Background
Outcomes such as complication rates, readmissions, and length of stay may be highly variable across different centers conducting colorectal surgery (Cohen et al.
2009). Enhanced recovery pathways (ERPs), initially led in Europe (by the surgeon Henrik Kehlet), were developed in the 1990s in an effort to reduce such variability (Kehlet
1997). ERPs generally share certain core features but also have subtle differences across and even within sites (reflecting unique institutional needs, capabilities, and resource availability). Most ERPs focus on setting patient expectations and involving the patient in their own care pathway for fast recovery, avoiding prolonged preoperative restriction of fluid intake, avoidance of empirical intravenous fluid loading, minimization of systemic opioid use, and early postoperative ambulation. In several studies examining effects of ERP implementation (versus data prior to implementation), an average reduction in length of stay of 3 days appeared to result in over 3000 subjects across several institutions and in a variety of surgical procedures (Thiele et al.
2015a). Meta-analyses on ERPs in colorectal surgical procedures found similar reductions in length of stay (~2.5 days) without an increase in readmission rates (Zhuang et al.
2013; Varadhan et al.
2010).
Retrospective and prospective studies of ERPs in colorectal surgery have typically examined “bundled” interventions making it difficult to estimate the relative value of specific elements related to perioperative fluid management. Outside the context of an ERP, investigators have defined outcomes following “liberal” and “restrictive” fluid strategies during colorectal surgery. However, there is no shared definition of what amount constitutes either (Chappell et al.
2008). Calculations of intraoperative fluid deficits during colorectal surgery have, prior to ERP, included so-called “third space” losses and perioperative fluid therapy was guided by static indicators of volume status. A recent comprehensive review summarized this as follows: “Research suffers from a lack of standardization…Investigators have normally named their traditional regimen the standard group and compared it with their own restrictive ideas… A restrictive regimen in one study is often designated as liberal in another setup…This shortcoming prevents even promising results from impacting daily clinical routine and makes any pooling of the data impossible
.” (Chappell et al.
2008) Thus, several specific questions, related to fluid therapy, remain. The “fluids” subgroup within the first Perioperative Quality Initiative (POQI) sought to define and answer important questions related to perioperative fluid management in patients undergoing colorectal surgery within the context of an ERP.
Group B – fluids
• Robert H. Thiele, Departments of Anesthesiology and Biomedical Engineering, University of Virginia School of Medicine, VA, USA (chair).
• Karthik Raghunathan, Department of Anesthesiology, Duke University Medical Center, USA (co-chair).
• CS Brudney, Department of Anesthesiology, Duke University Medical Center, USA.
• Dileep N Lobo, Division of Gastrointestinal Surgery, Nottingham University Hospitals and University of Nottingham, Nottingham, UK.
• Dr. Daniel Martin, Royal free Perioperative Research Group, Royal Free Hospital, London, UK.
• Anthony Senagore, Department of Surgery, University of Texas-Medical Branch at Galveston, Galveston, TX, USA.
• Maxime Cannesson, Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, CA, USA