UPDATE ON PERIOPERATIVE

FLUID THERAPY
Symposium Highlight
In line with the latest advances in surgical and an esthetic
techniques, new discoveries in perioperative fluid
management are also introduced in recent years and al so
contribute to the success of the surgery and the prognosis of
patients. Various protocols and guidelines on per ioperative
fluid and nutrition therapy have been developed and published
by world leading associations, such as BAPEN (British
Society of Parenteral and E nteral Nutrition), ESPEN
(European Society of Parenteral and Enteral Nutrition) and
ASPEN (American Society of Parenteral and Enteral
Nutrition). This was revealed in a symposium on 15 April 2012
at Hotel JW Marriott, Jakarta with the theme "Update on
perioperative Fluid and Nutrition Therapy". Scientific meeting
that was attended by 85 surgeon featured three speakers and
chaired by Dr Yarman Masni,SpB-KBD
As the first speaker, Dr. Iyan Darmawan, Medical Director of
PT Otsuka Indonesia shared that it has become a t radition
that many patients with gastrointestinal resection received
massive crystalloid fluids during and after surgery. Apparently
excessive fluids and electrolytes, results in significant weight
gain and edema. Also concluded that excess weight is a
major cause of postoperative ileus, and delayed gastric
emptying. When the amount of water is restricted merely to
maintain water and sodium balance, gastric emptying
occurred more quickly and patients can tolerate a normal diet
and bowel movements a few days earlier than patients with a
positive water balance.

phase do not necessarily reflect hydration status. Moreover,

water and sodium excretion tended to be slower after infusion
containing high sodium. These findings have spurred
recommendations of a m aximum of 2 l iters of water, and
sodium of less than 60 to 100 mmol/day postoperatively.

Low sodium does not aggravate interstitial expansion in

patients with hypoalbuminemia that could delay the healing of
surgical wound. This concept is in line with the ERAS concept
pioneered by Fearon et al.

Rationale of provision of moderate water and sodium

administration during postoperative period
It has long been known that the stress of surgery, as well as
other trauma, may induce water retention and lead to positive
sodium and water balance during the early phase of injury.
Therefore, the amount of urine in the early postoperative

Fearon KCH, Ljungqvist O, Von Meyenteldt M; Revhavy A, Dejong CHC, Lassen

K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet ; Enhanced recovery after
surgery: A consensus review of clinical care for patients undergoing colonic
resection. Clinical Nutrition 2005; 24: 466-477

Rationale of low glucose administration has long been known.

Blood sugar levels increased after the operation began.
Cortisol and catecholamines facilitate the production of
glucose as a r esult of increased glycogenolysis and
gluconeogenesis in the liver. In addition, glucose utilization is
reduced due to these hormones.
Although the usual formula 25 kcal / kg BW is used to meet
daily needs, and on the conditions of severe stress can
approach 30 kcal / kg BW, rational approach for early-flow
phase is providing 10-20 kcal / kg actual body weight or
adjusted weight if actual BW > 120% ideal weight.

1. Provide nutritional support in the period before and

after surgery: enteral or parenteral.
2. Surgical trauma has impact on changes in metabolism:
From Anabolisme to metabolism
3. Recovery from surgery needs healing from trauma
4. Nutritional support can minimize the catabolism
5. Nutritional support promotes anabolism.
6. Decrease morbidity and mortality

Further dr Iyan suggested that the effect of body protein

catabolism saving (Protein-Sparing effect) which is known by
providing 100-150 g of glucose per day is by 50% only, so
administration of amino acids is also required to minimize the
negative nitrogen balance. It is known from the calculation,
that obligatory nitrogen excretion via urine, feces and skin is
about 54 m g / kg / day. This is equivalent to 30 g rams of
amino acids in adults. This is represented by one litre of
Aminofuid as a new generation maintenance solution. There
are compelling reasons for giving Aminofluid to surgical
patients to speed recovery.

10-20 kcal/kg BW is ideal during flow phase, moderate

supply of glucose prevents worsening of s tressinduced hyperglyc emia and insulin resistance
Patients with mild to mederate stress and anticipated to
lack of oral intake for 7 day , require only 500-600
kcal/day
Simultaneous administration of BCAA enriched amino
acids and glucose in dual-chamber soft bag will
improve nirogen balance and combat postoperative
fatigue
Zinc promotes wound healing, support immune function
and cellular growth, and improtant as body antioxidant
system
Na+ in moderate concentration prevents water retention
and iatrogenic fluid overload; the content of
K+
prevents further depletion of potassium

The second speaker of this symposium was Dr Toar

Lalisang,PhD, SpB-KBD, Head of Department of Digestive
Surgery, FKUI/RSCM. At the beginning of his presentation Dr
Toar mentioned that the recovery of nutritional status to the
pre-illness level in patients with major surgery, especially with
resection of the colon, stomach or esophagus may take up to
weeks.

Metabolism during fasting period is characterized by the

following:

TEE (totalEnergy expenditure) 1500 kcal/day

Catabolism of muscle/protein 75 g/
Gluconeogenesis to yield glucose from alanine.

Fat deposit 120 g/day will be metabolized

day

Surgical intervention/trauma increased catabolism and has

the features of:

TEE (total Energy expenditure) 3000 kcal/day

Catabolism of muscle protein ; 180 g /day

Patient with good nutritional status can withstand up to 3-4

days. But if it continues can slow wound healing, reduce
protein synthesis and lower immune system function
Changes of nutritional status after elective surgery have been
investigated by Dr Toar Lalisang as follows:

Weight loss occurred in 76% of patients (mean weight

loss was 4%)

Decreased serum albumin concentration occurred in

88% of patients(mean derease was 15%)

Dr Toar further stated that from the existing publications found

to date, ther were no benef its of giving albumin solution to
cases of early postoperative hypoalbuminemia.
Dosages of macronutrients required during acute surgical
stress can be summarized below (Barton RG. Nutr. Cln. Pract.
1994.8.127-139 ASPEN Board of D irectors. JPRN 2002;26 S uppl
1:22SA):

Carbohydrate

DR Toar further explained that the definition of perioperative

nutritional support included following:

At least 100 g of glucose/day is needed to prevent

ketosis and as fuel to the brain

Carbohydrate intake during stress should range from

50%-60% of total caloriesi

Glucose infusion rate should not exceed 5mg/kg/min

Provides 20%-35% of total calories

Recommended maximum administration rate of lipid

1.0 1.5 g/kg/day

Monitor triglyceride levels to ensure adequate lipid

clearance

Sources of fatty acids should be considered

Fat

6. Excessive nutrient loss

a. Malabsorption
b. Short bowel syndrome
c. Fistula
d. Draining abscess or wound (burn)
e. Dialysis
7. Increased nutrient requirements
a. Trauma
b. Burn
c. Sepsis
d. Medications with anti-nutrient property

Amino acids

Requirement range from 1.2 2.0 g/kg/day in stress

Constitutes 20% - 30% of total calories during stress

As additional information, branched-chain amino acids aka

BCAA (Leucine, isoleucine, valine) have special advantage in
surgical patients as precursors glutamine and alanine in
skeletal muscle. Healthy person needs daily BCAA estimated
at 144 m g/kg/day. In certain circumstances of metabolic
stress more exogenous BCAA might be required.
The third speaker of this symposium was Dr. Benny Philippi,
SpB-KBD with the topic of Parenteral Nutrition in Critically
Surgical Patients. At the beginning of his presentation, Dr.
Benny emphasized that malnutrition is common in critically ill
patients, where 20-40% of them showed evidence of proteinenergy malnutrition. Therefore, serial assessment of
nutritional status should be a routine component of care in the
ICU, and adequate nutrient intake is critical for cell and organ
function and wound healing
Many critical surgical patients released chemical mediators,
including hormones and c ytokines. Counter-regulatory
hormones (catecholamines, cortisol, glucagon) tends to
increase blood sugar and insulin resistance, while ADH and
aldosterone lead to Na+ and water retention. Pro-inflammatory
cytokines such as TNF-, IL-1 and IL-6 are responsible for
the excessive catabolism in surgical patients, major trauma
and sepsis through activation of the neuroendocrine axis.

Most critically ill patients who require nutritional support (85 to

90%) can be administered by enteral tube feeding through the
stomach or intestines, and t hen switch to oral food with
supplements..
However, in approximately 10 to 15% of such patients, enteral
nutrition is contraindicated. This is where the role of parenteral
nutrition is very helpful
TPN (total parenteral nutrition) supplies water, dextrose,
amino acids, lipid emulsion, electrolytes, vitamins and
microminerals.
The indications of
PN in critically-ill patients(ESPEN
Guideline on PN : Intensive Care. Clinical Nutrition 2009;
28:387400) can be summarized as follows:

All patients anticipated to be NPO within 3 day s

should be given a PN within 24 to 48 ho urs if EN is
contraindicated or if the patient does not tolerate EN
All patients who received less EN after 2 day s
according to the target should be considered to
supplementation with the PN
Ideally the total caloric needs are measured by indirect
calorimetry. But if there is no indirect calorimetry, ICU
patients should receive 25 k cal / kg / day which is
increased gradually to reach the target in the next 2-3
days.

To conclude the presentation of Dr. Benny Philippi, when

enteral nutrition is impossible, parenteral nutrition should be
started
Assessment of nutritional status in critically ill patients needs
to be done if the following is found:

'Do not rush in approach to parenteral nutrition "should be

adopted

1.
2.
3.
4.
5.

If you need t o give a high caloric parenteral nutrition and

osmolarity of more than 900-1000 mOsmol / L and t he
necessary monitoring of central venous pressure, central

Too thin (< 80% ideal BW)

Too fat (>120% ideal BW)
Recent weight loss(>10% within 3 months)
Alcohol/drug dependence
NPO (nothing per oral) > 5 days

transition before patients can eat and drink enough,

because of protein-sparing effect and prevention of
ketosis. BCAA and microminerals contained in
Aminofluid make patients feel more fresh and recover
faster.

venous access with the preparation of "all-in-one bag" is the

preferred route for parenteral nutrition

DISCUSSION
Q

What is the background of intraoperative

administration of amino acids?

In some experimental studies with intraoperative

administration 200 ml of 10% amino acids, thermogenic
effect was obtained to maintain core temperature,
instead of nutritional effect of protein synthesis.

Do you recommend albumin administration to

correct early postoperative hypoalbuminemia?

Although pre-operative hypoalbuminemia is an

independent risk factor for postoperative complications
after colorectal surgery(World J Gastroenterol. 2008

February 28; 14(8): 12481251)( Asia Pac J Clin Nutr.

2007;16(2):213-7., and preoperative values should be >3
g/dl (Ann Surg. 2003 March; 237(3): 319334.), kcorrection

of potoperative hypoalbuminemia is controversial, and

many studies did not confirm the benefits.

Is administration of Aminofluid adequate for

complicated surgical patients and severe metabolic
stress?

The rationale of Aminofluid administration in surgical

patients with complications and severe stress is as
follows:
1. In acute phase of severe surgical stress, insulin
resistance occurs so the calorie provision must be
start low go slow
2. 10-20 kcal/ kg BW is ideal during flow phase;
Moderate content of glucose in Aminofluid has
protein-sparing effect and avoids worsening of
stress-induced hyperglycemia. Therefore Aminofluid
can be given as starting solution.
3. BCAA-enriched amino acids combined with glucose
are required to minimize negative nitrogen balance
and combat postoperative fatigue
4. Na+ in moderate amount prevents iatrogenic fluid
overload and K+ prevents potassium depletion

Is it reasonable to administer Aminofluid to

patients with straightforward surgery where as they
can be discharged early?

In patients with straightforward surgery, Aminofluid can

be given straight after the patient is transferred from OT
to the ward,as complete maintenance solution and

Do you recommend fat emulsion premixed to

Aminofluid?

Preferably Aminofluid and fat emulsion given by 3-way,

although empiric experience of many clinicians
suggests that premixture is not problematic and
with good results.

With pre-operative oral carbohydrate loading, what

is the concentration and can iv glucose yield the
same result in reducing postoperative insulin
resistance?

800 ml midnight and 200 ml 2 hour before induction of

anesthesia, clear liquid containing 12.5% of
carbohydrate or equivalent. Parenteral glucose gives the
same results to minimize postoperative insulin
resistance.

CONCLUSION
Surgical patients have a wide spectrum in terms of nutritional
status and metabolic stress experienced and the complexity of
surgery
and anes
thesia
techniques.
Therefore,
individualization in the management of perioperative fluid and
nutrition needs serious attention.
In modern surgical practice, various protocols have been
developed where patients can recover quickly and return to
normal food intake after a few days. This applies especially for
surgical patients who are not malnourished or without
complications of infection / sepsis. Therefore, there are scanty
of indications for routine provision of nutritional support, in
which patients were given nutritional support "full dose". In
this case, patients in the early postoperative phase needs only
a complete maintenance fluid therapy to improve outcomes
and speed up recovery.