Perioperative Fluid Administration in Pancreatic Surgery: a Comparison of Three Regimens

Abstract

Background

Optimization of perioperative fluid management is a controversial issue. Weight-adjusted, fixed fluid strategies do not take into account patient hemodynamic status, so that individualized strategies guided by relevant variables may be preferable. We studied this issue in patients undergoing pancreatic surgery within our institution.

Methods

All patients who underwent a laparotomy for pancreatic cancer during a 5-month period at our hospital (AOUI of Verona, Italy) were eligible to be included in this prospective, observational study. According to the responsible anesthesiologist’s free choice, patients received, during surgery, either liberal (12 ml/kg/h) or restricted (4 ml/kg/h) fixed-volume weight-guided replacement fluids or goal-directed (GD) fluid replacement using stroke volume variation (SVV) determined by the FloTrac Vigileo device.

Results

Eighty-six patients were included: 29 in the liberal group, 23 in the restricted group, and 34 in the GD group. The mean duration of surgery was 6 [4–7] h. Patients in the liberal group received more perioperative fluid than those in the GD and restricted groups. Nearly one third of all patients had a major complication, including delayed enteral feeding, and presented a longer duration of hospital stay. Despite the biases related to our limited cohort, there were significantly fewer postoperative complications (such as postoperative fistula, abdominal collection, and hemorrhage) in the restricted and GD groups of patients than in the liberal one.

Conclusion

In patients undergoing pancreatic surgery, a restricted or individually guided GD strategy for management of perioperative fluids can result in fewer complications than a liberal fluid strategy. Larger and randomized investigations are warranted to confirm these data on this domain.

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References

  1. 1.

    Pugalenthi A, Protic M, Gonen M, Kingham TP, Angelica MI, Dematteo RP et al. Postoperative complications and overall survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. J Surg Oncol 2016 Feb;113(2):188–93.

    Google Scholar 

  2. 2.

    Amini N, Spolverato G, Kim Y, Pawlik TM. Trends in hospital volume and failure to rescue for pancreatic surgery. J Gastrointest Surg. 2015 Sept; 19 (9): 1581–92.

    Google Scholar 

  3. 3.

    Čečka F, Jon B, Čermáková E, Šubrt Z, Ferko A: Impact of postoperative complications on clinical and economic consequences in pancreatic surgery. Ann Surg Treat Res 2016 Jan;90(1):21–8.

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    De Schryver N, Wittebole X, Hubert C, Gigot JF, Laterre PF, Castanares-Zapatero D. Early hyperlactatemia predicts pancreatic fistula after surgery.BMCAnesthesiol. 2015 Jul 28;15:109.

    Google Scholar 

  5. 5.

    Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K et al. Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Annals of surgery. 2003;238(5):641.

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology. 2005;54(1):25–32

    Google Scholar 

  7. 7.

    Holte K, Foss NB, Andersen J, Valentiner L, Lund C, Bie P et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Br J Anaesth. 2007;99(4):500-8.

    CAS  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Bellamy MC. Wet, dry or something else. Br J Anaesth 2006;97(6):755-7.

    CAS  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F. Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit care. 2007;11(5):R100.

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Bundgaard-Nielsen M, Holte K, Secher N, Kehlet H. Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta anaesthesiol Scand. 2007;51(3):331–40.

    CAS  Google Scholar 

  11. 11.

    Lassen K, Coolsen M M E, Slim K, Carli F, de Aguilar-Nascimento J E, Schäfer M et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS(®)) society recommendations. World Journal of Surgery, 2013. 37(2), 240–58.

    Google Scholar 

  12. 12.

    Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14(3):R118.

    PubMed  PubMed Central  Google Scholar 

  13. 13.

    Claudio Bassi, Giovanni Marchegiani, Christos Dervenis, Micheal Sarr, Mohammad Abu Hilal, Mustapha Adham et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017 Mar;161(3):584–591.

    Google Scholar 

  14. 14.

    Malleo G, Crippa S, Butturini G, Salvia R, Partelli S, Rossini R et al. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford). 2010;12(9):610–8.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988;16(3):128–40.

    CAS  Google Scholar 

  16. 16.

    Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017 Mar;43(3):304–377.

    Google Scholar 

  17. 17.

    ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526–33.

    Google Scholar 

  18. 18.

    Jacob M, Chappell D, Rehm M. Clinical update: perioperative fluid management. Lancet. 2007;369(9578):1984–6.

    Google Scholar 

  19. 19.

    Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A rational approach to perioperative fluid management. Anesthesiology.2008;109(4):723–40.

    Google Scholar 

  20. 20.

    Prien T, Backhaus N, Pelster F, Pircher W, Büe H, Lawin P. Effect of intraoperative fluid administration and colloid osmotic pressure on the formation of intestinal edema during gastrointestinal surgery. J Clin Anesth.1990;2(5):317–23.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Behman R, Hanna S, Coburn N, Law C, Cyr DP, Truong J et al. Impact of fluid resuscitation on major adverse events following pancreaticoduodenectomy. Am J Surg. 2015;210(5):896–903.

    PubMed  PubMed Central  Google Scholar 

  22. 22.

    Eng OS, Melstrom LG, Carpizo DR. The relationship of perioperative fluid administration to outcomes in colorectal and pancreatic surgery: a review of the literature. J Surg Oncol. 2015;111(4):472–7.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P, et al. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study. Ann Surg.2004;240(5):892–9.

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    Magner JJ, McCaul C, Carton E, Gardiner J, Buggy D. Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: comparison of 30 and 10 ml kg(−1). Br J Anaesth.2004;93(3):381–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Mayer J, Boldt J, Mengistu AM, Röhm KD, Suttner S. Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Crit Care. 2010;14(1):R18.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Forget P, Lois F, De Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management. Anesth Analgesia. 2010;111(4):910–4.

    Google Scholar 

  27. 27.

    Challand C, Struthers R, Sneyd JR, Erasmus PD, Mellor N, Hosie KB 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(1):53–62.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Davies SJ, Yates D, Wilson RJT. Dopexamine has no additional benefit in high-risk patients receiving goal-directed fluid therapy undergoing major abdominal surgery. Anesth Analg. 2011;112(1):130–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth.2009;103(5):637–46.

    CAS  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Lees N, Hamilton M, Rhodes A. Clinical review: Goal-directed therapy in high risk surgical patients. Crit Care.2009;13(5):231.

    PubMed  PubMed Central  Google Scholar 

  31. 31.

    Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care.2005;9(6):R687–93.

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Reyad AR, Elkharboutly W, Wahba A, Elmorshed M, Hasaneen NA. Effect of intraoperative dobutamine splancnic tissue perfusion and outcome after Wipple surgery. J Crit Care. 2013;28(4):531.e7–15.

    CAS  Google Scholar 

  33. 33.

    Kuper M, Gold SJ, Callow C, Quraishi T, King S, Mulreany A et al. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ. 2011 May 24;342:d3016.

    Google Scholar 

  34. 34.

    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(3):466–70.

    CAS  Google Scholar 

  35. 35.

    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(1):44–51.

    CAS  Google Scholar 

  36. 36.

    Rollins KE, Lobo DN. Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials. Ann Surg. 2016;263(3)465–76.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Som A, Maitra S, Bhattacharjee S, Baidya DK. Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analisys of randomized controlled trials. J Anesth. 2017 Feb;31(1):66–81.

    Google Scholar 

  38. 38.

    Brandstrup B. Fluid therapy for the surgical patient. Best Pract Res Clin Anaesthesiol.2006;20(2):265–83.

    Google Scholar 

  39. 39.

    Boldt J. Volume therapy in the intensive care patient—we are still confused, but... Intensive Care Med. 2000;26(9):1181–92.

    CAS  Google Scholar 

  40. 40.

    Bruegger D, Jacob M, Rehm M, Loetsch M, Welsch U, Conzen P, et al. Atrial natriuretic peptide induces shedding of endothelial glycocalyx in coronary vascular bed of guinea pig hearts. Am J Physiol Heart Circ Physiol. 2005;289(5):H1993–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Senagore AJ, Emery T, Luchtefeld M, Kim D, Dujovny N, Hoedema R. Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. Dis Colon Rectum.2009;52(12):1935–40.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013 Aug 1;369(5):428–37.

    CAS  PubMed  PubMed Central  Google Scholar 

  43. 43.

    De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent JL. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med. 2005 Apr;31(4):517–23.

    PubMed  PubMed Central  Google Scholar 

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Funding

This study was not supported by any grant.

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Authors

Contributions

LG, AM, NM, VS, and EP conceived and designed the study; NM, AM, KD, GM, and LP collected all sensitive data; AM, LG, and VS performed the statistical analysis; LG, AM, and NM first drafted the manuscript; all authors participated to manuscript preparation and finalization and agreed on its final version.

Corresponding author

Correspondence to Katia Donadello.

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The authors declare that they have no competing interests.

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Approval from the Institutional Review Board was obtained (local committee acceptance number 884CESC) along with written informed consent from all patients.

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Gottin, L., Martini, A., Menestrina, N. et al. Perioperative Fluid Administration in Pancreatic Surgery: a Comparison of Three Regimens. J Gastrointest Surg 24, 569–577 (2020). https://doi.org/10.1007/s11605-019-04166-4

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Keywords

  • Fluid strategy
  • Volume replacement
  • Crystalloids
  • Colloids
  • Abdominal surgery
  • Postoperative complications