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Royal Surrey County Hospital; Guildford, United Kingdom; wjfawcett{at}ukonline.co.uk
To the Editor:
Recent articles on fluid restriction for patients undergoing noncardiac surgery (1,2) rekindle the debate as to which is better: restricting or administering fluid. Many studies from the last 15 yr have emphasized fluid administration, sometimes with the addition of inotropes, to improve outcomes (3). However for our patients undergoing major liver resection, we have demonstrated improved outcomes when we withheld fluid until the liver resection was complete, and then the fluid was administered very judiciously.
Since 1996 we have performed anesthesia for more than 300 elective liver resections. Since 2002 we have used an aggressive technique of fluid restriction. Our technique consisted of combined thoracic epidural anesthesia/general anesthesia. We withheld preoperative fluids. After induction of anesthesia with propofol, alfentanil, and cisatracurium, the trachea was intubated, and anesthesia was then maintained with nitrous oxide (67%) and isoflurane (1–1.3%) in oxygen. In addition, patients received an infusion of remifentanil. Just before starting surgery, we administered 1 mg/kg furosemide and then infused nitroglycerine to maintain central venous pressure at, or less than, 1 mm Hg. Systolic arterial blood pressure was maintained using a phenylephrine infusion. In our view, this approach improved surgical operating conditions and reduced blood loss. However, this technique appeared to reduce liver damage (as measured by postoperative aspartate aminotransferase) and coagulation dysfunction (measured by international normalized ratio). No patient had evidence of tissue hypoperfusion. Instead, we observed a trend toward reduced systemic acidosis, defined by a base excess of >–4 mmol/L. There were no deaths in patients with aggressive fluid restriction. The usual mortality from liver resection is approximately 4%–5% (4,5). Table 1 summarizes our experience, with Group 1 representing the first consecutive 132 patients from 1996 to 2002, undertaken without aggressive fluid restriction, and Group 2 representing the second consecutive 133 patients from 2002 to 2005.
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Thus we feel that major surgery can be safely undertaken with aggressive fluid restriction. This technique not only reduces blood loss, but may reduce end-organ damage patient mortality.
REFERENCES
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