What is the goal-directed fluid therapy approach for a patient with perforation peritonitis in the postoperative period in the Intensive Care Unit (ICU)?

From the Guidelines

Goal-directed fluid therapy (GDFT) is recommended in the postoperative ICU management of perforation peritonitis patients to achieve optimal intravascular volume while avoiding fluid overload. I recommend using dynamic parameters rather than static measures to guide fluid administration. Start with balanced crystalloids (such as Ringer's lactate) at 1-2 ml/kg/hr as maintenance, with additional boluses (250-500 ml over 15-30 minutes) guided by predefined targets. These targets should include maintaining mean arterial pressure >65 mmHg, urine output >0.5 ml/kg/hr, lactate <2 mmol/L, and central venous oxygen saturation >70%. Utilize dynamic parameters such as stroke volume variation (SVV <13%), pulse pressure variation (PPV <12%), or passive leg raise test to assess fluid responsiveness. Reassess frequently, ideally every 2-4 hours initially, then extending intervals as the patient stabilizes. If fluid boluses fail to improve hemodynamics, consider starting norepinephrine (0.05-0.5 mcg/kg/min) or vasopressin (0.01-0.04 units/min) as needed. This approach is justified because perforation peritonitis patients are at high risk for both hypovolemia due to third-spacing and sepsis, as well as pulmonary complications from fluid overload. GDFT has been shown to reduce postoperative complications, ICU stay, and mortality by ensuring adequate tissue perfusion while minimizing the risks of pulmonary edema, prolonged ileus, and anastomotic leakage, as supported by recent studies 1.

Key Considerations

• The goal of GDFT is to maintain fluid homoeostasis, avoiding fluid excess and organ hypoperfusion 1.
• GDFT should be adopted especially in high-risk patients and in patients undergoing surgery with large intravascular fluid loss (blood loss and protein/fluid shift) 1.
• A recent meta-analysis has shown that GDFT was associated with a significant reduction in morbidity, hospital length of stay, intensive care length of stay, and time to passage of feces 1.
• The use of dynamic parameters such as SVV and PPV can help predict fluid responsiveness and guide fluid administration 1.
• Postoperative intravenous fluids should be minimized to maintain normovolaemia and avoid fluid excess, with the enteral route preferred and the drip taken down at the earliest opportunity 1.

Monitoring and Adjustments

• Reassess the patient's fluid status and hemodynamics frequently, ideally every 2-4 hours initially, then extending intervals as the patient stabilizes.
• Adjust the fluid administration rate and composition as needed to achieve the predefined targets.
• Consider starting norepinephrine or vasopressin if fluid boluses fail to improve hemodynamics.
• Continuously monitor for signs of fluid overload, such as pulmonary edema, and adjust the fluid administration strategy accordingly.

From the Research

Goal-Directed Fluid Therapy in Perforation Peritonitis Patients

Overview of Goal-Directed Fluid Therapy

• Goal-directed fluid therapy (GDFT) is a strategy used to optimize fluid administration in critically ill patients, including those with perforation peritonitis 2.
• The aim of GDFT is to ensure that patients receive the appropriate amount of fluid to maintain adequate blood flow and oxygen delivery to tissues, while avoiding excessive fluid administration that can lead to complications 2, 3.

Application of Goal-Directed Fluid Therapy in Perforation Peritonitis

• A study published in 2022 found that adapted ERAS (Enhanced Recovery After Surgery) pathways, which include goal-directed fluid therapy, can reduce the length of hospitalization and improve functional recovery parameters in patients undergoing emergency surgery for perforation peritonitis 4.
• The study suggested that goal-directed fluid therapy, as part of an adapted ERAS protocol, can be beneficial in reducing post-operative complications and improving patient outcomes in this patient population 4.

Choice of Fluids for Goal-Directed Fluid Therapy

• The choice of fluid for GDFT is an important consideration, with crystalloids and colloids being the two main options 5, 3.
• A study published in 2009 found that goal-directed colloid administration increased microcirculatory blood flow in the small intestine and intestinal tissue oxygen tension after abdominal surgery, compared to goal-directed crystalloid administration 5.
• However, a more recent study published in 2023 found that goal-directed fluid therapy using balanced crystalloids was effective in optimizing stroke volume and reducing perioperative complications in patients undergoing hip revision arthroplasty surgery 3.

Key Considerations for Goal-Directed Fluid Therapy in Perforation Peritonitis

• The use of balanced crystalloids as the primary fluid for GDFT is recommended, as they can help to avoid hyperchloremic acidosis and renal impairment 6, 3.
• The implementation of a GDFT protocol should be tailored to the individual patient's needs and should take into account factors such as cardiac output, blood pressure, and oxygen saturation 2, 3.
• Regular monitoring and adjustment of fluid administration is crucial to ensure that patients receive the optimal amount of fluid and to minimize the risk of complications 2, 3.