Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Overly negative?
- Dilip J DaCruz (30 June 2009)
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Dangerously misinforming
- R Jonathan T Wilson (3 July 2009)
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British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients
- Jeremy Powell-Tuck, Peter Gosling, Dileep N. Lobo, Simon P. Allison, Gordon L. Carlson, Marcus Gore, Andrew J. Lewington, Rupert M. Pearse and Monty G. Mythen. (13 July 2009)
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Intravenous fluids in adults surgical patients - A fluid concept?
- Ashok Inderraj Handa, Regent Lee, Vascular Trainee Nuffield Department of Surgery, Oxford (14 July 2009)
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Dilip J DaCruz, Consultant in Emergency Medicine Dubai UAE
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If everything one did was evidence-based, one would have little to do. So let's be grateful that these people have taken it upon themslves to produce this work. Of course, the recommendations are imperfect but those that perceive such imperfection do so through their own biases and opinions. As an Emergency Physician I could, for instance, rant about the fact that shock- ultrasound is overlooked. I also find the administeration of 200ml boluses in a shocked adult overly cautious, especially when a CVP line is in place. But I rise above such negativity when I encounter boldness and effort. These guidelines are a great start and a laudable attempt to wrap-up the current state of play. It is from work like this that trainees will identify areas for further focused research. And that's where the revised guidleines will come from. Competing interests: None declared |
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R Jonathan T Wilson, Consultant Anaesthetist York Hospital, York YO31 8HE
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The editorial comment on the BAPEN guidelines for intravenous fluids in adults undergoing surgery by Liu and Finfer has the potential to harm patients. Firstly, the authors make the common mistake of quoting the papers by Hayes and Gattinoni to argue the case against protocols that use fluids and inotropes to elevate oxygen delivery in surgical patients. These papers, however, studied critically ill patients, in whom the inflammatory process and mutli-organ failure sequence was already firmly established, and have little relevance to the general high-risk surgical population. Secondly, and more importantly, the authors' advice that clinicians would be better off making clinical decisions on the basis of primary data - whatever that is - could definitely lead to harm. Our study of pre-operative optimisation of oxygen delivery in high-risk surgical patients was essentially a comparison of fluid therapy determined by clinical judgement with fluid therapy titrated to specific haemodynamic goals[1]. The mortality rate in the clinical judgement group - the approach advocated by Liu and Finfer - was 17%, compared to 3% in the goal-directed therapy groups. To ignore the evidence from the appropriate trials, to then argue against recommendations from guidelines on the strength of inappropriate trials, and then finally to recommend treatment by clinical judgement alone are misleading and harmful strategies. I accept the need for further research, and am active in that area, but in the meantime, as a practising clinician, I will not throw away the recent advances in intravenous fluid therapy and peri-operative care to satisfy the requirements of the evidence-based medicine purists. 1. Wilson J, Woods I, Fawcett J et al. Reducing the risks of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 1999; 318:1099-1103. Competing interests: I have received an honorarium from Fresenius Kabi for lecturing on goal-directed fluid therapy. |
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Jeremy Powell-Tuck, Emeritus Professor of Clinical Nutrition Barts and The London, Queen Mary's School of Medicine and Dentistry, London W11 3NF, Peter Gosling, Dileep N. Lobo, Simon P. Allison, Gordon L. Carlson, Marcus Gore, Andrew J. Lewington, Rupert M. Pearse and Monty G. Mythen.
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Liu and Finfer entitle their criticism1 of the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients2 “Intravenous fluids in adults undergoing surgery: high quality research is needed before guidelines can be reliable and useful” and go on to suggest that “perhaps guidelines should be avoided completely, and clinicians would be better off making clinical decisions on the basis of primary data”. They deride the guidelines as “an eclectic mixture of topics, which seem to reflect the spheres of interest of the six specialist societies that came together to try to establish consensus for good perioperative fluid prescribing.” and go on to say that the covering of preoperative, intraoperative and postoperative management and the inclusion of topics such as mechanical bowel preparation, nutrition, and fluid management in acute kidney injury adds complexity rather than clarity”. While we trust Liu and Finfer appreciate that perioperative fluid therapy in the real world is complex and multidisciplinary (hence the involvement of six specialist societies), we feel that their review largely missed the point of the guidelines, which was to provide a synthesis of the available evidence that would support safe practice in an “orphan” area of clinical care, notorious for being poorly practiced and badly taught3, 4. Liu and Finfer accuse us of shying away from “a systematic evidence based approach because high quality evidence is lack¬ing”. We were of course, necessarily constrained by the evidence that exists and developed our guidelines according to internationally recognized criteria. A glance at our reference list might have reassured them that we considered and included the results of many systematic reviews, including those related to preoperative fasting, mechanical bowel preparation, oesophageal doppler monitoring, choice of fluid (crystalloids versus colloids), enhanced recovery programmes, as well as NICE guidance on surgical and nutritional management, which are themselves based on multiple, often new, meta- analyses. In this context it is surprising that they single out for criticism the recommendation on the use of dopexamine which was supported by both meta-analysis and systematic review5. The references they quote against this recommendation did not test dopexamine. Systematic reviews and meta-analyses have a vital role in the assessment of evidence, but by their nature must be focused on specific, usually robustly defined questions. They, therefore, represent an examination of selected aspects of treatment. Consensus guidelines such as ours on the other hand have a broader remit and serve an entirely different purpose. They try to synthesise the jigsaw of evidence into a coherent view of overall clinical policy. Liu and Fifner wrongly assume that the myriad of clinically relevant issues that make up safe and effective perioperative fluid therapy can be reduced to a series of limited questions for which a clinical evidence base might be found. What realistic question could possibly be asked which would enable a systematic review of all the different components which contribute to outcome over the whole of perioperative fluid management covered in our consensus document? Patients have to be treated now, not at some hypothetical time when every aspect of their care has been subjected to perfect double blind randomized clinical trials or systematic reviews. Indeed, many aspects of overall care can never be subjected to practical or ethical controlled trials. Clinicians have ultimately to weigh the evidence that exists, construct a logical approach, and teach their juniors coherently and as best they can. To expect every clinician to be aware of the primary sources to which Liu and Finfer so academically prefer to return, every time they see a patient is patently absurd. To expect them to weigh these references according to an internationally recognised system for evidence scoring, and then discuss the detail of each of these papers with expert colleagues from five other disciplines is equally unrealistic. The value of the guidelines, which have since been endorsed and adopted by The Royal College of Anaesthetists is that we have done precisely that for them. Liu and Finfer evidently disapprove of eclecticism which means deriving ideas, style, or taste from a broad and diverse range of sources. We do not. The fluid status of surgical patients is affected by individual factors such as bowel preparation, anaesthetic technique, postoperative analgesia and nutrition as well as the choice and quantity of intravenous infusions. A complete and effective clinical view therefore requires a patient-centred approach which is thus necessarily eclectic. We fully accept that no set of guidelines are perfect and it is entirely appropriate that they should be scrutinised and critically discussed. We are also aware that many clinicians will eschew guidelines as a matter of principle, while others may reject the Oxford system for weighing evidence. There will clearly be dissent over individual recommendations. We think, however, that it is unusual in medicine to be able to secure consensus on behalf of no less than six national societies. By producing them we have forced ourselves to consider where we stand practically and clinically rather than in the isolated compartments of the problem. We think this is a discipline others too should be bold enough to consider. The guidelines will be revised in due course as new evidence emerges, and will no doubt improve with the quality of the clinical evidence that informs them. Liu and Finfer’s comments should be interpreted with caution lest the baby gets thrown out with the bathwater and we end up unable to move forward in an area of poor clinical practice. Jeremy Powell-Tuck, Peter Gosling, Dileep N Lobo, Simon P Allison, Gordon L Carlson, Marcus Gore, Andrew J Lewington, Rupert M Pearse, Monty G Mythen References 1. Liu B, Finfer S. Intravenous fluids in adults undergoing surgery. BMJ 2009;338: b2418. 2. Powell-Tuck J, Gosling P, Lobo DN, Allison SP, Carlson GL, Gore M, et al. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients - GIFTASUP. 2008. Available from: http://www.ics.ac.uk/downloads/2008112340_GIFTASUP%20FINAL_31-10-08.pdf (Accessed 12 July 2009). 3. Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr 2001;20: 125-130. 4. Herrod P. The importance of fluid and electrolyte management--a medical student's perspective. Clin Nutr 2009;28: 218. 5. Pearse RM, Belsey JD, Cole JN, Bennett ED. Effect of dopexamine infusion on mortality following major surgery: individual patient data meta-regression analysis of published clinical trials. Crit Care Med 2008;36: 1323-1329. Competing interests: The authors have reviewed the literature and have written the GIFTASUP document. |
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Ashok Inderraj Handa, Reader and Consultant Surgeon Nuffield Department of Surgery, John Radcliffe Hospital,Oxford, Regent Lee, Vascular Trainee Nuffield Department of Surgery, Oxford
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We welcome Liu and Finfer’s editorial opinion as it reopens the debate regarding this topic. The British Consensus Guidelines highlighted several important areas of clinical practice in the care of adult surgical patients. We agree with the editorial’s comments that these guidelines were not generated based on rigorous evidence based methodologies. As such its clinical application may be limited and clinicians choosing to ignore them may easily justify their actions. In the era of evidence based practice, consensus opinion based on sub -optimal evidence should serve as a platform for hypothesis generation rather than gospels for best practice. This lack of high level evidence on fluid management in surgical patients identifies a potential area for surgical research and the urgent need for funding. Further, while teaching on the fluid management in surgical patients has largely remained unchanged in the last two decades, the patient profiles have evolved dramatically. In the UK, NHS trusts now treat the majority of their surgical cases as day cases. Those who require in- patient peri-operative care are in general older, with more co-morbidity or undergoing major surgery. Thus it is high time for closer scrutiny of our approach to fluid management in order to adapt to the fluidity of this increasingly dynamic cohort. The editorial’s opinion on the shortcomings of this consensus guideline should not be taken as mere criticism, but rather echoing the importance of prioritised funding to attract high quality research to inform and perhaps reshape our future surgical practice. Competing interests: None declared |
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