It’s not always clear how much fluid to give intraoperatively. Blood pressure and heart rate are two monitors to help determine how much fluid should be given, though the differential diagnosis for variations in each does not only include fluid volume. Dr. David Pestaña, originally from the Department of Anesthesiology and Critical Care, Hospital Universitario La Paz, Madrid, Spain (current affiliation: Department of Anesthesia and Critical Care, Hospital Universitario Ramón y Cajal, IRICYS, Madrid, Spain), and colleagues describe a prospective randomized study of goal-directed fluid therapy (GDT) in patients undergoing major abdominal surgery requiring postoperative ICU admission. Their results are published in this month’s Anesthesia & Analgesia in the article titled “Perioperative Goal-Directed Hemodynamic Optimization Using Noninvasive Cardiac Output Monitoring in Major Abdominal Surgery: A Prospective, Randomized, Multicenter, Pragmatic Trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery).”
One hundred forty-two patients scheduled for open colorectal, small bowel resection, or gastrectomy were included in the study between January 2011 and August 2012. A noninvasive cardiac output monitor (the NICOM™) was used to estimate stroke volume and cardiac output in the study (GDT) group (72 patients), and these results informed a uniform algorithm for fluid and inotropic management. All other elements of care, including fluid management in the control group (70 patients), were at the discretion of the anesthesia team. Six Spanish and Israeli centers participated in this study. At the time of study, none of the hospitals was following the Enhanced Recovery After Surgery (ERAS) pathway.
The authors found neither a difference in length of stay (11.5% in the GDT group vs. 10.5% in the control group) nor in the overall rate of most complications (40% vs. 41%) in the 142 patients studied. There was a barely significant reduction in the need for reoperation in the study group (5.6% compared to 15.7%), though the low overall rate of complications should suggest caution in interpreting any specific finding. In discussing the difference between their results and previous positive studies of goal-directed fluid therapy, the authors noted that global outcomes for colorectal surgery patients might be more dependent on comprehensive application of the ERAS guidelines rather than any specific component.