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

[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!

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[SLUser11]

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.

 

[dynx]

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.

 

[doc05]

Plasmalyte. More physiologic than LR or NS

 

[Buzz Me]

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

 

[Smurfette]

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).

 

[SLUser11]

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?

 

[Smurfette]

Regarding diabetics, if their sugars run pretty high or they are insulin dependent, I take out the D5. I do realize this is probably not going to make a big difference (especially for patients on clear liquids who are drinking sugary juices as it is), but it can increase their insulin requirement somewhat. As a bonus, it saves me the page about "patient's accucheck is 200, can I stop the D5?".

 

[doc05]

nonsense. its absurd to think that the dextrose content in a bag of d51/2ns will make any appreciable difference in blood sugar control for a diabetic.

 

[SLUser11]

nonsense. its absurd to think that the dextrose content in a bag of d51/2ns will make any appreciable difference in blood sugar control for a diabetic.

That's a tough call. While I agree with you that it probably doesn't matter for most patients, it's possible that adding 50 grams of dextrose to a liter of fluid can cause hyperglycemia in a diabetic, as they already have impaired glucose metabolism. I've never seen a study that proves or disproves this effect.

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.

And of course, it's hard to disagree with Smurfette's desire to avoid a phone call from the nurses.

This is a pretty interesting topic. I'm going to have to do a literature search in the near future.

Here's what I've found so far (not much):

http://www.ncbi.nlm.nih.gov/pubmed/19772177 (thanks to the Texas Medical Center Library being awesome, I actually have electronic access to this journal from home)

http://www.ncbi.nlm.nih.gov/pubmed/17061636

On a side note, this is probably a loaded question from Europeman, so go ahead and share whatever you've already looked up, please.

 

[Dr.LeoSpaceman]

I'm in the NS or LR with a switch to D5 1/2NS+20k on POD1 camp. Why? Because that's what I've been taught to do.

Corollary: What's your standard rate? Do you err on higher rate initially or conservative rate then bolus for UOP? For simplicity sake, exclude those with severe underlying heart, lung, or kidney issues.

Corollary 2: Does anyone bolus with colloid during the first 24-48 hours (excluding cirrhotics/liver resections)? I'm aware of the data regarding it's futility, but we have some surgical critical care guys that will do it.

 

[europeman]

I'm in the NS or LR with a switch to D5 1/2NS+20k on POD1 camp. Why? Because that's what I've been taught to do.

Corollary: What's your standard rate? Do you err on higher rate initially or conservative rate then bolus for UOP? For simplicity sake, exclude those with severe underlying heart, lung, or kidney issues.

Corollary 2: Does anyone bolus with colloid during the first 24-48 hours (excluding cirrhotics/liver resections)? I'm aware of the data regarding it's futility, but we have some surgical critical care guys that will do it.

Standard rate for me is as follows: If standard surgery that went well, say a hemicolectomy open with a nice mesentary that was easy, in and out (or laparascopic w/extracorpeal anastamosis) I will, in general, err on giving a little less maintance fluids... for for 70kg patient i'll give 100 (a little less than the calculated approriate rate of 110). If big wack which was big laparotomy for subtotal colectomy or long case or something, I may give more. Also depends on EBL and how aggressive anesthesia was intra-op. ALL VOO DOO!

Regarding bolusing with colloids... I only do this in patients who are cirrhotics who have liver resections. Otherwise, on the floor, I don't do it. Sometimes the ICU does it, but it's also VOO DOO (SAFE trial, NEJM).

 

[europeman]

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..

SLUser11, while you are right that dextrose increases the osmolarity of the solution, it clinically has no effect because glucose effecitvely has no TONICITY because it immediately/rapidly goes intra-cellular. In short, D51/2NS is hypoTONIC but ISOosmotic.

I have a question for anyone else.... DO ANY OF YOU ROUTINELY JUST GIVE D51/2NS POST-OP to your patients? If so, why?

 

[LucidSplash]

SLUser11, while you are right that dextrose increases the osmolarity of the solution, it clinically has no effect because glucose effecitvely has no TONICITY because it immediately/rapidly goes intra-cellular. In short, D51/2NS is hypoTONIC but ISOosmotic.

But is this still true in a diabetic? Especially those with poor control (I find that those with poor control pre-op are also more difficult to control post-op as it can be tough to gauge what their baseline requirements are).

 

[europeman]

But is this still true in a diabetic? Especially those with poor control (I find that those with poor control pre-op are also more difficult to control post-op as it can be tough to gauge what their baseline requirements are).

Yes, it is true. Unless the patient has absolutely NO insulin on board as in a type 1 diabetic (who isn't someone you will be giving d5 to anyway) who hasn't recieved their basal insulin, then, I guess theoretically, the dextrose will hang around for a bit until you ge tthem the insulin. For all intents and purposes though, clinically, isotonic NA/CL stays in the extra-cellular space, while glucose does not (and therefore, does not clinically act as a tonic solute which would help with resuscitative measures to increase intravascular/extracellular volume).

I'm surprised everyone is talking so much about gluocse though.... I'm really aiming for more discussion on actual electrolyte presciptions.

Anyone out there routinely just give 1/2 normal or D51/2 normal to your post op peeps?

WHat are you peeps all givng your post op appy patients? LR?

 

[filter07]

Doesn't matter for Appy, I feed them immediately after surgery and heplock soon thereafter. A lot of times I just give d5 1/2 ns with k so I don't have to remember to switch on pod2, unless I expect high fluid needs. Sometimes I start on isotonic and stay there until their labs show impending hypernatremia or hyperchloremia. A lot of this fine tuning is nitpicky in the majority of pts, IMO.

Although I religiously gave ns/LR pod 0 and switched to MIVF on pod 1, my interns often failed to do this for one reason or another and most people did fine, which is why I'm less particular about this topic.

 

[MediCane2006]

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

Same here.

 

[GregsAnatomy]

We routinely give D51/2NS with 20 KCl post-op and bolus with NS as needed. Except for the gastric bypass patients who get D5LR (not exactly sure of the reasoning there). I don't have any problem giving the D5 to diabetics unless their sugars our way out of whack. As one attending said to me : "do we routinely starve diabetic patients to keep their sugars down?"

 

[45408]

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

This.

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.

 

[neb85]

I have an article by a GI guy who makes a good argument for the use of D5 1/2NS as a maintenance fluid. The numbers make intuitive sense, but it is also all based on the normal physiology of someone who is NPO with no stressors or fluid shifts. As far as I know there's no actual clinical data.

Now I typically use D5 1/2NS + 20k once the patient is more or less euvolemic, and give NS for volume immediately postop and for boluses. Where I went to medical school, everyone just used NS. It doesn't seem to make much of a difference either way.


[PDF] http://www.medicine.virginia.edu/cl...rt-team/nutrition-articles/CorbettArticle.pdf http://forums.studentdoctor.net/www...rt-team/nutrition-articles/CorbettArticle.pdf

 

[europeman]

I have an article by a GI guy who makes a good argument for the use of D5 1/2NS as a maintenance fluid. The numbers make intuitive sense, but it is also all based on the normal physiology of someone who is NPO with no stressors or fluid shifts. As far as I know there's no actual clinical data.

Now I typically use D5 1/2NS + 20k once the patient is more or less euvolemic, and give NS for volume immediately postop and for boluses. Where I went to medical school, everyone just used NS. It doesn't seem to make much of a difference either way.


[PDF] http://www.medicine.virginia.edu/cl...rt-team/nutrition-articles/CorbettArticle.pdf

Yeah, I agree... this paper is just basically a review of maintence requirements for non-stressed, patiens and doesn't address the unqiue circumstances of post-operative resuscitation.

GregsAnatomy: Question.... you say your institution routinely gives d51/2NS post op. What about a patient who comes in with perforated diverticulitis, septic, goes to OR and post op is stable enough for a non-ICU bed (extubated, better, etc). You know... 40 year old patient who preop was febrile 40 tachy 120, you do Hartmans and post op fever less and heart rate now in 100-110s, still febrile 38.5, urine on the low side 15-20cc/hr but stable enough for stedpdown or something. You still write that person for d51/2 as your maintenece and just bolus prn? What's the thought? thanks!

 

[GregsAnatomy]

Yeah, I agree... this paper is just basically a review of maintence requirements for non-stressed, patiens and doesn't address the unqiue circumstances of post-operative resuscitation.

GregsAnatomy: Question.... you say your institution routinely gives d51/2NS post op. What about a patient who comes in with perforated diverticulitis, septic, goes to OR and post op is stable enough for a non-ICU bed (extubated, better, etc). You know... 40 year old patient who preop was febrile 40 tachy 120, you do Hartmans and post op fever less and heart rate now in 100-110s, still febrile 38.5, urine on the low side 15-20cc/hr but stable enough for stedpdown or something. You still write that person for d51/2 as your maintenece and just bolus prn? What's the thought? thanks!

We would probably still use D51/2NS but at a higher rate: calculated maintenance requirement + adjustment for fluid losses (probably something like 150 cc/hr for this patient). Can't give you any rationale behind it other than it's just what we do!

Seems like the overall theme of this thread is that your post-op fluid choice doesn't seem to matter too much....

 

[dpmd]

Elective whatever that needs to stay in house and isn't going to be taking po fast enough to saline lock right off the bat-D5 1/2NS +20 KCL unless they have some condition that makes me need to do something else. Why? Because I figure maintenance is what I want, then if they demonstrate a need for resusc I can just act accordingly. For someone who comes out sick I will usually opt for a maintenance type rate even if I switch to NS (I don't do LR much just because that is what I learned from those above me-no good reason) with a plan to bolus prn. It is easy to forget you have someone at 250 and hour or something and end up with an issue (especially with our ****ty EMR)

Trauma patient the first night (regardless of how stable they are)-NS. Why? Cultural norm at my institution. Most of my fellow residents will keep everyone NPO that first night too, regardless of how they are and what we kept them for. I'm fond of eating so I am more selective about who I make NPO

Lap appy, inpatient lap chole, other acute care stuff where the patient isn't really that sick, I will still do D51/2 +20KCL with an order to saline lock as soon as they tolerate sufficient po (I pick 800 for no particular reason except that I have to put a number or the nurses will not do it-and may not do it anyway).

Sick patients get NS unless there is a reason to give something else, again at a maintenance kind of rate with boluses as needed. It makes things more labor intensive for me and the resident covering at night, but I figure if they are sick they need a closer eye on them anyway (wouldn't try it for a floor patient because the nurses might wait till the end of the shift to tell me the patient hasn't made any urine-would either have the resident go by every so many hours if I thought the patient was PROBABLY going to be ok but had some issues I was worried about)

Anesthesia is more likely to give more fluids than I think is necessary except in the bad trauma patient where I think they don't resusc as I would want them to. That is why I try to have someone form the surgery team help at the head (if my night float is more senior I let them do the case and run the resusc with anesthesia so they can focus on their stuff while I push the product and make sure calcium gets given, etc)

 

[Buzz Me]

I've only used albumin for post-op liver patients, or in cirrhotics.

 

[Miami_med]

I am going to have to openly disagree regarding the use of D5 in diabetics. Diabetics are just as capable of converting to ketone metabolism for brain function in a prolonged NPO period as anyone else. The same theory that makes me utilize D5 in a non-diabetic should apply to a diabetic as well.

In the initial post-op period, I would generally give LR or NS until POD1, when the patient would be given PO. I might use a low rate of maintenance at this point depending on the clinical circumstances, but in a patient taking PO, the specific formulation is less relevant. If the patient had some indication to remain NPO, I would proceed with maintenance of D51/2 w 20K. I would place the diabetic patient on a sliding scale in anticipation of hyperglycemia. Additionally, atleast at our institution, we have a protocol for the temporary use of long acting insulin in NPO diabetics, regardless of whether they were insulin dependent pre-operatively. This helps with control, and it also helps prevent conversion to ketone metabolism. With the right regimen, we rarely receive calls from nursing, as the sliding scale covers the hyperglycemic spikes that outpace the lantus coverage. Perhaps its a little over the top, but it may help to keep the patient out of catabolic overdrive. Diabetics normally take in sugar and still need to do so.

The truth is, in an uncomplicated hemicolectomy on an otherwise fairly healthy patient, they will do fine almost regardless of which fluids you use.

 

[SLUser11]

I just read an interesting article on this topic from the May 2012 Annals of Surgery. The author's conclusion was that Plasmalyte infusion resulted in a lower morbidity than normal saline infusion.....


.....but then when you take a closer look, the paper is sort of crap, and has to use a lot of creative number crunching to support their pre-existing conclusion.

First of all, the paper is industry-sponsored, which often prevents me from taking anything too seriously. Baxter Healthcare funded the study, and I'm relatively sure they sell Plasma-Lyte after a short google search....not positive.

The only detail they really know of the fluid management is what the patients received on Day 1, so they have no idea how fluid was managed after that. Also, the patient populations receiving the two fluids were drastically different, with the NS group having significantly higher comorbidities and higher rates of emergency surgery, etc. There were several other major problems with the study design......

Basically, the paper started with 500,000 patients, whittled it down to 32,000, then started using creative math to compare apples to oranges.

I think I'm going to stick with NS until I see some more convincing evidence.

I'll try to attach the pdf when I get to a computer that allows it.

 

[Wustenfuchs]

I just read an interesting article on this topic from the May 2012 Annals of Surgery. The author's conclusion was that Plasmalyte infusion resulted in a lower morbidity than normal saline infusion.....


.....but then when you take a closer look, the paper is sort of crap, and has to use a lot of creative number crunching to support their pre-existing conclusion.

First of all, the paper is industry-sponsored, which often prevents me from taking anything too seriously. Baxter Healthcare funded the study, and I'm relatively sure they sell Plasma-Lyte after a short google search....not positive.

The only detail they really know of the fluid management is what the patients received on Day 1, so they have no idea how fluid was managed after that. Also, the patient populations receiving the two fluids were drastically different, with the NS group having significantly higher comorbidities and higher rates of emergency surgery, etc. There were several other major problems with the study design......

Basically, the paper started with 500,000 patients, whittled it down to 32,000, then started using creative math to compare apples to oranges.

I think I'm going to stick with NS until I see some more convincing evidence.

I'll try to attach the pdf when I get to a computer that allows it.

I am still waiting for the pdf...

 

[SLUser11]

I am still waiting for the pdf...

Here you go.

 

[Toennis]

Here you go.

Oh my gosh! Can you legally do this???

 

[Wustenfuchs]

Of course he can...It's not like he makes money out of it...He actually helps saving lives...

 

[Smurfette]

I don't bolus patients nearly as much as I did during residency, but will if the UOP is *truly* low and the labs reflect that. When I do bolus fluid in a post op pt, I find I give less volume than I did in training (usually 500 mL, but I'll give 1 L to young and healthy folks who need it). I found that the anesthesiologists here tend to keep patients fairly dry and most patients do just fine despite not getting that 1L per hour of open abdomen I was taught. I also am on the stingy side in my narc prescribing so I do not see nearly as many hypotensive patients post op anymore compared to in training; taking away a PCA or halving a dose of dilaudid/morphine can help a lot in this respect, which decreases both my overnight pages and fluid boluses ordered.

 

[Trauma Surgeon]

For not complicated (converted to open) lap appies I just have them mobilized in the post op and home, no more IV's in the post-op!

I don't do any elective hemi-colectomies, but our colorectal section is adhering firmly to ERAS protocol, so basically the patients is on PO as soon as possible after surgery. If they give any solution it is basically a glucose + electrolytes solution.

 

[bannie22]

LR to D51/2NS+20K @ POD1.
But secretly I think none of this matters in the otherwise healthy patient.

Bet if anyone did a study on outcomes it would be nil.
Its more religion than science.

Otherwise, for the sick patient fluid management should be patient specific.

 

[dpmd]

Most of my colectomies are not elective so i am ok with boluses if needed, but since i am not rushing people to the or usually (excluding the occasional perfed stercoral ulcer) they tend to be fairly well resuscitated before the or and probably less likely to seem dry postop than if they came in from home npo after midnight (especially if they get a bowel prep which i don't do) so i try to get them to the point where they can just drink more if they need to.

 

[VisionaryTics]

I'm gonna bump this thread.

I think fluid management has changed more over the course of my residency than just about anything we routinely do.

I haven't quite been able to impart this knowledge into my interns/PGY2s heads yet. They are still at the old "Surgery On Call" books mindsets of bolus bolus bolus for anything even approaching low urine output.

But with most of our major abdominal surgery patients, and particularly anyone with a bowel anastomosis or a laparoscopic approach, I'm a huge fan of less is more. Some of our attendings joke that if the Cr doesn't bump we've given too much fluid.

Be interested to see what some of our "old-timers" think on this one... @SLUser11 @Smurfette @dpmd

I don't get the use of D5 1/2 NS + 20 KCl. Why give a hypotonic fluid at all? While not give something physiologic, even as "maintenance" fluids? I disagree with the use of the terms maintenance vs. resuscitation fluids, the purpose of both is to maintain adequate circulatory volume.

In ENT, our patients that tend to require intensive post-op care tend to be our major head and neck patients, including free flaps. There's so many issues with wound healing, I can't bring myself to give a hypotonic fluid like 1/2 NS due to issues with tissue edema. You give the fluid that will maintain circulatory volume, minimize third spacing, and keep electrolytes in check. So I give LR in pretty much every situation.

-edit- I've attached an IVF review I give to interns and med students. I also like Marik's book "Evidence Based Critical Care".

 

[SLUser11]

I'm gonna bump this thread.

I think fluid management has changed more over the course of my residency than just about anything we routinely do.

I haven't quite been able to impart this knowledge into my interns/PGY2s heads yet. They are still at the old "Surgery On Call" books mindsets of bolus bolus bolus for anything even approaching low urine output.

But with most of our major abdominal surgery patients, and particularly anyone with a bowel anastomosis or a laparoscopic approach, I'm a huge fan of less is more. Some of our attendings joke that if the Cr doesn't bump we've given too much fluid.

Be interested to see what some of our "old-timers" think on this one... @SLUser11 @Smurfette @dpmd

Old timer?!? Sad but true.....

Truthfully, I put very little thought into the IVF choice because I don't think it matters much (LR vs. NS vs. D5___), and most of my elective cases are in an enhanced recovery pathway where the fluids don't stick around for too long.

I think it's clear from recent literature that surgeons tend to over-resuscitate. One of the theoretical consequences of this is bowel edema and increased rates of ileus. For most patients, over-resuscitation really happens in the OR. In general, I don't try to micro-manage the anesthesiologists, but thankfully they subscribe to "less is more" as well.

I don't dry people out until they are orthostatic and/or azotemic, but I definitely restrict fluids perioperatively.

Still, the pendulum tends to swing back on topics like this, and I reserve final judgment. Although it's a pretty theory that fluid restriction reduces ileus, Thomas Henry Huxley taught us all about the great tragedy of science.

Here's a couple articles from the CRS world that are relevant:
http://www.ncbi.nlm.nih.gov/pubmed/23132508

http://www.ncbi.nlm.nih.gov/pubmed/26445470

 

[dr zaius]

Do y'all use the ERAS protocol?

 

[SLUser11]

Do y'all use the ERAS protocol?

Yes, we use AN ERAS protocol, but there's not one great standardized pathway that we can call THE protocol.