RELIEF Study Challenges Restrictive Fluid: Oesophageal Doppler Removes Guesswork
The Royal College of Anaesthesia held its flagship event, Anaesthesia 2018 at The British Museum on May 22nd and 23rd. Comprising two days of talks, breakout sessions and debates, it also featured the presentation of the RELIEF study, just published in the New England Journal of Medicine. “Restrictive versus liberal fluid therapy in major abdominal surgery (RELIEF)” was a 3000 patient pragmatic study across 46 hospitals in 7 countries. TopMedTalk, purveyor of the latest medical news, interviewed principal author Professor Paul Myles about the study and its implications.
Prof Myles pointed to the consistent, coherent recurring theme of increased Surgical Site Infection (SSI) and Acute Kidney Injury (AKI) in the fluid-restricted group compared with liberal fluids group. He said researchers “could not find any positive feature whatsoever in the restrictive/zero fluid balance group.” When asked about Enhanced Recovery after Surgery (ERAS) principles (which talk of restrictive fluid regimes) Prof Myles stated “I think ERAS and ERAS principles remain incredibly important, but that one item of giving a more restrictive i/v fluid approach, I think needs to be changed.”
Here then is yet another study that highlights the importance of employing a Goal Directed Haemodynamic Therapy (GDHT) protocol for these patients. Haemodynamic monitoring in the RELIEF study was very limited, so it was primarily based on giving patients fixed fluid regimes. Both the restricted and liberal fluid protocols had significantly higher AKI and SSI than were seen in the recently published FEDORA RCT that implemented GDHT using the Oesophageal Doppler.
Deltex Managing Director Andy Mears comments; “When one compares incidence of AKI and SSI between the FEDORA and RELIEF trials the results are indisputable. In both studies it seems that suboptimal regimes deliver similarly suboptimal outcomes (AKI, 8.6% and 8.5% , SSI 16.5% and 16.1%). In RELIEF, when a more liberal, but still uncontrolled fluid regime is applied the incidences drop to AKI 5% and SSI 13%. However FEDORA demonstrates that implementing a GDHT protocol with Oesophageal Doppler Monitoring (ODM) improves outcomes significantly further (AKI 1.4% and SSI 5.7%). This can be seen as conclusive evidence that one needs to employ an individualised GDHT using the ODM to get the lowest possible AKI and SSI after surgery.”