Authors: Joshua A. Bloomstone, M.D., C.S.S.G.B., C.L.S. et al
Anesthesiology 3 2018, Vol.128, 681-682.
To the Editor:
It is with intrigue that we read Gómez-Izquierdo et al.’s paper demonstrating the lack of effectiveness of goal-directed fluid therapy (GDFT) in reducing ileus after elective laparoscopic colorectal surgery.1 We congratulate the authors for a well-done study and Anesthesiology for publishing an important negative trial. There are a few points we would like to discuss.
First, these authors join an increasingly large number of research groups whose results call into question the value of GDFT in mitigating complications and reducing hospital length of stay or cost after elective surgery. Specifically, several previous reports, and now that of Gómez-Izquierdo et al., collectively force us to critically examine the general applicability of GDFT in today’s surgical patients. Although GDFT has been shown to mitigate postsurgical complications in studies spanning three decades,2 its effectiveness in reducing postsurgical morbidity in patients on enhanced recovery pathways appears limited.3 Additionally, traditional proponents of GDFT recently have questioned its value within enhanced recovery.4,5 Even staunch proponents of standardized, best-evidence clinical pathway design and implementation have questioned the acceptance of all enhanced recovery elements without continued individual element evaluation.6,7 To be sure, the laparoscopic approach, avoidance of dehydrating bowel preparations, and clear liquid consumption until 2 h before surgery all play important roles in reducing the volume shifts that were typical of traditional surgical procedures. To these points, we agree with Gómez-Izquierdo et al. that important advancements in perioperative care have diminished the positive impact of GDFT.
Second, the implemented GDFT approach is not in line with the referenced perioperative fluid therapy consensus statement, which details a logical two-step rationale for intraoperative fluid administration. “First, determine if the patient requires hemodynamic support or augmentation of cardiovascular function. Second, if the need is apparent and the patient is fluid responsive, fluid bolus therapy should be considered.”8 As recently penned by Takala, “giving volume to fluid responders as long as they respond should not become the iatrogenic syndrome of the decade.”9 Bearing this sentiment in mind, and considering these two criteria for fluid administration, it is not surprising that the results of this trial are negative. Gómez-Izquierdo et al.’s important work critically underscores the notion that intraoperative fluid administration based solely on fluid responsiveness is neither physiologically sound nor should it be expected to improve surgical outcomes.
Gómez-Izquierdo, JC, Trainito, A, Mirzakandov, D, Stein, BL, Liberman, S, Charlebois, P, Pecorelli, N, Feldman, LS, Carli, F, Baldini, G . Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: A randomized controlled trial. Anesthesiology 2017; 127:36–49
Pearse, RM, Harrison, DA, MacDonald, N, Gillies, MA, Blunt, M, Ackland, G, Grocott, MP, Ahern, A, Griggs, K, Scott, R, Hinds, C, Rowan, K ; OPTIMISE Study Group: Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: A randomized clinical trial and systematic review. JAMA 2014; 311:2181–90
Rollins, KE, Lobo, DN . Intraoperative goal-directed fluid therapy in elective major abdominal surgery: A meta-analysis of randomized controlled trials. Ann Surg 2016; 263:465–76
Gupta, R, Gan, TJ . Peri-operative fluid management to enhance recovery. Anaesthesia 2016; 71Suppl 1:40–5
Miller, TE, Roche, AM, Mythen, M . Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth 2015; 62:158–68
Bloomstone, JA, Loftus, T, Hutchison, R . ERAS: Enhancing recovery one evidence-based step at a time. Anesth Analg 2015; 120:256
Nicholson, A, Lowe, MC, Parker, J, Lewis, SR, Alderson, P, Smith, AF . Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 2014; 101:172–88
Navarro, LH, Bloomstone, JA, Auler, JOJr, Cannesson, M, Rocca, GD, Gan, TJ, Kinsky, M, Magder, S, Miller, TE, Mythen, M, Perel, A, Reuter, DA, Pinsky, MR, Kramer, GC . Perioperative fluid therapy: A statement from the International Fluid Optimization Group. Perioper Med (Lond) 2015; 4:3
Takala, J . Volume responsive, but does the patient need volume? Intensive Care Med 2016; 42:1461–3