Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial

Abstract

We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. “precision” fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.

Population-based volume kinetics of Ringer’s lactate solution in patients undergoing open gastrectomy

“…Several studies have reported how to administer fluid in patients undergoing major abdominal surgeries, including open gastrectomy. Small trials have shown that a restrictive fluid regimen reduced the complication rate compared with a liberal fluid management regimen during elective surgery [3,4]. The restriction of fluid to achieve a zero balance is also an important element of the enhanced recovery after surgery (ERAS) protocol [19]; however, a recent study that compared liberal fluid therapy with restrictive fluid therapy in approximately 3000 patients undergoing abdominal surgery reported that restrictive therapy was not superior to liberal therapy, and it also increased the incidence of AKI [20].…”

“…Anesthesiologists select the appropriate fluid type for the patient and administer the appropriate amount of fluid. Previous studies have shown that the type of fluid therapy is associated with postoperative recovery and prognosis [1][2][3][4]. For successful fluid therapy, it is helpful to quantify how the administered fluid is distributed and eliminated from the body.…”

Associations of Fluid Amount, Type, and Balance and Acute Kidney Injury in Patients Undergoing Major Surgery

“…Prevailing evidence from our research group and others, has led to the notion of the "protocolised" perioperative "fluid-restrictive" approach [28][29][30] in order to reduce postoperative morbidity, including AKI. In this regard, our findings are consistent with the existing evidence reinforcing a strong association between fluid volume [31][32][33][34][35][36][37] and chloriderich fluid type [38][39][40][41] , and risk of AKI.…”

Impact of postoperative intravenous fluid administration on complications following elective hepato-pancreato-biliary surgery

“…GDFT involves titrating small boluses of intravenous fluid (250 mL) against stroke volume measured on a cardiac output monitor in order to optimise intravascular haemodynamics on an individual basis. Adopting this approach to fluid prescription post-HPB surgery could lead to a reduction in overall intravenous fluid administered and consequent improvement in outcomes [31]. It should be noted though, that when using GDFT there is a risk of harm in some patient subgroups if the overall intravenous fluid input remains high [32].…”