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Enhanced Recovery After Colorectal Surgery: Does Restrictive Fluid Management Result in Increased Acute Kidney Injury?
Michael Kwa, Stefan D. Holubar*
Colon & Rectal Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
Purpose: Enhanced recovery after surgery (ERAS) lowers complications and shortens lengths of stay (LOS) compared with standard recovery. A key management strategy of ERAS protocols, especially if goal-directed fluid management is not available, is restrictive fluid management. However, it is unknown whether this is a safe strategy. Thus we aimed to evaluate whether restrictive fluid management was associated with increased acute kidney injury.
Methods: We performed a retrospective review of consecutive patients undergoing abdominal surgery by a single ERAS-trained colorectal surgeon at an academic medical center from 1/11/2012 - 8/15/2013. Demographics, operative data, and short-term (30-day) outcomes are presented. Univariate analysis assessed between group differences to test the hypothesis that ERAS patients managed with restrictive fluids did not have an increased rate of post-operative acute kidney injury. Results are reported as median (interquartile range) or frequency (proportion).
Results: One hundred twenty-eight patients were included: 82 (64%) ERAS and 46 (36%) STD recovery. Patient in the two groups were of similar age (52.4 vs. 54.8 years old, p=0.74), and BMI (26.8 vs. 27.4 kg/m2, p=0.98). Similar proportions underwent protectomy (22% vs. 28%, p=0.52), but more ERAS patients underwent minimally invasive surgery (61% vs. 41%, p=0.04), primary anastomosis (61% vs. 43%, p=0.04), and fewer had an ostomy (40% vs. 63%, p=0.02). Perioperative fluids (in cc/kg/hour) and creatinine levels are shown in Table 1. There was a trend towards ERAS patients receiving significantly less intra-operative fluids (p=0.07), and ERAS patients made significantly less urine intra-operatively (p=0.04). Post-operatively ERAS patients received significantly less IV fluids on POD#1 and POD#2 (p<0.0001), but had similar urine output on POD#1 and a trend toward reduced UOP on POD#2 (p=0.06). A total of 11 patients (8.6%) had a peak post-op creatinine ≥1.5; of these 8 (73%) recovered to <1.5 except three patients (2 ERAS- 1 malignant ureteral obstruction, 1 chronic renal insufficiency; 1 STD - contrast induced nephropathy). No patients in the series required dialysis. ERAS patients, compared with STD patients, had earlier bowel function (POD 1.7 vs. 2.3, p=0.02), and shorter LOS 4 (3-6) vs. 6 (4-7) days, p=0.0002, and a similar readmission rate (8.5% vs. 10.9%, p=0.75), and need for return to the operating room (9.8% vs. 6.5%, p=0.75)
Conclusions: Restrictive perioperative management after colorectal surgery is safe and does not result in a clinically or statistically increased rate of post-operative acute kidney injury.
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