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high vs. low fluid administration to improve recovery after laparoscopic
cholecystectomy
Holte K, Klarskov B, Christensen DS, Lund C, Grubbe Nielsen K, Bie P, Kehlet H
Dpt of Surgical Gastroenterology and Dpt of Anesthesiology, Hvidovre University Hospital, Denmark,
Dpt Physiology and Pharmacology, University of Southern Denmark, Denmark
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perioperative fluid therapy
compensation fordehydration/preop
optimisation
improved outcome Holte & Kehlet
Acta Anaesth Scand 2002; 46: 1084
”large” volumes
morbidity (cardio. pulm, ileus, thrombo-embolic)
Brandstrup et al., Ann Surg 2003; 641 Holte,
Sharrock & KehletBr J Anaesth 2002;89:622
optimal regimen?
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methods• 48 ASA I-II patients• lap. cholecystectomy• randomize to:
– 15 ml/kg Ringer´s lactate intraop. (~1 liter)
– 40 ml/kg Ringer´s lactate intraop. (~3 liters)
• double-blinded• 175 ml water preop• only morning sessions• standardized
perioperative management
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primary outcome assessments
• hormonal responses (pre,0-2h)– aldosterone, ADH, renin, AT-II, ANP
• pulmonary function (pre, 0-4h, 24h)• exercise capacity (pre, 4h, 24h)• balance function (pre, 4h, 24h)• weight (pre, 4h, 24h)• pain, PONV, dizziness
– (early (0-4h) and late (1-3 days postop))• discharge (PADDS > 9, actual discharge)
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patient demograpics and anesthesia data
• sex, age, BMI, ASA class – no difference between groups
15 ml kg-1 RL 40 ml kg-1 RL p value
998 (722-1455) 2928 (1950-3920) <0,01
62 (28-144) 74 (40-215) 0,04
95 (63-191) 121 (63-253) 0,06
591 (222-1223) 708 (358-1821) 0,04
duration of surgery (min)
duration of anesthesia (min)
propofol (mg)
fluid infused (ml)
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weight
*
*
0,5
1
1,5
2
2,5
4 24time (hours postoperatively)
wei
ght d
iffer
ence
(kg) low fluid
high fluid
* p<0,05 between groups
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hormonal responses – aldosterone
* p<0,05 increase# p<0,05 decrease
* p<0,05 vs. preop
*
*
0
20
40
60
80
100
baseline 0 1 2
time (hours postoperatively)
aldo
ster
one
(pg/
ml)
low fluidhigh fluid
* p<0,05 vs. preop
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hormonal responses - ADH
* p<0,05 increase# p<0,05 decrease
**
0
0,5
1
1,5
baseline 0 1 2
time (hours postoperatively)
ADH
(pg/
ml)
low fluidhigh fluid
* p<0,05 vs. preop
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hormonal responses - ANP
* p<0,05**
**
40
80
120
baseline 0 1 2
time (hours postoperatively)
ANP
(pg/
ml)
low fluidhigh fluid
* p<0,05 vs. preop
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pulmonary function - FEV1
**
2,2
2,4
2,6
2,8
3
pre 1 2 4 24
time (hours postoperatively)
FEV
(l se
c-1)
low fluidhigh fluid
* p<0,05 between groups
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exercise capacity
*
0
20
40
60
80
100
pre 4 24
time (hours postoperatively)
wor
kloa
d (w
att)
low fluidhigh fluid
* p<0,05 between groups
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balance functionstatic and dynamic tests on force plates(BalanceMaster®)
results:•better balance function in high vs. low fluid
group 4h postop (p<0,05)•no difference 24 h postop
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subjective parameters
nausea dizziness thirst drowsiness wellbeing
effects of high vs. low fluid administration 0-4 hours postop:
p<0,05
in high fluid group:
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15 ml/kg Ringer
40 ml/kg Ringer p value
fulfilling discharge data (PADDS> 9) at day of surgery 67% 96% 0,01
discharge at day of surgery 65% 95% 0,02
discharge data
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• decreased vasoactive surgical stress response
• improved perioperative physiology (pulmonary function, exercise capacity, balance function)
• enhanced recovery (nausea, thirst, drowsiness, dizziness, well-being)
• shortened hospital stay
conclusions~3 liters compared to ~1 liter fluid in laparoscopic cholecystectomy lead to: