To the Editor:
The paper by Brandstrup et al1 is the first clinical trial to convincingly show that standard fluid replacement methods in colorectal surgery are associated with increased morbidity and mortality. Long ago, fluid and saline solutions were carefully administered during the antidiuretic perioperative phase of surgery, to maintain balance and prevent weight gain.2,3 However, these cornerstone ideas were somehow replaced in the last decades by the paradigm that surgical patients need exceptional high volume of fluids, irrespectively of measured requirements. The recommended standard fluid replacement4 seems to drive from principles of goal-directed therapy5 aimed at increasing cardiac output in high-risk surgical patients. However, the consequences of extrapolating these high requirements to major surgery were not, until now, assessed by clinical trials. Moreover, there is a surprising refusal in surgical and intensive care trainees to admit that excess perioperative fluid could be one of the underlying mechanisms of cardiopulmonary postoperative complications. Paradoxically, despite the lack of the studies supporting the benefit of the recommended high fluid replacement, actual researchers have to demonstrate that the old physiologic approach targeted toward maintenance of body weight is associated with a better outcome.
This paper also shows that the standard group received a greater fluid volume only during surgery and the first postoperative day, however, body weight was maintained higher in this group for 6 days. It must be pointed out that even the restricted group underwent an important positive fluid balance (not described in the paper) revealed by the weight gain (also maintained 5 days) respect the weight recorded the morning before surgery. Moreover, the author says nothing about the weight of neither the resected colon nor the expected 200-300g daily loss related to postoperative catabolism. These issues probably conceal the real weight gain in both groups and stress the inability of the kidneys to get rid of postoperative fluid excess. The latter findings are in close agreement with our own experience in medium complexity surgery6 and gives strong emphasizes to the growing risk of fluid overload by the end of the first postoperative week. Brandstrup's outstanding study might be the starting point to answer the basic question: what are fluid requirements during and after major surgery.
Miguel A. Jorge, MD
Hospital de Clinicas
Buenos Aires, Argentina
mialjorge@yahoo.com
REFERENCES
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