What IV fluid do you give post operatively after an elective hemi-colectomy?

I'm curious what peeps at other institutions in the country routinely prescribe after standard general surgery procedures for patients who are admitted. Lots of literature sorta tip-toeing around the issue, lots of debate in critical care about colloids, crystaloids, etc..... but when it comes down to WHAT ARE YOU ACTUALLY DOING for your patient who has an ELECTIVE (i.e. not septic, etc) hemicolectomy (say for cancer or whatever), what do you do? Lets assume the case was run-of-the-mill, and anesthesia did what you consider an appropriate job with fluids intra-op (whatever that means... i'm being vague I know... this is all sorta voo doo anyway).

What about after a lap appy?


Do you give LR? D5 1/2 with K? NS? Plasmalyte?

Thoughts? Obviously a difficult left hemi-colectomy open for a large tumor is a "bigger wack" than a laparoscopic sigmoid rxn, and their post-operative recovery/insult is different, so do you take that into account?

Are you concerned about so-called "SIADH" of surgery and potentially avoiding hyponatremia and don't prescribe hypotonic solutions immediately post op?

For those of you who give 1/2 or D51/2 NS... why do you do this? Are you trying to reduce the salt load? Do you just like giving dextrose and find it easier to order than adding dextrose to plasmalyte or LR? If your patient has low urine output overnight, do you just bolus them with NS or whatever and keep them on the 1/2NS or do you then switch them to a resusitative normo-tonic solution (eg. NS/LR/plasmalyte)?

Thanks!

Originally Posted by europeman

I'm curious what peeps at other institutions in the country routinely prescribe after standard general surgery procedures for patients who are admitted. Lots of literature sorta tip-toeing around the issue, lots of debate in critical care about colloids, crystaloids, etc..... but when it comes down to WHAT ARE YOU ACTUALLY DOING for your patient who has an ELECTIVE (i.e. not septic, etc) hemicolectomy (say for cancer or whatever), what do you do? Lets assume the case was run-of-the-mill, and anesthesia did what you consider an appropriate job with fluids intra-op (whatever that means... i'm being vague I know... this is all sorta voo doo anyway).

What about after a lap appy?


Do you give LR? D5 1/2 with K? NS? Plasmalyte?

Thoughts? Obviously a difficult left hemi-colectomy open for a large tumor is a "bigger wack" than a laparoscopic sigmoid rxn, and their post-operative recovery/insult is different, so do you take that into account?

Are you concerned about so-called "SIADH" of surgery and potentially avoiding hyponatremia and don't prescribe hypotonic solutions immediately post op?

For those of you who give 1/2 or D51/2 NS... why do you do this? Are you trying to reduce the salt load? Do you just like giving dextrose and find it easier to order than adding dextrose to plasmalyte or LR? If your patient has low urine output overnight, do you just bolus them with NS or whatever and keep them on the 1/2NS or do you then switch them to a resusitative normo-tonic solution (eg. NS/LR/plasmalyte)?

Thanks!

Normal saline.

D5 NS w/ 20

It got annoying seeing little old people get hyponatremic after surgery when they come in dehydrated and then hold onto water post op when under stress. Give NS to everyone and you avoid this problem. Sure sometimes the CL gets a little high but nobody ever stays an extra day in the hospital for high Cl.

Plasmalyte. More physiologic than LR or NS

NS or LR for the immediate post-operative resuscitative period, then switch to maintenance (D5 1/2NS) on POD #1.

Originally Posted by Buzz Me

NS or LR for the immediate post-operative resuscitative period, then switch to maintenance (D5 1/2NS) on POD #1.

+1 to switching to maintenance on POD 1.

I prefer LR over NS for the resuscitation period but prefer to bolus with NS for low UOP (this is how I was trained; my partners do things a little differently).

Originally Posted by Buzz Me

NS or LR for the immediate post-operative resuscitative period, then switch to maintenance (D5 1/2NS) on POD #1.

This just seems like an extra step to me. For my patients, they require "maintenance" fluid for 24-48 hours, then I'm decreasing it as I increase PO intake. For a routine colectomy, they will get clear liquids on POD #1 and I'll cut the IVF in half.

I also see hyperchloremia as being a non-issue for maintenance-level fluid rates. I usually don't see hyperchloremia unless I'm slamming a patient with large volumes of resuscitative normal saline. If a patient develops hyperchloremic acidosis (usually a trauma patient after massive resuscitation), the literature would say that they do just as well as patients who aren't acidotic, so I don't get too excited about that either....

I'd be surprised if there's any convincing evidence that one IVF is better than another. I would, however, be excited to read any literature that addresses the issue.

I'd also like to know if the SDNers treat diabetic patients differently. Is the D5 going to cause hyperglycemia and increase insulin requirements, or is the concentration low enough where it doesn't make a difference?

Originally Posted by Buzz Me

NS or LR for the immediate post-operative resuscitative period, then switch to maintenance (D5 1/2NS) on POD #1.

Same here.

Originally Posted by Buzz Me

NS or LR for the immediate post-operative resuscitative period, then switch to maintenance (D5 1/2NS) on POD #1.

This.

Originally Posted by SLUser11

I do think that adding D5 to the IVF makes the solution hypertonic, as D5W has 278 mOsm/L (according to google), which is roughly isotonic already. Adding 1/2NS or NS or LR should bump the numbers up significantly (NS is 308 mOsm/L, LR is 273). I'm not sure if this leads to a significant clinical effect.

I could be wrong, but I'm pretty sure D5 has no effect on tonicity, because it's not an ion. It just increases the osmalarity of the solution.