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; ANNSURG-D-17-01249; Total nos of Pages: 1;
ANNSURG-D-17-01249
Effects of Intraoperative
Fluid Management on
Postoperative Outcome:
What Is Our Limit in Fluid
Therapy?
To the Editor:
P rimarily, Shin et al1 evaluated the effect
of the volume used intraoperatively on
postoperative 30-day mortality and secondly,
they have assessed the pulmonary complica-
tions (pulmonary edema, reintubation, pneu-
monia, and respiratory insufficiency)
developed during the first postoperative 3
days. This is a very extensive patient series
and the statistics are quite treasured. Even
today, in patients undergoing surgery, the
doses of intravenous fluid administration
(liberal or restrictive) are still debatable.2,3
Therefore, this study carries and great
importance.
However, we believe that reporting
more details—mainly in the material method
section—can dissolve the questions the readers
may have and will be beneficial for the study.
First, in the study where data were col-
lected retrospectively, the type of the surgeries
the patients underwent is not given. The fluid
requirements differ vastly between a major
abdominal surgery (even the fluid need is dif-
ferent in patients undergoing lower or upper
abdominal surgery) and an ear–nose–throat
surgery. In addition, the definition of liberal
or restrictive fluid therapy and volumes given to
the patients cannot be understood clearly.
Disclosure: The authors declare no conflicts of interest
and no funding associated with this manuscript.
Copyright ß 2017 Wolters Kluwer Health, Inc. All
rights reserved.
ISSN: 0003-4932/16/XXXX-0001
DOI: 10.1097/SLA.0000000000002490
Annals of Surgery  Volume XX, Number XX, Month 2017
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTER TO THE EDITOR
Secondly, different patients were
administered with different types of colloids.
All these different colloids also have dissim-
ilar durations of staying in the circulation and
potentials to absorb fluid into the vein. As
this variance will change the fluid require-
ments it might complicate comparing the
groups where liberal or restrictive fluid ther-
apy was applied. It is also seen that different
crystalloid/colloid ratios are used in the
groups. Can these dissimilarities affect the
results of the study?
Thirdly, it is not very clear what type
of vasopressors and in what doses were used.
Hence, we have no knowledge of how the
hemodynamic stability was achieved and
what their heart failure symptoms were.
Lastly, what treatments were used in
the patients with pulmonary complications
such as postoperative respiratory failure,
pneumonia, and pulmonary edema? Was
noninvasive mechanical ventilation applied
as a prophylactic method in patients whom
liberal fluid therapy was used? What was the
first choice of treatment in patients who
suffered from pulmonary edema? What
was the reintubation time in the group of
patients who were reintubated and what
was the diagnosis for the reintubation? In
how many patients you encountered acute
renal insufficiency where hemofiltration
was needed? In these patients, during their
clinical deterioration, how were the changes
in the gas exchange and metabolic status
values in the arterial blood gas samples?
To conclude, what can we deduce
about the cut-off values of the fluid therapy
that causes all these complications? All these
explanations will enhance our understanding
of the article.
Guniz M. Koksal, MD
Department of Anesthesiology and Reani-
mation Istanbul University, Cerrahpasa
Medical Faculty, Istanbul, Turkey
Emre Erbabacan, MD
Department of Anesthesiology and Reani-
mation Istanbul University, Cerrahpasa
Medical Faculty, Istanbul, Turkey
Antonio M. Esquinas, MD, PhD, FCCP
Intensive Care Unit, Hospital Morales
Meseguer, Murcia, Spain.
Department of Anesthesiology and Reani-
mation Istanbul University, Cerrahpasa
Medical Faculty, Istanbul, Turkey
gunizkoksal@hotmail.com
REFERENCES
1. Shin CH, Long DR, McLean D, et al. Effects of
intraoperative fluid management on postoperative
outcomes: a hospital registry study. Ann Surg.
2017. doi: 10.1097/SLA.0000000000002220.
2. Pang Qianyun, Liu Hongliang, Chen Bo, et al.
Restrictive and liberal fluid administration in major
abdominal surgery. Saudi Med J. 2017;38:123–131.
3. Myles P, Bellomo R, Corcoran T, et al., Australian
and New Zealand College of Anaesthetists Clinical
Trials Network, and the Australian and New Zea-
land Intensive Care Society Clinical Trials Group.
Restrictive versus liberal fluid therapy in major
abdominal surgery (RELIEF): rationale and design
for a multicentre randomised trial. BMJ Open.
2017;7:e015358.
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