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Restricting Fluids During Abdominal Surgery Shows No Benefit, Possible Renal Risk

By Gene Emery

May 11, 2018

(Reuters Health) - In a discovery that goes against emerging surgical wisdom, a new study suggests that restricting intravenous fluids before major abdominal surgery not only fails to make the operation safer for higher-risk patients, it may cause short-term kidney injury.


The rate of acute renal injury was 8.6% among 1,490 volunteers with a restricted fluid regimen versus 5.0% in a group of 1,493 getting a liberal IV-fluid regimen (P<0.001).

限制输液组1490名患者中急性肾损伤的发生率为8.6%,自由输液组1493名患者中发生率为5.0% (P<0.001)。

The risk of septic complications or death within 30 days was similar in the two groups - as high as 21.8% in the restrictive fluid group - but the research team, reporting online May 10 in The New England Journal of Medicine, also saw modestly significant increases in the rates of surgical-site infection and the need for renal-replacement therapy when fluids were restricted to replacement only.


"Our results are really quite surprising," chief author Paul Myles of Monash University in Australia told Reuters Health in a telephone interview. "We could not identify any benefits of restrictive fluids, which is the technique experts have been using recently. In fact, we found more harm."

“我们的结果非常令人奇怪,”研究的第一作者,澳大利亚Monash大学的Paul Myles在电话访谈中对路透社健康频道谈到。“我们未能发现限制输液的任何好处,然而这确是专家们近期常规使用的输液策略。事实上,我们发现[限制输液]有更多危害。”

But the team stressed in their paper that the findings "should not be used to support excessive administration of intravenous fluid. Rather, they show that a regimen that includes a modestly liberal administration of fluid is safer than a restrictive regimen."


"There's been no debate that if you give too much or too little fluid, it causes harm," Dr. Myles said by phone. "But we didn't know where the sweet spot was, and that was the purpose of this study. We now know where the sweet spot is, and that really is going to change practice around the world."


"The result may surprise many surgeons and anesthesiologists, who no doubt expected that the outcome would favor the restrictive fluid group," said Birgitte Brandstrup of Holbaek Hospital, Denmark, in a Journal editorial.

“研究结果可能使很多外科医生及麻醉科医生感到奇怪,这些人无疑都预期研究结果倾向于限制输液组,”来自丹麦Holbaek医院的Birgitte Brandstrup在述评中写到。

"The findings we have in this setting are very generalizable to all types of patients having major abdominal surgery and, I would argue, any type of major surgery," Dr. Myles said.


The results were also reported Thursday at the Australian and New Zealand College of Anaesthetists' annual scientific meeting in Sydney, Australia.


Conventional fluid administration can add 3 to 6 kilograms to a patient's weight, and some small studies have suggested that restricting the amounts might reduce complications.


In the new pragmatic international study, known as RELIEF, patients in the restricted fluid group were only given enough fluid to replace what they were losing.


Their median intake was 3.7 liters during and up to 24 hours after surgery versus 6.1 liters in the liberal intake group.

限制输液组患者在手术期间直至手术后24小时中位液体入量为3.7 L,自由输液组为6.1 L。

All of the study participants were at higher risk for complications based on several criteria, such as being at least 70 years old, being morbidly obese or having heart disease, renal impairment or diabetes.


The odds of disability-free survival at one year showed no benefit for the restrictive-fluid regimen, with rates of 81.9% and 82.3% respectively (P=0.61).

限制输液组一年后无残疾生存率并无获益,两组患者分别为81.9% 和 82.3% (P=0.61)。

Surgical-site infection rates were 16.5% with restricted intake and 13.6% without. Renal-replacement therapy was provided to 0.9% of volunteers on restricted fluids, three times higher than the rate among patients receiving unrestricted fluids (P=0.48).


The study, which was not blinded and included a range of abdominal surgeries, was done at 47 centers in seven countries.


Dr. Brandstrup said there may be several reasons why earlier research suggested a benefit to restricted fluids while the RELIEF study does not. For example, the older tests were done when surgery was more invasive, producing more stress that leads to fluid retention.


SOURCE: https://bit.ly/2ryeT1j

N Engl J Med 2018.


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