Should fluid management in thoracic surgery be goal directed?

Abstract

Should fluid management in thoracic surgery be goal directed?Mert S ¸ent€ urk, Emre Sertac ¸Bing€ ul, and O ¨zlem Turhan Purpose of reviewTo find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed?Recent findings 'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks.

Update on guidelines and recommendations for enhanced recovery after thoracic surgery

“…To achieve this objective, a ‘moderate’ fluid strategy, defined variably in the literature, has become a topic of interest. While a ‘moderate’ fluid strategy may be sufficient for many thoracic surgery patients, some experts now advocate for goal-directed therapy (GDT) with hemodynamic endpoints as an alternate approach to a predetermined or fixed-volume strategy [33 ▪ ]. Meta-analyses in support of GDT report reduced postoperative complications, but most of these studies were performed with major abdominal surgery and with a low quality of evidence [34,35].…”

“…Studies in thoracic surgery patients using pulse wave analysis and/or esophageal doppler to guide intra-operative GDT reported reduced hospital length of stay (LOS), major morbidity, and mortality when compared to controls [36–38]. Ensuring that GDT is a valid technique to guide fluid administration in thoracic surgical patients with an open thorax has been a point of concern [33 ▪ ]. Consistent with the ERATS/ESTS guidelines, clinicians should consider the entire perioperative period as they determine the appropriate fluid management strategy [2].…”

“…Consistent with the ERATS/ESTS guidelines, clinicians should consider the entire perioperative period as they determine the appropriate fluid management strategy [2]. An individualized approach focused on limiting preoperative fasting, maintaining perioperative euvolemia with appropriate administration of balanced crystalloid solutions, and early resumption of enteral hydration will help to facilitate enhanced recovery pathways and improve outcomes [2,33 ▪ ].…”

Modern fluid management in thoracic surgery

“…This ultimately causes impaired tissue blood flow and interstitial edema. When combined with a liberal fluid regimen, lung injury and postoperative pulmonary complications (PPCs) are more likely [4,22 ▪▪ ,24,25 ▪ ]. The dogmatic practice of maintaining a dry lung with a volume-restrictive fluid regime of 1-2 ml/kg/hour was traditionally recommended in order to minimize the detrimental effects of fluid administration.…”

“…Concerns remain about extrapolating these results to patients undergoing lung resection [4,25 ▪ ] as there are only a few trials looking specifically at this (Table 2). Of these, several showed a benefit in reducing PPCs and length of stay [32,33].…”