Anestesia e Pesquisa Clínica
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Improving Fluid Management in the Enhanced Recovery after Surgery: A Plan-Do-Study-Act Cycle

Cheong Pei Chin Geraldine, Goh Gin Yuen, Chia Hooi Tzing, Ho Chin Swee and Kumaresh Venkatesan

Objective: Judicious fluid management, being an important intervention in Enhanced Recovery after Surgery (ERAS) for colorectal surgery, emphasizes on zero-balance fluid management. However, this concept can be difficult to translate to practice. In our plan-do-study-act cycle, we aimed to study the perioperative fluid usage and also set out to study its impact on outcomes.

Methods: We performed a retrospective baseline audit on all elective major colorectal surgical patients in 2015, made recommendations for improvement and repeated the audit in 2016. Data were collected from existing electronic medical records and analyzed. The rate of intraoperative fluid given was calculated using amount of fluid adjusted for patient’s weight and duration of surgery. Outcome measures such as length of stay, surgical complications and acute kidney injury were collected.

Results: The adjusted median rate of intraoperative fluid administered was reduced from 8.44 (IQR 5.49, 11.04) mlkg^-1hr^-1 to 2.67 (IQR 1.69, 4.07) mlkg^-1hr^-1 (p<0.001). The adjusted total fluid given in the 1st 24 hours also reduced from 2.28 (IQR 1.81, 3.10) ml/kg/hr to 1.26 (IQR 0.90, 1.63) mlkg^-1hr^-1 (p<0.001). The length of stay and incidence of surgical complications were similar. 12 patients (10.3%) in the 2016 group compared to only one in the 2015 group developed acute kidney injury with no patients requiring renal replacement therapy.

Conclusion: Compliance to appropriate fluid management for ERAS improved after raising awareness, implementing a fluid management algorithm and the use of a fluid infusion pump. These simple recommendations may be considered if any ERAS program finds ensuring fluid management a challenge. The clinical significance of acute kidney injury needs further exploration.