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Discussion in 'Anesthesiology' started by repititionition, May 10, 2018.
Link to NEJM
Am i seeing this correctly? 72% of the cases had invasive BP monitoring with 18% with CVP monitoring. What are they doing over there??? 93% were a combined ASA2/3, with a median surgery duration of 3.3 hours with a median blood loss of 200ml for both groups... They must really like those arterial lines over there...
On another note, i wouldve loved to see some data about mean pressures through out the case. There was a difference of about 1.3L of fluid for a ~3.3 hr surgery intraop between the two groups. relative hypotension in the restrictive group could be a reason for the results the study found.
Also, the ERAS pathway isn't just intraop/postop. It's also pre op such as pre op iv fluids or sugary drinks
Very weak study, from my point of view, typical statistical mumbo-jumbo, smoke and mirrors. Probably many centers, total chaos. It won't change my practice.
It's just sad how low the NEJM and other famous journals have sunk. Same goes for the public funds that are wasted on stuff like this.
I am not saying this because it goes against my current convictions and knowledge. It's just way too heterogeneous, too many types of surgeries, unblinded.
There was no MAP goal, for example, when AKI has been shown to depend significantly on duration of hypotension, especially when the kidney likes MAPs over 75-80, not the usual 65. They defined hypotension as SBP under 90, but they allowed clinicians to change that threshold depending on the patient arbitrarily. Seriously? And they draw p<0.001 conclusions (e.g. AKI) from there? If you read the study, a LOT was left at the latitude of the treating physician. The study was not blinded, for gods' sake, when most anesthesiologists and surgeons believe in liberal fluids. Do they really believe that doctors followed their trial religiously?
All this is good for is to give an excuse for those who flood their postop patients till they get anasarca, pulmonary edema and abdominal compartment syndrome. This just shows why most physicians shouldn't do "research".
A good paper is like a good business plan or 10-K: almost anybody can understand it (see BRK). It's not mumbo-jumbo, it's clear, not like this one. I actually had to google the trial to understand what exactly happened here. REstrictive Versus LIbEral Fluid Therapy in Major Abdominal Surgery: RELIEF Study - Full Text View - ClinicalTrials.gov . If one reads the description of the Liberal and Restrictive fluid regimens, there is a ton left at the latitude of the treating physicians.
And I still can't find how many centers were involved... Found them elsewhere. Centres. About 40. Yeah, I am sure it's a reliable high-quality study. </sarcasm>
I am sure the intentions were good, but this study stinks of chaos. Plus every time I need a PhD to understand the "Statistical Analysis" chapter, I don't trust the study. I want to see transparency, simplicity, reproducibility. I need things to be dumbed down to my level.
I thought the idea for aggressive fluid resuscitation in abdominal cases was based on high insensible losses from open abdomen. what is the point of aggressive fluid resuscitation in a laparoscopic case?
Even in open abdomen cases, the insensitive losses are probably not as high as the numbers previously pulled out of thin air by some "researcher" decades ago, and still taught in every dumb textbook together with the IQ base deficit.
There was a study done on open abdomen insensitive losses and they found it was something like a couple of mls.
I had the same thought about the mostly lap cases. Don’t know if hat really falls under major abdominal surgery. I was hoping they would have done a subgroup anaylsis for the open cases. Duration of 3 hrs definitely doesn’t fall under major abdominal surgery. The lack of intraoperative data is very unfortunate. Still I don’t think it’s completely useless.
I do think it helps with the overly aggressive people who think "a little fluid is better, so no fluid is best". I have seen people chase <1 L to the detriment of the patient. Every patient has different baseline symp/para output/vasomotor tone and responds differently to anesthesia. To treat one exactly same as the other is a bit too standardized.
The problem is that we have a ton of surgeons who think that (any) fluids (and blood products) are better than (any) pressors. When about critical care-related subjects, most surgeons are smatterers (and some anesthesiologists, too). So they love to point to studies like this, and think in black or white.
Of course it's best not to exaggerate neither fluids nor pressors. Both can cause harm. But every patient is different, different things happen in different surgeries, and the right way to do things is to continuously cycle through assessment - (a bit of) treatment - reassessment, keeping in mind that one can always give more but cannot take back.
There is also a third group nobody considered in this study: the non-liberal group. That's where I belong. I give fluids when needed, blood when needed, and pressors when needed, without exaggerating any of them. I just don't think either of the three is the solution to everything.
I agree. I believe I am in that "other" group. I think of it as modestly restrictive.
Of course you can take it back. Toss in a foley and give some iv lasix + ppv
or just disconnect the a line and let the blood pour out
Bloodletting, the cool thing to do since 69 BC
Some of our neurosurgeons seem to think so.
A few weeks ago in the middle of a spine I leaned over the drapes and asked the surgeon if he knew the CPT code for an exchange transfusion.
Of course you can't always. The more fluid you give, the higher the chances of an inflammatory response, especially coupled with the surgical inflammatory response. Not during the surgery, but after.
This study, like most of this conversation, is focusing on the wrong things. For most patients, it doesn't matter if they get 3-4L of extra crystalloid intraop. The problem is when that festival continues for a week postop, with "maintenance fluids", urine output chasing, BP chasing, BD chasing, and other dumb number-chasing.
That extra 10-15L can be much harder to take back, and can lead to a lot of bad stuff, especially if the patient had abdominal surgery. Fluids tend to follow gravity and inflammation, so they will initially go to the surgical site and to the most dependent areas of the patient. By the time one sees puffy hands, that extra fluid is everywhere (lung, belly, internal organs). There is a long list of problems fluid overload causes, the most obvious being prolonged ICU stay. The least obvious is internal organ congestion and decreased intra-organ perfusion.
Some people (e.g. most surgeons) seem to be unable to understand that one can give pressors and still have proper peripheral perfusion, or that a good BP may not mean crap if the organ is flooded with fluid and congested, because the capillaries care about tissue edema and pressure at venous end (i.e. perfusion pressure), not just about systemic MAP. On the other hand, giving just pressors to a hypovolemic patient won't help microcirculation either.
Btw, where did first do no harm go?
We should all give this a read: Context-sensitive fluid therapy in critical illness (if the beginning seems too dense, start at the Gap between macro-hemodynamics and microcirculation).
The fear of pressors is so deeply engraved in the minds of many people who treat surgical patients, and in my opinion it causes more complications than any other factor.
This is the main reason I try to avoid epidurals post-op because as soon as the patient gets a little hypotensive they want the epidural off, so the patient will have pain that would increase the patient's pressure and they don't have to give the scary evil pressors!
It’s fine to try to run them on the dry side, but often the patient’s condition doesn’t want to cooperate and you’ve got to do what you’ve got to do. Sepsis, coagulopathy, etc. You can’t treat that with 500cc of LR and some low dose pressors for 4 hours.