Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study

Abstract

Restrictive fluid management has been recommended for thoracic surgery. However, specific guidelines are lacking, and there is always concern regarding impairment of renal perfusion with a restrictive policy. The objective of this study was to find the net intraoperative fluid infusion rate which shows the lowest incidence of composite complications (either pulmonary complications or acute kidney injury) in open thoracotomy. We hypothesized that a certain range of infusion rate would decrease the composite complications within postoperative 30 days. All patients (n = 1,031) who underwent open thoracotomy at a tertiary care university hospital were included in this retrospective study. The time frame of fluid monitoring was from the start of operation to postoperative 24 hours. The cutoff value of the intraoperative net fluid amount was 4-5 ml. kg −1 .h −1 according to the minimum p-value method, thus, patients were divided into Low (≤3 ml.kg −1 .h −1), Cutoff (4-5 ml.kg −1 .h −1) and High (≥6 ml.kg −1 .h −1) groups. The Cutoff group showed the lowest composite complication rate (19%, 12%, and 13% in the Low, Cutoff, and High groups, respectively, P = 0.0283; Low vs. Cutoff, P = 0.0324, Bonferroni correction). Acute respiratory distress syndrome occurred least frequently in the Cutoff group (7%, 3%, and 6% for the Low, Cutoff, and High groups, respectively, P = 0.0467; Low vs. Cutoff, P = 0.0432, Bonferroni correction). In multivariable analysis, intraoperative net fluid infusion rate was associated with composite complications, and the Cutoff group decreased risk (odds ratio 0.54, 95% confidence interval: 0.35-0.81, P = 0.0035). In conclusion, maintaining intraoperative net fluid infusion at 4-5 ml.kg −1 .h −1 was associated with better results in open thoracotomy, in terms of composite complications, compared to more restrictive fluid management. Postoperative pulmonary complications are the leading cause of morbidity, mortality, and prolonged hospital stay after thoracic surgery 1. Fluid overload is one of the major risk factors 2-4 and is receiving significant attention as a preventable risk factor. Therefore, fluid restriction is usually recommended during and after thoracic surgery 2-6. Despite the well-known risk of fluid overload, few studies have provided a guideline for intraoperative fluid management. Some experts insist on extreme restriction, and even zero fluid balance, for thoracic surgery 5. However, evidence for the efficacy of zero balance only exists in the context of intensive care units (ICUs) 7. Guidelines for ICU patients may not be applicable to patients undergoing a major operation because of anesthesia-induced vasodilation, increased insensible loss from the open thoracic cavity, surgical trauma induced fluid shift, and hemodynamic instability related to surgery. In addition to the lack of solid evidence, impairment of perfusion of major organs, especially the kidney, is another major concern with restrictive fluid management.

The effect of intraoperative goal-directed fluid therapy combined with enhanced recovery after surgery program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection: a prospective randomized controlled study

“…Another study of 92094 patients undergoing noncardiac surgery showed an increased incidence of AKI when intraoperative uid volume was less than 900 ml for a 3-hour operation [28]. In open thoracic surgery, compared to intraoperative net infusion rate of more than 6 ml/kg/h, the AKI incidence was higher when intraoperative net infusion rate of less than 3 ml/kg/h [23]. In our study, the total infusion volume was larger in GDFT group than that in RFT group, though there was no signi cant difference of AKI incidence between the two groups, but the postoperative increase degree of serum creatinine was lower in GDFT group than that in RFT group.…”

“…Elderly, smoking, high American society of anesthesiologists classi cation, comorbidities such as hypertension, diabetes mellitus, and coronary artery disease (CAD) were all risk factors for AKI after thoracic surgery [3], One study showed that the incidence of AKI was 1.8% in patients undergoing thoracoscopic lobectomy, but elder patients and patients with CAD were excluded [22]. Another study showed that the incidence of AKI was 6% after open lobectomy surgery [23]. Because of the mini-invasive method, the incidence of AKI may be lower after thoracoscopic surgery.…”

Pulmonary hemodynamics and lung surgery: a narrative review

“…A recent retrospective cohort study divided patients undergoing open thoracotomy into three groups: low (≤3 mL•kg −1 •h −1 ), moderate (4-5 mL•kg −1 •h −1 ) and high (≥6 mL•kg −1 •h −1 ) fluid infusion rate from the beginning of the surgery to 24-h post-operative. The moderate group showed the lowest pulmonary and renal composite complication rate (46). Interestingly, the nature of lung injury after lung resection seems to be related to ventilator induced lung injury rather that increase in pulmonary capillary hydrostatic pressure.…”

Restricted, optimized or liberal fluid strategy in thoracic surgery: A narrative review

“…[ 62 ] Over the last 25 years, cohort studies involving thoracic surgical patients suggest a link between the amount IV fluids and the occurrence of postoperative ALI/ARDS, other complications and unplanned re-admission [ Table 2 ]. [ 34 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 ] Accordingly, RNT targeting a near-zero fluid balance can be adopted in the majority of cases (low/moderate risk) with utilization of noninvasive monitoring tools to ensure stability of circulatory volume and adequate DO 2 /VO 2 matching (PPV/SVV, SV, NIRS, bioimpedance/bioreactance monitors). [ 80 81 82 ] In patients with severe cardio-pulmonary dysfunction and those undergoing complex procedures, more advanced hemodynamic monitoring is preferable with direct measures of arterial pressure, SV, tissue oximetry, extravascular lung water and cardiac filling pressure, (arterial and central venous lines, transesophageal Doppler, TPTD) with application of GDHT algorithms.…”