• Sean Coeckelenbergh, Maxim Proux-Soucy, Philippe Van der Linden, Stephanie Roullet, Maya Moussa, Hiromi Kato, Leila Toubal, Salima Naili, Joseph Rinehart, Tristan Grogan, Maxime Cannesson, Jacques Duranteau, and Alexandre Joosten.
• Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique Hôpitaux de Paris, Villejuif, France.
• Anesthesiology. 2024 Jul 25.

BackgroundFluid therapy during major hepatic resection aims at minimizing fluids during the dissection phase to reduce central venous pressure (CVP), retrograde liver blood flow, and venous bleeding. This strategy, however, may lead to hyperlactatemia. The Acumen™ Assisted Fluid Management system uses novel decision support software whose algorithm helps clinicians optimize fluid therapy. We tested the hypothesis that using this decision support system could decrease arterial lactate at the end of major hepatic resection when compared to a more restrictive fluid strategy.MethodsThis two-arm, prospective, randomized controlled, assessor-and patient-blinded superiority study included consecutive patients undergoing major liver surgery equipped with an arterial catheter linked to an uncalibrated stroke volume monitor. In the decision support group, fluid therapy was guided throughout the entire procedure using the assisted fluid management software. In the restrictive fluid group, clinicians were recommended to restrict fluid infusion to 1-2 ml.kg-1.h-1 until the completion of hepatectomy. They then administered fluids based on advanced hemodynamic variables. Noradrenaline was titrated in all patients to maintain a mean arterial pressure >65mmHg. The primary outcome was arterial lactate level upon completion of surgery (i.e., skin closure).ResultsNinety patients were enrolled over a 7-month period. The primary outcome was lower in the decision support group than in the restrictive group (median[Q1-Q3] 2.5[1.9-3.7]mmol.L-1 vs 4.6[3.1-5.4]mmol.L-1, median difference -2.1, 95%CI(-2.7,-1.2), p<0.001). Among secondary exploratory outcomes, there was no difference in blood loss (median[Q1-Q3] 450[300-600]ml vs 500[300-800]ml, p=0.727) although CVP was higher in the decision support group (mean (SD) of 7.7(2.0)mmHg vs 6.6(1.1)mmHg, p<0.002).ConclusionPatients managed using a clinical decision support system to guide fluid administration during major hepatic resection had a lower arterial lactate concentration at the end of surgery when compared to a more restrictive fluid strategy. Future trials are necessary to make conclusive recommendations that will change clinical practice.Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.

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