Perioperative fluid therapy as a component of accelerated recovery after surgery (eras) in children

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Сатвалдиева, Э., Шорахмедов, Ш., Шакарова M., Ашурова, Г., & Митрюшкина, В. (2024). Perioperative fluid therapy as a component of accelerated recovery after surgery (eras) in children. in Library, 3(3), 22–31. извлечено от https://inlibrary.uz/index.php/archive/article/view/31830
Э Сатвалдиева, Ташкентский педиатрический медицинский институт
National Children's Medical Center, Tashkent, Uzbekistan.
Г Ашурова, Ташкентский педиатрический медицинский институт
National Children's Medical Center, Tashkent, Uzbekistan.
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Аннотация

Adequate fluid therapy in the perioperative period is important to improve postoperative outcomes, since normovolemia is an essential factor in hemodynamic stability and homeostasis. It's clear that the volume and composition of the administered infusion solutions thus affect the duration of the need for artificial lung ventilation (ALV), the duration of stay in the intensive care unit and intensive care. Optimization of perioperative infusion therapy helps to improve postoperative results, reduce perioperative complications and reduce hospital stays. Thus, optimal management of perioperative infusion is an important component of accelerated recovery after surgery (ERAS) pathways.

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PERIOPERATIVE FLUID THERAPY AS A COMPONENT OF

ACCELERATED RECOVERY AFTER SURGERY (ERAS) IN

CHILDREN

1

Satvaldieva E.A.,

2

Shorakhmedov Sh.Sh.,

3

Shakarova M.U.

4

Ashurova G.Z.,

5

Mitryushkina V.P.

1, 2, 3, 4, 5

Tashkent Pediatric Medical Institute

1, 2, 4

National Children's Medical Center, Tashkent, Uzbekistan.

https://doi.org/10.5281/zenodo.8349091

Abstract. Adequate fluid therapy in the perioperative period is important to improve

postoperative outcomes, since normovolemia is an essential factor in hemodynamic stability and
homeostasis. It's clear that the volume and composition of the administered infusion solutions thus
affect the duration of the need for artificial lung ventilation (ALV), the duration of stay in the
intensive care unit and intensive care. Optimization of perioperative infusion therapy helps to
improve postoperative results, reduce perioperative complications and reduce hospital stays.
Thus, optimal management of perioperative infusion is an important component of accelerated
recovery after surgery (ERAS) pathways.

Keywords: perioperative period, ERAS (Enhanced Recovery After Operations), infusion

therapy, childhood.

INTRODUCTION

Current trends in the development of anesthesiology require a change in the tactics of

managing patients in the perioperative period due to the introduction of new methods and
approaches that reduce the stress response to surgery [1]. Accelerated recovery after surgery
(ERAS) is a systematic approach aimed at the rapid comprehensive recovery of the patient's
functional state and improvement of clinical outcomes, increased patient satisfaction and reduced
financial costs.

Enhanced Recovery After Surgery (ERAS) protocols are now increasingly used in the

perioperative setting worldwide. The introduction of ERAS protocols has reduced the length of
hospital stay by 30-50%, reduced the risk of complications and significantly reduced the frequency
of readmissions [3].

The number of surgical teams studying ERAS in children is growing every year, and there

is growing evidence that this approach can improve surgical care for children worldwide. The first
ERAS World Pediatric Congress in 2018 laid the foundation for a new era of pediatric surgical
safety [4]. In today's world of pediatric surgery, ERAS is successfully used in almost all
disciplines, from congenital heart surgery to colorectal surgery. The evolution of ERAS continues
to evolve as a quality and safety paradigm.

Without a doubt, the implementation of ERAS requires a culture change based on

collaboration rather than traditional disparate approaches to treatment [4].

Optimal hydration management is an important component of the accelerated post-surgery

recovery (ERAS) pathways. Optimization of fluid management should begin in the preoperative
period and continue at all stages of the perioperative management of surgical patients [5,6].

Objective


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To study the role of perioperative fluid therapy tactics in accelerated recovery after surgery

(ERAS) protocols in children.

MATERIALS AND METHODS

Search. In the search for publications on perioperative fluid therapy in children in

improving the ways of recovery after surgery, the keywords ERAS (Enhanced Recovery After
Operations), perioperative period, fluid therapy, children's age were used. A systematic
comparative analysis of 167 publications was performed, including the results of original articles,
case reports and review publications. Of these, 38 papers that formed the basis of the review turned
out to be the most informative. Search queries were conducted in the databases of the Scientific
Electronic Library Elibrary.ru, PubMed, Cohrane, Clinicaltrials.gov, Google Scholar, Medline,
RSCI and Science Direct from 2005 to August 2023.

RESULTS AND ITS DISCUSSION

A meta-analysis of 38 studies pointed to the advantages of goal-oriented fluid therapy as

one of the components of the ERAS protocol, the tactics of which are based on the regulation of
cardiac output (CO) and stroke volume (SV) and the achievement of intraoperative fluid balance,
especially in high-risk patients [ 7.8].

When choosing a perioperative infusion regimen, it is also important to be guided by the

nature of the surgical intervention and its duration. So according to the results of the study
Ts.Tatara, Yo. Nagao, Ch. Tashiro (2009) showed that in patients (n=30) undergoing major
surgery lasting more than 5 hours, fluid overload significantly increased interstitial edema, as
capillary leakage peaked at 3–4 hours of surgical trauma. And based on this, the authors
recommended limiting the fluid regimen during long-term surgical interventions, while with small
surgical interventions lasting less than an hour, more benefit can be obtained from higher
maintenance doses of fluid [9].

Similar findings are presented in Birgitte Brandstrup et. al. (2006) according to which,

limiting the regimen of perioperative intravenous fluid administration reduces the number of
complications after elective surgical interventions [10].
Physiology of displacement volume

Adequate fluid and volume therapy before, during, and after anesthesia is important to

improve perioperative outcomes, as normovolemia is an essential factor in hemodynamic stability
and homeostasis between the intravascular fluid and the extravascular space.
In a review article, Monnet H., Teboul J. (2018) detailed all the circumstances under which a
volume bolus would result in increased perfusion and tissue function. The first step is to increase
the mean systemic filling pressure, which can be counteracted by capillary leakage and
venodilation [6].

Perioperative fluid therapy plays an important role in reducing the risk of surgical

infections. Both fluid overload and hypovolemia can impair tissue oxygenation, which adversely
affects wound healing as well as the development of surgical infections [5]. Surgical infections
lengthen hospital stays, increase the cost of treatment, and become a key indicator of the quality
of care. In addition, the systemic inflammatory response associated with tissue damage leads to
systemic capillary leak syndrome and tissue edema. One study showed that changing the fluid
regimen only on the day of surgery reduced postoperative complications by 50%. [5].



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Figure 1 Complication associated with inadequate perioperative fluid management.

Studies performed in recent years have confirmed the effect of infusion therapy on the

function of the vascular endothelium, the development and severity of capillary leak syndrome.

Modern aspects of perioperative infusion therapy.
Infusion management is an important and at the same time not a simple component of

accelerated recovery after surgery [11]. The volume and composition of the infused fluid directly
affect the state of homeostasis and hemostasis, the frequency of postoperative complications, the
duration of hospitalization, and the final result of treatment. Therefore, to this day, discussions
continue among the luminaries about what fluid should be used and at what rate it should be
administered to specific patients.

Thus, fluid therapy, as one of the components of the ERAS program, should be targeted to

ensure adequate hydration and maintain euvolemia while avoiding hyper- and hypovolemia.
In the perioperative period, one should distinguish between infusion volume load (bolus) and
maintenance (replacement) infusion therapy. The purpose of the volume load (bolus) is to quickly
stabilize hemodynamics, microcirculation and oxygen transport with a sharp decrease in preload
due to blood loss and/or vasodilation. If necessary, the volume load can be accompanied by
continuous maintenance replacement infusion, compensating for natural and pathological losses.

Preoperative period.
The main goal of preoperative fluid therapy is to correct any preoperative fluid and

electrolyte disturbances and maintain the euvolemic state as much as possible [12].

Prolonged preoperative fasting may lead to increased catabolism of gluconeogenesis,

increased insulin resistance, and potentially reduced intravascular volume. [12,13]. Oral intake of
a liquid carbohydrate drink 2 hours before surgery may reduce insulin resistance and insulin
requirements, reduce muscle catabolism by minimizing protein breakdown, improve
hemodynamic stability during surgery, and possibly promote earlier recovery of bowel function
[14,15 ,16].

In 2018, a joint statement from the Association of Pediatric Anesthesiologists of Great

Britain and Ireland, the European Society of Pediatric Anesthesiology and L'Association Des
Anesthesistes-Renamateurs Paediatriques d'Expression Francaise recognized that, in the absence


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of contraindications, children should be encouraged to drink clear liquids 1 hour before the
scheduled general anesthesia [17]. The liberalized clear liquid fasting policy is based on evidence
that water leaves the stomach within 30 minutes, and other clear liquids are nearly eliminated
within an hour. There is evidence from randomized control trials demonstrating no significant
difference in gastric volume or pH when children are fasted and given clear fluid for 1 hour versus
2 hours [18].

Given that existing ERAS programs adhere to the principle of avoiding prolonged

preoperative fasting and preloading with oral carbohydrates, children enter the operating room in
an euvolemic state. Which, in turn, avoids the introduction of an excessive amount of infusion.
Thus, in the preoperative period, patients should be encouraged to hydrate with carbohydrate-
containing clear fluids 2 hours before induction of anesthesia.

Intraoperative period
The goal of intraoperative fluid therapy is to maintain perfusion of target organs with

adequate circulating blood volume. Hypovolemia can lead to an increased risk of organ
hypoperfusion, sepsis, and multiple organ failure. Hypervolemia can be equally dangerous, leading
to peripheral and pulmonary edema, as well as an increased incidence of postoperative ileus. Thus,
maintaining euvolemia should be the goal of intraoperative fluid therapy [6].

For this, patients undergoing ERAS surgery should have an individual management plan

for infusion therapy. As part of this plan, excess crystalloids should be avoided. In low-traumatic
operations in patients with low operational and anesthetic risk, a "zero balance" approach should
be followed. Whereas for patients who have undergone major surgery, individual targeted infusion
therapy is recommended, taking into account surgical and individual-age risk factors.

After analyzing a number of works aimed at determining the optimal volumes of

perioperative infusion therapy, conflicting data were obtained [18].

Fig.2. The principle of liquid transfer through capillary membranes.

А. Classical Starling model: Jv - fluid flow through capillary membranes; K-factor of

filtration; pc – capillary hydrostatic pressure; pi – hydrostatic pressure in the interstitium outside
the capillary; ps is capillary osmotic pressure; pi – interstitial osmotic pressure;

В. The revised Starling model is depicted under physiological conditions (intact

glycocalyx, left panel) and under pathological conditions (damaged glycocalyx, right panel): ng is


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oncotic pressure in the subglycocalix space; pg is the hydrostatic pressure of a thin layer of
interstitial fluid in the subglycocalix space.

It has been proven that the endothelial glycocalyx also plays a key role in maintaining the

integrity of the endothelium. The introduction of an excess amount of fluid leads to hypervolemia
and a subsequent increase in intravascular hydrostatic pressure with the release of atrial natriuretic
peptides, which disrupt the integrity of the endothelial glycocalyx and provoke platelet
aggregation, increasing vascular permeability, resulting in tissue edema [20,21,22]. According to
the conclusion of the work of Daniel Chappella and colleagues, intravenous fluid administration
without signs of hypovolemia can damage the glycocalyx and transform from the intravascular
bed into the interstitial space (commonly called the "third space") [23].

However, in subsequent studies by Matthias Jacob and Daniel Chappell, in which

measurements were made using ultrasound techniques, they did not show convincing data on fluid
loss and it was decided to abandon the concept of compensating for losses in the “third space”
[7,24,25].

The most common manifestation of hypervolemia is edema of the intestinal wall, which

complicates the postoperative course of patients who underwent surgery for intestinal obstruction.
Even a modest positive fluid and electrolyte balance after elective colon resection has been shown
to be associated with delayed recovery of gastrointestinal function, increased morbidity, and
increased length of hospital stay. In addition, a study in rats undergoing intestinal resection and
anastomosis showed that an excess of crystalloids leads to swelling of the intestinal submucosa, a
decrease in anastomotic rupture pressure, and a decrease in the structural stability of intestinal
anastomoses in the early postoperative period [26].

The best term to describe low crystalloid regimens is zero-balance fluid therapy, with the

goal of maintaining central euvolemia while minimizing excess salt and water [27].

For many patients, minimizing excess fluid using the zero-balance method will be

sufficient for their clinical needs (see section on matching patient monitoring needs and surgical
risk). However, larger operations with more blood loss and more complex fluid transfers may
require fluid boluses to maintain euvolemia. This is often referred to in the literature as volume
therapy.

Postoperative period.
Refusal of intravenous therapy, when the patient can take fluids orally, is associated with

a shorter length of stay in patients in the hospital [28].

If oral fluid intake is not possible, provided there is no ongoing surgical loss, the same fluid

management principles used during surgery should continue, provided monitoring devices are
available [29].

A systematic review including 11 studies showed that early feeding reduces the risk of

infections of all forms [30].

In consideration of early enteral nutrition results in less bowel edema and faster passage of

flatus and stools, as well as a shorter hospital stay, early enteral nutrition is currently
recommended. In addition, patients are better able to maintain intravascular volume and maintain
fluid balance when they are given fluid control [31].

Infusion therapy in the postoperative period should be carried out only to maintain

euvolemia. In order to avoid fluid overload and ensure early mobilization, intravenous fluids are


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recommended to be discontinued on the 1st postoperative day after switching to oral
administration, provided that hourly diuresis is adequate [32].

In a study by Laura N. Purcell, et al. (2021) an increase in the amount of postoperative

intravenous fluid (1.0 ml/kg/hour) resulted in an increase in the length of stay in the hospital by
43.5 hours. According to the results of their retrospective cohort study of 139 patients under 18
years of age, a decrease in total postoperative fluid volume was associated with a decrease in length
of hospital stay with no difference in complication rates [33].

Intravenous fluid administration can be resumed only if clinically indicated [5].
In the absence of other concerns, harmful postoperative fluid overload is not warranted and

"tolerable oliguria" can be tolerated. patients undergoing surgery as part of an extended recovery
protocol should have an individual infusion management plan. As part of this plan, excess
crystalloids should be avoided in all patients.

Monitoring of perioperative fluid therapy
New technologies can help assess patient response to fluid (esophageal Doppler, non-

invasive cardiac output monitoring, pulse wave analysis, plethysmography index, peak aortic
blood flow). The goal of these technologies is to provide a metric to classify patients in whom
fluid administration will improve cardiac output and optimize tissue perfusion, and in whom
preloading therapy is unnecessary and will result in fluid overload. In mechanically ventilated
patients, dynamic preload measures, which depend on respiratory changes in stroke volume, are
better predictors of infusion response than static variables. Further research is needed in children
to determine fluid administration, evaluation, and optimal maintenance of euvolemia [13,32].

Respiratory plethysmographic waveform variations are the most commonly available fluid

management parameter, as pulse oximetry is the standard non-invasive intraoperative monitoring
method in mechanically ventilated patients [33]. The main problem in the clinical use of the
plethysmographic waveform is the significant effect of vasoconstriction (eg, hypotension,
hypothermia) on its shape. However, an increase in the plethysmographic wave may be the first
sign of the development of still latent hypovolemia and should prompt the idea of immediate fluid
administration [34].

Pulse contour analysis is a more recent innovation that is now widely used to measure

hemodynamics during surgery and, when combined with targeted fluid therapy, may result in a
reduction in postoperative complications, mirroring the results seen with more invasive cardiac
output measurements such as esophageal Doppler. [35,36].

In recent years, minimally invasive cardiac output monitoring has been shown to reduce

hospital stays [37].

With extensive surgical interventions, laboratory monitoring of the acid-base state (ACS),

control of osmolality and electrolyte composition of blood plasma is recommended; hemoglobin
concentration in relation to the hemotocrit index. In addition, dynamic monitoring of serum lactate
concentration and / or base deficiency is necessary as sensitive tests for assessing the degree of
bleeding, the need for blood transfusion, shock of any origin and multiple organ failure during
perioperative infusion therapy.

The amount of lactate produced due to anaerobic glycolysis is considered a marker of

oxygen deficiency, tissue hypoperfusion, and severity of shock [36]. Similarly, the value of base
deficiency in arterial blood gas analysis provides an indirect estimate of total tissue CBS in
impaired tissue perfusion [37].


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Another technique that is used to monitor fluid therapy in the perioperative period in

critically ill patients is transpulmonary thermodilution followed by pulse wave analysis. A number
of studies have demonstrated the effectiveness of thermodilution indicators and pulse wave
analysis, including global end-diastolic volume, extravascular lung water, pulse pressure and
stroke volume variations, for the purpose of perioperative monitoring, hemodynamic optimization
and targeted therapy [38].

CONCLUSION

ERAS protocols are associated with improved outcomes. Targeted fluid therapy is a key

element of ERAS protocols, which can only be achieved with good monitoring. Management of
the infusion system within the ERAS protocols should be considered as a continuous process in
the preoperative, intraoperative and postoperative periods. Fluid therapy is the cornerstone of
perioperative medicine, but being clear about when not to inject fluids is just as important as when
to inject.

The goals of the ERAS pathways are to reduce postoperative complications and facilitate

earlier recovery after major surgery. Optimal perioperative management of the infusion system,
an important component of this approach, is often underestimated.

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Scand. 2014 Nov 13;56(1):72. DOI: 10.1186/s13028-014-0072-0. PMID: 25391249

37.

Thiele RH, Raghunathan K, Brudney CS, et al. American Society for Enhanced Recovery
(ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on
perioperative fluid management within an enhanced recovery pathway for colorectal
surgery. Perioperative Medicine (Lond) 2016; 5:24 DOI: 10.1186/s13741-016-0049-9

38.

Dmytriiev D., Nazarchuk O., Melnychenko M., Levchenko V. Optimization of the target
strategy of perioperative infusion therapy based on monitoring data of central hemodynamics


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SCIENCE AND INNOVATION

INTERNATIONAL SCIENTIFIC JOURNAL VOLUME 2 ISSUE 9 SEPTEMBER 2023

UIF-2022: 8.2 | ISSN: 2181-3337 | SCIENTISTS.UZ

31

in

order

to

prevent

complications.

Frontiers

in

Medicine

2022:9:935331.

doi:10.3389/fmed.2022.935331

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Thiele RH, Raghunathan K, Brudney CS, et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioperative Medicine (Lond) 2016; 5:24 DOI: 10.1186/s13741-016-0049-9

Dmytriiev D., Nazarchuk O., Melnychenko M., Levchenko V. Optimization of the target strategy of perioperative infusion therapy based on monitoring data of central hemodynamics in order to prevent complications. Frontiers in Medicine 2022:9:935331. doi:10.3389/fmed.2022.935331

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