Correlation of postoperative fluid balance and weight and their impact on outcomes

Relationship between fluid bolus administration and the prognostic role of serum albumin in patients with sepsis

BACKGROUND

Serum albumin plays a pivotal role in the exchange between interstitial and vascular compartments, and reduced levels of this biomarker appear to be associated with negative prognosis in septic patients. The correlation between the volume effect in sepsis therapy and the kinetics of serum albumin is unclear.

AIM

To investigate the relationship between serum albumin and fluid bolus in relation to its prognostic role in septic patients.

METHODS

A single-center prospective observational study conducted from September 2022 to February 2024. All patients with sepsis admitted from the Emergency Department to the Intermediate Medical Care Unit (IMCU) were considered. Post-fluid bolus serum albumin was obtained after fluid bolus. The albumin value was correlated with the volume effect of the fluid bolus, and multivariate models were performed to evaluate its potential independent effect on 30-day mortality.

RESULTS

179 patients were enrolled. Pre-fluid bolus serum albumin was 2.55 g/dL (SD 0.51) with a multivariate OR for 30-day mortality of 1.170 (95 % CI 1.055-1.297, p = 0.003). After the fluid bolus, which resulted in a fluid balance percentage of +23.1 % (SD 7.1) and a mean Fractional Plasma Dilution of -0.48 (SD 0.18), albumin showed a mean decrease of -0.28 g/dL (SD 0.28) with a multivariate OR for 30-day mortality of 1.198 (95 % CI 1.065-1.348, p = 0.003). Post-fluid bolus albumin was negatively correlated with cumulative fluid balance and hemodilution.

CONCLUSIONS

The volume effect of fluid bolus is correlated with a decrease in serum albumin, and low albumin levels are associated with a high risk of mortality.

Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland

INTRODUCTION

The ERAS protocol is a set of international guidelines established to expedite patients' discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients' return to home at earlier rates than traditional practice.

METHODS

A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively.

RESULTS

In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin.

CONCLUSION

UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.

Small incisions still require great anesthesia: anesthesiology techniques to enhance recovery in robotic coronary bypass grafting

Robotic coronary artery bypass grafting (CABG) has emerged as a promising minimally invasive surgical technique for the treatment of coronary artery disease. This paper provides an in-depth analysis of the anesthetic management for robotic CABG. Challenges associated with robotic CABG are discussed and various anesthetic techniques, perioperative elements and pain management modalities that can contribute to enhanced patient recovery are explored.

Anesthesia-induced Lymphatic Dysfunction

General anesthetics adversely alters the distribution of infused fluid between the plasma compartment and the extravascular space. This maldistribution occurs largely from the effects of anesthetic agents on lymphatic pumping, which can be demonstrated by macroscopic fluid kinetics studies in awake versus anesthetized patients. The magnitude of this effect can be appreciated as follows: a 30% reduction in lymph flow may result in a fivefold increase of fluid-induced volume expansion of the interstitial space relative to plasma volume. Anesthesia-induced lymphatic dysfunction is a key factor why anesthetized patients require greater than expected fluid administration than can be accounted for by blood loss, urine output, and insensible losses. Anesthesia also blunts the transvascular refill response to bleeding, an important compensatory mechanism during hemorrhagic hypovolemia, in part through lymphatic inhibition. Last, this study addresses how catecholamines and hypertonic and hyperoncotic fluids may mobilize interstitial fluid to mitigate anesthesia-induced lymphatic dysfunction.

Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery

A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m2 (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients.

Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice

The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.

Perioperative continuous body weight measurements with load cells under the bed legs in patients undergoing abdominal surgery

BACKGROUND

Both excessive positive fluid balance and body weight increase after surgery are risk factors for poor postoperative outcomes. The use in clinical practice and the value of perioperative body weight measurements are unclear at present, possibly due to difficulty in measuring body weight in patients lying on the bed and insufficient clinical research.

OBJECTIVES

To investigate the relationship between intraoperative fluid balance and body weight change and perioperative nightly body weight change pattern throughout the hospital stay with contact-free unconstraint load cells placed under the bed legs.

DESIGN

Observational and exploratory study.

SETTING

A single university hospital.

PATIENTS

Twenty adult patients were undergoing elective abdominal surgery under general anaesthesia.

MAIN OUTCOME MEASURES

Body weight.

RESULTS

Immediately after surgery, body weight increased significantly by 2.7 ± 1.3 kg, equivalent to a 5% increase from the preoperative body weight. This increase was not correlated with (P = 0.178) the intraoperative fluid balance and was significantly greater than the intraoperative fluid balance 1.5 ± 0.4 kg (P < 0.001). The body weight returned to the preoperative level on postoperative day (POD)3 and further significantly decreased to 97% of the preoperative body weight at POD6 (P < 0.001). This physiological nocturnal weight loss pattern was maintained throughout hospitalisation except when fluid was infused. Compared with their preoperative status, patients stayed in bed longer with smaller body movements and left the bed less frequently during the daytime until POD3. Conversely, the patients had greater body movements in bed during the night leading to smaller diurnal variation in the body movements in bed after POD4.

CONCLUSION

Both perioperative fluid balance calculation and body weight measurement may have different but mutually complementary roles in perioperative managements. Postoperative fluid and nutrition management strategies are potentially new directions for treatment through continuous weight monitoring during the perioperative period.

Trial registration

: UMIN Clinical Trials Registry (UMIN000040164).

Postoperative Weight Gain within Enhanced Recovery after Cardiac Surgery

Optimal fluid therapy during perioperative care as part of enhanced recovery after cardiac surgery (ERACS) should improve the outcome. Our objective was finding out the effects of fluid overload on outcome and mortality within a well-established ERACS program. All consecutive patients undergoing cardiac surgery between January 2020 and December 2021 were enrolled. According to ROC curve analysis, a cut-off of ≥7 kg (group M, n = 1198) and <7 kg (group L, n = 1015) was defined. A moderate correlation was shown between weight gain and fluid balance r = 0.4, and a simple linear regression was significant p < 0.0001, R² = 0.16. Propensity score matching showed that increased weight gain was associated with a longer hospital length of stay (LOS) (L 8 [3] d vs. M 9 [6] d, p < 0.0001), an increased number of patients who received pRBCs (L 311 (36%) vs. M 429 (50%), p < 0.0001), and a higher incidence of postoperative acute kidney injury (AKI) (L 84 (9.8%) vs. M 165 (19.2%), p < 0.0001). Weight gain can easily represent fluid overload. Fluid overload after cardiac surgery is common and is associated with prolonged hospital LOS and increases the incidence of AKI.

Diuretic response to Ringer's solution is normal shortly after awakening from general anaesthesia: a retrospective kinetic analysis

Background

The elimination of Ringer's solution is severely depressed during general anaesthesia, but the degree to which this continues postoperatively is poorly established.

Methods

An intravenous infusion of Ringer's acetate solution 20 ml kg-1 was administered over 60 min in 12 patients undergoing laparoscopic cholecystectomy. Population kinetic analysis was performed based on repeated measurements of blood haemoglobin concentration and urinary excretion over 240 min regardless of when the operations were finished. The analysis contrasted the periods before and after awakening from general anaesthesia and compared them with data from 18 volunteers who received the same fluid at the same rate.

Results

Patients were monitored for approximately 2 h after awakening from general anaesthesia. The rate constant for redistribution of fluid from the extravascular space to the plasma (k21) and the rate constant for urinary excretion (k10) were significantly higher postoperatively than during the surgical period. Computer simulations indicated that urinary excretion after surgery was almost restored to the rate found in the volunteers. In contrast, the redistribution of fluid from the extravascular space to the plasma, which was almost nil during the surgery, showed only limited recovery during the postoperative phase, and was only approximately 10% of the flow rate found in the volunteers. The combination of nearly normalised urinary excretion and lack of adequate return of distributed fluid to the plasma promoted postoperative hypovolaemia.

Conclusion

The kinetic analysis indicates that plasma volume support should be given during the first 2 h after laparoscopic cholecystectomy.