What is the recommended fluid therapy and anaesthetic technique for a patient undergoing pancreaticoduodenectomy (Whipple resection)?

Fluid Therapy and Anaesthesia in Whipple's Resection

Use balanced crystalloids (Ringer's Lactate or Plasmalyte) at a restrictive rate of 2–4 mL/kg/h with goal-directed hemodynamic monitoring via transoesophageal Doppler or stroke volume variation, combined with mid-thoracic epidural analgesia for open pancreaticoduodenectomy. 1, 2

Fluid Management Strategy

Fluid Type Selection

• Administer exclusively balanced crystalloids (Ringer's Lactate or Plasmalyte) throughout the perioperative period 1, 2
• Avoid 0.9% saline completely due to hyperchloremic acidosis, renal vasoconstriction, and reduced cortical tissue perfusion 2, 3
• Do not use colloids routinely (albumin or synthetic starches) as they provide no outcome benefit over balanced crystalloids in pancreatic surgery 2

Intraoperative Fluid Rate and Volume

• Maintain restrictive crystalloid administration at 2–4 mL/kg/h (approximately 140–280 mL/h for a 70-kg patient) 2
• Target near-zero fluid balance throughout the perioperative period to avoid fluid overload 1, 2
• Excessive fluid administration causing 3–6 kg weight gain is strongly associated with increased postoperative complications and delayed gastric emptying 2, 4
• Higher positive fluid balance on postoperative day 0 is most strongly associated with major adverse events (OR 1.39, CI 1.16–1.66) 4

Goal-Directed Fluid Therapy (GDFT)

Implement continuous hemodynamic monitoring using one of the following:

• Transoesophageal Doppler 1, 2
• LiDCO system 2
• Stroke volume variation (SVV) monitoring 2, 5

Fluid bolus administration protocol:

• Give 200–250 mL boluses only when objective hypovolemia is present (>10% drop in stroke volume or SVV ≥10%) 2
• During the extirpative phase before pancreatic reconstruction, maintain SVV ≥12% (indicating relative fluid restriction) to minimize anastomotic edema 5
• Patients with SVV ≥12 during the extirpative phase had significantly lower rates of pancreatic leak (5.9% vs 21.3%) and delayed gastric emptying (41.2% vs 46.8%) 5

Critical pitfall: Treat epidural-induced hypotension in normovolemic patients with vasopressors, not additional fluids 1, 2

Anaesthetic Technique

Regional Analgesia

• Mid-thoracic epidural analgesia (T6-T8) is the gold standard for open pancreaticoduodenectomy, using local anaesthetics combined with low-dose opioids 1
• Epidural analgesia provides superior pain relief and reduces respiratory complications compared to intravenous opioids 1
• Epidural reduces the surgical stress response and insulin resistance, facilitating better glycemic control 1

Alternative Analgesic Options

• Patient-controlled analgesia (PCA) with morphine may be considered, though evidence is weaker than for epidurals 1
• Intravenous lidocaine infusion has some supporting evidence but insufficient outcome data specific to pancreaticoduodenectomy 1
• Wound catheters and transversus abdominis plane (TAP) blocks show conflicting results and are not recommended as primary techniques 1

General Anaesthesia Protocol

• Use short-acting agents allowing rapid awakening (sevoflurane, desflurane, or total intravenous anaesthesia with propofol) 1
• Total intravenous anaesthesia (TIVA) may be beneficial for patients at high risk of postoperative nausea and vomiting (PONV) 1
• Avoid deep anaesthesia, particularly in elderly patients; consider bispectral index (BIS) monitoring to titrate depth 1

Additional Perioperative Considerations

Preoperative Management

• Allow clear fluids until 2 hours before surgery and solids until 6 hours 1, 6
• Preoperative carbohydrate loading (oral carbohydrate drink 2 hours before surgery) reduces insulin resistance 1
• Avoid long-acting sedative premedication as it delays recovery 1

Intraoperative Monitoring and Prevention

• Maintain normothermia (>36°C) using forced-air warming devices and warmed intravenous fluids 1
• Hypothermia increases wound infections, cardiac ischemia, and bleeding 1
• Administer prophylactic antibiotics 30–60 minutes before incision, with additional doses for prolonged procedures 1

PONV Prophylaxis

• Use multimodal PONV prophylaxis in all patients with ≥2 risk factors (female sex, non-smoker, history of motion sickness, major abdominal surgery) 1
• Combine pharmacological agents (ondansetron, dexamethasone) with TIVA technique when appropriate 1

Postoperative Fluid Management

• Discontinue intravenous fluids as soon as oral intake is tolerated 1
• Early oral intake (within 24 hours) is safe and feasible after pancreaticoduodenectomy 1
• Nasogastric tubes should not be used routinely and if inserted intraoperatively should be removed before reversal of anaesthesia 1

Urinary Drainage

• Transurethral catheter can be safely removed on postoperative day 1 or 2 regardless of epidural use 1
• Suprapubic catheterization is superior only if drainage is needed for >4 days 1

Glycemic Control

• Avoid hyperglycemia without introducing risk of hypoglycemia 1
• Epidural analgesia and near-zero fluid balance both attenuate insulin resistance 1
• Insulin resistance and hyperglycemia are strongly associated with postoperative morbidity and mortality 1

Key Evidence Summary

The restrictive fluid strategy with GDFT is supported by high-quality evidence: A randomized controlled trial in high-risk surgical patients demonstrated that restrictive crystalloid administration (4 mL/kg/h) during oxygen delivery optimization resulted in a 52% lower rate of major postoperative complications compared to conventional rates (12 mL/kg/h) 7. This approach, combined with specific attention to fluid restriction during the extirpative phase of pancreaticoduodenectomy, directly reduces pancreatic leak and delayed gastric emptying 5, 4.