Journal Reading

MANAJEMEN CAIRAN PERIOPERATIF DALAM

ENHANCHED RECOVERY AFTER SURGERY (ERAS)

Oleh:

Adisty Chandra 1940312141

Preseptor :
dr. Rudy Permady Soetrisno, Sp.An

BAGIAN ANESTESI DAN TERAPI INTENSIF

FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP DR. M.DJAMIL PADANG
2021
 MANAJEMEN CAIRAN PERIOPERATIF DALAM
ENHANCHED RECOVERY AFTER SURGERY (ERAS)

ABSTRAK
Manajemen cairan merupakan komponen penting dari Enhanced Recovery After
Surgery (ERAS). Penatalaksanaan optimal dimulai pada periode pra operasi dan
berlanjut hingga fase intraoperatif dan post operasi. Dalam review ini, kami
menguraikan praktik berbasis bukti saat ini untuk pengelolaan cairan melalui
setiap fase periode perioperatif. Sebelum operasi, pasien harus terhidrasi sampai 2
jam sebelum induksi anestesi dengan cairan yang mengandung karbohidrat.
Ketika persiapan usus mekanis diperlukan, dengan larutan isoosmotik modern,
pengisian cairan tidak diperlukan. Intraoperatif, terapi cairan bertujuan untuk
mempertahankan euvolemia dengan pendekatan individual. Sementara beberapa
pasien mungkin mendapat manfaat dari goal-directed fluid therapy, pembatasan,
zero-balance approach dalam manajemen cairan intraoperatif mungkin masuk
akal. Pasca operasi, inisiasi awal asupan oral dan penghentian terapi intravena
dianjurkan.

Kata kunci: Enhanced Recovery after Surgery, manajemen cairan, goal-directed

fluid therapy
 Perawatan perioperatif modern dalam bedah kolorektal dipandu oleh Jalur
Enhanced Recovery After Surgery (ERAS). 1
Awalnya dikembangkan di Eropa
pada 1990an untuk mengurangi variabilitas dan meningkatkan hasil akhir, tujuan
dari rangkaian rekomendasi ini bertujuan memberikan intervensi pra-operasi,
intraoperatif, dan paasca-operasi untuk mengurangi komplikasi dan meningkatkan
pemulihan pasien.2 Sebagian besar jalur termasuk konseling pra-penerimaan,
modifikasi persiapan pra operasi (persiapan usus, puasa, pemuatan karbohidrat),
tromboemboli standar dan profilaksis antimikroba, anestesi standar (manajemen
cairan, multimodal hemat opioid analgesia, post-operative nausea and vomitting
[PONV] profilaksis), penekanan pada teknik, dan pendekatan standar untuk
perawatan pasca operasi (manajemen cairan, intubasi nasogastrik, bedah drainase,
kateter urin, analgesia, makan dini, dan dini mobilisasi) .3
Beberapa uji klinis acak telah menunjukkan ERAS sebagai protokol telah
menghasilkan pemendekan length of stay di rumah sakit (LOS), pengurangan
komplikasi seperti ileus pasca operasi dan infeksi tempat pembedahan, serta
pengurangan biaya dan pengulangan tindka.3–7 Namun, meskipun menunjukkan
keberhasilan dalam meningkatkan hasil pasien, masih sulit untuk mempelajari
manfaat masing-masing komponen pengelolaan ERAS, sebanyak mungkin studi
mengalami implementasi yang tidak lengkap dari ERAS. Sebuah tinjauan dari 14
studi yang mengevaluasi hasil setelah Implementasi ERAS menunjukkan bahwa
tidak ada yang menggunakan semua modaitas ERAS.8 Selain itu, analisis terbaru
dari internasional, Data registri ERAS multicenter menunjukkan bahwa kepatuhan
keseluruhan dengan protokol ERAS adalah sekitar 75% tetapi dengan variasi yang
signifikan antara pusat dan elemen.9
Manajemen cairan adalah salah satu komponen ERAS yang sukses, dan
seperti komponen tunggal lainnya, ada menjadi penelitian terbatas yang berfokus
secara khusus pada manajemen cairan sebagai bagian dari ERAS. Namun, satu
studi berhasil mengidentifikasi manajemen cairan perioperatif sebagai prediktor
independen untuk hasil klinis yang lebih baik, menemukan setiap tambahan liter
cairan intravena (IV) yang diberikan pada hari pembedahan menyebabkan
peningkatan risiko penundaan pemulihan gejala pasca operasi sebesar 16% , dan
peningkatan 32% risiko kompilkasi pasca operasi .10 Mengingat pentingnya
manajemen cairan untuk keberhasilan jalur ERAS, pernyataan konsensus bersama
baru-baru ini dirilis antara American Society for Enhanced Recovery and
Perioperative Qualty Initiative untuk membuat kerangka kerja untuk manajemen
cairan perioperatif dalam ERAS untuk bedah kolorektal. 11
Kontroversi terus berlanjut atas elemen-elemen tertentu ERAS seperti
penggunaan mechanical bowel preparation (MBP) dan goaldirected fluid therapy
(GDFT), dan manajemen cairan perioperatif yang optimal membutuhkan
investigasi lanjutan; namun, penelitian telah dilakuakan. Dalam ulasan kali ini,
kita akan membahas arus strategi berbasis bukti untuk manajemen cairan pada
pasien menjalani operasi kolorektal dalam jalur ERAS.
Manajemen Cairan Sebelum Operasi
Asupan Oral
Secara tradisional, pasien diinstruksikan untuk tetap berpuasa setelah
tengah malam, malam sebelum operasi sebagai praktik standar untuk mengurangi
risiko aspirasi paru. Saat ini, paling banyak pedoman yang diikuti secara luas,
diterbitkan oleh American Society of Anesthesiologists (ASA), merekomendasikan
puasa dari makanan padat 8 jam sebelumnya dan dari cairan bening 2 jam sebelum
induksi anestesi.12 Review Cochrane menyimpulkan bahwa dibandingkan dengan
puasa standar (nihil per os [NPO] setelah tengah malam), puasa cairan yang
diperpendek pada beberapa orang termasuk studi yang melibatkan asupan cairan
hingga 90 menit sebelum operasi tidak mengakibatkan peningkatan risiko aspirasi
atau peningkatan morbiditas dibandingkan dengan rekomendasi NPO standar
sebelumnya. 13
Masa puasa panjang yang sebelumnya dipromosikan, seringkali lebih dari
12 jam, dapat menyebabkan hipovolemia dan peningkatan stres metabolik dan
resistensi insulin.14,15 Koreksi defisit cairan terkait puasa pra operasi memperbaiki
pusing dan kantuk.16 Namun, jika pasien diizinkan untuk melanjutkan asupan
cairan oral sesuai ASA saat ini, penggantian cairan IV kemungkinan tidak
diperlukan.
Resistensi insulin adalah komplikasi lain yang terkait dengan puasa
panjang. Sebuah studi kohort prospektif menunjukkan hal itu untuk masing-
masing 1 mg / kg / menit penurunan sensitivitas insulin, mengakbatkan
peningkatan insiden komplikasi mayor secara keseluruhan, termasuk kematian,
kebutuhan pompa balon intra-aorta, dialisis, stroke, atau infeksi (rasio odds [OR]:
2,23) .17 Perlu diketahui, penelitian menunjukkan bahwa risiko infeksi parah
secara signifikan lebih tinggi karena sensitivitas insulin menurun (OR: 4,98).
Resistensi insulin juga dapat menyebabkan hiperglikemia pasca operasi yang
dikaitkan dengan peningkatan risiko sebesar 30% dari infeksi pascaoperasi dengan
setiap peningkatan 40 poin dari normoglikemia (<110 mg / dL) .18 Studi awal
memanfaatkan infus glukosa sebagai cara untuk memerangi defisit karbohidrat
yang disebabkan oleh puasa semalam. 19,20
Studi ini menunjukkan bahwa infus
glukosa menjadikan Sensitivitas insulin normal setelah operasi jika dibandingkan
dengan kontrol, memunculkan gagasan bahwa menjalani operasi pada orang yang
diberi makan karbohidrat dibandingkan dengan keadaan berpuasa
menguntungkan. Di sebuah Uji coba terkontrol acak (RCT) 2016 untuk
mengevaluasi dampak jalur ERAS pada resistensi insulin, pasien diacak ke salah
satu protokol ERAS atau perawatan konvensional. Pasien dalam kelompok ERAS
menerima 875 mL Cairan kaya karbohidrat (157 g) sampai 2 jam sebelum operasi,
sementara pasien dalam kelompok konvensional memulai berpuasa tengah malam
dan tidak menerima cairan karbohidrat apa pun. Meskipun tidak ada perbedaan
yang ditemukan secara keseluruhan antara ERAS dan kelompok konvensional,
subkelompok pasien dengan peningkatan resistensi insulin sebelum operasi
bermakna peningkatan resistensi insulin mereka pada pasca operasi hari 1 (POD 1)
dalam kelompok ERAS dibandingkan dengan kontrol. 21
Asupan karbohidrat oral menyebabkan efek menguntungkan lainnya
demikian juga. pada tahun 2014, tinjauan Cochrane membahas hasil dari 27
percobaan di mana pasien menerima setidaknya 45 g karbohidrat dalam waktu 4
jam sebelum operasi atau anestesi. Beban karbohidrat mempersingkat waktu flatus
sebesar 0,39 hari (Interval kepercayaan 95% [CI]: 0,70-0,07) dan sedikit
pengurangan lama rawat inap sebesar 0,30 hari (95% CI: 0,56– 0,04)
dibandingkan dengan persyaratan puasa tradisional atau kontrol plasebo.22 Namun,
tinjauan sistematis tidak menenumukan bukti bahwa beban karbohidrat dikaitkan
dengan setiap peningkatan atau perunan komplikasi pasca operasi. Sebuah meta-
analisis kedua yang mencakup 21 RCT menunjukkan pada pasien yang menjalani
operasi perut mayor, mengakibatkan pengobatan karbohidrat pra operasi
berkurang lama tinggal 1,08 hari (95% CI: 1,87 sampai 0,29) .23 Selain itu,
ketidaknyamanan perioperatif dan kecemasan ditemukan menurun saat diberi
minuman karbohidrat pagi hari operasi.24 Dalam sebuah penelitian, pasien
diberikan Minuman kaya karbohidrat mengalami penurunan kadar malaise dan
kelemahan bahkan 24 jam setelah operasi
Bukti terkini menunjukkan bahwa puasa dalam jangka waktu yang lama
sebaiknya tidak direkomendasikan secara rutin. Saat mengikuti pedoman yang
diterbitkan, pasien harus didorong untuk minum cairan sampai 2 jam sebelum
induksi anestesi untuk pembedahan kolorektal, yang harus mencakup minuman
kaya karbohidrat untuk mengurangi resistensi insulin.
Bowel Preparation
Mechanic bowel preparation diperkenalkan pada tahun 1940-an dan
dikaitkan dengan manfaat teoritis mengurangi infeksi tempat operasi, mengurangi
kebocoran anastomosis, dan pengurangan beban bakteri kolon. 26
Namun, banyak
di antara manfaat awal sekarang belum terbukti. Misalnya MBP belum terbukti
menurunkan jumlah bakteri di usus besar dan tidak mengurangi kontaminasi
peritoneal.27 Juga tidak ada peningkatan kebocoran anastomosis atau komplikasi
septik tanpa menggunakan MBP.28,29
Tidak hanya penelitian yang menunjukkan tidak ada manfaat dengan MBP,
tetapi beberapa bukti menunjukkan bahwa itu mungkin berbahaya. Satu RCT
masuk pasien yang menjalani operasi elektif untuk kanker usus besar dengan
menunjukkan bahwa pasien yang menerima anastomosis primer MBP pra operasi
memiliki peningkatan insiden luka infeksi dan infeksi intra-abdomen, serta
peningkatan waktu untuk flatus pertama dan tingkat prealbumin yang lebih rendah
pada hari pertama pasca operasi.30 Studi lain pada pasien dirawat untuk operasi
kolorektal elektif menemukan bahwa kejadian infeksi luka adalah 24% pada
pasien yang menerima MBP versus 12% pada kelompok kontrol. 31
MBP juga
telah terbukti berkontribusi pada hipovolemia. Junghans dkk menunjukkan indeks
volume darah intratoraks yang rendah pada pasien yang menjalani persiapan usus
dan semalaman puasa sesuai dengan hipovolemia relatif.32
 Padahal mayoritas literatur saat ini tidak mendukung penggunaan MBP, itu
terus digunakan. Tahun 2010 survei dari American Society of Colon and Rectal
Surgeons menunjukkan bahwa 76% peserta selalu menggunakan MBP, sedangkan
19% menggunakannya secara selektif.33 Salah satu manfaat potensial dari MBP
disorot dalam analisis retrospektif dari 32.359 pasien menggunakan American
College of Surgeons National Surgery Database Quality Improvement Program
(NSQIP), di mana pasien dikelompokkan sebagai tidak menerima persiapan usus
MBP, antibiotik oral saja, atau keduanya MBP plus oral antibiotik. Mereka
menemukan bahwa penggunaan MBP saja tidak terkait dengan penurunan risiko
infeksi tempat pembedahan dibandingkan dengan tanpa persiapan usus. Namun,
mereka berhasil menemukannya bahwa antibiotik oral dan antibiotik oral
ditambah MBP terkait dengan penurunan risiko infeksi tempat operasi.34
Sedangkan penggunaan MBP sendiri kontroversial, jenis MBP yang
digunakan juga masih diperdebatkan. Tiga kategori MBP termasuk agen osmotik,
pencahar stimulan, atau kombinasi keduanya. Meskipun ada banyak rejimen MBP,
yang paling banyak sediaan umum menggunakan polietilen glikol (PEG), agen
isosmotik, atau natrium fosfat, agen hiperosmotik. Secara teoritis, PEG, dengan
larutan elektrolit yang seimbang secara osmotik, meminimalkan cairan dan
elektrolit yang signifikan bergeser. Satu kelemahan dari PEG adalah bahwa untuk
persiapan usus yang adekuat, volume yang besar, kira-kira 4 L, dari PEG perlu
tertelan. RCT pada pasien rawat jalan muda dan sehat antara PEG dan natrium
fosfat menunjukkan kepuasan pasien dan akseptabilitas secara signifikan lebih
tinggi pada kelompok natrium fosfat.28 Natrium fosfat membutuhkan lebih sedikit
volume tertelan (8-16 ons). Namun, natrium fosfat telah dikaitkan dengan
nefropati fosfat akut pada beberapa kasus pasien, terutama mereka dengan fungsi
ginjal yang terganggu, hidrasi yang tidak adekuat, dan angiotensin-coverting
enzyme inhibitor atau penghambat reseptor angiotensin.35 Selain itu, telah terbukti
menyebabkan gangguan elektrolit pada pasien usia lanjut, dan pada pasien dengan
insufisiensi ginjal dan penyakit kardiovaskular.36 American Society of Colon dan
Ahli Bedah Rektal, Asosiasi Endoskopi Gastrointestinal, dan Society of American
Gastrointestinal and Endoscopic Pedoman konsensus ahli bedah tentang
persiapan usus untuk kolonoskopi saat ini merekomendasikan pendekatan
individual untuk MBP tanpa bukti signifikan untuk mendukung salah satu rejimen
berakhir yang lain kecuali dalam populasi khusus di mana natrium fosfat telah
terbukti menyebabkan efek samping.37
Saat ini, disarankan bahwa MBP, dan spesifik rejimen yang digunakan,
harus digunakan pada patient-specific manner.
Manajemen Cairan Intraoperatif
Tujuan dari manajemen cairan intraoperatif adalah untuk mempertahankan
perfusi organ akhir dengan volume sirkulasi yang adekuat. Hipovolemia dapat
meningkatkan risiko hipoperfusi organ, sepsis, dan kegagalan multiorgan. Bisa
hipervolemia berbahaya yang mengarah ke perifer dan paru edema serta
peningkatan insiden pasca operasi ileus. 38 Karena itu, mempertahankan euvolemia
harus menjadi tujuan untuk manajemen cairan intraoperatif.
Ada berbagai strategi manajemen cairan diterapkan untuk mencapai tujuan
ini. Secara tradisional, operasi perut telah dikaitkan dengan dehidrasi yang
signifikan dari puasa pra operasi dan persiapan usus, juga sebagai kerugian
intraoperatif karena perdarahan dan jarak ketiga. Untuk memperhitungkan
kerugian ini, pasien menjalani prosedur menerima cairan intraoperatif dalam
kisaran 10 sampai 15 mL / kg. Namun, beberapa terkontrol secara acak, penelitian
telah menunjukkan bahwa pemberian cairan perioperatif yang lebih besar pada
operasi perut mayor telah dikaitkan dengan peningkatan tingkat komplikasi, durasi
pemulihan yang lama, dan peningkatan lama tinggal di rumah sakit.38-43 Penelitian
ini telah dilakukan menghasilkan rekomendasi untuk pendekatan yang lebih
"terbatas" untuk memandu manajemen cairan dibandingkan dengan tradisional
Pendekatan "liberal". Namun, ada perbedaan keseragaman di jumlah cairan yang
didefinisikan sebagai "restriktif" versus "liberal" dalam cobaan ini. Dalam upaya
untuk mendefinisikan istilah-istilah ini lebih jauh, metaanalisis yang dilakukan
oleh Varadhan dan Lobo menetapkan batasan terapi cairan kurang dari 1,75 L /
hari dan terapi cairan aliberal sebagai lebih dari 2,75 L / hari. Mereka juga
membuat kategori lain, Terapi cairan “seimbang”, yang mereka definisikan
sebagai pemberian cairan antara 1,75 dan 2,75 L / hari. Baik terlalu membatasi
atau rejimen cairan yang terlalu liberal diberi label "tidak seimbang". Dengan
menggunakan definisi tersebut, sembilan RCT yang masing-masing memiliki
perbedaan definisi terapi cairan restriktif atau liberal direklasifikasi. Mereka
menemukan bahwa ketika rejimen cairan diperiksa ulang yang berada dalam
keadaan "keseimbangan" versus "ketidakseimbangan", mereka yang berada dalam
keadaan keseimbangan cairan memiliki komplikasi 59% lebih sedikit dan 3-
sampai 4- pengurangan hari rawat inap di rumah sakit.44 Sementara meta-analisis
ini tidak fokus pada terapi cairan dalam jalur ERAS, namun menyoroti kebutuhan
individual dan seimbang dalam pendekatan manajemen cairan.
Dalam konteks jalur ERAS, saat ini ada dua strategi manajemen fluida
yang sedang diperdebatkan: GDFT dan regimen zero-balance atau cairan
"restriktif" individual.45 Rejimen ini dibahas lebih rinci di bagian selanjutnya
Goal-Directed Fluid Therapy versus Zero-balance Fluid Regimen
Goal-Directed Fluid Therapy didasarkan pada pengoptimalan preload
untuk mencapai tujuan tertentu dalam stroke volume, indeks jantung, atau
pengiriman oksigen. GDFT pertama kali diperkenalkan pada akhir 1980-an pasien
bedah risiko tinggi yang menggunakan kateter arteri pulmonalis (PAC) untuk
menilai optimalisasi pengiriman oksigen jaringan global dan konsumsi oksigen.46
Dengan kemajuan teknologi, minimally invasive monitors sekarang digunakan
untuk penggunaan GDFT menggunakan berbagai teknologi untuk menghasilkan
hasil yang serupa secara klinis dengan PAC.47 Penggunaan Doppler
transesophageal, misalnya, memiliki dikaitkan dengan penurunan angka kematian
dan rawat inap di rumah sakit. Di bedah perut mayor, tinjauan sistematis
menunjukkan bahwa penggunaan Doppler transesofageal dikaitkan dengan lebih
sedikit komplikasi, penerimaan unit perawatan intensif, serta yang lebih cepat
kembali fungsi saluran cerna normal.48
Studi awal yang mengevaluasi keefektifan GDFT tidak dilakukan dalam
kombinasi dengan protokol ERAS. Sebuah meta analisis besar baru-baru ini
menilai GDFT baik dalam pengaturan ERAS dan tanpa ERAS.49 Analisis ini
berisi 23 RCT, hanya 10 dari yang menggunakan GDFT dengan protokol ERAS.
Mereka menemukan ketika GDFT digunakan untuk memandu terapi cairan dalam
hubungannya dengan ERAS, tidak ada penurunan morbiditas, mortalitas, lama
tinggal di rumah sakit, atau ileus pasca operasi. Namun, mereka menemukan
dalam studi yang lebih lama ketika GDFT digunakan sebagai perbandingan
dengan terapi cairan konvensional, itu terkait dengan 24% penurunan morbiditas
dan penurunan lama rawat inap 1,55 hari. Salah satu penjelasan atas kurangnya
penambahan manfaat yang signifikan dari GDFT ke jalur ERAS adalah
perubahan yang signifikan manajemen cairan telah terjadi selama dekade terakhir
mengarah pada penurunan keseluruhan dalam terapi cairan intraoperatif.
Zero-balance Fluid Regimen, yang sudah sering dilakukan disebut strategi
cairan "restriktif", bertujuan untuk meminimalkan penambahan berat badan pasca
operasi dengan mempertahankan normovolemia intravaskular. Hal ini dilakukan
dengan penggantian kehilangan cairan terukur tanpa penggantian kehilangan
ketiga jarak, dan pemeliharaan hemodinamik yang sesuai variabel dengan
penggunaan vasopresor.50 Sementara di masa lalu GDFT kemungkinan besar
menyebabkan lebih sedikit cairan yang diinfuskan dibandingkan dengan regimen
cairan tradisional, Phan dkk membandingkan GDFT dengan terapi cairan restriktif
dan menunjukkan bahwa pasien menerima GDFT berbasis Doppler esofagus
menerima GDFT lebih besar volume cairan intraoperatif dibandingkan dengan
kelompok terapi restriktif. Mereka juga mencatat tidak ada perbedaan dalam
tingkat komplikasi atau lama perawatan antara kedua kelompok50
Studi lain juga membandingkan GDFT dengan "restriktif" strategi cairan.
Uji coba multicenter acak, tersamar ganda, dan multisenter tahun 2012
menggunakan protokol ERAS oleh Brandstrup et al termasuk 150 pasien yang
menjalani reseksi kolorektal diacak ke GDFT tanpa keseimbangan atau esofagus
yang dipandu Doppler.51 Dalam kelompok restriktif, pasien diberikan infus
pemeliharaan koloid serta koloid untuk mengganti darah yang hilang, sesuai
volume. Dalam pengaturan hipotensi yang bukan sekunder akibat hipovolemia,
vasopresor digunakan. Pada kelompok Doppler, terapi cairan koloid dipandu oleh
volume kayuhan. Studi ini tidak menemukan hasil yang signifikan perbedaan
antara kedua kelompok dalam lama tinggal, kebutuhan vasopresor, atau
komplikasi. RCT berikutnya mempelajari 85 pasien yang mengikuti jalur ERAS
menemukan bahwa pasien yang diacak untuk menerima GDFT atau saldo nol,
Terapi cairan "restriktif" tidak memiliki perbedaan dalam waktu pemulihan
operasi, lama tinggal di rumah sakit, atau komplikasi52
 Saat ini, masih ada penelitian terbatas yang meneliti manfaat GDFT di
bawah protokol ERAS. Meskipun Doppler transesofageal telah direkomendasikan
berdasarkan banyak pedoman ERAS, pemilihan pasien secara individual adalah
penting. Satu RCT membandingkan manfaat GDFT pada pasien yang fit secara
aerobik dibandingkan dengan pasien yang tidak fit secara aerob. Pasien
didefinisikan sebagai tidak layak jika konsumsi oksigen mereka di anaerobik
ambang batas kurang dari 8,0 mL oksigen / kg / menit. Keduanya fit dan pasien
yang tidak layak kemudian diacak untuk menerima GDFT atau terapi cairan
standar. Terapi cairan standar dipandu oleh ahli anestesi individu, sedangkan
GDFT dipandu oleh transesophageal Doppler dan pengoptimalan volume. Pasien
dalam kedua kelompok GDFT (fit dan unfit) menerima jumlah koloid yang lebih
besar secara signifikan sebagai respons terhadap stroke volume protokol
pengoptimalan, dan membuat jumlah yang jauh lebih besar urin. Hasil penelitian
menunjukkan bahwa pada penderita yang fit aerobik, sebenarnya ada efek
merugikan dari GDFT, dengan peningkatan waktu untuk kesiapan pelepasan di
grup GDFT versus kontrol (7,0 vs. 4,7 hari, p ¼ 0,01) dan durasi yang lebih lama
tinggal (8,8 vs. 6 hari, p ¼ 0,01). Tidak ada yang signifikan perbedaan antara
waktu hingga kesiapan untuk keluar dan panjangnya tinggal di rumah sakit dalam
kelompok tidak layak.53 Studi ini menyoroti untuk sementara mungkin masih ada
sebagian pasien berisiko tinggi yang akan mendapat manfaat dari GDFTdalam
ERAS, studi lebih lanjut perlu dilakukan untuk mengidentifikasi grup ini.
Monitoring GDFT
Perangkat pertama yang digunakan untuk memandu GDFT adalah PAC.46
Seiring dengan kemajuan teknologi, semakin sedikit monitor invasif telah tersedia
dengan menggunakan berbagai teknologi, termasuk Doppler esofagus, analisis
bentuk gelombang tekanan arteri, analisis bioimpedansi listrik, dan
photoplethysmography. Sementara banyak dari teknologi tersebut belum
dimanfaatkan dalam studi pengukuran langsung dampak manajemen cairan dalam
protokol ERAS, mereka mewakili kemajuan yang memungkinkan penggunaan
GDFT lebih sering karena sifatnya yang kurang invasif.54,55
Kebanyakan penelitian melibatkan GDFT dalam konteks ERAS
mengandalkan Doppler transesophageal. Doppler transesofageal menggunakan
prinsip Doppler untuk mengukur kecepatan aliran darah di tingkat aorta yang
turun. Kecepatan ini kemudian digunakan dengan data nomogram pada luas
penampang aorta untuk menghitung volume langkah dan curah jantung.56 Salah
satu perangkat yang paling umum digunakan (CardioQ; Deltex Medical,
Chichester, UK) menggunakan nomogram berdasarkan usia, tinggi badan, berat
badan, dan jenis kelamin pasien. 54,55
Beberapa perangkat komersial telah menggunakan gelombang tekanan
arteri untuk memberikan pengukuran curah jantung berkelanjutan (FloTrac /
Vigileo, Edwards Lifesciences, Irvine, CA; PiCCO, Sistem Medis Pulsi, Munich,
Jerman; LiDCOrapid, LiDCO Group, plc., London, UK) .57,58 Perangkat ini
menggunakan teknologi yang dikembangkan berdasarkan pengamatan oleh
Erlanger dan Hooker pada tahun 1904 bahwa stroke volume dan tekanan nadi
adalah berbanding lurus.59 Menggunakan bentuk gelombang tekanan arteri dari
jalur arteri, sistem ini dapat memberikan informasi tentang curah jantung, volume
langkah, volume langkah variasi, dan resistensi vaskular sistemik.
Sistem bioimpedansi listrik toraks adalah salah satu bentuk pemantauan
jantung noninvasif yang menerapkan tegangan rendah, arus frekuensi tinggi
melalui dada menggunakan elektroda permukaan. Pengisian dan ejeksi jantung
menyebabkan osilasi dalam impedansi arus yang diterapkan ini dengan volume
langkah sebanding dengan amplitudo osilasi. Namun, Teknologi ini dibatasi oleh
cairan intratoraks seperti pleura efusi dan gangguan dari gerakan dinding dada.
Dalam sebuah upaya untuk mengatasi keterbatasan tersebut, bioreaktansi listrik
kardiografi dikembangkan. Teknologi ini, saat ini tersedia dalam sistem NICOM
(Cheetah Medical, Newton Centre,MA), menggunakan elektroda dada untuk
memancarkan bolak-balik arus. Namun dibandingkan dengan bioimpedance yang
mana difokuskan pada perubahan amplitudo, teknologi bioreaktansi menggunakan
perubahan frekuensi untuk pengukuran curah jantungnya
Photoplethysmography juga telah diperkenalkan sebagai teknologi untuk
pengukuran curah jantung non-invasif. Salah satu perangkat terbaru adalah sistem
ClearSight (Edwards Lifesciences, Irvine, CA) yang menggunakan teknik penjepit
volume dengan manset jari tiup untuk memberikan informasi tentang stroke
volume dan curah jantung bersama dengan parameter hemodinamik lainnya.60
 Dalam konteks ERAS, Doppler esofagus terus menjadi yang paling
didukung oleh bukti saat ini. Namun, pengenalan beberapa teknologi yang lebih
baru dan bahkan kurang invasif dapat mengarah pada studi lebih lanjut dari GDFT
dalam pengaturan perioperatif, dan diharapkan akan menghasilkan bukti yang
lebih baik untuk pasien mana yang paling diuntungkan dari penggunaannya.
Jenis Cairan
Penelitian hanya berfokus pada manfaat dari berbagai jenis cairan
intraoperatif dalam konteks ERAS saat ini kurang. Kebanyakan studi yang
melibatkan GDFT dalam protokol ERAS telah menggunakan pati hidroksietil
(HES) sebagai cairan bolus pilihan. Namun, produk HES terbukti mengalami
peningkatan risiko cedera ginjal akut dan terapi penggantian ginjal pada pasien
sakit kritis.61-63
Sekunder dari temuan ini, HES dilarang pada pasien sakit kritis oleh orang
European Medicines Agency pada tahun 2013 dan peringatan kotak hitam
peningkatan cedera ginjal dan kematian dengan penggunaan HES itu ditempatkan
oleh U.S. Food and Drug Administration (FDA) .64,65
Setelah pengumuman ini, penggunaan HES telah dipertanyakan tidak
hanya pada populasi yang sakit kritis tetapi juga perioperatif. Satu percobaan
mengacak pasien yang menjalani pembedahan kolorektal untuk menerima HES
atau kristaloid sebagai cairan bolus pilihan di GDFT dan menemukan bahwa tidak
ada manfaat dalam menggunakan HES dibandingkan kristaloid.66 Sebuah
metaanalisis baru-baru ini menganalisis enam RCT yang membandingkan
penggunaan koloid. versus kristaloid di GDFT intraoperatif di pembedahan non-
kardiak. Meta-analisis ini menemukan bahwa tidak ada perbedaan dalam
komplikasi pasca operasi saat menggunakan kristaloid atau koloid; Namun, GDFT
dengan koloid adalah terkait dengan kecenderungan peningkatan mortalitas.67
Perdebatan terus berlanjut seputar cairan yang sesuai protokol GDFT dan
ERAS. Karena kemampuan mereka meningkatkan volume intravaskular dengan
lebih andal dan lebih lama periode waktu daripada kristaloid, koloid telah
mendapatkan tempat dalam jalur ERAS. Namun, tanpa ketersediaan HES, satu-
satunya koloid yang tersedia di banyak institusi adalah albumin, dan rasio biaya-
manfaat menggunakan albumin versus kristaloid untuk perawatan intraoperatif
masih belum diketahui. Studi lebih lanjut adalah diperlukan untuk
membandingkan kristaloid versus albumin dalam pengaturan perioperatif, dan
efek pada komplikasi perioperatif, morbiditas, dan mortalitas. Selain itu, larutan
pati yang lebih baru telah dikembangkan yang mungkin memiliki manfaat koloid
dengan pengurangan risiko bahaya yang disebabkan oleh larutan pati generasi
sebelumnya, meskipun hal ini masih belum jelas
Pertimbangan Pasca Operasi
Durasi Status NPO
Pasien yang menjalani operasi kolorektal harus ditawarkan lebih awal
makan enteral. Secara tradisional, pasien diberi NPO untuk istirahat bowel untuk
melindungi dari kebocoran anastomosis dan untuk mencegahnya melawan PONV.
Namun, pemberian makanan enteral lebih awal telah ditunjukkan untuk menjadi
bermanfaat. Carr et al menemukan bahwa pasien yang dapat pemberian makanan
enteral tidak mengalami peningkatan permeabilitas mukosa usus yang tercatat
pada kelompok kontrol. 70
El Nakeeb dkk melakukan RCT yang menunjukkan
bahwa intake oral lebih awal dikaitkan dengan waktu perjalanan yang lebih cepat
untuk flatus juga BAB pada kelompok pemberian makan awal. Mereka juga
menemukan masa tinggal rumah sakit secara signifikan lebih pendek pada
kelompok pemberian makan awal.71 Sebuah tinjauan sistematis termasuk 11 studi
menemukan bahwa pemberian makan dini mengurangi risiko infeksi dalam segala
bentuk (risiko relatif: 0,72) .72
Mengingat bahwa pemberian makanan enteral lebih awal menyebabkan
penurunan edema usus dan waktu lebih cepat untuk flatus dan BAB bersama
dengan lebih pendek mas dirawat di rumah sakit, pemberian makanan enteral dini
saat ini direkomendasikan. Selain itu, pasien lebih mampu mempertahankan
volume intravaskular dan pertahankan keseimbangan cairan saat diberikan kontrol
atas asupan cairan.
Cairan Perawatan
Penelitian telah menunjukkan bahwa kebutuhan perawatan untuk fluida
berkisar dari 1,75 hingga 2,75 L / hari. 44
Namun, di masa lalu, pasien menjalani
operasi kolorektal mayor menerima pemberian cairan jauh melebihi tujuan ini.
Satu uji coba terkontrol secara acak menunjukkan bahwa pertambahan berat badan
3 kg setelah reseksi kolon elektif dikaitkan dengan peningkatan tingkat komplikasi
dan rumah sakit tinggal serta penundaan pemulihan gastrointestinal. Lembaga
sejak itu mengadopsi cairan yang lebih restriktif strategi manajemen sebagai
bagian dari protokol ERAS yang menghilangkan penggunaan cairan perawatan
setelah asupan oral yang memadai dimulai.73,74 Satu studi keseimbangan cairan
pasien pasca operasi di bawah penggunaan protokol ERAS mengungkapkan tidak
Kelebihan cairan yang signifikan secara klinis atau gangguan elektrolit.75
Pemantauan yang hati-hati terhadap status cairan harus dilanjutkan pada periode
pasca operasi untuk menjaga keseimbangan cairan
Kesimpulan
Protokol ERAS dikaitkan dengan hasil yang lebih baik. Manajemen cairan
merupakan landasan manajemen ERAS dengan elemen penting dalam pra operasi,
intraoperatif, dan periode pasca operasi.
Perawatan pasien di jalur ini harus ditujukan untuk keadaan euvolemik.
Dalam pengaturan pra operasi, ini melibatkan meminimalkan berpuasa dari cairan
bening hingga 2 jam sebelum dimulainya anestesi, dengan menelan minuman
kaya karbohidrat. MBP dengan rejimen isoosmotik dapat diberikan dalam
pengaturan pasien yang sesuai dengan memperhatikan keseimbangan cairan.
Manajemen cairan intraoperatif harus bertujuan untuk zero-balance dengan
populasi pasien yang sesuai menerima panduan hemodinamik lebih lanjut dengan
terapi GDFT. Pasien harus didorong untuk makan dan minum segera setelah
operasi dengan terapi cairan intravena terbatas pasca operasi.
Investigasi lanjutan diperlukan untuk mengidentifikasi mereka yang lebih
baik pada populasi pasien yang paling terpengaruh oleh MBP dan mereka yang
paling diuntungkan dengan GDFT serta untuk mengidentifikasi monitor mana
yang paling membantu dan apakah ada jenis cairan yang untuk pasien ERAS.

Konflik kepentingan
Tidak ada yang diumumkan.
114

Perioperative Fluid Management in the Enhanced

Recovery after Surgery (ERAS) Pathway
Alyssa Cheng-Cheng Zhu, MD1 Aalok Agarwala, MD, MBA1 Xiaodong Bao, MD, PhD1

1 Department of Anesthesia, Critical Care and Pain Medicine, Address for correspondence Aalok Agarwala, MD, MBA, Division of
Massachusetts General Hospital, Boston, Massachusetts General Surgery Anesthesia, Department of Anesthesia, Critical Care
and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street,
Clin Colon Rectal Surg 2019;32:114–120. GRB 444, Boston, MA 02114 (e-mail: aagarwala@mgh.harvard.edu).

Abstract Fluid management is an essential component of the Enhanced Recovery after Surgery
(ERAS) pathway. Optimal management begins in the preoperative period and con-
tinues through the intraoperative and postoperative phases. In this review, we outline
current evidence-based practices for fluid management through each phase of the
perioperative period. Preoperatively, patients should be encouraged to hydrate until

Downloaded by: MCP Hahnemann University. Copyrighted material.

2 hours prior to the induction of anesthesia with a carbohydrate-containing clear liquid.
Keywords When mechanical bowel preparation is necessary, with modern isoosmotic solutions,
► Enhanced Recovery fluid repletion is not necessary. Intraoperatively, fluid therapy should aim to maintain
after Surgery euvolemia with an individualized approach. While some patients may benefit from
► fluid management goal-directed fluid therapy, a restrictive, zero-balance approach to intraoperative fluid
► goal-directed fluid management may be reasonable. Postoperatively, early initiation of oral intake and
therapy cessation of intravenous therapy are recommended.

Modern perioperative care in colorectal surgery is guided by
Enhanced Recovery after Surgery (ERAS) pathways.1 Initially
developed in Europe in the 1990s to reduce variability and
improve outcomes, these sets of recommendations aim to
provide preoperative, intraoperative, and postoperative
interventions to decrease complications and enhance patient
recovery.2 Most pathways include preadmission counseling,
modified preoperative preparation (bowel preparation, fast-
ing, carbohydrate loading), standardized thromboembolism
and antimicrobial prophylaxis, standardized anesthetic
approaches (fluid management, opioid-sparing multimodal
analgesia, postoperative nausea and vomiting [PONV] pro-
phylaxis), an emphasis on laparoscopy-assisted surgical
techniques, and a standardized approach to postoperative
care (fluid management, nasogastric intubation, surgical
drains, urinary catheters, analgesia, early feeding, and early
mobilization).3
Multiple randomized clinical trials have shown that ERAS
protocols have resulted in shorter hospital lengths of stay
(LOS), a reduction in complications such as postoperative ileus
and surgical site infection, as well as a reduction in costs and
readmissions.3–7 However, despite showing success in improv-
ing patient outcomes, it has been difficult to study the benefit
of each component of ERAS management on its own, as many
studies have suffered from incomplete implementation of
ERAS. A review of 14 studies that evaluated outcomes after
ERAS implementation showed that none had used all ERAS
modalities.8 In addition, a recent analysis from international,
multicenter ERAS registry data showed that overall compli-
ance with ERAS protocols was approximately 75% but with
significant variation between both centers and elements.9
Fluid management is one component of successful ERAS
pathways, and as with other single components, there has
been limited research focusing specifically on fluid manage-
ment as part of ERAS. One study, however, was able to identify
perioperative fluid management as an independent predictor
for improved clinical outcome, finding that each additional
liter of intravenous (IV) fluid given on the day of surgery led to
a 16% increased risk of postoperative symptoms delaying
recovery, and a 32% increase in the risk of postoperative
complications.10 Given the importance of fluid management
to the success of ERAS pathways, a joint consensus statement
was recently released between the American Society for
Enhanced Recovery and Perioperative Quality Initiative to

Issue Theme Enhanced Recovery after Copyright © 2019 by Thieme Medical DOI https://doi.org/
Surgery (ERAS) for Colorectal Surgery; Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0038-1676476.
Guest Editor: Hiroko Kunitake, MD, MPH New York, NY 10001, USA. ISSN 1531-0043.
Tel: +1(212) 584-4662.
 Perioperative Fluid Management in the ERAS Pathway
create a framework for perioperative fluid management
within ERAS for colorectal surgery.11
Controversy continues over certain elements of ERAS such
as use of mechanical bowel preparation (MBP) and goal-
directed fluid therapy (GDFT), and optimal perioperative fluid
management requires continued investigation; however,
research does exist. In this review, we will discuss current
evidence-based strategies for fluid management in patients
undergoing colorectal surgery within the ERAS pathway.
Preoperative Fluid Management
Oral Intake
Traditionally, patients have been instructed to remain fasting
after midnight the night before surgery as standard practice
for reducing pulmonary aspiration risk. Currently, the most
widely followed guidelines, published by the American
Society of Anesthesiologists (ASA), recommend fasting
from solid foods 8 hours prior and from clear liquids 2 hours
prior to the induction of anesthesia.12 A Cochrane review
concluded that compared with a standard fast (nil per os
[NPO] after midnight), a shortened fluid fast which in some
included studies involved fluid intake up until 90 minutes
prior to surgery did not result in an increased risk of
aspiration or increased morbidity as compared with the
previous standard NPO recommendations.13
The long period of fasting that was previously promoted,
often greater than 12 hours, can lead to hypovolemia and
increased metabolic stress and insulin resistance.14,15 Cor-
rection of the fluid deficit related to preoperative fasting
improved dizziness and drowsiness.16 However, if patients
are allowed to continue oral fluid intake as per current ASA
guidelines, IV fluid replacement is likely unnecessary.
Insulin resistance is another complication associated with
long fasts. A prospective cohort study showed that for each
1 mg/kg/min decrease in insulin sensitivity, there was an
overall increased incidence of major complications, includ-
ing death, need for intra-aortic balloon pump, dialysis,
stroke, or infection (odds ratio [OR]: 2.23).17 Of note, the
study showed that the risk for severe infection was signifi-
cantly higher as insulin sensitivity decreased (OR: 4.98).
Insulin resistance can also lead to postoperative hypergly-
cemia which has been associated with a 30% increase in risk
of a postsurgical infection with every 40-point increase from
normoglycemia (<110 mg/dL).18 Initial studies made use of
glucose infusions as a way to combat the carbohydrate
depletion caused by overnight fasts.19,20 These studies
showed that glucose infusions normalized postoperative
insulin sensitivity when compared with controls, introdu-
cing the idea that undergoing surgery in a carbohydrate-fed
state as compared with a fasted state was advantageous. In a
2016 randomized controlled trial (RCT) to evaluate the
impact of an ERAS pathway on insulin resistance, patients
were randomized to either an ERAS protocol or a conven-
tional care. Patients in the ERAS group received 875 mL of
carbohydrate-rich (157 g) fluid until 2 hours before the
surgery, while patients in the conventional group began
fasting at midnight and did not receive any carbohydrate-
Zhu et al. 115
rich fluid. While no difference was found overall between the
ERAS and conventional groups, a subgroup of patients with
elevated preoperative insulin resistance had significant
improvement in their insulin resistance on postoperative
day 1 (POD 1) in the ERAS group as compared with the
control.21
Oral carbohydrate loading leads to other beneficial effects
as well. In 2014, a Cochrane review discussed the results of
27 trials where patients received at least 45 g of carbohy-
drates within 4 hours before surgery or anesthesia. A carbo-
hydrate load led to a shortened time to flatus by 0.39 days
(95% confidence interval [CI]: 0.70–0.07) and a small reduc-
tion in length of hospital stay by 0.30 days (95% CI: 0.56–
0.04) compared with traditional fasting requirements or
placebo controls.22 However, the systematic review did not
find evidence that the carbohydrate load was associated with
any increase or decrease in postoperative complications.
A second meta-analysis which included 21 RCTs showed
that in patients undergoing major abdominal surgery, pre-
Downloaded by: MCP Hahnemann University. Copyrighted material.
operative carbohydrate treatment resulted in a reduced
length of stay by 1.08 days (95% CI:
1.87 to
0.29).23 In
addition, perioperative discomfort and anxiety has been
found to be decreased when given a carbohydrate drink on
the morning of surgery.24 In one study, patients provided a
carbohydrate-rich beverage had decreased levels of malaise
and weakness even 24 hours after the operation.25
Current evidence suggests that long periods of fasting
should not be routinely recommended. While adhering to
published guidelines, patients should be encouraged to drink
clear liquids until 2 hours prior to the induction of anesthesia
for colorectal surgery, which should include a carbohydrate-
rich drink to mitigate insulin resistance.
Bowel Preparation
Mechanical bowel preparation was introduced in the 1940s
and was associated with the theoretical benefits of reduced
surgical site infection, reduced anastomotic leakage, and a
reduction in colonic bacterial load.26 However, many of these
initial benefits have now been disproven. For example, MBP
has not been shown to decrease the amount of bacteria in the
colon and does not reduce contamination of the peritoneal
cavity.27 There is also no increase in anastomotic leak or
septic complications without the use of MBP.28,29
Not only have studies shown no benefit with MBP, but
some evidence has shown that it may be harmful. One RCT in
patients undergoing elective surgery for colon cancer with
primary anastomosis showed that patients who received
preoperative MBP had an increased incidence of wound
infection and intra-abdominal infection, as well as an
increased time to first flatus and a lower prealbumin level
on the first postoperative day.30 Another study in patients
admitted for elective colorectal surgery found that the
incidence in wound infection was 24% in patients who
received MBP versus 12% in the control group.31 MBP has
also been shown to contribute to hypovolemia. Junghans et al
demonstrated low intrathoracic blood volume index of
patients who underwent bowel preparation and overnight
fasting consistent with relative hypovolemia.32
Clinics in Colon and Rectal Surgery Vol. 32 No. 2/2019
116 Perioperative Fluid Management in the ERAS Pathway
Even though the majority of current literature does not
support the use of MBP, it continues to be used. A 2010
survey of the American Society of Colon and Rectal Surgeons
showed that 76% of participants always used MBP, while 19%
used it selectively.33 One potential benefit of MBP was
highlighted in a retrospective analysis of 32,359 patients
using the American College of Surgeons National Surgery
Quality Improvement Program (NSQIP) database, in which
patients were stratified as either receiving no bowel pre-
paration, MBP, oral antibiotics alone, or both MBP plus oral
antibiotics. They found that the use of MBP alone was not
associated with any decreased risk of surgical site infection
compared with no bowel preparation. However, they did find
that both oral antibiotics and oral antibiotics plus MBP were
associated with a decreased risk of surgical site infections.34
While the use of MBP itself is controversial, the type of MBP
used is also still under debate. The three categories of MBP
include osmotic agents, stimulant laxatives, or a combina-
tion of both. While many MBP regimens exist, the most
common preparations use either polyethylene glycol (PEG),
an isosmotic agent, or sodium phosphate, a hyperosmotic
agent. Theoretically, PEG, with an osmotically balanced elec-
trolyte solution, minimizes significant fluid and electrolyte
shifts. One downside of PEG is that for adequate bowel pre-
paration, large volumes, approximately 4 L, of PEG need to be
ingested. An RCT in young, healthy outpatients between PEG
and sodium phosphate showed that patient satisfaction and
acceptability were significantly higher in the sodium phos-
phate group.28 Sodium phosphate requires significantly less
volume ingested (8–16 ounces). However, sodium phosphate
has been linked with acute phosphate nephropathy in certain
patients, especially those with compromised renal function,
inadequate hydration, and those on angiotensin-converting
enzyme inhibitors or angiotensin receptor blockers.35 In addi-
tion, it has been shown to cause electrolyte disturbances in
elderly patients, and in patients with renal insufficiency and
cardiovascular disease.36 The American Society of Colon and
Rectal Surgeons, Association of Gastrointestinal Endoscopy,
and Society of American Gastrointestinal and Endoscopic
Surgeons consensus guidelines on bowel preparation for colo-
noscopy currently recommend an individualized approach to
MBP without significant evidence to support one regimen over
the other except in specialized populations where sodium
phosphate has proven to lead to adverse effects.37
At this time, it is recommended that MBP, and any specific
regimen used, should be employed in a patient-specific
manner.
Intraoperative Fluid Management
The goal of intraoperative fluid management is to maintain
end-organ perfusion with an adequate circulating volume.
Hypovolemia can lead to an increased risk of organ hypo-
perfusion, sepsis, and multiorgan failure. Hypervolemia can
be equally dangerous leading to peripheral and pulmonary
edema as well as increasing incidence of postoperative
ileus.38 As such, maintaining euvolemia should be the goal
for intraoperative fluid management.
Clinics in Colon and Rectal Surgery Vol. 32 No. 2/2019
Zhu et al.
There have been various fluid management strategies
implemented to achieve this goal. Traditionally, large abdominal
surgeries have been associated with significant dehydration
from both preoperative fasting and bowel preparation, as well
as intraoperative losses due to bleeding and third spacing.
To account for these losses, patients undergoing these
procedures often received intraoperative fluid in the range of
10 to 15 mL/kg. However, multiple randomized controlled
studies have shown that greater perioperative fluid adminis-
tration in major abdominal surgery has been associated with
increased complication rates, prolonged duration of recovery,
and increased hospital length of stay.38–43 These studies have
resulted in a recommendation for a more “restrictive” approach
to guide fluid management as compared with the traditional
“liberal” approach. There is, however, a lack of uniformity in the
amount of fluid that is defined as “restrictive” versus “liberal” in
these trials. In an effort to further define these terms, a meta-
analysis performed by Varadhan and Lobo defined a restricted
fluid therapy as less than 1.75 L/day and a liberal fluid therapy as
Downloaded by: MCP Hahnemann University. Copyrighted material.
greater than 2.75 L/day. They also created another category,
“balanced” fluid therapy, which they defined as fluid adminis-
tration between 1.75 and 2.75 L/day. Either overly restrictive or
overly liberal fluid regimens were labeled as “unbalanced.”
Using these definitions, nine RCTs that each had different
definitions of a restrictive or liberal fluid therapy were reclassi-
fied. They found that when fluid regimens were re-examined as
those in a state of fluid “balance” versus “imbalance,” those in a
state of fluid balance had 59% fewer complications and a 3- to 4-
day reduction in hospital stay.44 While this meta-analysis did
not focus on fluid therapy within the ERAS pathway, it high-
lighted the necessity of an individualized and balanced
approach to fluid management.
Within the context of ERAS pathways, there are currently
two fluid management strategies under debate: GDFT and
individualized zero-balance or “restrictive” fluid regimens.45
These regimens are discussed in further detail in later sections.
Goal-Directed Fluid Therapy versus Zero-balance Fluid
Regimen
Goal-directed fluid therapy is based on optimization of preload
to achieve a certain goal in stroke volume, cardiac index, or
oxygen delivery. GDFT was first introduced in the late 1980s in
high-risk surgical patients using pulmonary artery catheter
(PAC) to assess for optimization of global tissue oxygen delivery
and oxygen consumption.46 With technological advancement,
minimally invasive monitors are now being used for GDFTusing
various technologies to produce clinically similar results to the
PAC.47 The use of transesophageal Doppler, for example, has
been associated with decreased mortality and hospital stay. In
major abdominal surgery, a systematic review showed that the
use of transesophageal Doppler was associated with fewer
complications, intensive care unit admissions, as well as a faster
return of normal gastrointestinal function.48
Initial studies evaluating the effectiveness of GDFTwere not
done in combination with ERAS protocols. A large meta-
analyses recently assessed GDFT both in the setting of ERAS
and without.49 This analysis contained 23 RCTs, only 10 of
which used GDFT with an ERAS protocol. They found that
 Perioperative Fluid Management in the ERAS Pathway
when GDFT was used to guide fluid therapy in conjunction
with ERAS, there was no reduction in morbidity, mortality,
hospital length of stay, or postoperative ileus. However, they
did find that in older studies when GDFTwas used as compared
with conventional fluid therapy, it was related to a 24%
reduction in morbidity and decreased hospital length of stay
of 1.55 days. One explanation for the lack of significant added
benefit of GDFT to ERAS pathways is that a significant shift in
fluid management has occurred over the last decade leading to
an overall decrease in intraoperative fluid therapy.
A zero-balance fluid regimen, which has often been
termed the “restrictive” fluid strategy, aims to minimize
postoperative weight gain by maintaining intravascular nor-
movolemia. This is accomplished with replacement of mea-
sured fluid losses without a replacement of loss to third
spacing, and maintenance of appropriate hemodynamic
variables with use of vasopressors.50 While in the past
GDFT likely led to significantly less fluid infused as compared
with traditional fluid regimens, Phan et al compared GDFT to
a restrictive fluid therapy and demonstrated that patients
receiving esophageal Doppler-driven GDFT received a larger
volume of intraoperative fluid as compared with the restric-
tive therapy group. They also noted no difference in compli-
cation rates or length of stay between the two groups.50
Other studies have also compared GDFT with “restrictive”
fluid strategies. A 2012 randomized, double-blinded, multi-
center trial utilizing an ERAS protocol by Brandstrup et al
included 150 patients undergoing colorectal resection that
were randomized to either zero-balance or esophageal Dop-
pler-guided GDFT.51 In the zero-balance group, patients were
given a colloid maintenance infusion as well as colloid to
replace lost blood, volume for volume. In the setting of
hypotension that was not secondary to hypovolemia, vaso-
pressors were used. In the Doppler group, colloid fluid therapy
was guided by stroke volume. This study found no significant
difference between the two groups in length of stay, need for
vasopressors, or complications. A subsequent RCT studying 85
patients following an ERAS pathway found that patients who
were randomized to receive either GDFT or zero-balance,
“restrictive” fluid therapy had no difference in surgery recov-
ery time, length of hospital stay, or complications.52
Currently, there remains limited research examining the
benefit of GDFT under ERAS protocols. Though transesopha-
geal Doppler has been recommended under many ERAS guide-
lines, individualized patient selection continues to be
important. One RCT compared the benefits of GDFT in aero-
bically fit versus aerobically unfit patients. Patients were
defined as unfit if their oxygen consumption at the anaerobic
threshold was less than 8.0 mL of oxygen/kg/min. Both fit and
unfit patients were then randomized to receive either GDFT or
standard fluid therapy. Standard fluid therapy was guided by
the individual anesthetist, while the GDFT was guided by
transesophageal Doppler and stroke volume optimization.
Patients in both GDFT groups (fit and unfit) received signifi-
cantly greater amounts of colloid in response to stroke volume
optimization protocol, and made significantly greater amounts
of urine. Results showed that in patients who were aerobically
fit, there was actually a detrimental effect of GDFT, with
Zhu et al. 117
increased time to readiness for discharge in the GDFT group
versus the control (7.0 vs. 4.7 days, p ¼ 0.01) and longer length
of stay (8.8 vs. 6 days, p ¼ 0.01). There were no significant
differences between time to readiness for discharge and length
of hospital stay in the unfit group.53 This study highlights that
while there may still exist a subset of high-risk patients who
would benefit from GDFT within ERAS, further studies need to
be conducted to identify this group.
Monitoring in Goal-Directed Fluid Therapy
The first device used to guide goal-directed fluid manage-
ment was the PAC.46 As technology has advanced, less
invasive monitors have become available utilizing a variety
of technologies, including esophageal Doppler, arterial pres-
sure waveform analysis, electrical bioimpedance analysis,
and photoplethysmography. While many of these technolo-
gies have not been utilized in studies directly measuring the
impact of fluid management within ERAS protocols, they
represent advancements that may allow GDFT to be used
Downloaded by: MCP Hahnemann University. Copyrighted material.
more frequently due to their less invasive nature.54,55
Most studies involving GDFT within the context of ERAS
have relied on transesophageal Doppler. The transesopha-
geal Doppler makes use of the Doppler principle to measure
the velocity of blood flow at the level of the descending aorta.
This velocity is then used with nomogram data on the cross-
sectional area of the aorta to calculate stroke volume and
cardiac output.56 One of the most commonly used devices
(CardioQ; Deltex Medical, Chichester, UK) uses a nomogram
based on patients’ age, height, weight, and gender.54,55
Several commercial devices have used arterial pressure
waveform to provide continuous cardiac output measure-
ment (FloTrac/Vigileo, Edwards Lifesciences, Irvine, CA;
PiCCO, Pulsion Medical Systems, Munich, Germany; LiDCOr-
apid, LiDCO Group, plc., London, UK).57,58 These devices use
technology that expands on observations by Erlanger and
Hooker in 1904 that stroke volume and pulse pressure are
directly proportional.59 Using the arterial pressure wave-
form from an arterial line, these systems can provide infor-
mation on cardiac output, stroke volume, stroke volume
variation, and systemic vascular resistance.
Thoracic electrical bioimpedance systems are a form of
noninvasive cardiac monitoring that applies a low-voltage,
high-frequency current through the thorax using surface elec-
trodes. Cardiac filling and ejection lead to oscillation in impe-
dance to this applied current with stroke volume being
proportional to the amplitude of oscillation. However, this
technology is limited by intrathoracic fluid such as pleural
effusion and interference from chest wall movement. In an
effort to overcome these limitations, electrical bioreactance
cardiography was developed. This technology, currently avail-
able in the NICOM system (Cheetah Medical, Newton Center,
MA), continues to use chest electrodes to emit an alternating
current. However, as compared with bioimpedance which
focused on changes in amplitude, bioreactance technology
uses changes in frequency for its cardiac output measurement.58
Photoplethysmography has also been introduced as a
technology for noninvasive cardiac output measurement.
One of the newest devices is the ClearSight system (Edwards
Clinics in Colon and Rectal Surgery Vol. 32 No. 2/2019
118 Perioperative Fluid Management in the ERAS Pathway
Lifesciences, Irvine, CA) which uses a volume clamp techni-
que with an inflatable finger cuff to provide information on
stroke volume and cardiac output along with other hemo-
dynamic parameters.60
In the context of ERAS, esophageal Doppler continues to
be the most supported by current evidence. However, the
introduction of several newer and even less-invasive tech-
nologies may lead to further study of GDFT in the periopera-
tive setting, and will hopefully lead to better evidence for
which patients might most benefit from its use.
Fluid Type
Research focused solely on the benefits of various intrao-
perative fluid types in the context of ERAS is currently
lacking. Most studies involving GDFT in ERAS protocols
have used hydroxyethyl starch (HES) as the bolus fluid of
choice. However, HES products have been found to increase
the risk of acute kidney injury and renal replacement therapy
in critically ill patients.61–63 Secondary to these findings, HES
use was banned in critically ill patients by the European
Medicines Agency in 2013 and a black box warning of
increased kidney injury and death with use of HES was
placed by the U.S. Food and Drug Administration (FDA).64,65
Following these announcements, HES use has been ques-
tioned not only in the critically ill population but also
perioperatively. One trial randomized patients undergoing
colorectal surgery to receive either HES or crystalloid as the
bolus fluid of choice in GDFT and found that there was no
benefit in using HES over crystalloid.66 A recent meta-
analysis analyzed six RCTs that compared the use of colloids
versus crystalloids in intraoperative GDFT in noncardiac
surgery. This meta-analysis found that there was no differ-
ence in postoperative complications when using either crys-
talloids or colloids; however, GDFT with colloids was
associated with a trend toward increased mortality.67
Continued debate exists surrounding the appropriate fluid
type in GDFT and ERAS protocols. Due to their ability to
increase intravascular volume more reliably and for a longer
period of time than crystalloids, colloids have earned a place in
many ERAS pathways. However, without the availability of
HES, the only colloid available in many institutions is albumin,
and the cost–benefit ratio of using albumin versus crystalloid
for intraoperative care is still unknown. Further study is
needed to compare crystalloid versus albumin in the perio-
perative setting, and the effect on perioperative complications,
morbidity, and mortality. In addition, newer starch solutions
have been developed that may have the benefits of colloids
with a reduced risk of harms attributed to previous genera-
tions of starch solutions, though this remains unclear.68,69
Postoperative Considerations
Duration of NPO Status
Patients undergoing colorectal surgery should be offered early
enteral feeding. Traditionally, patients were kept NPO for bowel
rest to protect against an anastomotic leak and to prevent
against PONV. However, early enteral feeding has been shown
to be beneficial. Carr et al found that patients who were
Clinics in Colon and Rectal Surgery Vol. 32 No. 2/2019
Zhu et al.
provided enteral feeding did not have an increase in gut
mucosal permeability that was noted in the control group.70
El Nakeeb et al conducted a RCT which showed that early oral
feeding was associated with faster passage time to flatus as well
as stool in the early feeding group. They also found that hospital
stay was significantly shorter in the early feeding group.71 A
systematic review including 11 studies found that early feeding
reduced the risk of infections of all forms (relative risk: 0.72).72
Given that early enteral feeding leads to decreased gut
edema and faster time to flatus and stool along with shorter
hospital stays, early enteral feeding is currently recom-
mended. In addition, patients are better able to preserve
intravascular volume and maintain fluid balance when given
control over fluid intake.
Maintenance Fluids
Research has shown that maintenance requirements for fluid
range from 1.75 to 2.75 L/day.44 However, in the past, patients
undergoing major colorectal surgery received fluid administra-
Downloaded by: MCP Hahnemann University. Copyrighted material.
tion far in excess of this goal. One randomized, controlled trial
showed that a weight gain of 3 kg after elective colonic resection
was associated with an increased complication rate and hospital
stay as well as a delay in gastrointestinal recovery.41
Institutions have since adopted more restrictive fluid
management strategies as part of ERAS protocols that elim-
inate use of maintenance fluids once adequate oral intake has
commenced.73,74 One study of patients’ fluid balance post-
operatively under use of an ERAS protocol revealed no
clinically significant fluid overload or electrolyte distur-
bances.75 Careful monitoring of fluid status should be con-
tinued in the postoperative period to maintain fluid balance.
Conclusion
ERAS protocols are associated with improved outcomes.
Fluid management is a cornerstone of ERAS management
with important elements in the preoperative, intraoperative,
and postoperative periods.
Patient care in these pathways should aim for a euvolemic
state. In the preoperative setting, this involves minimizing
fasting from clear liquids to 2 hours prior to the start of
anesthesia, with ingestion of a carbohydrate-rich beverage.
MBP with isoosmotic regimens can be provided in appro-
priate patient settings with attention to fluid balance. Intrao-
perative fluid management should aim for zero-balance with
appropriate patient populations receiving further hemody-
namic guidance with goal-directed fluid therapy. Patients
should be encouraged to eat and drink soon after surgery
with limited intravenous fluid therapy postoperatively.
Continued investigation is necessary to better identify those
patient populations who are most affected by mechanical
bowel preparation and those who will benefit most from
goal-directed fluid therapy, as well as to identify which moni-
tors might be most helpful and whether there is an optimal
type of fluid for ERAS patients.
Conflict of Interest
None declared.
 Perioperative Fluid Management in the ERAS Pathway
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