Fluid Management for Colorectal Enhanced Recovery: a consensus statement

American Society for Enhanced Recovery (ASER) and Peri-operative Quality Initiative (POQI) joint consensus statement on peri-operative fluid management within an enhanced recovery pathway for colorectal surgery

 

Robert H. Thiele, Karthik Raghunathan, C. S. Brudney, Dileep N. Lobo, Daniel Martin, Anthony Senagore, Maxime Cannesson, Tong Joo Gan, Michael Monty G. Mythen, Andrew D. Shaw, Timothy E. Miller and For the Perioperative Quality Initiative (POQI)  Workgroup

 

Consensus Statement, Open Access; Perioperative Medicine (2016) 5:24

DOI 10.1186/s13741-016-0049-9

Summary by Dr Rita Saha

ST6, St George's Hospital London

Expanded abstract

 

Background

Enhanced recovery Pathways (ERPs) are now well established to improve patient outcome inmajor surgery. This article focuses on colorectal surgeries only, wherethe difficulties of adopting the ’Bundles’ of ERPs are highlighted as a consequence of multiple simultaneous changes in clinical practice when ERPs were initiated. The writers recommend several alternative approaches.

 

Methods/design

This consensus statement was prepared by an international group of experts from around North America & Europe.  With a preliminary literature search of both prospective and retrospective studies the most important and relevant questions around perioperative fluid management in patients scheduled for colorectal surgeries were identified. The answers to those questions were determined by the consensus of the Peri-operative Quality Initiative (POQI) group on the  basis of present available evidence.

 

Results

Below are the questions identified by the working group:

Prior to surgery

(I) What are the effects of preoperative oral intake of clear solutions (containing complex versus simple carbohydrates) up to 2 h prior to the induction of anaesthesia?

(ii)Does mechanical bowel preparation contribute to preoperative hypovolemia?

During and after surgery

(iii) Is urine output a valid indicator of perioperative fluid needs?

(iv) Is there a rational approach to intraoperative fluid management based on the current evidence?

(v) Which types of fluids should be used intraoperatively?

(vi) How do variations in surgical and anaesthesia technique affect intraoperative fluid management?

(vii)How should fluid therapy be managed postoperatively?

 

Summary

The authors recommended that iso-osmolar bowel preparation is unlikely to lead to preoperative hypovolemia requiring intravenous fluid therapy provided patients are given unrestricted access to clear fluids orally.

Oliguria is a common response to surgical stress but anuria needs urgent attention

They also emphasized that with low tidal volume and high PEEP produces an increase in ‘false negative’ responses by decreasing arterial respiratory variation based measures of “fluid responsiveness”

To the extent possible, the approach to intra-operative fluid management should continue postoperatively.

 

Strengths

The report provides an extensive coverage of evidence for fluid management in colorectal surgeries ERPs

A modified Delphi method was used to gain quality consensus opinion

Several alternative strategies to manage Peri-operative fluid management are made in line with ERPs for colorectal surgeries.

 

Weakness

The report showed different study results in a very short but informative way but was not explicit about the study periods involved.

Difficult to reach a conclusion about any single practice, which is left with clinician’s ability to judge according to circumstance.

As a whole this article lends support to freedom of practice of clinical judgment with emphasis on the simultaneous use oflatest technologies such as cardiac output monitoring and up to date evidence in our day to day practice .