Perioperative Fluid Utilization Variability and Association With Outcomes

Thacker, Julie K.; Mountford, William K.; Ernst, Frank R.; Krukas, Michelle R.; Mythen, Monty

doi:10.1097/sla.0000000000001402

Cited by 194 publications

(77 citation statements)

References 11 publications

(15 reference statements)

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“…After abdominal operations, one of the most important drivers of length of stay in the absence of major postoperative complications is the occurrence of postop ileus, 1,22,28 which has been associated, in turn, with the volume of fluid administration during surgery. 18,22 Thus, a common element of modern enhanced recovery protocols is the limitation of excessive intravenous fluid, and a focus on maintenance of normovolemia. 1,10,29,30 However, in the absence of clinical guidelines to direct intraoperative fluid management, 15 it is unclear to what extent practices have changed in real-world practice.…”

Section: Discussionmentioning

confidence: 99%

“…22,23 These previous analyses are potentially confounded at the patient level, however, by the association between adverse intraoperative events and greater fluid volume administration. Many common predictors of poor postoperative outcomes, including prolonged operative time, excessive blood loss, intraoperative hypotension, tachycardia, and others, 31–38 are also potentially associated with excessive fluid administration.…”

Section: Discussionmentioning

confidence: 99%

“…11,14,18–21 In observational studies with analyses at the patient level, there is an association between fluid administration volume and pLOS and ileus in colorectal surgery. 22,23 But it remains unclear whether these outcomes, and the differences in fluid volume, are driven more by differences in patient characteristics and intraoperative events or by true differences in the approach to fluid balance.…”

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confidence: 99%

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Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties

Regenbogen

Shah

Collins³

et al. 2017

Annals of Surgery

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Objective To assess the variation in hospitals’ approaches to intraoperative fluid management and their association with postoperative recovery. Background Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices. Methods Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS). Results There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings. Conclusions Hospitals’ approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties

Regenbogen

Shah

Collins³

et al. 2017

Annals of Surgery

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“…Both liberal and the most restrictive fluid resuscitation strategies have been associated with respiratory complications (pulmonary edema or increased deadspace during hypovolemia, respectively), whereas moderately restrictive fluid volumes are consistently associated with optimal postoperative outcomes [37 ▪▪ ,38,39 ▪ ]. Some data suggest that very high doses of opioids administered during surgery are associated with increased 30-day readmission rate [40].…”

Section: Introductionmentioning

confidence: 99%

Prevention of respiratory complications of the surgical patient

Ruscic

Grabitz

Rudolph

et al. 2017

Current Opinion in Anaesthesiology

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Purpose of reviewPostoperative respiratory complications (PRCs) increase hospitalization time, 30-day mortality and costs by up to $35 000. These outcomes measures have gained prominence as bundled payments have become more common.Recent findingsResults of recent quantitative effectiveness studies and clinical trials provide a framework that helps develop center-specific treatment guidelines, tailored to minimize the risk of PRCs. The implementation of those protocols should be guided by a local, respected, and visible facilitator who leads proper implementation while inviting center-specific input from surgeons, anesthesiologists, and other perioperative stakeholders.SummaryPreoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function.

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“…The ability to provide for these demands with an increase in oxygen delivery (driven by cardiac output) is an important factor of good outcome (1). It seems that just the right amount of fluids to support organ perfusion is necessary and too little or too much fluids can increase complication rate and length of hospital stay (2). Reduction of postoperative complications and duration of stay has a dramatic impact on costs (3).…”

Section: Introductionmentioning

confidence: 99%

Current concepts in fluid therapy and non-invasive haemodynamic monitoring

2017

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Advantages of goal directed therapy (GDT) have recently become more and more difficult to prove in the face of newly implemented protocolised patient care approaches that also clearly improve patient outcome. However, individualised approach using GDT has been suggested to be superior to protocolised care and large meta-analyses still consistently show beneficial effects of GDT. Concerns of invasiveness were the reason why some patients' haemodynamics was not measured and in turn were not included in any GDT protocols. Recently, non-invasive devices to measure arterial blood pressure and haemodynamic variables emerged, and although they are very appealing and easy to use, they require further validation both by comparison to more invasive methods and by outcome trials.

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Perioperative Fluid Utilization Variability and Association With Outcomes

Abstract: According to results from this review of current practice in US hospitals, fluid optimization would likely lead to decreased variability and improved outcomes.

Cited by 194 publications

References 11 publications

Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties

Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties

Prevention of respiratory complications of the surgical patient

Current concepts in fluid therapy and non-invasive haemodynamic monitoring

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