Newly Published
Perioperative Medicine  |   May 2020
Goal-directed versus Standard Fluid Therapy to Decrease Ileus after Open Radical Cystectomy: A Prospective Randomized Controlled Trial
Author Notes
  • From the Department of Anesthesiology and Critical Care Medicine, Anesthesiology Service (V.A.-C., A.C.P., M.F.), the Department of Epidemiology and Biostatistics (K.S.T.), and the Department of Surgery, Urology Service (G.D., H.W.H., B.H.B., E.K.C., T.F.D., S.M.D.), Memorial Sloan Kettering Cancer Center, New York, New York; and the Departments of Urology (G.D., H.W.H., B.H.B., E.K.C., S.M.D.) and Anesthesiology (A.C.P., M.F.), Weill Cornell Medical College, New York, New York.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication July 1, 2019. Accepted for publication April 20, 2020.
    Submitted for publication July 1, 2019. Accepted for publication April 20, 2020.×
  • Correspondence: Address correspondence to Dr. Arslan-Carlon: Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C336, New York, New York 10065. arslancv@mskcc.org. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Gastrointestinal and Hepatic Systems / Renal and Urinary Systems / Electrolyte Balance
Perioperative Medicine   |   May 2020
Goal-directed versus Standard Fluid Therapy to Decrease Ileus after Open Radical Cystectomy: A Prospective Randomized Controlled Trial
Anesthesiology Newly Published on May 26, 2020. doi:https://doi.org/10.1097/ALN.0000000000003367
Anesthesiology Newly Published on May 26, 2020. doi:https://doi.org/10.1097/ALN.0000000000003367
Abstract

Background: Postoperative ileus is a common complication of intraabdominal surgeries, including radical cystectomy with reported rates as high as 32%. Perioperative fluid administration has been associated with improvement in postoperative ileus rates, but it is difficult to generalize because earlier studies lacked standardized definitions of postoperative ileus and other relevant outcomes. The hypothesis was that targeted individualized perioperative fluid management would improve postoperative ileus in patients receiving radical cystectomy.

Methods: This is a parallel-arm, double-blinded, single-center randomized trial of goal-directed fluid therapy versus standard fluid therapy for patients undergoing open radical cystectomy. The primary outcome was postoperative ileus, and the secondary outcome was complications within 30 days post-surgery. Participants were at least 21 yr old, had a maximum body mass index of 45 kg/m2 and no active atrial fibrillation. The intervention in the goal-directed therapy arm combined preoperative and postoperative stroke volume optimization and intraoperative stroke volume variation minimization to guide fluid administration, using advanced hemodynamic monitoring.

Results: Between August 2014 and April 2018, 283 radical cystectomy patients (142 goal-directed fluid therapy and 141 standard fluid therapy) were included in the analysis. Postoperative ileus occurred in 25% (36 of 142) of patients in the goal-directed fluid therapy arm and 21% (30 of 141) of patients in the standard arm (difference in proportions, 4.1%; 95% CI, −5.8 to 13.9; P = 0.418). There was no difference in incidence of high-grade complications between the two arms (20 of 142 [14%] vs. 23 of 141 [16%]; difference in proportions, −2.2%; 95% CI, −10.6 to 6.1; P = 0.602), with the exception of acute kidney injury, which was more frequent in the goal-directed fluid therapy arm (56% [80 of 142] vs. 40% [56 of 141] in the standard arm; difference in proportions, 16.6%; 95% CI, 5.1 to 28.1; P = 0.005; P = 0.170 after adjustment for multiple testing).

Conclusions: Goal-directed fluid therapy may not be an effective strategy for lowering the risk of postoperative ileus in patients undergoing open radical cystectomy.

Editor’s Perspective:

What We Already Know about This Topic:

  • Postoperative ileus is a common complication after intraabdominal surgeries

  • Previous studies have found mixed evidence for benefit in goal-directed intraoperative fluid therapy over standard fluid therapy

What This Article Tells Us That Is New:

  • In a randomized trial of goal-directed versus standard fluid therapy in patients having radical cystectomy, there was no difference in the primary outcome of postoperative ileus

  • There was no difference between fluid therapies in the secondary outcome of high-grade complications