Cerrahi Yoğun Bakım Hastalarında İntraoperatif ve Postoperatif Sıvı Dengesi: Hangisi Daha Önemli?

Abstract

Amaç: Perioperatif sıvı yönetimi, cerrahi bakımın temel bir bileşenidir. Ancak intraoperatif ve postoperatif sıvı dengesinin yoğun bakım ünitesi (YBÜ) sonuçları üzerindeki göreceli etkisi net değildir. Bu çalışmanın amacı, elektif cerrahi geçiren hastalarda intraoperatif, postoperatif ve toplam perioperatif sıvı dengesinin temel YBÜ sonuçları üzerindeki etkisini değerlendirmektir. Materyal ve metod: Bu retrospektif gözlemsel çalışmaya, 1 Ocak-31 Aralık 2024 tarihleri arasında elektif cerrahi sonrası entübe şekilde YBÜ’ye kabul edilen 570 erişkin hasta dâhil edildi. Sıvı dengesi, vücut ağırlığının yüzdesi olarak hesaplandı ve üç zaman dilimi için (intraoperatif, postoperatif, toplam perioperatif) ≥%5 olanlar pozitif, <%5 olanlar negatif-normal olarak sınıflandırıldı. YBÜ sonuçları; mekanik ventilasyon süresi, YBÜ kalış süresi ve YBÜ mortalitesi olarak belirlendi. Tek değişkenli regresyon analizlerinin ardından, mortalitenin bağımsız belirleyicilerini saptamak için çok değişkenli lojistik regresyon kullanıldı. Bulgular: Her üç dönemde de pozitif sıvı dengesi, ayarlanmamış analizlerde anlamlı şekilde daha uzun mekanik ventilasyon süresi ile ilişkiliydi. Postoperatif ve toplam sıvı yüklenmesi, YBÜ kalış süresi ile anlamlı ilişkili bulundu (sırasıyla; β=0,23, p=0,021 ve β=0,11, p=0,014). İntraoperatif sıvı oranı, YBÜ mortalitesi ile ters yönlü anlamlı ilişki gösterdi (OR=0,71, p=0,039), ancak postoperatif ve toplam sıvı dengeleri ile anlamlı ilişki bulunmadı. Çok değişkenli analizde SOFA ve APACHE II skorları ile cerrahi süresi mortalite ile bağımsız ilişkiliydi. Ayrıca, toplam sıvı oranı da mortalite ile istatistiksel olarak anlamlı düzeyde ters yönlü bir ilişki gösterdi (OR=0,65, p=0,006). Sonuç: Pozitif postoperatif sıvı dengesi, özellikle uzamış YBÜ kalış süresi ile en güçlü ilişkili parametreydi. Pozitif intraoperatif sıvı dengesi ise beklenmedik şekilde düşük mortalite ile ilişkiliydi. Bu bulgular, hedefe yönelik perioperatif sıvı yönetiminin önemini vurgulamakta ve nedensel ilişkilerin açıklığa kavuşturulması için ileriye dönük çalışmalara ihtiyaç olduğunu göstermektedir.

Keywords

• Sıvı tedavisi
• Postoperatif dönem
• Yoğun bakım üniteleri

Which Matters More: Intraoperative or Postoperative Fluid Balance? Insights From a Surgical ICU Cohort

Abstract

Background: Perioperative fluid management is a key component of surgical care, yet the relative impact of intraoperative versus postoperative fluid balance on intensive care unit (ICU) outcomes remains unclear. This study aimed to evaluate the effect of intraoperative, postoperative, and total perioperative fluid balance on major ICU outcomes in patients undergoing elective surgery. Materials and Methods: This retrospective observational study included 570 adult patients who were admitted intubated to the ICU after elective surgery between January 1 and December 31, 2024. Fluid balance was calculated as a percentage of body weight and categorized into positive (≥5%) or negative-to-normal (<5%) for three time periods: intraoperative, postoperative, and cumulative perioperative. ICU outcomes included mechanical ventilation (MV) duration, ICU length of stay, and ICU mortality. Univariableregression analyses were performed, followed by multivariablelogistic regression to identify independent predictors of ICUmortality. Results: Positive fluid balance in all three timeframes wassignificantly associated with longer MV duration in unadjustedanalyses. Postoperative and cumulative fluid overload weresignificantly associated with prolonged ICU stay (β=0.23, p=0.021and β=0.11, p=0.014, respectively). Intraoperative fluid percentageshowed a significant inverse association with ICU mortality(OR=0.71, p=0.039), whereas postoperative and cumulativebalances were not. In multivariable analysis, SOFA and APACHEII scores and surgical duration were independently associated withICU mortality. Additionally, total fluid percentage demonstrated astatistically significant inverse association with mortality (OR=0.65,p=0.006). Conclusions: Postoperative positive fluid balance was the strongestpredictor of adverse ICU outcomes, particularly prolonged ICU stay.Intraoperative positive fluid balance demonstrated an unexpectedinverse relationship with mortality. These findings highlight theimportance of targeted perioperative fluid stewardship and supportthe need for prospective studies to clarify causal relationships.

Keywords

• Fluid therapy
• Postoperative period
• Intensive careunits

Ethical Statement

This study was approved by the Ondokuz Mayıs University Clinical Research Ethics Committee (approval no: 2025/239; date: April 30, 2025).

Thanks

We want to express our sincere gratitude to Prof. Melda Dilek for her unwavering support and invaluable guidance throughout this work.

References

1. 1. Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, et al. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med. 2018;378(24):2263-2274.
2. 2. Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding 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. 3. Lewis SR, Pritchard MW, Evans DJ, Butler AR, Alderson P, Smith AF, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018;8(8):Cd000567.
4. 4. Malbrain M, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care. 2018;8(1):66.
5. 5. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344-353.
6. 6. Sun LY, Wijeysundera DN, Tait GA, Beattie WS. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology. 2015;123(3):515-523.
7. 7. Brotfain E, Koyfman L, Toledano R, Borer A, Fucs L, Galante O, et al. Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge. Am J Emerg Med. 2016;34(11):2122-2126.
8. 8. Acheampong A, Vincent JL. A positive fluid balance is an independent prognostic factor in patients with sepsis. Crit Care. 2015;19(1):251.

9. 9. Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017;43(2):155-170.
10. 10. Ma YT, Xian-Yu CY, Yu YX, Zhang C. Perioperative fluid management for adult cardiac surgery: network meta-analysis pooling on twenty randomised controlled trials. Perioper Med (Lond). 2024;13(1):76.
11. 11. O'Connor ME, Prowle JR. Fluid Overload. Crit Care Clin. 2015;31(4):803-821.
12. 12. van Mourik N, Metske HA, Hofstra JJ, Binnekade JM, Geerts BF, Schultz MJ, et al. Cumulative fluid balance predicts mortality and increases time on mechanical ventilation in ARDS patients: An observational cohort study. PLoS One. 2019;14(10):e0224563.
13. 13. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114(3):640-651.
14. 14. Sakr Y, Rubatto Birri PN, Kotfis K, Nanchal R, Shah B, Kluge S, et al. Higher Fluid Balance Increases the Risk of Death From Sepsis: Results From a Large International Audit. Crit Care Med. 2017;45(3):386-394.
15. 15. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369(18):1726-1734.
16. 16. Shin CH, Long DR, McLean D, Grabitz SD, Ladha K, Timm FP, et al. Effects of Intraoperative Fluid Management on Postoperative Outcomes: A Hospital Registry Study. Ann Surg. 2018;267(6):1084-1092.
17. 17. Wang N, Jiang L, Zhu B, Wen Y, Xi XM. Fluid balance and mortality in critically ill patients with acute kidney injury: a multicenter prospective epidemiological study. Crit Care. 2015;19:371.
18. 18. Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore PM, Hoste E, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med. 2017;43(6):730-749.
19. 19. Pearse RM, Harrison DA, MacDonald N, Gillies MA, Blunt M, Ackland G, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. Jama. 2014;311(21):2181-2190.
20. 20. Edwards MR, Mythen MG. Fluid therapy in critical illness. Extrem Physiol Med. 2014;3:16.
21. 21. Scheeren TWL, Wiesenack C, Gerlach H, Marx G. Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. J Clin Monit Comput. 2013;27(3):225-233.
22. 22. Minne L, Abu-Hanna A, de Jonge E. Evaluation of SOFA-based models for predicting mortality in the ICU: A systematic review. Crit Care. 2008;12(6):R161.