REVOLUTION: Restrictive- vs Individualized Goal Directed Fluid Therapy in Liver Surgery
Study Details
Study Description
Brief Summary
"Low central venous pressure (low-CVP) or a restrictive fluid administration strategy is usually used worldwide during major liver resection surgery. Although individualized goal directed fluid therapy (GDFT) has been associated with reduced morbidity and mortality in major abdominal surgery, concerns remain on blood loss when applying GDFT in liver surgery. Indeed, GDFT could lead to a higher CVP with the risk of increased blood loss and reduced quality of the surgical field especially during liver dissection.
Since evidence is scarce, this randomized controlled trial investigates the impact of a restrictive vs an individualized GDFT strategy assisted by an assisted fluid management (AFM) system on lactate level, blood loss, and postoperative morbidity including acute kidney injury (AKI) in major liver resections."
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
N/A |
Detailed Description
Major liver resection surgery is a frequent but complex surgery with high morbidity, even in high activity centers. The morbidity is mainly related to the size of the liver resection and to bleeding, responsible for postoperative hepatocellular failure.
Intraoperative fluid administration is a major component of the anesthetic strategy to optimize the hemodynamic status and peripheral tissue perfusion of the patient. However, high-level evidence recommendations are still lacking regarding the optimal fluid strategy in patients undergoing major liver resection.
On the one hand, it has been accepted for decades that anesthetic management should focus on minimizing intraoperative bleeding by limiting fluid administration. The objective of a restrictive fluid strategy has often been to maintain a low central venous pressure (CVP), allowing to decrease the venous pressure at the level of the suprahepatic veins and the hepatic section. The lower this pressure, the more limited the bleeding by backflow. This strategy is supported by surgeons because it allows them to maintain a relatively bloodless operating field (by reducing bleeding) and thus facilitates their dissection/surgical work. Under these conditions, however, an infusion of vasopressors is often necessary to maintain adequate perfusion pressure to all organs. In addition, a liberal fluid administration is often required after liver transection to compensate for blood loss and delayed vascular filling accumulated during most of the surgical procedure. This strategy therefore potentially exposes the patient to the deleterious effects of hypovolemia as reflected by an increase in blood lactate levels. Lactate is considered an indirect marker of the degree of tissue hypoperfusion.
On the other hand, in high-risk abdominal surgery, the anesthesia community recommends a more individualized fluid strategy, based on the optimization of stroke volume also called goal directed fluid therapy (GDFT) with the aim of decreasing postoperative complications. It is now even possible to apply this strategy using a real time clinical decision support system (assisted fluid management or AFM). However, the concept of GDFT assisted by AFM (GDFT-AFM) could possibly be accompanied by an increase in CVP and therefore intraoperative bleeding. However, to date, no randomized study has compared these 2 fluid therapy strategies (restrictive vs GDFT-AFM) on lactate level as the primary outcome "
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Active Comparator: restrictive fluid therapy group Patients in this group will have a restrictive fluid therapy (1 ml/kh/h) from anesthesia induction until end of liver resection. |
Procedure: Restrictive fluid therapy strategy
from anesthesia induction until end of the liver resection, patient will have a restrictive fluid therapy strategy
|
| Experimental: individualized GDFT group In this group, from anesthesia induction until skin closure, fluid will be given to the patients based on the recommendation of the AFM software in order to optimize patient's stroke volume (SV) |
Procedure: individualized GDFT
In this group, from anesthesia induction until skin closure, fluid will be given to the patients based on the recommandation of the AFM software in order to optimize patient's SV
|
Outcome Measures
Primary Outcome Measures
- Lactate level at the end of the surgery [Up to the end of surgenry (intraoperatively)]
lactate level measured at the end of the surgery (skin closure)
Secondary Outcome Measures
- Total intraoperative blood loss [Up to the end of surgenry (intraoperatively)]
We will measure blood loss at the end of the surgery
- Total amount of vasopressors used during surgery [Up to the end of surgenry (intraoperatively)]
We will report the total amount of vasopressor used during surgery
- Total amount of fluid used during surgery [end of the surgery]
We will report the total amount of fluid used during surgery
- Incidence of acute kidney injury (AKI) [postoperative day 7]
We will report the incidence of AKI at postoperative day 7 using the KDIGO classification
- Incidence of postoperative complications [postoperative day 30]
We will report the incidence of postoperative complications using the clavien dindo classification
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Adult patient
-
Major liver surgery
Exclusion Criteria:
-arrythmia -Linguistic barrier -Pregnant women
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | PAUL BROUSSE, centre hepato -biliaire | Villejuif | VAL DE Marne | France | 94800 |
Sponsors and Collaborators
- Assistance Publique - Hôpitaux de Paris
Investigators
- Principal Investigator: ALEXANDRE JOOSTEN, MD PhD, APHP
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- APHP 220682