013;100:1701–8.CrossRefPubMedGoogle Scholar
  76. 76.
    Arumainayagam N, McGrath J, Jefferson KP, Gillatt DA. Introduction of an enhanced recovery protocol for radical cystectomy. BJU Int. 2008;101:698–1.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Anaesthesiology and Pain MedicineBern University HospitalBerneSwitzerland
  2. 2.Department of UrologyBern University HospitalBerneSwitzerland

Personalised recommendations