Association of perioperative weight-based fluid balance with 30-day mortality and acute kidney injury among patients in the surgical intensive care unit

  • Tak Kyu Oh
  • In-Ae Song
  • Sang-Hwan Do
  • Sanghoon Jheon
  • Cheong LimEmail author
Original Article



Perioperative positive fluid balance has negative effects on short-term outcomes, such as surgical complications, although the associations with postoperative mortality remain unclear. This study evaluated the associations of perioperative fluid balance (FB) with 30-day mortality and acute kidney injury (AKI) after postoperative intensive care unit (ICU) admission.


This retrospective study evaluated data from adult patients who were admitted to the ICU after surgery during 2012–2016. Weight-based cumulative FB (%) was calculated for 3 time periods [postoperative day (POD) 0 (24 h), 0–1 (48 h), and 0–2 (72 h)] and was categorized as positive (≥ 5%), mild to moderate positive (5–10%), severe positive (> 10%), normal (0–5%), or negative (< 0%).


Data from 7896 patients were included in the analysis. The multivariable Cox regression model revealed that increased 30-day mortality was associated with positive FB groups (≥ 5%) compared to normal FB groups (0–5%) during 3 time periods [hazard ratio (HR) on POD 0 (24 h): 1.87, HR on POD 1 (48 h): 1.91, and HR on POD 2 (72 h): 4.62, all P < 0.05]. These trends were more evident in the severe positive FB group across the three time periods. Additionally, similar association was found for incidence of AKI during POD 0–2.


Perioperative cumulative weight-based FB was positively associated with increased postoperative 30-day mortality or postoperative AKI in ICU patients; this association was consistent with the positive FB on POD 0 (24 h), 0–1 (48 h), and 0–2 (72 h).


Anesthesia Critical care Mortality 



The authors thank the Medical Research Collaborating Center at Seoul National University Bundang Hospital for the revisions with regard to statistical analyses. They are particularly grateful to their statistician, Eunjeong Ji, Ph.D., for her contribution on the statistical analysis.

Supplementary material

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  1. 1.
    Jacob M, Chappell D, Rehm M. Clinical update: perioperative fluid management. Lancet. 2007;369(9578):1984–6.CrossRefGoogle Scholar
  2. 2.
    Voldby AW, Brandstrup B. Fluid therapy in the perioperative setting—a clinical review. J Intensive Care. 2016;4:27.CrossRefGoogle Scholar
  3. 3.
    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):640–51.CrossRefGoogle Scholar
  4. 4.
    Futier E, Constantin JM, Petit A, Chanques G, Kwiatkowski F, Flamein R, Slim K, Sapin V, Jaber S, Bazin JE. Conservative vs restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial. Arch Surg. 2010;145(12):1193–200.CrossRefGoogle Scholar
  5. 5.
    Gomez-Izquierdo JC, Trainito A, Mirzakandov D, Stein BL, Liberman S, Charlebois P, Pecorelli N, Feldman LS, Carli F, Baldini G. Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: a randomized controlled trial. Anesthesiology. 2017;127(1):36–49.CrossRefGoogle Scholar
  6. 6.
    Grant F, Brennan MF, Allen PJ, DeMatteo RP, Kingham TP, D’Angelica M, Fischer ME, Gonen M, Zhang H, Jarnagin W. Prospective randomized controlled trial of liberal vs restricted perioperative fluid management in patients undergoing pancreatectomy. Ann Surg. 2016;264(4):591–8.CrossRefGoogle Scholar
  7. 7.
    Huang Y, Chua TC, Gill AJ, Samra JS. Impact of perioperative fluid administration on early outcomes after pancreatoduodenectomy: a meta-analysis. Pancreatology. 2017;17(3):334–41.CrossRefGoogle Scholar
  8. 8.
    Malbrain M, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, Teboul JL, Rice TW, Mythen M, Monnet X. 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.CrossRefGoogle Scholar
  9. 9.
    Marik PE, Malbrain M. The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL/kg fluid! Anaesthesiol Intensive Ther. 2017;49(5):323–8.CrossRefGoogle Scholar
  10. 10.
    Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014;46(5):361–80.CrossRefGoogle Scholar
  11. 11.
    Cordemans C, De Laet I, Van Regenmortel N, Schoonheydt K, Dits H, Huber W, Malbrain ML. Fluid management in critically ill patients: the role of extravascular lung water, abdominal hypertension, capillary leak, and fluid balance. Ann Intensive Care 2012;2(Suppl 1):S1.CrossRefGoogle Scholar
  12. 12.
    Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, Micek ST, Kollef MH. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136(1):102–9.CrossRefGoogle Scholar
  13. 13.
    Rivers EP. Fluid-management strategies in acute lung injury-liberal, conservative, or both? N Engl J Med. 2006;354(24):2598–600.CrossRefGoogle Scholar
  14. 14.
    Ghorra S, Reinert SE, Cioffi W, Buczko G, Simms HH. Analysis of the effect of conversion from open to closed surgical intensive care unit. Ann Surg. 1999;229(2):163–71.CrossRefGoogle Scholar
  15. 15.
    Lowell JA, Schifferdecker C, Driscoll DF, Benotti PN, Bistrian BR. Postoperative fluid overload: not a benign problem. Crit Care Med. 1990;18(7):728–33.CrossRefGoogle Scholar
  16. 16.
    Glatz T, Kulemann B, Marjanovic G, Bregenzer S, Makowiec F, Hoeppner J. Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: a retrospective study in 335 patients. BMC Surg. 2017;17(1):6.CrossRefGoogle Scholar
  17. 17.
    Xu J, Shen B, Fang Y, Liu Z, Zou J, Liu L, Wang C, Ding X, Teng J. Postoperative fluid overload is a useful predictor of the short-term outcome of renal replacement therapy for acute kidney injury after cardiac surgery. Medicine (Baltimore). 2015;94(33):e1360.CrossRefGoogle Scholar
  18. 18.
    Balakumar V, Murugan R, Sileanu FE, Palevsky P, Clermont G, Kellum JA. Both positive and negative fluid balance may be associated with reduced long-term survival in the critically ill. Crit Care Med. 2017;45(8):e749-e57.CrossRefGoogle Scholar
  19. 19.
    Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T, Kommareddi M, Kershaw DB, Shanley TP, Heung M. Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med. 2011;37(7):1166–73.CrossRefGoogle Scholar
  20. 20.
    Chen J, Li X, Bai Z, Fang F, Hua J, Li Y, Pan J, Wang J, Feng X, Li Y. Association of fluid accumulation with clinical outcomes in critically ill children with severe sepsis. PLoS One. 2016;11(7):e0160093.CrossRefGoogle Scholar
  21. 21.
    O’Connor ME, Prowle JR. Fluid overload. Crit Care Clin. 2015;31(4):803–21.CrossRefGoogle Scholar
  22. 22.
    Kellum JA, Lameire N, Group KAGW. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (part 1). Crit Care. 2013;17(1):204.CrossRefGoogle Scholar
  23. 23.
    Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, Glass P, Lipman J, Liu B, McArthur C, McGuinness S. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367(20):1901–11.CrossRefGoogle Scholar
  24. 24.
    Asklid D, Segelman J, Gedda C, Hjern F, Pekkari K, Gustafsson UO. The impact of perioperative fluid therapy on short-term outcomes and 5-year survival among patients undergoing colorectal cancer surgery—a prospective cohort study within an ERAS protocol. Eur J Surg Oncol. 2017;43(8):1433–9.CrossRefGoogle Scholar
  25. 25.
    Bouchard J, Mehta RL. Fluid balance issues in the critically ill patient. Contrib Nephrol. 2010;164:69–78.CrossRefGoogle Scholar
  26. 26.
    Shen Y, Zhang W, Cheng X, Ying M. Association between postoperative fluid balance and acute kidney injury in patients after cardiac surgery: a retrospective cohort study. J Crit Care. 2018;44:273–7.CrossRefGoogle Scholar
  27. 27.
    Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics. 2001;107(6):1309–12.CrossRefGoogle Scholar
  28. 28.
    Leary TS, Milner QJ, Niblett DJ. The accuracy of the estimation of body weight and height in the intensive care unit. Eur J Anaesthesiol. 2000;17(11):698–703.CrossRefGoogle Scholar
  29. 29.
    Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, Christophi C, Leslie K, McGuinness S, Parke R, Serpell J. Restrictive versus liberal fluid therapy for major abdominal surgery. N Engl J Med. 2018;378(24):2263–74.CrossRefGoogle Scholar
  30. 30.
    Brown RM, Semler MW. Fluid management in sepsis. J Intensive Care Med. 2018. Scholar

Copyright information

© Japanese Society of Anesthesiologists 2019

Authors and Affiliations

  • Tak Kyu Oh
    • 1
  • In-Ae Song
    • 1
  • Sang-Hwan Do
    • 1
  • Sanghoon Jheon
    • 2
  • Cheong Lim
    • 2
    Email author
  1. 1.Department of Anesthesiology and Pain MedicineSeoul National University Bundang HospitalSeongnamSouth Korea
  2. 2.Department of Thoracic and Cardiovascular SurgerySeoul National University Bundang HospitalSeongnamSouth Korea

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