Is patient outcome affected by the administration of intravenous fluid during bowel preparation for colonic surgery?

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Choice of fluids in critically ill patients

Background

Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia.

Main text

Until recently, because of their excellent safety profile, fluids were not considered “medications”. However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions.

Conclusions

The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma).

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0669-3) contains supplementary material, which is available to authorized users.

Plasma magnesium should be monitored perioperatively in patients undergoing colorectal resection

OBJECTIVE

Hypomagnesemia has been shown to have several clinically important sequelae. The aims of this study were: to assess the impact of bowel preparation, with sodium picosulphate (Picolax), on plasma electrolytes, with particular regard to plasma magnesium, in patients undergoing bowel preparation for colonoscopy and colorectal resection and to evaluate the influence of perioperative magnesium levels on postoperative cardiac dysrhythmias.

METHOD

Sixty-one patients receiving sodium picosulphate (Picolax) bowel preparation were studied in two groups: Colonoscopy (31 patients) and Colorectal resection (30 patients). Plasma sodium, potassium, magnesium, calcium, urea, creatinine and blood haematocrit were measured in all patients prior to commencement of bowel preparation, at the time of colonoscopy or colorectal resection and 24 h postoperatively (surgery group only). Mean electrolyte and haematocrit levels were then compared. Postoperative cardiac dysrhythmias were recorded and analysed.

RESULTS

No significant changes following bowel preparation were observed in plasma sodium, potassium, calcium or creatinine. Plasma urea fell following bowel preparation (colonoscopy P < 0.001, resection P = 0.004) and rose following resection (P = 0.002). Magnesium levels increased following bowel preparation in both groups (colonoscopy P < 0.001, resection P = 0.007) and fell following resection (P < 0.001). Thirty-four per cent (21/60 patients) were hypermagnesemic following bowel preparation and 20% (6/30 patients) became hypomagnesemic following surgery. Postoperative cardiac dysrhythmias were associated with lower magnesium levels at induction and postoperatively (P = 0.022 and P = 0.033).

CONCLUSION

Bowel preparation with Picolax does not appear to cause significant electrolyte disturbance, except in elevating plasma magnesium. Postcolorectal resection plasma magnesium dropped significantly suggesting perioperative monitoring and replacement should be routine following colorectal surgery.