Goal directed fluid therapy in major hepatic resection surgeries, a prospective randomized study - Trial PACTR202012816670352

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Summary

Major liver resection is a complex procedure with a high incidence of perioperative complications, even in high volume centres. Optimization of perfusion and oxygen delivery to the residual liver and other organs, whilst avoiding hyper and hypovolemia, remain the cornerstones of best hemodynamic care and is associated with reduced intraoperative bleeding, perioperative complications and hospital length of stay. Traditionally, fluid intervention for major hepatic resection includes fluid restriction and low central venous pressure during the dissection and transection phases to reduce venous bleeding, with restoration of euvolemia post transection with judicious fluid intervention. However, restrictive fluid regimen was not associated with a higher rate of dis- ability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury1–3.In the context of fluid management, the importance of the prediction of fluid responsiveness (FR) relies on the fact that the fluid loading in such condition may be hazardous and dangerous for the patient, e.g., by causing or worsening pulmonary edema. Moreover, the fluid management of cirrhotic patients undergoing orthotopic liver transplantation (OLT) may be challenging and still remains controversial. The expected response to fluid infusion is an increase of cardiac output (CO) or stroke volume (SV), and this response depends mostly on the position of an individual patient on the cardiac function curve, i.e., the Frank-Starling curve4–6.Many indices have been proposed to predict FR, which are considered related to the Frank-Starling curve and a sort of an estimation of curve slope, i.e., the so-called dynamic indices (pulse pressure variation (PPV), stroke volume variation (SVV), and systolic pressure variation (SPV). However, these studies mainly concern ICU settings, septic, or postoperative patients7–9.In this study, we will compare the intraoperative goal directed fluid therapy in hepatic surgery, directed by systolic pressure variability, versus traditional low CVP approach. The primary objective will be the impact of GDT on patient outcome presented as length of hospital stay. Secondary variables will be the intraoperative fluid infusion, the need for vasopressors, perioperative end-organ function (kidney, liver, and brain), intraoperative tissue perfusion, perioperative electrolyte disturbances.

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