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Liberal or restrictive fluid administration in fast-track colonic surgery.
- Vladyslav Kushakovskyy, Olena Kushakovska (6 November 2007)
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Vladyslav Kushakovskyy, Specialist Registrar Worthing Hospital, Olena Kushakovska
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Editor – We read with great interest the recent paper by Dr Holte and colleagues on liberal or restrictive fluid administration in fast track colonic surgery . As it is a matter that has been debated recently, and still remains unresolved, we feel the need to make a few comments. First of all, the authors state that hypothesis tested was that ‘intraoperative fluid administration leading to perioperative fluid excess (i.e. in excess of normohydration) may adversely affect perioperative organ function and delay recovery’. We find it difficult to understand why then they chose spirometry as a primary outcome measure. There are several problems with that. Firstly, as the authors rightly stated in the discussion part that spirometry is not very sensitive measure of perioperative pulmonary function assessment and it can be influenced by a number of factors like the amount of postoperative pain, drowsiness and many more others possibly including the amount of perioperative fluids. Secondly, if spirometry values may not predict postoperative pulmonary complications why use it as an outcome measure as the relevance to clinical practice could be questioned. Finally, we know very well that excessive fluid administration can adversely affect respiratory function. We certainly see it everyday in every intensive care unit in the country. Secondly, assessing fluid regimens on the respiratory function authors did not control for cardiovascular or respiratory diseases. The only comment in the study is that 7/9 and 8/8 patients had cardiovascular disease in restrictive and liberal groups respectively. It is quite clear, in our opinion, that cardiovascular disease could range from mild well controlled hypertension to class III NYHA (class IV was one of the exclusion criteria), and that could play a significant part in response to fluid therapy. The patient s with significantly impaired ventricular function could demonstrate significant deterioration in ventilation mechanic and gas exchange in the face of fluid challenges. The same to a lesser degree could be applicable to respiratory pathology. And lastly, it is no longer a question of ‘wet or dry’ but giving the right amount of fluids periopertively based on the best evidence as has been discussed in the recent editorial of this journal. There is some fairly convincing evidence for the use of transoesophageal Doppler monitoring, pulse power analysis and some other monitoring modalities in an attempt to rationalise perioperative fluid management. Credit should be given to the authors as they accept that ‘goal-directed’ approach is needed. In summary, we feel that the study did not tell us anything that we did not know all along – not enough fluids perioperatively is bad but too much is not good either. The way of determining the right amount is debatable but the best current evidence suggests that it should be tailored to the needs of an individual patient taking into account not only the extent and duration of surgery but also, and perhaps more importantly, cardio-respiratory reserves of this patient. V Kushakovskyy1* O Kushakovska2 1Worthing, UK 2Brighton, UK *E-mail: vladku@doctors.org.uk 1. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomised, double-blind study. Br J Anaesth 2007; 99: 500-508 2. Ballanthyne JC, Carr DB, deFerranti, et al. The comparative effects of postoperative analgesictherapies on pulmonary outcome: cumulative meta-analyses of randomised, controlled trials. Anesth Analg 1998; 86: 598-612 3. Bellamy MC. Wet, dry or something else? Br J Anaesth 2006; 97: 755 -7 4. Wakeling HG, McFall MR, Jenkins C. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005; 95: 634-42 5. Pearse R, Dawson D, Fawcett J, et al. Early goal directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care 2005; 9:R687-93 Conflict of Interest:None declared |
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