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No benefit with restrictive fluid strategy during perioperative period for major abdominal surgery
Clinical Question
For patients undergoing major abdominal surgery, does a restrictive fluid strategy during the perioperative period, as compared with a liberal fluid strategy, improve outcomes?
Bottom line
Traditionally, a liberal fluid strategy has been used during the perioperative period for major abdominal surgery to make up for fluid deficits and blood loss and to maintain urine output. More recently, the Enhanced Recovery After Surgery pathways have suggested a restrictive fluid strategy to avoid tissue edema and weight gain and promote early recovery. In this international trial, however, a restrictive fluid strategy did not improve long-term disability-free survival and led to more acute kidney injury. This study suggests that modestly liberal fluid administration, erring on the side of a positive net fluid balance, may be the safest option. 1b
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
Patients undergoing major abdominal surgery who were at increased risk of complications were randomized to receive either a liberal fluid strategy (n = 1493) or a restrictive fluid strategy (n = 1490) during the perioperative period. Increased surgical risk was defined as being 70 years or older, or the presence of heart disease, diabetes, renal impairment, or morbid obesity. In the liberal strategy group, patients received a bolus of a balanced salt crystalloid solution at 10 mL/kg at anesthesia induction, then an 8 mL/kg per hour infusion until the end of surgery, followed by a 1.5 mL/kg per hour infusion for at least 24 hours after surgery. In the restrictive strategy group, patients received approximately half the fluid of the liberal group with a goal of achieving a fluid balance of zero. Baseline characteristics were similar in the 2 groups: the mean age was 66 years and 43% had colorectal surgery. Overall, the liberal fluid group received a median of 3 liters fluid during surgery and 3 liters in the postoperative 24-hour period, whereas the restrictive group received 1.7 liters and 1.9 liters, respectively. This led to a gain of 1.6 kg of weight in the liberal group, compared with 0.3 kg in the restrictive group. For the primary outcome of disability-free survival at 1 year, the restrictive group did not fare any better than the liberal group (81.9% in restrictive group vs 82.3% in liberal group; P = 0.61). However, patients in the restrictive group had a higher risk of acute kidney injury (8.6% vs 5.0%; P < .001) and were more likely to receive vasopressor support, have lower urine output, and have a higher rate of oliguria and anuria.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
This is an issue that needs definitive direction. The liierature gives an unclear message as to wether to fluid restrict or not
The information is very clinically relevant and dispels the notion that restrictive fluid strategy is more beneficial to patients than liberal fluid strategy.
Good poem
Excellent