Restrictive Fluid Therapy:How much restrictive?

Presenter:Dr.Abhishek V.Lonikar
-Introduction:-
-The essential objective of perioperative fluid management is to
achieve a delicate balance between underresuscitation and
overresuscitation.
-Underresuscitation results in hypovolemia-induced hypotension
with impaired tissue perfusion and insufficient oxygenation.
-Overresuscitation results in volume overloaded
cardiopulmonary complications, interstitial edema with
gastrointestinal dysfunction, and anastomotic compromise.
-For decades Liberal therapy was used but it was found later in
many studies that it was responsible for many post operative
complications and prolonged ICU stay.So the concept of
Restrictive Fluid Therapy came forward.
-50% decrease in post operative complications just because of
proper intraoperative fluid management.
-Zero-Balance or Restrictive Fluid Management-replaces blood
loss on a milliliter-for-milliliter basis with colloid and minimal to
no maintenance crystalloid rate for insensible losses.
-Optimal fluid management in ERAS uses a balanced approach with
crystalloids and colloids titrated to hemodynamic stability
and urine output maintenance of 0.5 mL/kg/h. Maintenance
crystalloid fluids, when used, should be restricted to less than 2
mL/kg/h, accounting for volume associated with drug infusions.
-Guptas Perioperative Cardiac Risk Calcuator –
1.Type of surgery

2.Dependent functional status

3.Abnormal creatinine

4.American Society of Anesthesiologists’ class (table 5)

5.Increased age
 Restrictive Deferred Hydration Combined with Preemptive
Norepinephrine Infusion during Radical Cystectomy Reduces
Postoperative Complications and Hospitalization Time A Randomized
Clinical Trial
-Wuethrich et al, conducted this prospective, single-center, double-blind
(patient, data assessor, and surgeon), parallel-group, randomized, controlled
trial.
-Exclusion criteria were known coagulopathies, significant hepatic
dysfunction (prothrombin ratio <50%), significant renal dysfunction
(estimated glomerular filtration rate <60 ml/min), congestive heart failure
,and contraindications for epidural analgesia.
-Methods:-
-Restrictive Deferred Fluid Group with Preemptive Norepinephrine
Administration (“Low-volume Group”). After induction of anesthesia, a
preemptive norepinephrine infusion was started at a rate of 2 μg/kg/h until
the end of surgery and a balanced Ringer’s solution was infused at a rate of 1
ml/kg/h until the bladder was removed, followed by 3 ml/kg/h of balanced
Ringer’s solution until the end of surgery (deferred hydration). If hypotension
was observed (MAP <60 mmHg), norepinephrine infusion rate was titrated to
maximum 8 μg/kg/h after an initial bolus of 10 μg. If hypotension persisted, a
bolus of 250 ml of balanced Ringer’s solution was given.
-Control Group-preload bolus of 6 ml/kg of balanced Ringer’s
solution was administrated during induction of anesthesia. After
that, balanced Ringer’s solution was infused at a constant rate of
6 ml/kg/h until the end of surgery. If hypotension was observed
(MAP <60 mmHg) a bolus of 250 ml balanced Ringer’s solution
was given and in case of persistent hypotension this procedure
was repeated to a maximum of 10 boluses.
-Colloid solution were only infused as a rescue medication if a
MAP less than 60 mmHg persisted after the abovementioned
correction with balanced Ringer’s solution, and in case of severe
metabolic acidosis (base excess <−5, pH <7.25) attributable to
severe hypovolemia.
-Results:-
-
-lower inhospital and 90-day postoperative complication rates, and
reduced hospitalization time.
Single centre review for CRS-HIPEC study
-Recorded variables included demographics,
intraoperative factors, 60-day postoperative
complications, and length of stay (LOS).
-Total of 169 consecutive CRS/HIPEC cases , of which 84
(50%) were managed with an intraoperative permissive
fluid therapy(PFT) approach and 85 (50%) were
managed with an restricted fluid therapy (RFT)
approach.
-Methods:-
-Standard intraoperative monitoring devices were
employed throughout the 8-year study period.
-From January 2009 through September 2014, the PFT
approach was applied in which patients received an
average 1000 mL/h of crystalloid plus or minus
additional colloid. Beginning in October 2014, after
multidisciplinary discussions regarding intraoperative
resuscitation, a concerted effort was made to reduce
fluid delivery to 500 mL/h with more
liberal utilization of peripheral vasopressors.
-Results:-
(1)Significant decrease in 60-day morbidity,
(2)length of hospital stay,
(3) reduction in complications,&
(4) association between intraoperative fluid therapy
and postoperative morbidity.
-Regarding transfusion protocols, the PFT group were more
likely to receive an intraoperative blood transfusion.
-The liberal intraoperative fluid resuscitation strategy received
blood products unnecessarily due to induced a transient state of
hemodilution.
-Conclusions:-
-CRS/HIPEC can be performed safely with a restrictive
intraoperative fluid management strategy. Minimizing the
volume of intraoperative crystalloid and colloid to approximately
500 mL/h is associated with a decrease in 60-day complications
and hospital LOS.
 Grants et al.,
-Prospective Randomized Controlled Trial of Liberal Vs Restricted
Perioperative Fluid Management in Patient Undergoing
Pancreatectomy.
-prospective RCT in 330 patients
-Objective:- The aim of this study is to examine, by a prospective
randomized
controlled trial, the influence of liberal (LIB) vs restricted (RES)
perioperative
fluid administration on morbidity following pancreatectomy.
-Materials & Methods :- During Preoperative and Intraoperative
Management after formal medical evaluation and optimisation.
-The RES Arm - maintenance IV crystalloid at 6 mL/kg/h. Blood loss
was replaced mL: mL with 5% albumin until transfusion criteria
[hemoglobin (Hb) <8 mg/dL] were met.
-Additional fluid boluses of 100 mL of crystalloid and
pressors were used for maintainence of
haemodynamic stability .
- Fluid boluses of 250 mL crystalloid-urine output less
than 0.5 mL/kg for 2 hours. For later starting cases, an
additional bolus of crystalloid of 0.5 mL/kg was given
for each fasted hour from 8 AM until induction.
-The LIB Arm, additional crystalloid was given to bring the
maintenance fluids to 12 mL/kg/h. Blood loss was similarly
replaced as in the RES Arm, as well as additional fluid boluses.
Crystalloid 250 mL boluses were used to maintain urine output
at >1 mL/kg for 2 hours. For later starting cases, an additional
bolus of crystalloid of 1.5 mL/kg/fasted hour from 8 AM was
given to bring the total crystalloid to 2 mL/kg/fasted hour.
-POD 0 (PACU):-All patients had strict inputs and outputs
measured. Overnight stable patient were shifted to inpatient
department next morning .
-Restrictive arm received crystalloid at a rate of 60 mL/h. Urine
output was maintained at >40 mL/2 hours with boluses of 250
mL of a crystalloid solution.Fluid boluses were administered to
maintain hemodynamic stability as needed.
-Liberal arm received crystalloid at a rate of 125 mL/h (100 mL/h
for those weighing <50 kg.) Urine output was maintained at 0.5
mL/kg/h with crystalloid boluses of 250 mL.
-POD 1:-
-RES Arm patients received D5W/0.5%NS with 20 mEqKCl/L or
equivalent solution at 50 mL/h until their oral intake was >500
mL/24 hours. Urine output -160 mL/8 hours with crystalloid
boluses of 250 mL.
-LIB Arm patients received the same at 100 mL/h until their oral
intake was >500 mL/24 hours. Urine output was maintained at
240 mL/8 hours (pretrial standard) with crystalloid boluses of
250 mL.
-If the urine output increased to greater than 80 mL/h over 8
hours, or the patient appeared clinically volume overloaded, the
IV rate was decreased. Furosemide was used at the discretion of
the attending surgeon
-Results and discussions :-
(1)no statistical difference rate complications following
pancreatic resection in patients in either the LIB or RES groups.
-Conclusions:-
- This trial represents a definitive analysis of the effect of
moderate degrees of LIB and RES fluid management on the
complication rate after pancreatic resection. Complication rates
are not significantly altered by regimens of perioperative fluid
management that differ by 1.5 to 2-fold.
- Limitations :-A single institution study, the attending surgical
investigators were not blinded to the randomization, did not use
such physiologic measures as degree of tissue edema or tissue
oxygen tension nor did we follow a goal-directed fluid
management protocol.
-Introduction:-
-RELIEF is a large, multicentre, randomised, international,
single blind, pragmatic trial, with patients randomly
assigned to either restrictive or liberal fluid
groups, stratified by site and by planned high dependency
unit (HDU) or intensive care unit (ICU) admission.
-Their primary hypothesis is that a restrictive fluid regimen
for adults undergoing major abdominal surgery leads to
reduced complications and improved disability-free survival
when compared with a liberal fluid regimen.
-Exclusion criteria
1. Urgent or time-critical surgery
2. ASA physical status 5
3. Chronic renal failure requiring dialysis
4. Pulmonary or cardiac surgery
5. Liver resection
6. Minor or intermediate surgery, such as laparoscopic
cholecystectomy, transurethral resection of the prostate,
inguinal hernia repair, splenectomy and closure
of colostomy.
-Methods:-
-Liberal (‘traditional practice’) intravenous fluid group-at the
initiation ofsurgery, a bolus of Hartmann’s or comparable
balanced salt crystalloid 10 mL/kg followed by 8 mL/kg/hour was
administered until the end of surgery—the latter could be
further downtitrated after 4 hours if clinically indicated.
-maintenance infusion-at 1.5 mL/kg/hour, for at least 24 hours.
-Restrictive (‘zero balance’) intravenous fluid group-main aim
was to administer <2L of fluid.On induction bolus-<5ml/kg given
and there after maintenance fluid at 5ml/kg/hr was given till the
end.Postoperative infusion rate of 0.8 mL/kg/hour until
cessation of intravenous fluid therapy within 24 hours.
-Conclusions:-In RELIEF, the restrictive group were administered a
postoperative IV crystalloid infusion at an average rate of 0.8 ml · kg−1
· h−1 (calculated with a maximum weight of 100 kg) or up to 80 ml/h
for at least 24 h, and the liberal group were administered a crystalloid
infusion of 1.5 ml · kg−1 · h−1. There was a lower urine output and
more oliguria during and after surgery, and a near doubling of the
incidence of postoperative acute kidney injury, in the restrictive group.
-Take Home Message:-
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