Pulse pressure variation-guided versus low central venous pressure-guided fluid management during elective open hepatectomy: a randomized non-inferiority trial.

Abstract

Background: Low central venous pressure (LCVP)-guided fluid management is widely used to reduce blood loss during liver resection; however, LCVP is an unreliable marker of preload. Pulse pressure variation (PPV) is a dynamic index of fluid responsiveness. This study evaluated whether a PPV-guided fluid management strategy is non-inferior to conventional LCVP-guided management in reducing intraoperative blood loss during elective open hepatectomy.

Methods: In this single-center, randomized, non-inferiority trial, adult patients (18-65 years) with American Society of Anesthesiologists physical status I-II scheduled for elective, non-donor open hepatic resection involving two or more segments were randomized to either an LCVP-guided group or a PPV-guided group. Fluid administration in both groups followed predefined hemodynamic algorithms. The primary outcome was intraoperative blood loss. Secondary outcomes included total intraoperative fluid administration, urine output, serum lactate concentrations, and postoperative renal function. Non-inferiority was assessed using a prespecified margin of 98 ml.

Results: Sixty-four patients (32 in each group) were included in the final analysis. Intraoperative blood loss was comparable between the LCVP and PPV groups (683 ± 276 ml vs. 726 ± 223 ml, respectively). The mean difference in blood loss was - 43 ml (95% confidence interval: -169 to 83 ml), with the upper limit remaining below the predefined non-inferiority margin, confirming non-inferiority of the PPV-guided strategy. Total crystalloid and colloid administration, urine output, surgical field grading, and perioperative serum lactate levels were similar between the two groups. Postoperative serum creatinine levels at 24 h did not differ significantly.

Conclusions: PPV-guided fluid management was non-inferior to an LCVP-based strategy for reducing intraoperative blood loss during elective open hepatic resection, without evidence of compromised tissue perfusion. These findings suggest that PPV-guided fluid management may be a feasible alternative to CVP-targeted fluid management in this setting.

Trial registration: The trial was registered prospectively with the Clinical Trials Registry of India (CTRI/2018/01/011547; registered on 24 January 2018).