Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P, Kehlet H: Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: A randomized, double-blind study

Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark.
Annals of Surgery (Impact Factor: 8.33). 12/2004; 240(5):892-9. DOI: 10.1097/01.sla.0000143269.96649.3b
Source: PubMed


The objective of this study was to investigate the effects of 2 levels of intraoperative fluid administration on perioperative physiology and outcome after laparoscopic cholecystectomy.
Intraoperative fluid administration is variable as a result of limited knowledge of physiological and clinical effects of different fluid substitution regimens.
In a double-blind study, 48 ASA I-II patients undergoing laparoscopic cholecystectomy were randomized to 15 mL/kg (group 1) or 40 mL/kg (group 2) intraoperative administration of lactated Ringer's solution (LR). All other aspects of perioperative management as well as preoperative fluid status were standardized. Primary outcome parameters were assessed repeatedly for the first 24 postoperative hours and included pulmonary function (spirometry), exercise capacity (submaximal treadmill test), cardiovascular hormonal responses, balance function, pain, nausea and vomiting, recovery, and hospital stay.
Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR led to significant improvements in postoperative pulmonary function and exercise capacity and a reduced stress response (aldosterone, antidiuretic hormone, and angiotensin II). Nausea, general well-being, thirst, dizziness, drowsiness, fatigue, and balance function were also significantly improved, as well as significantly more patients fulfilled discharge criteria and were discharged on the day of surgery with the high-volume fluid substitution.
Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR improves postoperative organ functions and recovery and shortens hospital stay after laparoscopic cholecystectomy.

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Available from: Peter Bie, Jun 26, 2014
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    • "Another randomized trial has shown an improvement in postoperative pulmonary function (forced vital capacity, forced expiratory volume in first second) and exercise capacity after laparoscopic cholecystectomy by a more liberal crystalloid regimen (40 ml/kg lactated Ringer’s solution versus 15 ml/kg) and no use of colloids [20]. A contrary effect regarding postoperative pulmonary function could be revealed after fast-track colonic surgery [21]. "
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    ABSTRACT: Background Robotic-assisted laparoscopic prostatectomy (RALP) gained much popularity during the last decade. Although the influence of intraoperative fluid management on patients’ outcome has been largely discussed in general, its impact on perioperative complications and length of hospitalization in patients undergoing RALP has not been examined so far. We hypothesized that a more restrictive fluid management might lead to a shortened length of hospitalization and a decreased rate of complications in our patients. Methods Retrospective analysis of data of 182 patients undergoing RALP at an University Hospital (first series of RALP performed at the center). Results The amount of fluid administered was initially normalized for body mass index of the patient and the duration of the operation and additionally corrected for age and the interaction of these variables. The application of crystalloids (multiple linear regression model, estimate = -0.044, p = 0.734) had no effect on the length of hospitalization, whereas a negative effect was found for colloids (estimate = -8.317, p = 0.021). Additionally, a significant interaction term between age and the amount of colloid applied (estimate = 0.129, p = 0.028) was calculated. Evaluation of the influence of intraoperative fluid administration using multiple logistic regression models corrected for body mass index, duration of the surgery and additionally for age revealed a negative effect of crystalloids on the incidence of an anastomotic leak between bladder and urethra (estimate = -23.860, p = 0.017), with a significant interaction term between age and the amount of crystalloids (estimate = 0.396, p = 0.0134). Colloids had no significant effect on this particular complication (estimate = 1.887, p = 0.524). Intraoperative blood loss did not alter the incidence of an anastomotic leak (estimate = 0.001, p = 0.086), nor did it affect the length of hospitalization (estimate = 0.0001, p = 0.351). Conclusions In accordance to the findings of our study, we suggest that a standardized, more restrictive fluid management might be beneficial in patients undergoing RALP. In older patients this measure would be able to shorten the length of hospitalization and to decrease the incidence of anastomosis leakage as a major complication.
    BMC Anesthesiology 07/2014; 14(1):61. DOI:10.1186/1471-2253-14-61 · 1.38 Impact Factor
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    • "Another study by Holte et al. [31] in patients who underwent laparoscopic cholecystectomy demonstrated the superiority of a restrictive over a liberal regime only in the preservation of lung function and hypoxemia, without any other benefit. "
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    ABSTRACT: In some studies including small populations of patients undergoing specific surgery, an intraoperative liberal infusion of fluids was associated with increasing morbidity when compared to restrictive strategies. Therefore, to evaluate the role of excessive fluid infusion in a general population of high-risk surgery is very important. The aim of this study was to evaluate the impact of intraoperative fluid balance on the postoperative organ dysfunction, infection and mortality rate. We conducted a prospective cohort study during 1 year in four ICUs from three tertiary hospitals, which included patients aged 18 years or more who required postoperative ICU after undergoing major surgery. Patients who underwent palliative surgery and whose fluid balance could change in outcome were excluded. The calculation of fluid balance was based on the preoperative fasting, insensible losses from surgeries and urine output minus fluid replacement intraoperatively. The study included 479 patients. Mean age was 61.2 +/- 17.0 years and 8.8% of patients died at the hospital during the study. The median duration of surgery was 4.0 [3.2 to 5.5] h and the value of the SAPS 3 score was 41.8 +/- 14.5. Comparing survivors and non-survivors, the intraoperative fluid balance from non-survivors was higher (1950 [1400 to 3400] mL vs. 1400 [1000 to 1600] mL, P <0.001). Patients with fluid balance above 2000 mL intraoperatively had a longer ICU stay (4.0 [3.0 to 8.0] vs. 3.0 [2.0 to 6.0], P <0.001) and higher incidence of infectious (41.9% vs. 25.9%, P = 0.001), neurological (46.2% vs. 13.2%, P <0.001), cardiovascular (63.2% vs. 39.6%, P <0.001) and respiratory complications (34.3% vs. 11.6%, P <0.001). In multivariate analysis, the fluid balance was an independent factor for death (OR per 100 mL = 1.024; P = 0.006; 95% CI 1.007 to 1.041). Patients with excessive intraoperative fluid balance have more ICU complications and higher hospital mortality.
    Critical care (London, England) 12/2013; 17(6):R288. DOI:10.1186/cc13151 · 4.48 Impact Factor
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    • "Some studies have been performed on day surgical cases where the endpoints (well-being, less nausea, vomiting and dizziness) are different compared to more high-risk surgical patients where length of hospital stay and mortality are more relevant as endpoints. Healthy subjects undergoing short procedures seem to benefit from a moderate infusion of a crystalloid to prevent postoperative nausea [97] while patients undergoing colorectal surgery have benefited from zero-balanced protocols with a restrictive goal-directed protocol pattern, even though the total amount of fluid could exceed that administered during day surgery protocols due to the length of surgery. "
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    ABSTRACT: The assessment and maintenance of perioperative blood volume is important because fluid therapy is a routine part of intraoperative care. In the past, patients undergoing major surgery were given large amounts of fluids because health-care providers were concerned about preoperative dehydration and intraoperative losses to a third space. In the last decade it has become clear that fluid therapy has to be more individualized. Because the exact determination of blood volume is not clinically possible at every timepoint, there have been different approaches to assess fluid requirements, such as goal-directed protocols guided by invasive and less invasive devices. This article focuses on laboratory volume determination, capillary dynamics, aspects of different fluids and how to clinically assess and monitor perioperative blood volume.
    05/2013; 2(1). DOI:10.1186/2047-0525-2-9
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