How are fluid volume and core temperature maintained in enhanced recovery after surgery (ERAS) programs for emergency GI surgical procedures?

Updated: Jan 20, 2021
  • Author: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed); Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Answer

As noted, surgical trauma leads to the release of various inflammatory mediators and catabolic hormones that enhance the retention of fluid and sodium in order to maintain intravascular volume, sustain blood pressure, induce vasoconstriction, and deliver substrates for body metabolism. Body temperature falls in order to reduce oxygen utilization and shunting of blood to vital organs. Hence, maintaining the core body temperature throughout the procedure is crucial. [11]

The release of various inflammatory mediators and the suppression of mitochondrial activity due to surgical trauma leads to altered gut permeability and initiates a hypercoagulable state. [11] The human body has not evolved the capacity to adapt rapidly to such changes. [22, 23]

A hypervolemic state is one of the primary factors leading to prolonged ileus. Maintaining a zero balance intraoperatively is a key component of intraoperative GDFT. [24, 25] Maintenance of a zero balance in an emergency setting is challenging, especially when fasting, hemorrhage, volume losses, and poor oral intake must also be taken into account.

A number of invasive, minimally invasive, and noninvasive techniques are available for monitoring volume status. Euvolemia is maintained by monitoring the pulse rate, arterial blood pressure, urine output, central venous pressure (CVP), end-tidal CO2, stroke volume, and cardiac output. [24, 26] Although urine output has been used as a marker for volume status, it is limited in this regard by its dependence on other factors (eg, prerenal causes of volume depletion and postrenal outflow tract obstruction). [27, 28] However, some studies have reported urine output to be a sensitive marker for volume status. [27]

Commonly used techniques for assessing volume status include the following:

  • Transesophageal echocardiography (TEE), which can measure stroke volume, cardiac output, and CVP [29]
  • Pulmonary artery catheterization, which can measure CVP, mixed venous oxygen saturation (SvO 2), left ventricular end-diastolic pressure and volume, stroke volume, cardiac output, cardiac index, and SVR [29]
  • Arterial waveform analysis–based techniques
  • Esophageal Doppler- and bioimpedance-based technologies [24]

Individualized fluid therapy is warranted for achieving euvolemia prior to surgery. GDFT consists of a continuum of preoperative, intraoperative, and postoperative fluid therapy. Some authors also suggest a zero-balance approach in low-risk surgical procedures. Although there is no established consensus on the parameters and endpoints of GDFT, the following values have been advocated [30] :

  • CVP 8-12 cm H 2O
  • Mean arterial pressure (MAP) 65-90 mm Hg
  • SvO 2 >70%
  • Central venous oxygen saturation (ScvO 2) >65%
  • Urine output >0.5 mL/kg/hr
  • Hematocrit >30%

Many studies have reported better outcomes with GDFT in patients undergoing emergency surgery, as have studies from our center, in which the authors monitored the volume status by measuring CVP by means of an internal jugular vein catheter. [1, 2] There are other studies which have shown no significant outcomes between the GDFT and control group in patients undergoing laparoscopic colorectal surgeries. [31]


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