Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery

Abstract

Objectives:To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols.Methods:Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality.Results:A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66–0.89, P = 0.0007), hospital length of stay (LOS; mean difference −1.55 days, 95% CI −2.73 to −0.36, P = 0.01), intensive care LOS (mean difference −0.63 days, 95% CI −1.18 to −0.09, P = 0.02), and time to passage of feces (mean difference −0.90 days, 95% CI −1.48 to −0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference −0.63 days, 95% CI −0.94 to −0.32, P < 0.0001) and time to passage of feces (mean difference −1.09 days, 95% CI −2.03 to −0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to −0.84, P = 0.0002) and total hospital LOS (mean difference −2.14, 95% CI −4.15 to −0.13, P = 0.04).Conclusions:GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting.

Current concepts of fluid management in enhanced recovery pathways

“…35 However, established ERPs used in a number of GDT studies have not shown the same benefit on patient outcomes. 38 This in many ways is not surprising: as perioperative care pathways have improved, the value of a single practice change on outcomes is diminished and therefore small, single centre trials are unlikely to show benefit. 39 The first multicentre trial of GDT in moderate to high risk patients, the Optimisation of Cardiovascular Management to Improve Surgical Outcome (OPTIMISE) study, failed to find a definitive answer: although there was a trend towards a reduction in the primary outcome (a composite of postoperative complications and mortality) in the GDT group, this did not reach clinical significance (P¼0.07).…”

Targeted Intraoperative Radiotherapy Is a Safe Approach for Patients with Pacemakers: A Case Study and Literature Review

“…IORT paired with breast conservation therapy involves the application of a single high dose of radiation directly to the surgical margins immediately after tumor resection, reducing the radiation exposure to the surrounding tissues [3,9]. Further benefits include breast preservation, increased compliance, shortened treatment time, and reduced journey times with complementary environmental benefits [10].…”

Perioperative Surgical Home. Meeting tomorrow’s challenges

“…This represents a judicious management initiative that has proven to have better outcomes in settings such as the ICU or in the management of cardiac patients. While there is still a gap in how anesthesiologists manage fluid administration perioperatively, a study published by Rollins & Lobo showed a decrease in morbidity and length of stay with a significantly shorter intensive care length of stay for the patients that were on the enhanced recovery pathway [19]. This is complemented by another study, a 2012 meta-analysis of multiple studies from as early as 1988.…”