Goal directed fluid therapy reduces major complications in elective surgery for abdominal aortic aneurysm: liberal versus restrictive strategies

Abstract

Background: Optimal fluid management is crucial for patients undergoing surgical repair of abdominal aortic aneurysm (AAA). Persistent hypovolemia is associated with complications but fluid overload is also harmful. Aim: This study evaluates that perioperative fluid restriction would reduce complications and improve outcome through goal-directed strategies in patients undergoing AAA. Methods: Fifty patients, aged from 60 to 75 years undergoing elective surgical repair of AAA were included in this randomized study. Patients were divided into two groups, 25 for each: liberal group (L) receives 12 ml/kg/h and restrictive group (R) receives 4 ml/kg/h. Goal-directed-therapy approach was concerning assessment of tissue oxygenation. Dobutamine and fluid challenges were used to maintain adequate tissue perfusion during surgery. Results: The patients of the (L) group received a significant greater amount of Lactated Ringer's solution (3586.76 ± 473.21) than the (R) group (1219 ± 140.6). The (R) group had 50% lower rate of major postoperative complications than the (L) group (24% vs 48%) and less hospital stay. Conclusion: A restrictive strategy of fluid maintenance during optimization of oxygen delivery with early treatment directed to maintain oxygen extraction ratio estimate (O 2 ERe) at <27% reduces major complications and hospital stay of surgical patients undergo abdominal aortic aneurysm.

Perioperative liberal versus restrictive fluid strategies and postoperative outcomes: a systematic review and metanalysis on randomised-controlled trials in major abdominal elective surgery

“…All the studies, except two [ 25 , 26 ], were conducted on patients with a median age > 60 years old (Table 1 ). Interestingly, in 5 studies (27.7%), including the largest one [ 16 ], the perioperative fluid administration algorithm was guided by the optimisation of predefined or flow haemodynamic pressure variables, by means of a goal-directed therapy [ 16 , 25 , 27 – 29 ] (Additional file 1 : Table 4).

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“…Only two studies reported the mean postoperative overall fluid balance among restrictive and liberal subgroups [ 16 , 33 ]. Nine studies (50.0%) did not report postoperative weight gain [ 25 , 26 , 29 – 31 , 33 , 34 , 36 , 37 ], moreover, in Myles et al’s study, data regarding this variable were missing for 1,036 (69.5%) patients in the restrictive fluid group and 999 (66.9%) in the liberal fluid group [ 16 ].…”

“…The overall amount of fluid (perioperative target) should be integrated into an individualised goal-directed fluid replacement strategy (perioperative policy), to prevent fluid overload and fluid shortage by closely monitoring the effects of each bolus administered, as long as the individual plateau of the impact on predefined flow or pressure variables is achieved [ 12 , 44 ]. Interestingly, this approach was incorporated into the intraoperative protocol of 5 studies [ 16 , 25 , 27 – 29 ], including the study of Myles et al who assessed central venous pressure and stroke volume variation in case of intraoperative hypotension to guide resuscitation (supplementary appendix of the trial [ 16 ]). Moreover, a recent metanalysis showed a trend towards the reduction of postoperative complications when a goal-directed therapy is used in patients receiving large amounts of perioperative fluids [ 45 ].…”

Ameliyat Sürecinde Uygulanan Sıvı Tedavisi Yöntemleri

“…30,[49][50][51] Özellikle büyük cerrahi girişimlerde, sıvı tedavisinin ameliyat sırasında hemodinamik monitörizasyon eşliğinde ve hastanın gereksinimlerine göre uygulanması önerilmekte-dir. 44 Yüksek riskli cerrahi girişimlerde ameliyat esnasında standart sıvı tedavisi ile bireye özgü hedefe yönelik sıvı tedavisinin karşılaştırıldığı 33 hasta ile yapılan bir çalışmada bireye özgü hedefe yönelik sıvı tedavisi alan grupta (toplam sıvı miktarı ortalama 4618ml) komplikasyon gelişimi, hastanede ve yoğun bakım ünitesinde kalış süresi standart sıvı tedavisi alan gruba göre (toplam sıvı miktarı ortalama 1694ml) istatistiksel olarak anlamlı düzeyde düşük bulunmuştur.…”