Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy

Abstract

Background: Goal-directed fluid therapy (GDFT) has been compared with liberal fluid administration in non-optimized perioperative settings. It is not known whether GDFT is of value within an enhanced recovery protocol incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy. Results: Eighty-five patients were randomized, and there were 37 patients in each group for analysis. Nine patients in the GDFT and four in the fluid restriction group received oral bowel preparation for either anterior resection (12) or subtotal colectomy (1). Patients in the GDFT group received more colloid during surgery (mean 591 versus 297 ml; P = 0·012) and had superior cardiac indices (mean corrected flow time 374 versus 355 ms; P = 0·018). However, no differences were observed between the GDFT and fluid restriction groups with regard to surgical recovery (mean SRS after 7 days 47 versus 46 respectively; P = 0·853), other secondary outcomes (mean aldosterone/renin ratio 9 versus 8; P = 0·898), total postoperative fluid (median 3750 versus 2400 ml; P = 0·604), length of hospital stay (median 6 versus 5 days; P = 0·570) or number of patients with complications (26 versus 27; P = 1·000). Conclusion:GDFT did not provide clinical benefit in patients undergoing elective colectomy within a protocol incorporating fluid restriction. Registration number: NCT00911391 (http://www.clinicaltrials.gov).

State-of-the-art fluid management in the operating room

“…This is perhaps not surprising, as care within the control group has significantly improved making it harder to observe a difference versus GDFT. Srinivasa et al randomized 85 patients to GDFT or a zero-balance fluid regimen within an ERAS program for colorectal surgery [49]. Total fluid given in both groups intraoperatively was statistically higher in the GDFT group (1994 vs. 1614 ml; p ¼ 0.010), but at a glance the volumes are comparable, and much lower overall than previous GDFT studies outside of an ERAS program.…”

“…Importantly, in both the Srinivasa and Brandstrup studies, GDFT was not associated with harm when compared with a zero-balance strategy [12,49]. By contrast, the multicenter OPTIMISE study focused on GDFT on high-risk patients undergoing major abdominal surgery [50].…”

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

“…Patients undergoing surgery within an ERAS protocol are less likely to be fluid responsive after induction of anesthesia when compared with patients undergoing traditional fluid management preoperatively. 14 …”

“…Srinivasa et al randomized 85 patients to GDFT or no GDFT within an ERAS protocol. 14 The protocol utilized in the GDFT study was identical to that used in the Noblett study of GDFT in 2006 before the introduction of an ERAS protocol (Fig. 1).…”

“…Finally, and extremely importantly, in both the Srinivasa and Brandstrup studies, GDFT was not associated with harm when compared with a zero-balance strategy. 14,22 Matching monitoring needs to patient and surgical risk What conclusions can we draw from these recent studies of GDFT within an ERAS protocol? Undoubtedly, ERAS protocols have made intraoperative fluid management easier.…”