Correspondence  |   December 2019
IV Fluids for Major Surgery: Reply
Author Notes
  • Alfred Hospital and Monash University, Melbourne, Australia (P.S.M.). p.myles@alfred.org.au
  • (Accepted for publication September 3, 2019.)
    (Accepted for publication September 3, 2019.)×
Article Information
Correspondence
Correspondence   |   December 2019
IV Fluids for Major Surgery: Reply
Anesthesiology 12 2019, Vol.131, 1368-1369. doi:https://doi.org/10.1097/ALN.0000000000003003
Anesthesiology 12 2019, Vol.131, 1368-1369. doi:https://doi.org/10.1097/ALN.0000000000003003
Drs. Bahlmann and Hahn mention the existence of some published studies supporting a restrictive approach to perioperative IV fluid therapy, but do not mention others (aside from the RELIEF [Restrictive Versus Liberal Fluid Therapy in Major Abdominal Surgery] trial1 ) that identified possible harms or at least no measurable benefit.2–4  The RELIEF trial clearly identified an increased risk of acute kidney injury when a more restrictive zero-balance approach was used.
We agree with Drs. Bahlmann and Hahn that any unnecessary preoperative fasting should be avoided, and that clinicians should encourage unrestricted intake of fluids until 2 h before elective surgery as a standard of care. This was one of our recommendations.5  Although unnecessarily lengthy preoperative fasting times will create a state of relative dehydration, it is quite usual for most people to not drink between the late evening hours and morning (8 to 10 h period of fasting), so this duration is very unlikely to induce dehydration. More importantly, the RELIEF trial investigators analyzed and reported their results for acute kidney injury according to fasting times and the adverse effect of the restrictive zero-balance approach remained. That is, the risk of acute kidney injury occurred in those with short, intermediate, and longer fasting times (P value for interaction equals 0.47; see fig. S8 in the supplementary material of Myles et al.1 ). A similarly consistent finding was observed in those who did or did not receive bowel preparation (P value for interaction equals 0.55).