A master stroke or recipe for heartache?

Published Date: 19th July 2016

Publication Authors: Hughes E, Yoxall PF, Waits R

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Background

Intra-operative fluid management technologies (FMT) have been identified as a high impact intervention by the Department of Health. This is due to savings from reduced complication rates, improved utilisation of critical care resources and reduced length of stay for patients undergoing major procedures when FMT are used. The trust has had historically low levels of FMT usage. With the potential for improved patient outcomes and a financial benefit to the Trust, an audit of the uptake of FMT was conducted.

Methods 

Patients undergoing major surgical procedures where FMT are recognised to be of benefit were identified prospectively. The patients were classified by procedure type and as Monitored (n = 23) or Unmonitored (n = 39) dependent on the use of FMT. The patients were followed up to discharge. Demographic, anaesthetic, procedural, biochemical and postoperative data were collected. Statistical analysis was performed with Microsoft Excel using Paired and Unpaired t-test where appropriate. 

Results 

FMT were used in 37% of recommended cases. There were no significant baseline differences between the Monitored and Unmonitored groups (p values >0.05). Comparing the two groups there were no significant differences in the types or volumes of fluid administered to the groups in any surgical specialty (p = 0.39). Furthermore there were no differences in the biochemistry, length of stay (p = 0.48), time to mobile (p = 0.44) or time to bowels open (p = 0.36) between the groups. Chart 1 shows the postoperative outcomes for Monitored and Unmonitored patients. (table present). 

Discussion 

The results show that FMT are underutilised and are mainly used by dual anaesthesia and critical care consultants. Reasons for low uptake included dislike of an algorithm for fluid administration, availability of monitors, technical problems with monitor setup and a perceived negligible improvement in patient outcome. Comparing the Monitored and Unmonitored groups, the results show no significant improvement in any of the measured outcomes when FMT are used. This is in contrast to the established evidence. Due to enhanced recovery, the standard of care that FMT were developed against (i.e. use of central venous pressure to monitor fluid status) is no longer commonly used. This results in a lower pressure to admit patients to intensive care and fewer barriers to mobility and discharge. For this reason the benefits and cost savings of FMT do not materialise in our Trust. Other proposed reasons include failure of practitioners to utilise the fluid administration algorithm and how different surgeons manage their patients xpostoperatively.

Hughes, E; Smith, K; Yoxall, P; Waits, R. (2015). A master stroke or recipe for heartache? An audit of the uptake and effects of intra-operative fluid management technologies for major surgery in a large district general hospital . Anaesthesia. 70 (Suppl 4), 70

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