Fluid management and vasopressor use during colorectal surgery: the search for the optimal balance

Abstract

Background Although it is known that excessive intraoperative fluid and vasopressor agents are detrimental for anastomotic healing, optimal anesthesiology protocols for colorectal surgery are currently lacking. Objective To scrutinize the current hemodynamic practice and vasopressor use and their relation to colorectal anastomotic leakage. Design A secondary analysis of a previously published prospective observational study: the LekCheck study. Study setting Adult patients undergoing a colorectal resection with the creation of a primary anastomosis. Outcome measures Colorectal anastomotic leakage (CAL) within 30 days postoperatively, hospital length of stay and 30-day mortality. Results Of the 1548 patients, 579 (37%) received vasopressor agents during surgery. Of these, 201 were treated with solely noradrenaline, 349 were treated with phenylephrine, and 29 received ephedrine. CAL rate significantly differed between the patients receiving vasopressor agents during surgery compared to patients without (11.8% vs 6.3%, p < 0.001). CAL was significantly higher in the group receiving phenylephrine compared to noradrenaline (14.3% vs 6%, p < 0.001). Vasopressor agents were used more often in patients treated with Goal Directed Therapy (47% vs 34.6%, p < 0.001). There was a higher mortality rate in patients with vasopressors compared to the group without (2.8% vs 0.4%, p = 0.01, OR 3.8). Mortality was higher in the noradrenaline group compared to the phenylephrine and those without vasopressors (5% vs. 0.4% and 1.7%, respectively, p < 0.001). In multivariable analysis, patients with intraoperative vasopressor agents had an increased risk to develop CAL (OR 2.1, CI 1.3–3.2, p = 0.001). Conclusion The present study contributes to the evidence that intraoperative use of vasopressor agents is associated with a higher rate of CAL. This study helps to create awareness on the (necessity to) use of vasopressor agents in colorectal surgery patients in striving for successful anastomotic wound healing. Future research will be required to balance vasopressor agent dosage in view of colorectal anastomotic leakage.

Prevention of Anastomotic Leak in Colorectal Surgery: Current Knowledge and Next Steps

“…Multivariate analysis also showed that phenylephrine use was associated with a higher risk of anastomotic leak compared to noradrenaline with an odds ratio of 4.2. 10 It is thought that vasopressors lead to vasoconstriction, deterioration of microcirculation, and potentially result in local tissue hypoxia. 11 These findings are consistent with those of older studies.…”

Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice

“…On the other hand, fluid overload may result in harmful "third space" weight gain, associated with higher rates of pulmonary complications, postoperative ileus, altered mental status, and edema-related anastomotic complications, thus impeding postoperative recovery [12][13][14][15][16]. Furthermore, an excessive extracellular fluid volume may lead to abdominal compartment syndrome, which by itself may trigger adverse physiologic effects such as respiratory failure and renal failure [17].…”