CURRENT TREND IN PERIOPERATIVE FLUID & NUTRITION MANAGEMENT

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INTRODUCTION

A better understanding of surgical metabolism and optimum nutrition support has considerably improved the outcome of many surgical patients. Perioperative fluid therapy and nutrition support requires an understanding of physiology. The introduction of ERAS protocol  (Enhanced Recovery after Surgery) and recommendation from the British Society of Parenteral and Enteral Nutrition have highlighted the problems associated with fluid and sodium overload, hyponatremia from excess plain dextrose and hypercloremic acidosis following plain 0.9% saline.⁽¹⁾.

A common approach in perioperative fluid therapy can be outlined below:

Preoperative Management

Preoperative carbohydrate helps prevent or minimize insulin resistance in postoperative period. Nowadays more than 2-h fasting for clear fluids (water, tea, coffee, pulp-free fruit juices) in elective patients, both adults and children and including pregnant women not in labour. Importantly, this does not apply to milk, any other fat-containing fluids, or solids. To provide sufficient safety margins, the fasting period after intake of solids should not be less than 6 h ⁽⁷⁾. Delayed gastric emptying needs to be considered in patients with diabetes, pain, opioids, alcohol, smoking etc.

Intraoperative fluid management

The amount, type and rate of intraoperative fluid administration should be tailored to individual patients. We will not discuss about the crystalloid colloid controversies here. The administration of isotonic eletrolyte solution (acetated ringer’s) combined with 1% glucose and magnesium has been widely used in Japan and has been reported to reduce ketogenesis and maintain magnesium levels⁽⁸⁾ and helps to avoid perioperative acid-base imbalance, hyponatremia, hyperglycemia, and ketoacidosis in infants and toddlers and may therefore enhance patient safety⁽⁹⁾. The infusion of a small dose of glucose (1%) during minor otorhinolaryngeal, head and neck surgeries may suppress protein catabolism without hyperglycemia and hypoglycemia ⁽¹⁰⁾.

Postoperative Fluid and Nutrition Management

For practical purpose,  a concept of “4 Ls” ( Low volume, Low sodium, Low glucose and Low amino acid) will be introduced to describe a  useful strategy in handling surgical patients in postoperative period, taking account the surgica/metabolic stress imposed by major complicated operations and anesthesia

Low Volume

Pulmonary oedema may ensue within 36 hr postoperatively if net water retention > 67 ml/kg/d⁽¹¹⁾, and recovery of adult gastrointestinal function after colon resection is faster when postoperative water intake was < 2L ⁽¹²⁾. Giving large volume of  parenteral fluid after massive replacement of 3^rd space loss is also dangerous.

Low Sodium

To meet maintenance requirements, patients should receive sodium 50-100 mmol/day, potassium 40-80 mmol/day in 1.5-2.5 litres of water by the oral, enteral or parenteral route ^(12,13). The reason behind this low sodium requirement is the increased secretion of arginine vasopressin (ADH) and aldosterone by surgical stress, and potential risk of volume overload. Patients with hypoabuminemia are prone to interstitial fluid overload when receiving high sodium, which in turn may delay postoperative wound healing and in extreme case can impair gut anastomosis after bowel resection ⁽¹⁴⁾.

Low Glucose

It has been universally known that Injury and surgery immediately cause a series of stress responses in the body. The most important reactions involve the release of stress hormones (glucagon, cortisol and cathecolamines) and cytokines⁽¹⁵⁾. Hyperglycaemia is one such cause of complications and the development in surgical hyperglycaemia is similar to that described for hyperglycaemia in diabetic patients. Therefore it reasonable that in highly stressed patients “start low go slow” concept applies by giving 400-600 kcal/day during the first 3 postoperative days instead of providing full calories. In severely malnourished surgical patients, addition of fat-emulsion may be helpful to increase calorie without causing or aggravating hyperglycemia

Low Amino acid

Although there were already previous sporadic reports about the use of early administration of amino acids, the importance has been obvious after the protein-sparing effect of exogenous amino acids was reported recently by Schriker⁽¹⁶⁾.  As shown in the following diagram there is a good rationale of giving early amino acids (POD2)  with or without glucose in surgical patients. The amino acid requirement in non-stressed patient  has been calculated based on the obligatory excretion of nitrogen via skin, feces and urine which is approximately 30 g/day.

However, in the following instances, the requirement of amino acids is increased to 1-2 g/kg/day:

1   

     1.   Infectious complications
2.     Trauma
3.     Burn
4.     Fistula
5.     Kwashiorkor

Administration of 10% Amino Acids at Postoperative Day 2 in Digestive Surgery

Administraion of only AA has also protein-sparing without risk of increasing hyperglycemia.

Gann Chart.

Gann chart is a simple way to illustrate the fluid and nutrition management in surgical patients in whom the type and amount of parenteral solutions/nutrition can be plotted. This should be included in patient clinical path to best evaluate the requirement and progress of surgical patients.

Perioperative Fluid and Nutrition Management in Gastric and Bowel Resection

CONCLUSION

In addition to  recent advances in surgical techniques and anesthesia, surgeons the outcome of surgical patients is also influenced by proper perioperative fluid and nutrition management.  Enhanced recovery protocols have been developed. Within the context of perioperative fluid therapy and nutrition, the following points can be  recommended:

    

1) Preoperative carbhydrate loading to prevent or to minimize postoperative insulin resistance

2) Intraoperative fluid management should be adjusted to hemodynamic requirements

3) Early Postoperative 4 Ls (low volume, low sodium, low glucose and low amino acids)

References:

1. Rebecca J; Simon M Postoperative fluid and electrolyte balance: alarming audit results The Journal of Perioperative Practice; Sep 2009; 19, 9; ProQuest Health & Medical Complete pg. 291

2. Nygren J. Best Practice & Research Clinical Anaesthesiology Vol. 20, No. 3, pp. 429e438, 2006

3. Fearon KCH. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection Clinical Nutrition (2005) 24, 466–477

4. Futier E et al. Conservative vs Restrictive Individualized Goal-Directed Fluid Replacement Strategy in Major Abdominal Surgery. Arch Surg. 2010;145(12):1193-1200

5. Lobo DN et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection. Lancet 2002 May 25.359(5320):1792-3

6. Brandtsruo B. Fluid therapy for the surgical patient. Best Practice & Research Clinical Anaesthesiology Vol. 20, No. 2, pp. 265–283, 2006

7. SØREIDE E, et al. Pre-operative fasting guidelines: an update Acta Anaesthesiol Scand 2005; 49: 1041—1047

8. Yokoyama T, Suwa K, Yamasaki F, Yokoyama R, Yamashita K, Sellden E Intraoperative infusion of acetated Ringer solution containing glucose and ionized magnesium reduces ketogenesis and maintains serum magnesium. Asia Pac J Clin Nutr. 2008;17(3):525-9.

9. Sümpelmann R, Mader T, Eich C, Witt L, Osthaus WA.A novel isotonic-balanced electrolyte solution with 1% glucose for intraoperative fluid therapy in children: results of a prospective multicentre observational post-authorization safety study (PASS). Paediatr Anaesth. 2010 Nov;20(11):977-81.

10. Yamasaki K, Inagaki Y, Mochida S, Funaki K, Takahashi S, Sakamoto S. Effect of intraoperative acetated Ringer's solution with 1% glucose on glucose and protein metabolism. J Anesth. 2010 Jun;24(3):426-31. doi: 10.1007/s00540-010-0926-1. Epub 2010 Mar 19.

11. Arieff Allen L. Fatal Postoperative Pulmonary Edema. Pathogenesis & Literature Review. CHEST 1999;115:1371-1377

12. Lobo DN et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection. Lancet 2002 May 25.359(5320):1792-3

13. Powell-Tuck J, et al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients GIFTASUP Revised 7 March 2011.

14. Hill G.L. Disorders of nutrition and metabolism in clinical surgery. Churchill Livingstone 1990

15. Ljungqvist O, The Metabolic Stress Response and Enhanced Recovery N. Francis et al. (eds.), Manual of Fast Track Recovery for Colorectal Surgery, 37, © Springer-Verlag London Limited 2012

16. Schricker T Parenteral nutrition and protein sparing after surgery: do we need glucose? Original Research Article Metabolism, Volume 56, Issue 8, August 2007, Pages 1044-1050,)