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Fluid resuscitation in abdominal surgery and sepsis

By: Cathy King

11 Apr 2023

Goal Directed

  • Alb 5% in boluses of 3ml/kg until increase in SV <10% (measured every 15mins)
  • Maintenance fluid 2ml/kg/hr
  • Vasopressors given to ensure MAP >/= 65mmHg

Fluid therapy in emergency abdominal surgery

VS

Standard

  • IVT given to ensure MAP >/= 65mmHg & diuresis >/= 0.5ml/kg/hr
  • Vasopressors given to ensure MAP >/= 65mmHg

DOI: 10.1016/J.BJA.2021.06.031

Compared with standard therapy, goal directed therapy DID NOT improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay.

Outcomes

  • Multi-centre (5 hospitals across Denmark)
  • Randomised

Analysis

  • Unblinded
  • Small sample (304 patients)
  • Mostly ASA 2 patients
  • Median BMI 24
  • Intraoperative difference between the 2 groups were small (~500ml)

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery

Restrictive

  • Induction: </=5ml/kg
  • Maintenance: 5ml/kg
  • Post-op: 0.8ml/kg

Liberal

  • Induction: Balanced salt crystalloid @ 10ml/kg
  • Maintenance: 8ml/kg
  • Post-op: 1.5ml/kg for at least 24hrs

*max. weight 100kg, dose reduced if clinically indicated

Fluid therapy in elective abdominal surgery

Outcomes

  • At 1 year, the rate of disability- free survival was not significantly higher with the restrictive fluid regimen than with the liberal fluid regimen.
  • Patients in the restrictive fluid group had a significantly higher risk of acute kidney injury than those in the liberal fluid group.
  • Higher rate of surgical site infection in the restrictive fluid group, possibly because of wound or anastomotic hypoperfusion

DOI: 10.1056/NEJMoa1801601

Initial Resus

Initial fluid

resus in sepsis

Surviving Sepsis Campaign Guidelines 2021

Findings

Fluid Resus

  • Failure to receive 30ml/kg of crystalloid fluid within 3hrs of sepsis onset was associated with increased odds of in hospital mortality, delayed resolution of hypotension, increased ICU length of stay, irrespective of ESRD and HF

  • If fluid therapy beyond the initial 30ml/kg is required, clinicians may use repeated small boluses guided by objective measures of SV +/- CO

*Note: HR, SBP or CVP alone are poor indicators of fluid status

Ongoing Fluid Balance

Ongoing fluid balance in sepsis

Surviving Sepsis Campaign Guidelines 2021

Conservative vs Liberal Approach to Fluid Therapy in Septic Shock in Intensive Care

IV fluid restriction did not result in fewer deaths at 90 days compared to standard IV fluid therapy.

CLASSIC trial

  • Multi-centre (31 ICUs across 8 European countries)
  • Randomised
  • High completeness of data

  • ~2/3 of patients were given >/= 30ml/kg of fluid in the 24hrs prior to randomisation
  • Cumulative fluid balance difference by Day 5 ~800mLs
  • Unblinded
  • Some protocol violations occurred
  • Large numbers eligible but not enrolled

DOI: 10.1056/NEJMoa2202707

Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis

The restrictive fluid strategy that was used did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy.

CLOVERS trial

  • Multi-centre, 60 U.S. Centres
  • Achieved separation in fluid administration in first 24hrs
  • High adherence to protocol
  • Randomisation after refractory to initial fluid resuscitation (1-3L)
  • Fluid regimes did not account for patient weight
  • Some protocol violations still occurred
  • Unblinded

DOI: 10.1056/NEJMoa2212663

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