■ Feature Article

Intraoperative Fluid Therapy and Pulmonary Complications

KRZYSZTOF SIEMIONOW, MD; JACEK CYWINSKI, MD; KRZYSZTOF KUSZA, MD, PHD; ISADOR LIEBERMAN, MD, MBA, FRCSC

abstract Full article available online at ORTHOSuperSite.com. Search: 20120123-06

The purpose of this study was to evaluate the effects of intraoperative fl uid therapy on length of hospital stay and pulmonary complications in patients undergoing spine surgery. A total of 1307 patients were analyzed. Sixteen pulmonary complications were observed. Patients with a higher volume of administered crystalloids, colloids, and total intravenous fl uids were more likely to have postoperative respiratory com- plications: the odds of postoperative respiratory complications increased by 30% with an increase of 1000 mL of crystalloid administered. The best cutoff point for total fl uids was 4165 mL, with a sensitivity of 0.8125 and specifi city of 0.7171, for postoperative pulmonary complications. A direct correlation existed between fl uids and length of stay: patients who received Ͼ4165 mL of total fl uids had an average length of stay of 3.88Ϯ4.66 days vs 2.3Ϯ3.9 days for patients who received Ͻ4165 mL of total fl uids (PϽ.0001).

This study should be considered as hypothesis-generating to design a prospective trial comparing high vs low intraoperative fl uid regiments for patients undergoing spine surgery.

Dr Siemionow is from the Department of Orthopaedic Surgery, University of Illinois, Chicago, Illinois; Dr Cywinski is from the Department of Anesthesia, Cleveland Clinic, Cleveland, Ohio; Dr Kusza is from the Department of Anesthesia, Centrum Medyczne Bydgoszcz, Bydgoszcz, Poland; and Dr Lieberman is from Texas Back Institute, Plano, Texas. Drs Siemionow, Cywinski, Kusza, and Lieberman have no relevant fi nancial relationships to disclose. Correspondence should be addressed to: Krzysztof Siemionow, MD, Department of Orthopaedic Surgery, University of Illinois, 835 S Wolcott Ave, Room E-270, Chicago, IL 60612 ([email protected]). doi: 10.3928/01477447-20120123-06

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ntraoperative fl uid administration open abdominal aortic aneurysm repair. This included patients who underwent strategies vary widely as a result of In a study of 1280 consecutive patients vertebral augmentation procedures, mi- Ithe limited understanding of the phys- undergoing isolated on-pump coronary ar- crodiskectomies, single and multilevel de- iologic and clinical consequences of dif- tery bypass grafting, a total fl uid balance compressive procedures, single and mul- ferent fl uid replacement regimens on post- Ͼ500 mL at the end of the surgical pro- tilevel fusions, and osteotomies. Patients operative outcomes.1 The stress response cedure was predictive of increased length who did not have a reported intraoperative to surgery has been shown to profoundly of stay.7 estimated blood loss (EBL) or total vol- alter fl uid homeostasis, leading to fl uid In patients undergoing elective spine ume of crystalloids, colloids, red blood conservation, maintenance of intravas- surgery, intraoperative blood loss var- cells (RBC), fresh frozen plasma (FFP), cular volume, and preservation of blood ies but can be signifi cant (1 to 2 L).8 platelets administered, or urine output perfusion to vital organs. Primary media- Intraoperative blood loss is replaced with were excluded from the analysis. tors of surgical stress response are the re- various combinations of crystalloids, col- Respiratory complications were de- nin–angiotensin system, aldosterone, and loids, and blood products; however, the fi ned as clinical diagnosis of postopera- antidiuretic hormone; however, the effect replacement strategy varies among clini- tive acute respiratory distress syndrome, of the different fl uid regimens (liberal vs cians, with no clear guideline as to the op- clinical diagnosis of pulmonary edema, restrictive) on these mediators is largely timal management of intraoperative fl uid or clinical diagnosis of respiratory insuffi - unknown. Furthermore, the infl amma- replacement. Patients undergoing spinal ciency. The diagnosis was made by a con- tory response to surgical stress results in procedures differ signifi cantly from pa- sulting service, such as internal medicine, increased capillary permeability and a tients undergoing abdominal or thoracic pulmonology, or cardiology. Patients with tendency toward edema formation.2 Thus, surgery. Patients undergoing spine sur- a diagnosis of a pulmonary embolus and controversy exists about the optimal fl uid gery are often in the prone position, un- deep vein thrombosis were excluded from replacement strategy and the consequenc- dergo surgeries of varying time lengths, this study. Patients with obvious nonanes- es of intraoperative fl uid management on require anterior exposures through the thetic causes (eg, postoperative seizure or postoperative outcomes. chest or abdomen, and undergo signifi cant aspiration pneumonia) were also excluded Intraoperative administration of 40 bone and soft tissue manipulation, curve from this study. mL/kg compared with 15 mL/kg of lac- correction, osteotomy, or neural manipu- All intraoperative events, including tated Ringer’s solution was shown to lation, all of which can result in signifi - electrocardiogram changes (eg, tachy- improve postoperative organ functions cant blood loss. cardia, bradycardia, or arrythmias), hy- and recovery and shorten the length of The purpose of this retrospective study potension (Ͻ90 systolic blood pressure), stay in patients undergoing laparoscopic was to evaluate the effects of intraop- decreased partial pressure of oxygen cholecystectomy.3 However, the same in- erative fl uid therapy on length of hospital (Ͻ90%), fl uid balance (fl uids in minus vestigators later reported that restrictive stay and pulmonary complications in pa- fl uid outs), and American Society of (median, 1640 mL; range, 935-2250 mL) tients undergoing spine surgery. Anesthesiologists (ASA) scores, were ob- compared with liberal fl uid administra- tained from the intraoperative anesthesia tion (median, 5050 mL; range, 3563-8050 MATERIALS AND METHODS record. mL) led to a signifi cant improvement in After Institutional Review Board ap- Categorical variables were sum- pulmonary function and a reduction of proval, a review of the Cleveland Clinic marized using frequency and percent. postoperative hypoxemia.4 Department of General Anesthesiology Continuous variables were summarized Functional residual capacity decreases Perioperative Health Documentation using mean and standard deviation. Chi- by 10% and diffusing capacity by 6% in System was undertaken. The Perioperative square test or Fisher’s exact test was used response to an intravenous (IV) saline Health Documentation System combines to compare categorical variables between load of 22 mL/kg in healthy volunteers.5 pre-, intra-, and postoperative in-hospital patients with and without postoperative Neither parameter returned to normal up and post-discharge follow-up health in- respiratory complications. A 2-sample to 40 minutes after the infusion. McArdle formation fed automatically by compo- t test was used to compare continuous et al6 reported that a positive fl uid balance nents of the hospital electronic medical variables. A univariate logistic regression is predictive of major adverse morbid record, anesthesia information manage- model was used to analyze the associa- events (eg, myocardial infarction, pulmo- ment system, administrative claims data, tion between the crystalloid, colloid, and nary edema), increased intensive care unit and provider-entered health information. total fl uids and postoperative respiratory stay, and increased overall length of stay All patients who underwent spine surgery complications. Receiver operating char- in 100 consecutive patients undergoing between 2005 and 2007 were included. acteristic (ROC) analysis predicting post-

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Table 1 Categorical Variables in Complication Versus No Complication Groups operative respiratory complications was performed based on crystalloid, colloid, Complication No Complication and total fl uids, respectively. Sensitivity Variable Total Group, N (%) Group, N (%) P a and specifi city for each predictor was cal- Sex .19 Female 604 10 (62.5) 594 (46) culated. Sensitivity is the predicted proba- Male 703 6 (37.5) 697 (54) bility of postoperative respiratory compli- Race .083b cation when a patient has a complication. Other 140 4 (25) 136 (10.5) Specifi city is the predicted probability of White 1167 12 (75) 1155 (89.5) no complication when a patient has no Preop CAD .62b complication. The best cutoff point for No 1228 16 (100) 1212 (93.9) each predictor was chosen by minimizing Yes 79 0 (0) 79 (6.1) the distance to the perfect point with sen- Preop MI .99b sitivity of 1 and specifi city of 1. Based on No 1304 16 (100) 1288 (99.8) the total fl uid cutoff point, a subanalysis Yes 3 0 (0) 3 (0.23) b was performed to correlate this predictor Preop hyperlipidemia .15 No 1118 16 (100) 1102 (85.4) with the length of stay. Yes 188 0 (0) 188 (14.6) Multivariable logistic regression with Preop atherosclerosis .99b stepwise selection was used to develop a No 1295 16 (100) 1279 (99.1) multivariable model to analyze the rela- Yes 12 0 (0) 12 (0.93) tionship between postoperative respirato- Preop CHF .99b ry complications and the volume of crys- No 1293 16 (100) 1277 (98.9) talloids, colloids, and total fl uids infused Yes 14 0 (0) 14 (1.08) intraoperatively. Patient age, sex, and race Preop AF .99b were the potential covariates. For all the No 1287 16 (100) 1271 (98.5) other fl uid measurements, a univariate lo- Yes 20 0 (0) 20 (1.6) b gistic regression model was used to assess Preop valve disease .99 No 1283 16 (100) 1267 (98.1) the association between each of those fl u- Yes 24 0 (0) 24 (1.9) id measures and postoperative respiratory Preop asthma .99b complication and length of stay. All tests No 1274 16 (100) 1258 (97.5) were 2-sided at a signifi cant level of .05. Yes 32 0 (0) 32 (2.5) All analyses were performed using SAS Preop COPD .99b 9.2 software (SAS Institute, Cary, North No 1299 16 (100) 1283 (99.4) Carolina). Yes 8 0 (0) 8 (0.62) Preop emphysema .99b RESULTS bronchitis No 1301 16 (100) 1285 (99.5) A total of 1307 patients underwent Yes 6 0 (0) 6 (0.46) surgery between January 1, 2005, and Preop acute respiratory n/a July 25, 2008. Seventy-four patients had failure repeated surgeries (up to 4). Data of the No 1307 16 (100) 1291 (100) fi rst surgery were retained for analysis. Preop chronic .99b respiratory failure Of the 1307 patients, 16 (1.22%) had No 1299 16 (100) 1283 (99.4) postoperative respiratory complications. Yes 8 0 (0) 8 (0.62) Six hundred four (46.2%) patients were Preop acute renal n/a women and 703 (53.8%) were men. Mean failure patient age was 55.7Ϯ17.5 years. Patient No 1307 16 (100) 1291 (100) demographics and comorbidity data are Preop chronic renal .99b failure presented in Table 1. Characteristics of No 1304 16 (100) 1288 (99.8) patients who developed pulmonary com- Yes 3 0 (0) 3 (0.23) plications are presented in Table 2. Table Abbreviations: AF, atrial fi brillation; CAD, coronary artery disease; CHF, congestive heart failure; 3 presents the odds ratio estimates from COPD, chronic obstructive pulmonary disease; MI, myocardial infarction; Preop, preoperative. aChi-square test. bFisher’s exact test.

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istered crystalloids, colloids, and total Table 2 fl uids, respectively. The areas under ROC Continuous Variables in Complication Versus No Complication Groups for infused crystolloid and colloids were 0.7699 and 0.7202, respectively. Total MeanϮSD fl uids had the largest area under ROC of Complication Group No Complication 0.8078. However, the pair-wise compari- ϭ ϭ a Variable (N 16) Group (N 1291) P sons indicated no statistical signifi cant Age, y 65.7Ϯ12.7 55.6Ϯ17.5 .006 differences in the areas under ROC among Height, in 47.8Ϯ28.7 60.0Ϯ21.6 .11 the 3 predictors (Table 5). Weight, kg 77.4Ϯ32.2 77.4Ϯ24.5 .99 EBL, mL 647.8Ϯ1060.4 251.4Ϯ692.8 .16 Sensitivity and Specifi city Preoperative HCT, mL 37.9Ϯ2.3 39.8Ϯ0.25 .42 The best cutoff point for crystolloid was 3500 mL, with a sensitivity of 0.6875 ASA score 2.94Ϯ0.41 2.38Ϯ0.75 .0001 and a specifi city of 0.7078, for postop- Urine, mL 471.1Ϯ386.7 172.5Ϯ372.1 .008 erative pulmonary complications (Table Ϯ Ϯ RBC, cc 172.5 412.6 27.9 199.2 .18 6). The best cutoff point for colloid was FFP, cc 101.6Ϯ280.5 4.3Ϯ61.1 .19 500 mL, with a sensitivity of 0.8125 and Platelets, cc 1.3Ϯ5.3 3.6Ϯ45.1 .21 a specifi city of 0.6553, for postopera- Cell saver, cc 114.2Ϯ312.3 26.6Ϯ160.0 .28 tive pulmonary complications (Table 7). Crystalloid, mL 4868.8Ϯ2644.2 2850.8Ϯ1845.8 .008 The best cutoff point for total fl uids was Colloid, mL 1015.6Ϯ766.3 454.6Ϯ738.9 .011 4165 mL, with a sensitivity of 0.8125 and a specifi city of 0.7171, for postoperative Blood products, mL 389.6Ϯ862.8 62.4Ϯ354.1 .001 pulmonary complications (Table 8). Total fl uids, mL 6273.9Ϯ3395.2 3368.2Ϯ2469.9 .004 Ϯ Ϯ Fluids out, mL 1118.9 1304.2 458.2 915.7 .062 Total Fluid as a Predictor Fluid balance, mL 5155.1Ϯ2477.2 3210.2Ϯ2081.9 .007 A subanalysis was performed based Length of stay, d 13.6Ϯ12.0 2.7Ϯ4.1 .003 on the total fl uid cutoff point of 4165 Length of anesthesia, min 155.6Ϯ152.9 133.5Ϯ106.8 .40 mL. Patients who received Ͼ4165 mL Intraoperative hypotensive 0.56Ϯ0.51 0.35Ϯ1.1 .47 total fl uids had a higher ASA score, EBL, episodes, no.b total anesthesia time, and length of stay, Intraoperative ECG 3 194 .85 and were more likely to have a fusion c changes, no. (Table 9). Vertebral augmentation, no. 3 275 .92 Lumbar laminectomy, no. 5 822 .94 Estimated Blood Loss as a Predictor Cervical fusion, no. 1 87 .21 Estimated blood loss was an indepen- Lumbar fusion, no. 5 123 .002 dent predictor of developing a pulmonary Abbreviations: ASA, American Society of Anesthesiologists; EBL, estimated blood loss; complication. Patients who developed a ECG, electrocardiogram; FFP, fresh frozen plasma; HCT, hematocrit; RBC, red blood cells. pulmonary complication had an EBL of a 2-sample t test. 647.8Ϯ1060.4 mL vs 250.5Ϯ684.6 mL bSystolic blood pressure Ͻ90. cAtrial fi brillation; bradycardia (heart rate Ͻ50); tachycardia (heart rate Ͼ130). for those who did not develop a pulmo- nary complication (Pϭ.022) the univariate logistic regression analy- of postoperative respiratory complica- Total Fluids and Length of Stay sis based on volume of intraoperatively tions increased by 30% with an increase A direct correlation was found be- infused crystalloids, colloids, total fl u- of 1000 mL of crystalloid administered. tween fl uids and length of stay. Patients ids, and other fl uid levels, respectively. who had Ͼ4165 mL of total fl uids had Patients with a higher volume of admin- Receiver Operating Characteristic Analysis an average length of stay of 3.88Ϯ4.66 istered crystalloids, colloids, and total IV Table 4 presents the ROC analysis days vs 2.3Ϯ3.9 days for patients who fl uids were more likely to have postopera- predicting postoperative respiratory com- had Ͻ4165mL of total fl uids (PϽ.0001) tive respiratory complications. The odds plications based on the volume of admin- (Table 9).

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Effects of Fluid Administration on Postoperative Wound Infections Table 3 Thirteen postoperative wound infec- Odds Ratio Estimate tions were diagnosed prior to discharge. No statistically signifi cant difference was Variable Odds Ratio Estimate 95% CI Pa found in the amount or type of fl uid re- Crystalloid, mLb 1.300 1.132-1.493 Ͻ.001 ceived, duration of anesthesia, presence Colloid, mLb 1.877 1.223-2.880 .004 of fusion procedure, ASA score, or EBL Total fl uids, mLb 1.205 1.091-1.332 Ͻ.001 in patients who developed a postopera- EBL, mLb 0.746 0.555-1.002 .052 tive wound infection when compared with Urine, mLb 0.362 0.182-0.720 .004 those without the complication (Table 10). RBC, ccb 0.431 0.198-0.936 .033 Patients diagnosed with a postoperative b wound infection had a signifi cantly pro- Blood products in, mL 0.544 0.349-0.849 .007 b longed length of stay (13.9Ϯ9.9 days vs Fluid out, mL 0.732 0.573-0.934 .012 2.6Ϯ3.9 days; Pϭ.0001). Fluid balance, mLb 0.789 0.688-0.905 Ͻ.001 FFP, ccc 0.716 0.585-0.877 .001 DISCUSSION Platelets, ccc 1.233 0.149-10.211 .85 Intraoperative fl uid management poses Cell saver, ccc 0.890 0.787-1.007 .065 unique challenges. Although the mainte- Abbreviations: CI, confi dence interval; EBL, estimated blood loss; FFP, fresh frozen plasma; nance of normovolemia is considered de- RBC, red blood cells. a sirable, data in the literature document the Univariate logistic regression. bPer 1000 units. benefi ts of restrictive intraoperative fl uid cPer 100 units. management. Part of the dilemma is that no easy way to precisely assess intraop- erative volume status exists; although in- Table 4 vasive monitoring techniques (eg, pulmo- Receiver Operating Characteristic Analysis Predicting nary artery catheter, central venous pres- Postoperative Respiratory Failure sure, and intraoperative transesophageal echo) provide some insight, they are not Predictor Area Under ROC 95% CI routinely used in all patients undergoing Crystalloid 0.7699 0.6638-0.8760 spine procedures. Most commonly, fl uid requirements are assessed by calculation Colloid 0.7202 0.6089-0.8315 of volume defi cits from different formu- Total fl uids 0.8078 0.7148-0.9008 las and an analysis of indirect signs of Abbreviation: CI, confi dence interval; ROC, receiver operating characteristic. euvolemia (eg, urine output, respiratory variations of systemic blood pressure, and heart rate). However, none of these are Table 5 specifi c and may lead to erroneous assess- Comparison of Area Under Receiver Operating Characteristic ment of the fl uid needs causing fl uid over- or under-resuscitation. Contrast Estimate 95% CI P This study demonstrated an associa- Crystalloid–colloid 0.0497 Ϫ0.0700 to 0.1694 .42 tion between the amount of intraoperative Crystalloid–total fl uids Ϫ0.0379 Ϫ0.0805 to 0.00463 .081 fl uids administered and pulmonary com- Colloid–total fl uids Ϫ0.0876 Ϫ0.1833 to 0.00815 .073 plications. Our hypothesis was that intra- operative fl uid administration leading to Abbreviation: CI, confi dence interval. perioperative fl uid excess (ie, in excess of normohydration) may adversely affect perioperative organ functions and delay this hypothesis remains diffi cult to prove. ids was the most sensitive and specifi c recovery. Because fl uid balance is diffi - In our analysis, a cutoff point of 4165 marker for developing postoperative pul- cult to accurately assess intraoperatively, mL of intraoperatively administered fl u- monary complications. In retrospective

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Table 6 Table 7 Table 8 Sensitivity, Specifi city, and Best Sensitivity, Specifi city, and Sensitivity, Specifi city, and Best Cutoff Point for Crystalloid Best Cutoff Point for Colloid Cutoff Point for Total Fluids in Predicting Postoperative in Predicting Postoperative in Predicting Postoperative Respiratory Failure Respiratory Failure Respiratory Failure

Volume, mL Sensitivity Specifi city Volume, mL Sensitivity Specifi city Volume, mL Sensitivity Specifi city 100 1.0000 0.0000 0 1.0000 0.0000 100 1.0000 0.0000 1000 1.0000 0.0690 500a 0.8125 0.6553 1000 1.0000 0.0659 2000 0.9375 0.3388 700 0.6250 0.6600 2000 0.9375 0.3202 3000 0.8750 0.5248 800 0.5625 0.6631 3000 0.9375 0.4620 3500a 0.6875 0.7078 900 0.5625 0.6677 4000 0.8125 0.6736 4000 0.5625 0.8194 1000 0.5625 0.6724 4165a 0.8125 0.7171 4500 0.5000 0.8597 1250 0.3125 0.9094 4500 0.6875 0.7597 5000 0.4375 0.8876 1400 0.3125 0.9102 5000 0.6250 0.8163 6000 0.1875 0.9535 1500 0.3125 0.9109 6000 0.4375 0.8892 7000 0.1250 0.9729 1700 0.3125 0.9148 7000 0.3125 0.9248 8000 0.0625 0.9814 1800 0.3125 0.9179 8000 0.1875 0.9589 9000 0.0625 0.9868 2000 0.3125 0.9187 9000 0.1250 0.9729 10,400 0.0625 0.9930 3000 0.0000 0.9814 9045 0.1250 0.9752 12,100 0.0625 0.9961 4000 0.0000 0.9938 10,000 0.1250 0.9814 13,000 0.0625 0.9985 5000 0.0000 0.9992 11,054 0.0625 0.9845 16,250 0.0000 0.9985 aBest cutoff point. 12,070 0.0625 0.9899 21,500 0.0000 0.9992 13,004 0.0625 0.9930 aBest cutoff point. 14,576 0.0625 0.9969 However, in these studies, the procedures 16,190 0.0625 0.9985 were considered minor (eg, laparoscopic 23,572 0.0000 0.9985 studies, a 24-hour fl uid replacement of cholecystectomy), with minimal blood 31,744 0.0000 0.9992 Ͼ3 liters and intraoperative fl uid load of loss, ASA class I and II, and average pa- aBest cutoff point. у2000 mL were predictive factors for the tient age of 37.5 years. In another study development of postpneumonectomy pul- by Holte et al,4 in which patient age, ASA monary edema.9,10 However, other authors score, duration of surgery, and EBL were reported that postpneumonectomy pulmo- similar to those of our patients, the au- not clear why these patients received sig- nary edema was not related to the volume thors reported that restrictive (median, nifi cantly more crystalloids, colloids, and of administered fl uids.11,12 1640 mL) compared with liberal fl uid total fl uids intraoperatively than patients In our study, a subanalysis was per- administration (median, 5050 mL) led to who did not have the complication. It is formed on patients who received Ͼ4165 improvements in pulmonary function and possible that the differences were related mL of total fl uids. Patients who received postoperative reduction of hypoxaemia. to the judgment of the attending anesthe- Ͼ4165 mL of total fl uids were older; had In our study, patients with pulmonary siologist based on his or her clinical ex- a higher ASA score, greater blood loss, complications had a signifi cantly higher perience or circumstances not recorded in longer surgery, and longer length of stay; ASA score, were signifi cantly older, and our data set. Examination of intraopera- and were more likely to have a fusion were more likely to undergo a lumbar fu- tive hypotensive episodes and electrocar- procedure. This is in contrast to a study sion than those without the complication. diogram changes (eg, atrial fi brillation or by Holte et al,3 who reported improved No difference was found in the length of bradycardia) revealed no difference be- outcomes and shorter lengths of stay for surgery or EBL in patients who had pul- tween the 2 groups. patients receiving a liberal fl uid regimen monary complications when compared In nonspine procedures, excessive (40 mL/kg of lactated Ringer’s solution). with those who did not. Therefore, it is fl uid administration has been shown to re-

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sult in adverse respiratory function. In 13 patients, the development of lung edema Table 9 after various elective surgical procedures Continuous Variables in Ͼ4165 mL Versus Ͻ4165 mL Total Fluid Groups correlated with a net fl uid retention 67 mLϫkg-1ϫday-1.13 In a randomized study MeanϮSD between general and regional anesthesia Ͼ4165 mL Total Fluid Ͻ4165mL Total Fluid ϭ ϭ a in peripheral vascular surgery with mini- Variable (N 378) (N 928) P mal blood loss, patients received Ͼ6 L Age, y 58.77Ϯ15.6 55.7Ϯ25.4 .02 of crystalloid infusion within 24 hours Weight, kg 78.5Ϯ26.4 76.6Ϯ23.5 .18 postoperatively.14 Despite the low to in- EBL, mL 573.2Ϯ1110.18 92.436Ϯ111.03 .0001 termediate surgical stress, the overall pul- Preoperative HCT, mL 39.6Ϯ9.6 39.8Ϯ9.3 .73 monary morbidity was high; 10% of the ASA score 2.51Ϯ0.64 2.34Ϯ0.72 .0001 patients developed respiratory failure.14 Urine, mL 413.3Ϯ529.8 79.5Ϯ232.4 .0001 A retrospective case-control study of pa- Crystalloid, mL 4825.0Ϯ2031.6 2075.8Ϯ1032.8 .0001 tients undergoing cardiac surgical inter- Ϯ Ϯ ventions found a statistically signifi cant Colloid, mL 1230.6 867.3 147.7 360 .0001 difference in intraoperative fl uid balance Blood products in, mL 214.7Ϯ638 4.64Ϯ41.8 .0001 between patients who were successfully Fluid out, mL 1006.1Ϯ1375.9 190.5Ϯ315.8 .0001 weaned and those who required reintuba- Fluid balance, mL 5344.0Ϯ2061.3 2163.1Ϯ1068.4 .007 15 tion. In a prospective study of 87 ven- Length of stay, d 3.88Ϯ4.66 2.3Ϯ3.9 .0001 tilated medical patients, a positive fl uid Length of anesthesia, min 198.2Ϯ139.1 107.7Ϯ77.5 .0001 balance (inputsϾoutputs) at 24, 48, and Intraoperative hypotensive 0.32Ϯ0.5 0.44Ϯ1.1 .09 72 hours and cumulatively (from hospital episodes, no.b admission) was signifi cantly greater in Intraoperative ECG 62 135 .53 weaning failures than in successes.16 changes, no.c In a double-blind study, 32 ASA class Vertebral augmentation, no. 15 263 .001 I through III patients undergoing elec- Fusion, no. 119 40 .0001 tive colonic surgery were randomized to Abbreviations: ASA, American Society of Anesthesiologists; EBL, estimated blood loss; restrictive or liberal perioperative fl uid ECG, electrocardiogram; HCT, hematocrit; SD, standard deviation. administration groups. A liberal fl uid a2-sample t test. bSystolic blood pressure Ͻ90. regimen led to a transient improvement cAtrial fi brillation, bradycardia (heart rate Ͻ50), tachycardia (heart rate Ͼ130). in pulmonary function and postoperative hypoxemia but no other differences in all-over physiological recovery compared ported that the intraoperative use of re- power. Our sample was heterogeneous in with a restrictive fl uid regimen after fast- strictive fl uid management may be advan- terms of the spinal procedures performed, track colonic surgery. The authors found tageous because it reduces postoperative hence the wide variation in intraoperative that morbidity tended to be increased with morbidity and shortens hospital stay. In fl uid administration, blood loss, and blood the restrictive fl uid regimen.3 contrast, Holte et al3 showed that intraop- product administration. To our knowl- Our study demonstrated that patients erative administration of 40 mL/kg com- edge, this is the fi rst time that the effects who had longer procedures, underwent pared with 15 mL/kg lactated Ringer’s so- of intraoperative fl uid therapy on pulmo- lumbar fusion, had a higher EBL, and lution improved postoperative organ func- nary complications in patients undergo- had greater total fl uid administration had tions and recovery and shortened hospital ing spine surgery have been evaluated. a longer length of stay. It was not pos- stay after laparoscopic cholecystectomy. This investigation should be considered sible to directly correlate excessive fl uid Signifi cant limitations of our investi- as hypothesis-generating to design a pro- administration with length of stay in the gation were its retrospective nature and spective trial comparing high vs low intra- entire sample reviewed. Reports confl ict the inability to account for all possible operative fl uid regimens. as to the effects of intraoperative fl uid important factors infl uencing the rate of Many factors contribute to the develop- therapy on length of stay. In a prospective postoperative pulmonary complications. ment of postoperative pulmonary compli- study of 152 patients undergoing intra- Also, the number of pulmonary complica- cations in patients undergoing spine sur- abdominal surgery, Nisanevich et al17 re- tions was low in our cohort, limiting its gery. The best treatment is prevention. All

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colonic surgery: a randomized, double-blind Table 10 study [published online ahead of print August 6, 2007]. Br J Anaesth. 2007; 99(4):500-508. Continuous Variables in Postoperative Infection 5. Hillebrecht A, Schulz H, Meyer M, Baisch F, Versus Noninfection Groups Beck L, Blomqvist CG. Pulmonary respons- es to lower body negative pressure and fl uid loading during head-down tilt bedrest. Acta Physiol Scand Suppl. 1992; 604:35-42. MeanϮSD 6. McArdle GT, Price G, Lewis A, et al. Positive Infection Group Noninfection Group fl uid balance is associated with complica- Variable (Nϭ13) (Nϭ1293) Pa tions after elective open infrarenal abdomi- Age, y 54.9Ϯ15.7 56.6Ϯ23.3 .9 nal aortic aneurysm repair [published online ahead of print September 6, 2007]. Eur J Weight, kg 77.1Ϯ0.6 77.4Ϯ6.4 .99 Vasc Endovasc Surg. 2007; 34(5):522-527. EBL, mL 147.8Ϯ153.4 257.4Ϯ695.8 .58 7. Toraman F, Evrenkaya S, Yuce M, et al. Ϯ Ϯ Highly positive intraoperative fl uid balance Preoperative HCT, mL 34.6 2.6 39.7 0.25 .051 during cardiac surgery is associated with ad- ASA score 2.76Ϯ0.7 2.39Ϯ0.72 .057 verse outcome. Perfusion. 2004; 19(2):85-91. Crystalloid, mL 3223.0Ϯ2158.2 2864.4Ϯ1869.7 .44 8. Behrman MJ, Keim HA. Perioperative red blood cell salvage in spine surgery. A pro- Colloid, mL 365.385Ϯ600.4 461.6Ϯ743.0 .35 spective analysis. Clin Orthop Relat Res. 1992; (278):51-57. Blood products in, mL 78.46Ϯ206.6 65.13Ϯ358 .89 Ϯ Ϯ 9. Parquin F, Marchal M, Mehiri S, Hervé P, Total fl uids, mL 3666.9 2787.2 3391.3 2501.9 .36 Lescot B. Post-pneumonectomy pulmo- Fluid balance, mL 3076.2Ϯ2616.8 3248.2Ϯ2110.9 .44 nary edema: analysis and risk factors. Eur J Cardiothorac Surg. 1996; 10(11):929-932. Length of stay, d 13.9Ϯ9.9 2.6Ϯ3.9 .001 10. Patel RL, Townsend ER, Fountain SW. Length of anesthesia, min 121.7Ϯ97.9 133.9Ϯ107.5 .68 Elective pneumonectomy: factors associated Vertebral augmentation, no. 1 277 .26 with morbidity and operative mortality. Ann Thorac Surg. 1992; 54(1):84-88. Fusion, no. 2 157 .65 11. Turnage WS, Lunn JJ. Postpneumonectomy Abbreviations: ASA, American Society of Anesthesiologists; EBL, estimated blood loss; HCT, pulmonary edema. A retrospective analy- hematocrit; SD, standard deviation. sis of associated variables. Chest. 1993; a2-sample t test. 103(6):1646-1650. 12. Waller DA, Gebitekin C, Saunders NR, Walker DR. Noncardiogenic pulmonary ede- ma complicating lung resection. Ann Thorac patients undergoing spine surgery at our Ͼ4165 mL of total fl uids, other factors, Surg. 1993; 55(1):140-143. institution are evaluated preoperatively by such as increased procedure duration, 13. Arieff AI. Fatal postoperative pulmonary an anesthesiologist and, based on this as- higher ASA score, and greater EBL, made edema: pathogenesis and literature review. Chest. 1999; 115(5):1371-1377. sessment, are optimized for surgery. All it diffi cult to directly correlate increased 14. Christopherson R, Beattie C, Frank SM, et al. chronic conditions are stabilized preoper- total fl uid administration with increased Perioperative morbidity in patients random- atively, the presence and extent of cardiac length of stay. ized to epidural or general anesthesia for low- er extremity vascular surgery. Perioperative and pulmonary disease is established, and Ischemia Randomized Anesthesia Trial Study an anesthesia plan is developed. REFERENCES Group. Anesthesiology. 1993; 79(3):422- 1. Grocott MP, Mythen MG, Gan TJ. 434. CONCLUSION Perioperative fl uid management and clini- 15. Engoren M, Buderer NF, Zacharias A, Habib cal outcomes in adults. Anesth Analg. 2005; RH. Variables predicting reintubation after Our study found an association be- 100(4):1093-1106. cardiac surgical procedures. Ann Thorac tween the amount of intraoperative fl uids 2. Ware LB, Matthay MA. The acute respira- Surg. 1999; 67(3):661-665. administered and pulmonary complica- tory distress syndrome. N Engl J Med. 2000; 16. Upadya A, Tilluckdharry L, Muralidharan V, tions. In addition, patients who developed 342(18):1334-1349. Amoateng-Adjepong Y, Manthous CA. Fluid balance and weaning outcomes [published postoperative respiratory complications 3. Holte K, Klarskov B, Christensen DS, et al. Liberal versus restrictive fl uid administration online ahead of print September 29, 2005]. were older, had a higher ASA score, and to improve recovery after laparoscopic cho- Intensive Care Med. 2005; 31(12):1643-1647. were more likely to undergo lumbar fu- lecystectomy: a randomized, double-blind 17. Nisanevich V, Felsenstein I, Almogy G, sion procedures. Although length of stay study. Ann Surg. 2004; 240(5):892-899. Weissman C, Einav S, Matot I. Effect of in- traoperative fl uid management on outcome was increased in patients who received 4. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fl uid administration in fast-track after intraabdominal surgery. Anesthesiology. 2005; 103(1):25-32.

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