Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.38478.568067.AE (Published 16 June 2005) Cite this as: BMJ 2005;330:1420
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Editor – Lassen et al1 has pointed out that surgical practice differs
between Northern European centres but uses misleading evidence to compare
them to the gold standard. In judging those centres that fluid restrict as
following best evidence, Lassen ignores the point: there is an important
difference between encouraging fluid restriction and avoiding fluid
overload.
The study he quotes to support his hypothesis2, which was published
several months after he began his own, suggests that an excess of normal
saline is associated with an increase in morbidity post-operatively. There
is no doubt that large amounts of normal saline causes metabolic
acidosis3l, and that an excess of crystalloid impairs tissue perfusion.
But we know also that goal-directed therapy produces superior outcome to a
traditional ‘one-size-fits-all’ approach4.
It is with relief, therefore that we find that few centres dogmatically
restrict fluid therapy after laparotomy, but with concern that Lassen
believes they should.
Reference List
(1) Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, von
Meyenfeldt MF et al. Patterns in current perioperative practice: survey of
colorectal surgeons in five northern European countries. BMJ 2005;
330(7505):1420-1421.
(2) Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording
H, Lindorff-Larsen K et al. Effects of intravenous fluid restriction on
postoperative complications: comparison of two perioperative fluid
regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003;
238(5):641-648.
(3) Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline
infusion produces hyperchloremic acidosis in patients undergoing
gynecologic surgery. Anesthesiology 1999; 90(5):1265-1270.
(4) Gan TJ, Soppitt A, Maroof M, El-Moalem H, Robertson KM, Moretti
E et al. Goal-directed intraoperative fluid administration reduces length
of hospital stay after major surgery. Anesthesiology 2002; 97(4):820-826.
Competing interests:
None declared
Competing interests: No competing interests
Lassen and colleagues highlight the important issue of variation in
surgical practice which currently exists across Europe.1 Clearly this
study may under estimate the true variation in practice seen throughout
the whole of Northern Europe by only sampling countries containing ERAS-
group (Enhanced Recovery After Surgery) consultants. After all, the ERAS
Group has an expressed interest in enhancing recovery after surgery by
optimising perioperative care through modulating the areas of patient
management examined within the survey.2
None-the-less such variation will either be due to an absence of
evidence guiding management of patients or, alternatively, insufficient
implementation of effective treatments derived from rigorous evidence.
The authors assume it is the latter problem. Rather than implicitly
blaming some surgeons and surgical centres for not implementing ‘best
practice’ it might be that these surgeons and anaesthetists do not accept
current evidence for such practice as being sufficiently robust in order
to change their practice.
Take Brandstrup et al’s paper on fluid restriction for example, would
the authors not agree that we are right to be cautious of a trial that
reports methods of allocation concealment which allows for potential
subversion of randomisation, and has a post-randomisation exclusion rate
of 18%?3,4
In effect what Lassen et al’s study actually represents are the
perceptions that lead ERAS surgeons and their national colleagues hold, or
feel they should hold, about their current perioperative management. In
order to promote uniformity in perioperative practice surely the first
step is to reach a consensus about what represents current and robust best
-evidence by using sound and systematic evaluations of the available
literature.
1 Lassen K, Revhaug A, Meyenfelt M, Dejong C, Hannemann P,
Ljungqvist O, Nygren J, Hausel J, Fearon K, Andersen J. Patterns in
current perioperative practice: survey of colorectal surgeons in five
northern European countries. BMJ 2005;1420
2 The National Research Register
http://www.nrr.nhs.uk/ViewDocument.asp?ID=N0217110493 [19.06.05]
3 Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H,
Lindorff-Larsen K, et al. Effects of intravenous fluid restriction on
postoperative complications: comparison of two perioperative fluid
regimems: a randomised assessor-blinded multicenter trial. Ann Surg 2003;
238: 641
4 Schultz K. Subverting Randomization in Controlled Trials. JAMA 1995;
274: 1456
Competing interests:
None declared
Competing interests: No competing interests
Dr Brown's views will be supported by many who read this paper which
might have been less contentious in some of its statements if an
anaesthetist had been amongst the authors. If groups are going to make
comments about the use (or lack of use) of a particular technique then
they should include a relevant expert among them to provide the necessary
input. Having relieved myself of that whinge, I think that there are other
issues which need further comment.
The name of the area (general ward or high dependency area) in which
patients are managed after major surgery (with or without an epidural)
matters naught: what matters is the quality/quantity of medical and
nursing care available. However, the staff involved must also have
expertise and experience in the supervision of patients receiving epidural
analgesia if it is to be used safely and effectively. In many hospitals
that level of care can only be guaranteed in the defined high dependency
unit, although if the level of care available in a general ward is not
appropriate to epidural supervision I am not sure I would want major
surgery there anyway, no matter what type of analgesia was used!
As to the debate about the influence of epidural analgesia on
surgical outcome, Dr Brown refers correctly to two important studies, but
ignores the many questions which surround these papers and the subject as
a whole. Space precludes full consideration of these questions here, but
one key point is that no one has ever disputed that the quality of pain
relief is vastly superior. In a perfect world that should be evidence
enough, but the other questions do need to be addressd[1]. I believe that
properly conducted and managed (easy to state, harder to achieve) epidural
analgesia can provide marked benefits: we simply have not proved it yet in
the wider setting.
1. Wildsmith JAW. No sceptic me, but the long day’s task is not yet
done: The 2002 Gaston Labat Lecture. Regional Anesthesia & Pain
Management 2002; 27: 503-8.
Competing interests:
I have acted as a consultant to, and received research funding from, AstraZeneca
Competing interests: No competing interests
Editor- Lassen et al1 have published an interesting survey of
perioperative practice in colorectal surgery. The authors consider
epidural analgesia to be optimal and failure to use it outside a high
dependency unit to be conservative. They also advocate the use of a fluid
restricted strategy.
The use of epidural analgesia leads to vasodilatation which in the
ward setting is likely to be managed with increased intravenous fluids. It
seems likely that the units in their survey which routinely use epidurals
on wards are simply unable to use the fluid restricted strategy which the
authors favour.
Two large randomised controlled trials have failed to demonstrate any
mortality or morbidity benefit from the use of epidural analgesia in major
intra-abdominal surgery2,3. The use of epidurals outside a high dependency
setting cannot be considered superior care and may contribute to post
operative fluid problems.
1. Lassen K, et al on behalf of the Enhanced Recovery After Surgery
(ERAS) Group Patterns in current perioperative practice: survey of
colorectal surgeons in five northern European countries BMJ 2005:1420-
1421
2. Rigg JRA, Jamrozik K, Myles PS, et al and the MASTER Anaesthesia
Trial Study Group. Epidural anaesthesia and analgesia and outcome of major
surgery: a randomised trial. Lancet 2002; 359: 1276-1282
3. Park WY, Thompson J, Lee KK. Effect of epidural anesthesia and
analgesia on perioperative outcome. A randomised controlled Veterans'
Administration study. Ann Surg 2001; 234: 560-571
Competing interests:
None declared
Competing interests: No competing interests
Starved, stressed ...and drowned? Perioperative practice and a choice of perspective.
Editor!
We have with interest read the 4 commentary letters by UK doctors
Brown, Wildsmith, Burdett and Walter to our recent paper in this
journal.(1) We feel that the presented remarks do not address the central
issues of our paper, nor do they affect the main conclusion, which is that
in areas where there is no controversy about the evidence, there is still
no uniformity in practice. We maintain that by available documentation, an
unacceptable proportion of patients are treated sub-optimally, and that
many are literally starved, stressed and – if not actually drowned –
surely in rough waters.
We do not dispute that there are issues that deserve a more detailed
discussion. Avoidance of sodium and fluid overload is clearly a better
term than fluid/saline restriction, and notably the one we used in three
out of four places in our paper. The use of Brandstrups study,(2) as the
only reference was due to the space- and reference restrictions imposed by
the format our paper was given. While one study alone does not justify a
fluid/sodium restricted regimen, literature published prior to our
investigation quite clearly warns against sodium/fluid overload.(3,4) As
more recent studies have emerged,(5,6) it is easy to agree that the
optimal sodium/fluid regimen perioperatively is still unclear. Avoidance
of overload remains however, both clinically and semantically, a safe
recommendation!
Is the use of postoperative epidurals part of optimal evidence-based
perioperative care? As commented, the pain-relieving effect of a well
placed epidural is very good, and not even questioned by Rigg and co-
workers.(7,8) The other important benefit is that it does not preclude
immediate mobilisation and oral diet (from the evening of the day of
operation). If you do not plan to mobilise your patient immediately after
surgery, or if you plan to keep him nil-by-mouth for 48 hours, there is
probably no reason to avoid opioids parenterally. Only a multimodal and
enhanced regimen will exploit the real benefits of postoperative
epidurals.(9,10) In our own centres, the epidurals are handled by ward
nurses and hypotension countered mainly by individual dose adjustments.
Dr. Wildsmith finds it contentious that surgeons write about peri-
operative care without the auspices of an anaesthetist. We can only hope
that this remark was made in jest as all the surveyed modalities are the
responsibility of the surgeon, and administered or withheld by the
surgical ward nurses.
Dr. Walter commendably suggests that we "reach a consensus about what
represents current and robust best-evidence by using sound and systematic
evaluations of the available literature". We completely agree with her
view, and base our current work on such a document.(11)
On behalf of the authors.
Reference List
1. Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH,
Meyenfeldt MF et al. Patterns in current perioperative practice: survey of
colorectal surgeons in five northern European countries. BMJ 2005;330:1420
-1.
2. Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H,
Lindorff-Larsen K et al. Effects of intravenous fluid restriction on
postoperative complications: comparison of two perioperative fluid
regimens: a randomized assessor-blinded multicenter trial. Ann Surg
2003;238:641-8.
3. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical
implications of perioperative fluid excess. Br J Anaesth 2002;89:622-32.
4. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison
SP. Effect of salt and water balance on recovery of gastrointestinal
function after elective colonic resection: a randomised controlled trial.
Lancet 2002;359:1812-8.
5. Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P et
al. Liberal versus restrictive fluid administration to improve recovery
after laparoscopic cholecystectomy: a randomized, double-blind study. Ann
Surg 2004;240:892-9.
6. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot
I. Effect of intraoperative fluid management on outcome after
intraabdominal surgery. Anesthesiology 2005;103:25-32.
7. Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW
et al. Epidural anaesthesia and analgesia and outcome of major surgery: a
randomised trial. Lancet 2002;359:1276-82.
8. Kehlet H, Holte K. Epidural anaesthesia and analgesia in major
surgery. The Lancet 2002;360:568-9.
9. Brodner G, Van Aken H, Hertle L, Fobker M, Von Eckardstein A,
Goeters C et al. Multimodal perioperative management--combining thoracic
epidural analgesia, forced mobilization, and oral nutrition--reduces
hormonal and metabolic stress and improves convalescence after major
urologic surgery. Anesth Analg 2001;92:1594-600.
10. Kehlet H. Multimodal approach to control postoperative
pathophysiology and rehabilitation. Br J Anaesth 1997;78:606-17.
11. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH,
Lassen K et al. Enhanced recovery after surgery: A consensus review of
clinical care for patients undergoing colonic resection. Clin Nutr
2005;24:466-77.
Competing interests:
None declared
Competing interests: No competing interests