Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Abstract

Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a ''zero-balance'' approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and ''permissive oliguria'' could be tolerated.Résumé La gestion périopératoire optimale des liquides est un élément important des programmes de récupération rapide après la chirurgie (RRAC). La gestion des liquides dans le cadre de la RRAC doit être vue comme un continuum au travers des phases pré-, per-et postopératoires. Chaque phase est importante pour améliorer la condition du patient et des soins sous-optimaux au cours d'une de ces phases peuvent miner les meilleures pratiques déployées tout au long de la RRAC. L'objectif de la gestion préopératoire des liquides est de faire en sorte que le patient entre en salle d'opération correctement hydraté et dans un état euvolémique. Pour y parvenir, un jeûne prolongé n'est pas recommandé et le nettoyage mécanique de l'intestin est à éviter. Les patients doivent être encouragés à absorber une boisson claire riche en hydrates de carbone, deux à trois heures avant la chirurgie. Les buts de la gestion peropératoire des liquides sont de maintenir une euvolémie centrale et d'éviter un excès de sel et d'eau. Pour y parvenir, les patients subissant une intervention chirurgicale dans le cadre d'un protocole de récupération rapide devraient avoir un programme personnalisé de gestion des liquides. Dans le cadre de ce plan, l'excès de cristalloïdes doit être évité chez tous les patients. Pour des patients à faible risque subissant une intervention c...

In reply: Fluid management issues in Enhanced Recovery After Surgery and Canadian Anesthesiologists’ Society standards

“…Merchant and Davies 1 for clarifying the wording in our recent review regarding fluid management in Enhanced Recovery After Surgery programs. 2 We agree that the Canadian Anesthesiologists' Society and the American Society of Anesthesiologists should change their practice guidelines for preoperative fasting to encourage consumption of clear fluids up to two hours preoperatively.…”

It is time for enhanced recovery after surgery in cardiac surgery

“…The above protocol is in agreement with the guidelines of the American Society of Anaesthesiologists. Fasting since midnight on the day preceding surgery does not decrease the volume of gastric contents and does not increase the pH of gastric juice [40]. The administration of fluids with carbohydrates prevents thirst and hunger, reduces the level of anxiety, and additionally prevents insulin resistance in the postoperative period.…”

Fluid Therapy and Management

“…Cerrahi sonrası iyileşmenin pekiştirilme-si amacıyla programlanan ve 20 değişkenin takip edildiği ERAS çalışması sonucunda, sıvı tedavisinin preoperatif karbonhidrat verilmesi ile birlikte, postoperatif iyileşmede en önemli bağımsız belirleyici faktör olduğu gösterildi. Perioperatif olarak her 1 lt. sıvı infüzyonu ile postoperatif dönemde risk oranının %16, postoperatif komplikasyon oranının ise %32 oranında arttığı belirlendi [18,19] . Hastalar cerrahiden 2 saat öncesine kadar su içer ve ameliyattan sonra da olabilen en erken dönemde su içmeleri sağlanırsa (ERAS, PSH vb.…”