PERioperative Fluid Management in Elective ColecTomy (PERFECT)—a national prospective cohort study

Abstract

Background

There is contradictory evidence regarding the merits of restricted versus liberal perioperative intravenous (IV) fluid administration in bowel surgery. This study sought to audit perioperative fluid management in elective colectomy in Ireland and to analyse the impact of such on operative outcomes.

Methods

A national surgical trainee collaborative audit of perioperative fluid management was performed. Data from each site was collected prospectively over a selected 3-week period within a pre-defined 2-month block. Collected variables included demographics, type of operation/anaesthethic, volume/type of fluid administration pre-, intra- and post-operatively, 30-day morbidity and mortality. Primary outcome was fluid balance 24-h post-operatively with further analysis to identify the impact of this on 30-day morbidity. ROC curves were generated to identify the critical volume at which fluid balance was associated with 30-day morbidity.

Results

Ninety-four patients were enrolled from 17 hospitals. Mean age was 64 years. A total of 48.9% (N = 46) were managed by ERAS and 51.1% (N = 48) received bowel preparation. Almost 70% of cases (N = 63) were completed by minimally invasive techniques. Significant 30-day morbidity requiring hospital readmission was low [6.4% (n = 6)]. Median fluid balance at 24 h was + 715 ml (IQR 165–1486 ml). On multivariate analysis, high BMI (p = 0.02), indication for surgery (p = 0.02) and critical care admission (p = 0.008) were significantly predictive of 30-day morbidity. Twenty-four hour fluid balance >+ 665 ml was associated with increased risk of 30-day morbidity on univariate but not multivariate analysis, implying association but not causation.

Conclusion

Overall, perioperative fluid management was within an acceptable range with minimal impact on 30-day morbidity following elective colorectal surgery.

Appendix

Pre-operative
MRN (for data collection only)
Age (years)
Gender
ASA
Indication
Admission date
Enhanced recovery (Y/N)
Pre-op weight (kg)
BMI
Diabetic (Y/N)
Baseline creatinine
Baseline haemoglobin
Baseline diuretic   Type   Dose
IV fluid preop   Type   Volume
Pre-op bowel prep (Y/N)   Type
Intra-operative
Date of surgery
Time of induction
Time of skin closure
Lap/converted/open/robotic
Operation
Operation duration (min)
General anaesthesia (Y/N)
Spinal anaesthesia (Y/N)
Epidural (Y/N)
Cannula   Size   Number
Urinary catheter
Goal-directed fluid therapy (Y/N)   Type
Oesophageal Doppler use (Y/N)
IV fluids   Type   Volume
Blood products   Type   Volume
Intra-op urinary output
Intra-op blood loss (ml)
Intra-op complications (Y/N)   Type
Inotropes (Y/N)
Post-op day 1
POD1 fluid balance (ml)
Total post op fluid input (ml)
Total post op fluid output (ml)
Weight (kg)
IV fluid post op to 24 h   Type   Volume
Blood products post op to 24 h   Type   Volume
Enteral fluid input post-op to 24 h   Tpye   Volume
Urinary output POD-24 h (ml)
GI output POD-24 h (ml)
Stoma (Y/N)   Volume POD-24 h
Creatinine day 1
Post-op diuretic   Type   Dose
Post-op day 30
HDU (Y/N)–planned (Y/N)
ICU (Y/N)–planned (Y/N)
Total LOS (days)
High output stoma (Y/N)
Renal compromise from HOS (Y/N)
Return to theatre (Y/N)
Time to return to oral fluids (POD)
Time to return to oral diet (POD)
Time to passing flatus (POD)
Time to BO (POD)
30-day morbidity (Y/N)
Specific morbidity
Clavien-Dindo grade
Complication description
All cause 30-day ED attendance
All cause 30-day re-admission
All cause 30-day mortality
Cause of death