Elsevier

Surgery

Volume 147, Issue 4, April 2010, Pages 542-552
Surgery

Original Communication
Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy

https://doi.org/10.1016/j.surg.2009.10.036Get rights and content

Background

Our objective was to compare the effect of a restricted intravenous fluid regimen adjusted by serum lactate level with a standard restricted regimen on complications after major elective surgery for gastrointestinal malignancy.

Methods

This is a randomized, observer-blinded, single-center trial conducted across a time span of 13 months. A total of 299 patients were allocated to either a restricted intravenous fluid regimen with supplementary intravenous fluids given based on serum lactate level (group A) or a standard restricted regimen (group R). In group A, the serum lactate level was monitored closely postoperatively to maintain a normal pre-operative serum lactate level. Group R involved patients treated with a restricted fluid regimen in whom additional fluid and electrolytes were administered when deemed necessary based on the usual clinical criteria. The primary outcome measure was complications; the secondary measures were death and adverse effects.

Results

Additional fluid supplementation was needed in some patients in both groups (group A [28%] vs group R [26%]). In group A, the time for additional fluid infusion occurred earlier in the postoperative period than group R. Patients in group A received their first supplementary fluid treatment within the first 12 h more commonly than those in group R (74% vs 37%, respectively; P < .004). The regimen adjusted by serum lactate decreased systemic postoperative complications in group A versus group R (10% vs 22%, respectively; P = .023) but not overall total complications (23% vs 33%, respectively; P = .090). In contrast, in patients who required additional fluid infusion, the difference in complications between the 2 groups was greater (overall complication, 45% vs 85%, respectively; P = .023; major complication, 16% vs 44%, respectively; P = .018; systemic complications, 19% vs 63%, respectively; P = .001). One patient died in group A and 4 died in group R (1% vs 4%, respectively; P = .206).

Conclusion

A fluid-restricted regimen after elective gastrointestinal operations for malignancy may lead to fluid insufficiency and low tissue perfusion in up to 28% of patients. Close monitoring of serum lactate levels with adjustment of intravenous fluid administration intraoperatively and in the early postoperative period may improve the early detection and correction of inadequate tissue perfusion, thereby decreasing the rate of complications.

Section snippets

Patients

This study was approved by the Institutional Ethics Committee of Medical College, Nanjing University, and written informed consent was obtained from patients or the closest relative of each patient. This was a prospective, randomized study conducted from July 1, 2007 to July 31, 2008 in the Research Institute of General Surgery of Medical College, Nanjing University. Patients enrolled in the clinical trial were selected from 5 different units of our department. A minimum of 30 patients was

Results

During the period of study, 415 patients presented for operative resection of a gastrointestinal neoplasm. Of these, 103 were excluded (28 were unfit for operation or opted not to undergo the operation, 24 had metastatic disease, 4 had clinical depression, and 9 underwent operation with another surgical specialty; in addition, informed consent was not possible for 38 patients). Of the remaining 312 patients, 13 patients declined to take part in the study. Therefore, 299 patients were recruited

Discussion

We performed a study to compare a regimen of restricted intravenous fluid with supplemental intravenous fluids given according to the serum lactate concentration with a more standard restricted regimen with supplemental intravenous fluid administered according to the usual clinical parameters (blood pressure, pulse, urine output, etc.) on complications after major elective operation for gastrointestinal malignancies. We found that a fluid-restricted regimen after gastrointestinal operation may

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    Supported by Grant 01Z011 from the Key Project of the Tenth-Five-year Plan Foundation of PLA and Grant BK2007573 from the Foundation of JiangSu Natural Science.

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