Fluid Management in Colorectal Surgery

Theodor Asgeirsson, MD Staff Colorectal Surgeon

Assistant Director of Outcomes ResearchDepartment of Colorectal Surgery

Spectrum HealthGrand Rapids, Michigan

Faculty Disclosure

It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.

Theodor Asgeirsson, MD, has no financial relationships to disclose.

Educational Learning Objective

• Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures

Clinical Presentation

• 78-year-old female who was taken for a transanal excision via transanal endoscopic microsurgery (TEM) of a 2 cm mobile rectal cancer approximately 8 cm from the anal verge

• Patient recovered without difficulty and was discharged on postoperative day (POD) 1– Pathology revealed a pT2 lesion

• Follow-up in office 2 weeks later– After discussion and consultation, patient opted for further

treatment and a low anterior resection with diverting ileostomy was offered

Medical History• PMH

– Hypertension, hyperlipidemia, obesity (BMI 45 kg/mm3), pancreatitis, cholelithiasis, rectal cancer

• PSH– Appendectomy, cholecystectomy, hysterectomy, transanal endoscopic

microsurgery• SH/FH

– Widowed with 3 children– Negative for colon cancer, uterine, and breast– Negative for smoking and alcohol

• Allergies– NKDA

• Medications– Metoprolol– Tylenol– MVI– Calcium– Glucosamine

Physical Exam• Patient has full continence to urine and stool• Lungs

– Normal breath sounds– No rales or wheezing

• Heart– Regular rate and rhythm– No murmurs, rubs or gallops

• Abdomen – Well-healed scars after open appendectomy, cholecystectomy and

hysterectomy– No hernias appreciated– No masses or tenderness

• Rectal– Patient has anal wink– Good tone and squeeze– Can palpate prior transanal excision site, which is soft and positioned

posteriorly in rectum• Anoscopy: grade II internal hemorrhoids and well-healed transanal

excision site

Preop Workup and Labs

• EKG– Normal sinus rhythm, HR 68

• CXR: calcified nodule in right upper lobe• CT chest/abd: calcified granuloma in right upper

lobe; no evidence of metastatic disease in the chest or abdomen

• CEA 2ng/ml• Fasting glucose: elevated at 110 mg/dl• Preop clearance: low risk; continue beta-blocker

through surgery

CEA: carcinoembryonic antigen

Preoperative Measures

• Day before– Bowel preparation– Clear liquid diet starting during bowel prep and nil per

mouth from midnight prior to surgery day

• Holding – NS bolus of 800 mL– 12 mg mu-opioid receptor antagonist (alvimopan) po– 1 gram ertapenem iv

Intraoperative Measures

• Anesthesia/Analgesia– Premedication: fentanyl and midazolam– Induction/maintenance: propofol, succinylcholine,

sevoflurane– IVF: normal saline maintained at 6 ml/kg/h during

procedure

• Normothermia maintained with Bair Hugger®

Surgical Procedure

• Open Low Anterior Resection with Diverting Loop Ileostomy– Oral gastric tube during case– Operative time: 4 hours and 20 min– Estimated blood loss: 460 ml– Urine output: 30-50 ml/h (maintained with crystalloid

and colloid boluses)– No drains placed

Intravenous Fluids in the First 24 Hours

• Preop – 800 ml crystalloid

• Intraop (4 hours)– Maintenance

2400 ml crystalloid

– Blood loss 900 ml crystalloid 150 ml colloid

• Post-anesthesia care unit (4 hours) – Maintenance

600 ml crystalloid

– Low blood pressure < 90 systolic 1000 ml bolus crystalloid

• Floor (18 hours) – Maintenance

1500 ml crystalloid

– Low urine output < 2 ml/kg/h for 3 hours

500 ml bolus crystalloid

• 7850 ml over 24 hours– Urine output 500 ml

Enhanced Recovery

• Mu-opioid receptor antagonist (alvimopan, 12 mg twice daily for up to 7 days for a maximum of 15 doses)

• Full liquids started the evening of OR day

• PCA for 24 hours postop and iv NSAIDs

• Oral narcotics, ibuprofen and gabapentin on POD #1

• Ambulate 5 days times daily starting POD #1

• IVF fluids discontinued on POD #2 if tolerating diet

Postoperative Course

KUB: kidneys, ureters, and bladder; abdominal radiograph

• Followed enhanced recovery until evening of POD #2 when patient started having nausea

– 3000 ml positive in fluid balance since surgery

– 10 mg of iv hydromorphone since admitted to floor

• NG tube was placed after 3 emesis episodes on POD #3

• KUB showed diffuse dilatation of small bowel with multiple air fluid levels

• NG tube was removed on POD #8

• Patient stayed in the hospital for 6 more days due to high output ileostomy and was subsequently discharged on POD #14

Outcome

• Hospital course complicated and prolonged by postoperative ileus

• No residual cancer in specimen and all nodes were negative

• 3 months later, bowel continuity was restored and patient had an uneventful 3-day hospital stay after ileostomy takedown

Postoperative Ileus (POI)

• Activation of opioid receptors has been demonstrated to play a key role in POI regulatory pathways and correlates with daily iv narcotic dose– Pathways that contribute to POI

Neurogenic/Hormonal/Inflammatory Pharmacologic

Taguchi A, et al. N Eng J Med. 2001;345:935-940.Barletta JF, et al. Ann Pharmacother. 2011;45:916-923.Bauer AJ, Boeckstaens GE. Neurogastroenterol Motil. 2004;16(S2):54-60.Luckey A, et al. Arch Surg. 2003;138:206-214.

The use of liberal perioperative fluid regimens in colorectal surgery patients can have deleterious effects on which of the following?

Question

A) Recovery of GI motility

B) Wound healing

C) Coagulation

D) Cardiac/pulmonary functioning

E) All of the above

Answer

E. All of the above

Perioperative fluid therapy that results in over-hydration or fluid excess may have harmful effects on cardiac and pulmonary function, recovery of gastrointestinal motility, tissue oxygenation, wound healing and coagulation. However, the optimal approach to perioperative fluid management is a subject of ongoing study and debate.

Body Fluid Distribution

• The goal of operative fluid resuscitation is the maintenance of adequate tissue perfusion and oxygenation to vital end organs

Total Body Water = 60% Body Weight

Intracellular water40% body weight

Extracellular water20% body weight

Osm

ola

rity

—m

Osm

/L

28 LitersInterstitial10 Liters

Pla

sma

3.5

Lit

ers

Tran

scel

lula

r 1

Lit

er

300

200

100

0

14% 5% 1%

Impact of Surgical Trauma

• Fluid and electrolyte balance is maintained by the action of ADH and the renin-angiotensin-aldosterone axis

– Sodium and fluid retention and potassium excretion

• Fasting, bleeding, and insensible losses– Reduces extracellular volume

• Inflammatory cascade increases capillary permeability

– Depletes intravascular volume which is further exacerbated by the increase in tissue oncotic pressure

ADH: anti-diuretic hormone

The Debate

• The net effect of the metabolic-endocrine response to trauma is conservation of sodium and water, so fluid delivery should be restricted1

• The acute changes in extracellular fluids associated with major surgical procedures are impacted by “third space” losses and should be compensated with volume resuscitation2

1. Moore FD. Metabolic Care of the Surgical Patient. Philadelphia: WB Saunders Co. 1959.2. Shires T, et al. Ann Surg. 1961;154:803-810.

The Dogma• Pros

– Superior outcomes in the ICU and in high-risk surgical patients if supra-normal values of tissue-oxygen delivery were maintained1,2

• Cons– 8000 postoperative

deaths per year were attributed to pulmonary edema without other causes except excess iv fluid therapy3

– Tissue edema in the gut wall impairs gastric emptying and bowel motility4

1. Shoemaker WC, et al. Arch Surg. 1973;106:630-636.2. Shoemaker WC, et al. Am J Surg. 1983;146:43-50.3. Kirby R. Chest. 1999;115:1224-1226.4. Lobo DN, et al. Lancet. 2002;359:1812-1818.

The Ultimate Goal

• Increase preload to optimize cardiac output

• Reduce the risk of perioperative morbidity

Holte K, et al. Br J Anaesth. 2002;89:622-632.Bellamy MC. Br J Anaesth. 2006;97:755-757.

Current Guidelines for Perioperative Fluid Administration

• Venodilatation and cardiac depression– 5-7 ml/kg

• Fasting deficit – 4 ml/kg per hour for first 10

kg

– 2 ml/kg per hour for second 10 kg

– 1 ml/kg per hour for bodyweight exceeding 20 kg

• Maintenance– 4-6 ml/kg per hour for every

hour of surgery

• Epidural– 10 ml/kg

• Blood loss– 3:1 with crystalloids

– 1:1 with colloids

Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Elsevier/Churchill Livingstone, 2005.

Fluid Volume Calculation

• 70 kg patient/8 hour fasting/3 hour procedure/250 cc blood loss– Venodilatation and cardiac depression: 420 ml– Fasting deficit: 880 ml– Maintenance: 1050 ml– Epidural: 700 ml– Blood loss: 750 ml

~3800 ml

Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Elsevier/Churchill Livingstone, 2005.

Liberal vs. Restrictive Intravenous Fluids Postoperative I.

• N = 20 in each group• Urine output did not

differ between the groups

• Restrictive regimen– Shorter gastric

emptying times– Quicker GI recovery– Shorter LOS– Fewer complications

Lobo DN, et al. Lancet. 2002;359:1812-1818.

Liberal vs. Restrictive Intravenous Fluids Postoperative II.

• Restriction of postoperative iv fluid and sodium does not reduce hospital stay following elective colorectal surgery

MacKay G, et al. Br J Surg. 2006;93:1469-1474.

Liberal vs. Restrictive Intravenous Fluids Intraoperative and Postoperative

• The restricted regimen aimed at maintaining preoperative body weight

Brandstrup B, et al. Ann Surg. 2003;238:641-648.

Liberal vs. Restrictive Intravenous Fluids

• Of note, there was a higher percentage of ileocolic vs colocolic anastomosis in the restricted group

• Liberal group received a median of 5,388 ml on the day of surgery vs 2,740 ml in the restricted group

Brandstrup B, et al. Ann Surg. 2003;238:641-648.For more information on this study, click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/14578723

Liberal vs. Restrictive Intravenous FluidsIntraoperative I.

• ¼ patients with ASA III• Not only colorectal resections

Nisanevich V, et al. Anesthesiology. 2005;103:25-32.

For more information on this study, click here: http://www.ncbi.nlm.nih.gov/pubmed/15983453

Liberal vs. Restrictive Intraoperative II.

• Improvement in pulmonary function and postoperative hypoxemia

• Total complications higher in restrictive group: 18 vs 1 P < 0.01

Holte K, et al. Br J Anaesth. 2007;99:500-508.

• “ …the standardized amounts of fluid administered to both study groups may not be ideal, since some patients may receive too much and others too little fluid. It may therefore be more appropriate to individualize fluid administration, preferably guided by flow-oriented as opposed to static measurements of intravascular pressure.”

Liberal vs Restrictive Intraoperative II.

Holte K, et al. Br J Anaesth. 2007;99:500-508.

The Contradictions

• Static measurements of pressure as detectors of tissue hypoperfusion is unproven and hypovolemia may be present despite normal systemic and filling pressures1

• There is no evidence of an association between low urine out per se and the development of renal failure– Providing hypovolemia is not present2

• Sequestration of fluids and/or expansion of intracellular volume in major abdominal surgery have been contradicted3

1. Grocott MP, et al. Anesth Analg. 2005;100(4):1093-1106.2. Alpert RA, et al. Surgery. 1984;95:707-711.3. Nielsen OM, et al. Acta Chir Scand. 1985;151(3):221-225.

Compared with standard fluid management, goal-directed fluid management for colorectal surgery patients is associated with fewer postoperative complications. True or False?

Question

Answer

A. True

As illustrated in the next series of slides, intraoperative Doppler-optimized fluid management for patients undergoing colorectal surgery has been associated with reduced complications compared with standard fluid management protocols

Liberal vs Goal Directed I.

• Doppler (SV) vs CVP • Doppler group received

greater volumes of colloid 2L vs 1.5L P < 0.05

• Similar volumes of crystalloid, median 3L

• Total number of complications and GI complications favored Doppler group

Wakeling HG, et al. Br J Anaesth. 2005;95:634-642.

For more information on this study, click here: http://bja.oxfordjournals.org/content/95/5/634.full.pdf+html

Liberal vs. Goal Directed II.

Noblett SE, et al. Br J Surg. 2006;93:1069-1076.

Noblett SE et al, BJS, 2006

• Hemodynamic parameters q10min

– FTc (descending aortic corrected flow time) maintained > 350 ms

– Stroke volume corrected if deviation > 10%

• Total volume the same for intervention and control

– Early boluses rather than overall fluid volume allowed a sustained increase in cardiovascular parameters

Noblett SE, et al. Br J Surg. 2006;93:1069-1076. Intervention: Doppler-optimized fluid management

Liberal vs. Goal Directed III.

• Laparoscopic segmental colectomies within an ERP

• Three armed study– Standard

– GD-LR/300cc bolus

– GD-HS/200 cc bolus

• Boluses based on SV

• Standardized postop iv fluid regimen for all groups

• Colloids did not show any benefit over balanced salt solutions

Senagore AJ, et al. Dis Col Rectum. 2009;52:1935-1940.

Senagore et al, DCR, 2009

Senagore AJ, et al. Dis Col Rectum. 2009;52:1935-1940.

Doppler-Guided Intraoperative Fluid Management vs Standard Practice

Systematic Reviews

• Walsh SR; 2007– 4 RCTs, 393 patients– Doppler-guided fluid

management associated with: Fewer complications Shorter LOS No difference in volume

administered between the arms

• Abbas SM; 2008– 5 RCTs, 420 patients– Doppler-guided fluid

management associated with: Shorter LOS Fewer complications

and ICU admissions Less inotrope

requirements Quicker return of GI

function

Walsh SR, et al. Int J Clin Pract. 2008;62:466-470.Abbas SM, Hill AG. Anaesthesia. 2008;63:44-51.

To read more, click on this link: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05233.x/pdf

Summary

• Restrictive perioperative and intraoperative Doppler-guided fluid therapy are likely beneficial in open major abdominal surgery with regards to LOS, GI recovery, and complications

• These benefits have not been proven in laparoscopic surgery and/or within an enhanced recovery program

Conclusion• Operative fluid management in colorectal

surgery should be tailored to the individual patient and involve monitoring of flow-based parameters by a minimally-invasive technique

– Our patient may also have benefitted from non-opioid based pain management options such as an epidural

– The role of laparoscopic proctectomy in rectal cancer remains to be defined but current data support its safety and oncologic adequacy