Effect Of Three Intraoperative Fluid Management On Outcome After Major Abdominal Surgery

Background and objectThe primary goal of volume administration is to guarantee stablehemodynamics and microcirculation, to improve oxygen delivery to vitalorgans and keep the internal environment homeostasis. To summarizeprevious studies, in approximately 50ï¼…of septic patients, adequatevolume replacement alone can reverse hypotension and restorehemodynamics,decrease potential for the development of bacterial translocation, andthe development of multiple organ dysfunction syndrome. It appears thatvolume administered before spinal block could significantly reduce therisk of cardiovascular side effects (CVSE) and increase splanchnic bloodflow. But significantly more "high volume" perioperative fluid therapymay have deleterious effects, especially to older patients and to thepatients with pre-cardiac worsening of cardiacfunction. Besides, nomatter Crystalloid or Colloid, "high volume" infusion result incoagulation dysfunction and increased bleeding tendency. Furthermore,"high volume" infusion may increase renal loading. But some studiesfound that restrictive volume administration could decrease positivefluid balance, promote earlier return to bowel function, lower incidenceof postoperative mortality rate, and decrease the length of postoperativehospital stay.In this study, our primary arm is to investigate the effect of threedifferent restrictive fluid therapy on perioperative hemodynamics,coagulation function,renal and hepatic function and postoperativefunction recovery in patients undergoing majoy abdominal surgery. Methods297 cases undergoing elective majoy intraabdominal surgery undergeneral-epidural Anesthesia were studied. The patients were randomizedinto group Crystalloid (n=96), group Crystalloid-Colloid (n=99), andgroup Colloid (n=102).Electrocardiogram and heart rate, mean arterial pressure, centralvenous pressure, pulse oxygen saturation and P_ET-CO₂ were monitored withthe multi-function monitor. Anesthesia was induced using intravenouspropofol, fentanyl, and vecuronium, and was maintained with a balancedtechnique involving infusion of propofol and remifentanil with venouspump. Neuromuscular blockade was performed with intravenous vecuronium.Ventilation was adjusted to maintain P_ET-CO₂ 30-33mmHg, and temperaturewas maintained at greater than 35.5℃throughout surgery. Patientsreceived epidural analgesia for postoperative pain relief.All patients in the study received 5ml·kg^-1·h^-1 solution throughoutthe intraoperative period, whereas the Crystalloid is Ringer lactatesolution(LRS),and the Colloid is hydroxyethyl starch 130/0.4(Voluven,Volu).All hemodynamic changes during this period were treatedpharmacologically. If SBP＜90mmHg or＞20ï¼…below baseline, and to last＞1min, 0.1-0.3mg intravenous metaradrine were given result to SBP＞90mmHg.If blood pressure (＜90mmHg or＞20ï¼…below baseline) accompanied bytachycardia (heart rate＞100 beats/min or＞20ï¼…above baseline) or low CVP,boluses of solution were administered to a maximum of 1000ml. Indicationsfor blood transfusion were acute massive hemorrhage, when the hematocritwas less than 24ï¼…. In the postoperative period, the surgical staff, whowere unaware of the patient's group assignment and were not part of theinvestigator team, guided fluid therapy.These parameters HR,SBP,DBP,MAP,CVP,SPO₂,P_ET-CO₂ were recordedrespectively at the time of pre-anesthesia(T₀),induction(T₁),intubation(T₂),pre-incision (T₃),incision 30 min (T₄),incision 60 min (T₅),incision 90 min (T₆),incision 120 min (T₇),before close (T₈) andend-operation (T₉). Arterial blood gas analysis respectively at the timeof T₃ and T₈. Blood coagulation, liver and renal function were testedrespectively at the time of before operating, the end of operation, thefirst day after operation and the second day after operation. Blood loss,urine output, and doses of drugs (fentanyl, propofol, vecuronium, remifentanil) given during the surgical procedure, the need to startvasoactive infusion and the were volume of fluid were recorded.The volumes and the kinds of fluid and the number of units of bloodand blood products administered in the first 2 postoperative days wererecorded. Postoperative follow-up included measurements hematocrit,potassium, sodium, chloridion concentrations, and coagulation function,renal and hepatic function indes in the first 2 postoperative days. Timeto first passage of flatus and feces, feed, duration of postoperativehospital stay were also recorded.Analysis was performed using Statistical Analysis System softwareSPSS 11.5. All the quantitative data of the three groups were comparedwith one-way analysis of variance(ANOVA), the categorical data withchi-square test.p＜0.05 was considered to represent statisticalsignificance.Result1. The average sex, age, weight, ASA physical status and the type ofsurgery among the three groups were not have significantly different(p＞0.05).2. The doses of every anesthesia, the volumes of blood products, theduration of surgery, the estimated blood loss and urine output were nothave significantly different among the three groups (p＞0.05). But theintraoperative volumes of fluid administered were significantly lower ingroup Colloid compared with group Crystalloid (p＜0.05) andCrystalloid-Colloid (p＜0.01).3. All patients' HR, SBP, MBP, DBP do not have significantlydifferent among the three groups at many differents stages(p＞0.05), butthe CVP have increased tendency, which increased from incision 60 min(T₅) in three groups. Significantly in group Colloid, CVP increased morethan group Crystalloid and group Crystalloid-Colloid.4. As to arterial blood gas analysis, compared with pre-incision,three groups average PH,TCO₂,BE decreased and PCO₂ increased, but allin normal confine. Significantly more high lactate level and BE in groupCrystalloid than group Colloid. The other do not have any statisticaldifferents.5. The volumes and the kinds of fluid and the number of units of blood and blood products administered in the first 2 postoperative days weresmaller in the three groups.6. The significantly longer PT, INR, APTT and lower AT in thepostoperative compared with the preoperative in all patients. Theincrease of FIB happened in all groups at the first postoperation day,significantly in group Crystalloid. The serum platelet count decreasedin the day and the first day after operation in three groups, and restoredto the level of baseline, and even advanced to higher level than baselinein group Crystalloid.7. The postoperative hypotension, tachycardia, high fever, nauseaand vomiting, itching and postoperative mortality rate were smaller inthe three groups. But the number of patients with incision fat liquoringsignificantly greater more in group Crystalloid than groupCrystalloid-Colloid and group Colloid. Pulmonary infection was more ingroup Colloid than other two groups. There were no significant differencesamong the three groups in the time of postoperative flatus and feces, feedand duration of postoperative hospital stay.Conclusion1. In patients undergoing elective majoy intraabdominal surgery, ifintraoperative loss blood＜400ml, intraoperative received 5ml·kg^-1·h^-1,Colloid solution or cocktail solution(Crystalloid and Colloid, 1:1mixture) could have maintain high CVP, more stable arterial pressure andless vasoactive drug than Crystalloid solution.2. The intraoperative three options fluid management do not have anydifferent effects on arterial blood gas and organization oxygenmetabolism. And do not have any temporary negative effects onpostoperative fluid therapy.3. Three groups of hematology target and the blood coagulation functiontarget change is similar after operation, but serum WBC and PLT countsand serum FIB level have increased tendency in group Crystalloid.4. The intraoperative three options fluid management do not have anydifferent effects on renal and hepatic function and the level of bloodplasma electrolyte after operation.5. The intraoperative three options fluid management have similareffects on postoperative function earlier return, although there is slightly more patients with incision fat liquoring in group Crystalloidand pulmonary infection in group Colloid.