OBES SURG (2018) 28:358–363
DOI 10.1007/s11695-017-2840-1
ORIGINAL CONTRIBUTIONS
Efficacy of Goal-Directed Fluid Therapy via Pleth Variability
Index During Laparoscopic Roux-en-Y Gastric Bypass Surgery
in Morbidly Obese Patients
İsmail Demirel 1 1 1
& Esef Bolat & Aysun Yıldız Altun & Mustafa Özdemir & Azize Beştaş
Published online: 31 July 2017
# Springer Science+Business Media, LLC 2017
Abstract
Background There is no well-recognized guideline for intra-
operative fluid management in bariatric surgery. Goal-directed
fluid therapy (GDFT) is a new concept of perioperative fluid
management which was shown to improve patients’ progno-
ses. Dynamic indicators may better predict fluid response
compared to static indicators. In this study, we aimed to assess
effects of administering GDFT protocol via Pleth Variability
Index (PVI) in morbidly obese patients undergoing laparo-
scopic Roux-en-Y gastric bypass (RYGB) surgery.
Methods The study included 60 patients who underwent elec-
tive laparoscopic RYGB surgery. Subjects were randomized
to two groups as being managed with either standard fluid
regimen (control group) or PVI (PVI group) during intraoper-
ative period. After induction of general anesthesia, control
group received 500 ml crystalloid bolus followed by 4–8 ml/
kg/h infusion. Fluid management of the control group was
guided by central venous pressure and mean arterial pressure.
PVI group received 500 ml crystalloid bolus followed by
2 ml/kg/h infusion. If PVI had been > 14%, 250 ml colloid
* İsmail Demirel
ismaildemirel23@gmail.com
Esef Bolat
esefbolat@gmail.com
Aysun Yıldız Altun
draysunaltun@gmail.com
Mustafa Özdemir
drutaci@gmail.com
Azize Beştaş
bestasa@gmail.com
1
Medicine Faculty, Anesthesiology and Reanimation Department,
Firat University, 23119 Elazig, Turkey
1
1
was administered. Norepinephrine was given by infusion to
keep mean arterial pressure > 65 mmHg, if needed.
Perioperative lactate levels, hemodynamic parameters, and
renal functions were recorded.
Results In PVI group, volume of crystalloid and total fluid
infusion during intraoperative period was significantly lower
than the control group (p < 0.05). The groups did not signif-
icantly differ in terms of lactate or creatinine levels before or
after the surgery (p > 0.05).
Conclusions There is no need to administer extra volume of
fluid to obese patients undergoing laparoscopic bariatric sur-
gery. Use of dynamic indicators like PVI helps to decrease
intraoperative volume of infused fluids with no effects on
either intraoperative or postoperative lactate levels in laparo-
scopic bariatric interventions.
Keywords Anesthesia . Morbid obesity . Pleth Variability
Index . Bariatric surgery
Introduction
It is very critical for the patient that the anesthesiologist mon-
itors fluid status of the patient and administers individualized
therapy appropriate for that patient [1, 2]. Though being used
to guide intravascular fluid therapy for years, static indicators
(cardiac filling pressures such as central venous pressure
[CVP] and pulmonary capillary wedge pressure [PCWP])
have low sensitivity and specificity [3].
Dynamic indicators of fluid responsiveness relying on car-
diopulmonary interactions in mechanically ventilated patients,
such as DeltaPOP (respiratory variations in the pulse oximeter
plethysmographic waveform amplitude) or DeltaPP (respira-
tory variations in arterial pulse pressure) [4], have been shown
to be superior to static indicators to predict fluid
OBES SURG (2018) 28:358–363 359

responsiveness [5]. However, DeltaPP monitoring is invasive
and not routinely available in daily clinical practice [6]. The
Pleth Variability Index (PVI) is a novel algorithm allowing for
automated and continuous calculation of DeltaPOP. PVI is
related to DeltaPOP [7] and can predict fluid responsiveness
noninvasively in mechanically ventilated patients under gen-
eral anesthesia [8].
A new concept of Bgoal-directed fluid therapy^ (GDFT)
has been introduced in recent years. Defined as the monitoring
of hemodynamic parameters, GDFT is based on the optimiza-
tion of tissue perfusion by rational fluid management. By
measuring parameters, GDFT algorithms are designed to
avoid excessive fluid infusion and to maximize cardiac output
[9, 10]. Numerous meta-analyses showed outstanding benefits
of GDFT over standard fluid therapies in terms of reducing
morbidity and mortality rates in high-risk surgeries [9, 11–15].
Furthermore, administration of GDFT protocols were reported
to decrease length of hospital stay, incidence of respiratory
failure, acute renal failure, and surgical site infections, and
reduce postoperative morbidity such as nausea and vomiting
[16].
Though fluid therapy is one of the main areas of anesthesia
practice, there are no recognized, accessible guidelines for
intraoperative fluid therapy in bariatric surgery. Obesity is
associated with an increase in total and lean body mass; how-
ever, intracellular, extracellular, and absolute total body fluids
are relatively reduced compared to those with normal weight.
There are limited data for the optimal fluid regimen in mor-
bidly obese patients. Some studies reported the possibility to
harm on the patient by conventional practices due to fluid
overload [17]. Moreover, only few studies assessed GDFT
administration in laparoscopic bariatric surgery.
In our study, we aimed to assess effects of fluid manage-
ment by GDFT protocol via PVI monitoring on tissue perfu-
sion and renal functions in morbidly obese patients undergo-
ing laparoscopic Roux-en-Y gastric bypass (RYGB) surgery.
Table 1 Baseline characteristics of the study population (mean ± SD
(range))
Control group PVI group p value
(n = 30) (n = 30)
Table 2 Volumes of crystalloid and colloid fluids administered during
intraoperative period (mean ± SD (range))
Control group PVI group p value
(n = 30) (n = 30)
Intraoperative 1499.00 ± 516.87 1126.67 ± 234.98 0.001*
crystalloids (ml)
Intraoperative 533.33 ± 194.02 491.67 ± 153.73 0.360
colloids (ml)
*means statistically significant
Methods
The study was approved by the Ethics Committee for Non-
Interventional Trials of Firat University. After giving written
consent, 60 patients who would undergo elective laparoscopic
RYGB surgery with the following characteristics were includ-
ed to the study. Patients below 18 years of age, having cardiac
arrhythmia, cardiac ejection fraction of ≤ 30%, pulmonary
disease interfering with mechanical ventilation by ≥ 8 ml/kg
tidal volume, or chronic renal failure were excluded.
Subjects were randomized to either control group or PVI
group. Heart rate, arterial blood pressure, oxygen satura-
tion, and body temperature were continuously monitored
by Datex S/5 monitor (DatexOhmeda®, GE Healthcare).
All patients were pre-oxygenized for 2 min after brought
into ramp position. Anesthesia induction was established
by 2–4 mg/kg propofol based on total body weight and
1.2 mg/kg rocuronium and 2 μg/kg fentanyl based on ideal
body weight. Maintenance was performed with sevoflurane
and desflurane. Repeated doses of rocuronium and fentanyl
were administered during the surgery, if deemed necessary.
The lungs were ventilated as 8–10 ml/kg with I:E ratio of
1:2. Respiration frequency was set to maintain
normocapnia (PaCO2: 35–45 mmHg). After induction, both
groups were cannulated with 20 G radial artery catheters.
Afterwards, central venous access catheter was placed for
the control group, and aMasimo Set version V7.1.1.5 pulse
oximeter (Masimo Co, Irvine, CA) is put on the index fin-
ger of subjects in PVI group for the continuous monitoring
of PVI. Metoclopramide 10 mg and dexamethasone 8 mg
were given against postoperative nausea and vomiting.

Age (years) 40.07 ± 11.92 36.33 ± 10.80 0.209

Weight (kg) 126.47 ± 15.97 125.20 ± 18.94 0.780 Table 3 Intraoperative lactate levels (mmol/L) (mean ± SD (range))
Height (cm) 169.40 ± 11.42 165.80 ± 14.38 0.287 Control PVI p value
BMI 43.60 ± 4.50 43.07 ± 3.29 0.602 group group
Sex (female/male) 18/12 19/11 0.500 (n = 30) (n = 30)
ASA score II/III 12/18 15/15 0.302
Intraoperative lactate levels ind. 1.27 ± 0.40 1.23 ± 0.36 0.266
Duration of surgery 109.00 ± 33.17 98.00 ± 34.73 0.215
Intraoperative lactate levels 1 h 1.57 ± 0.45 1.37 ± 0.40 0.070
(min)
Intraoperative lactate levels 2 h 1.33 ± 0.37 1.26 ± 0.33 0.640
ASA American Society of Anesthesiologists physical status, BMI body Intraoperative lactate levels 3 h 1.35 ± 0.05 1.33 ± 0.15 0.840
mass index
360 OBES SURG (2018) 28:358–363

Table 4 Postoperative lactate

levels (mmol/l) (mean ± SD Control group (n = 30) PVI group(n = 30) p value
(range))
Postoperative lactate levels 6 h 1.47 ± 0.40 1.33 ± 0.48 0.220
Postoperative lactate levels 12 h 1.43 ± 0.34 1.27 ± 0.40 0.110
Postoperative lactate levels 18 h 1.27 ± 0.31 1.12 ± 0.39 0.090
Postoperative lactate levels 24 h 1.16 ± 0.24 1.08 ± 0.37 0.290
Postoperative lactate levels 36 h 1.07 ± 0.29 0.96 ± 0.23 0.110
Postoperative lactate levels 48 h 1.06 ± 0.42 0.91 ± 0.18 0.080

Control group: Bolus fluid 500 ml (0.9% NaCl or Ringer
Laktat®, Baxter) was administered in anesthesia induction,
followed by continuous infusion of crystalloid 4–8 ml/kg/h. If
mean arterial pressure had been < 65 mmHg or central venous
pressure < 6 mmHg, 250 ml bolus colloid (succinylated gelatin,
Gelofusine®, B. Braun) was administered. This was repeated if
no improvement had been observed. If there had been no re-
sponse to fluid therapy in case of mean arterial pressure of
< 65 mmHg, norepinephrine was given to maintain it above
65 mmHg.
PVI group: Bolus fluid 500 ml (0.9% NaCl or Ringer
Laktat®, Baxter) was administered in anesthesia induction,
followed by continuous infusion of crystalloid 2 ml/kg/h. If
PVI had been measured as > 14% for 5 min, 250 ml bolus colloid
(succinylated gelatin, Gelofusine®, B. Braun) was administered.
This was repeated if PVI had been still > 14%. Norepinephrine
was administered to those with PVI < 14% to maintain mean
arterial blood pressure < 65 mmHg.
Arterial blood samples were taken at the time of skin incision,
at 1-h intervals during surgery, and at postoperative hours 6, 12,
18, 24, 36, and 48. Lactate concentrations were measured by
ABL analyzer (Radiometer, Copenhagen, Denmark). Serum cre-
atinine levels were obtained preoperatively and at postoperative
hours 24 and 48. If intraoperative blood pressure had been re-
corded to decrease by > 20% compared to preoperative reading,
this was regarded as intraoperative hypotension.
Statistical Analysis
SPSS için 22.00 (Statistical Packages for the Social Sciences,
SPPS Inc., Chicago, IL, USA) software pack was used for sta-
tistical analysis. Parametric values were taken as mean ± SD, and
nonparametric values were taken as median (min ± max). For the
inter-group comparison of parametric tests, their distributions
were established and Student’s t test was implemented. Mann-
Whitney U test was applied in nonparametric measurements.
Paired t test and Wilcoxon’s test were carried out for the evalu-
ation of in-group repeated measurements. p < 0.05 was accepted
to be statistically significant.
Results
The study enrolled 60 patients. No significant difference was
detected between the two groups in terms of demographic

Fig. 1 Intraoperative and

postoperative blood lactate levels
OBES SURG (2018) 28:358–363 361

Table 5 Creatinine levels (mg/dl) (mean ± SD (range)) protocols. Ventilation-induced plethysmographic wave form
Control group PVI group p value variations were shown to be directly associated with intravas-
(n = 30) (n = 30) cular volume [12]. To our knowledge, there was no study
regarding use of PVI in GDFT protocol for RYGB surgery
Preoperative creatinine 0.95 ± 0.11 0.99 ± 0.12 0.151 in obesity.
levels
Postoperative creatinine 1.06 ± 0.09 1.04 ± 0.09 0.591
PVI is the calculation of alterations of measured perfusion
levels 24 h index (PI) during respiratory cycle by Masimo Set pulse ox-
Postoperative creatinine 1.10 ± 0.19 1.03 ± 0.20 0.699 imeter (Masimo Co., Irvine, CA) device. PI is the percentage
levels 48 h of amplitude difference between pulsatile infrared signal and
non-pulsatile infrared signal. PVI is calculated by measuring
alterations of PI during respiratory cycle as follows:
characteristics (age, height, weight, body mass index, gender),
PVI = [(PImax − PImin) / PImax] × 100. Some studies showed
ASA scores, and duration of surgery (p > 0.05) (Table 1).
that PVI > 14% was used to predict fluid requirement of pa-
The volume of crystalloid fluid administered intraopera-
tients during the surgery [4, 8]. We also preferred this thresh-
tively was significantly higher in the control group
old value of 14% for our study.
(1499.00 ± 516.87 ml) compared to the PVI group
Dynamic parameters were reported to have lower accuracy in
(1126 ± 234.98 ml). There was no significant difference
predicting the fluid responsiveness when used in patients with
between groups in terms of volume of colloids adminis-
low pulmonary compliance or when tidal volume < 8 ml/kg was
tered (p = 0.36) (Table 2).
administered [18, 19]. For increased elastic resistance of chest
Study groups did not significantly differ in terms of intra-
wall and decreased respiratory compliance in obesity, some stud-
operative and postoperative blood lactate levels (p > 0.05)
ies reported clinical benefits of lung-protective ventilation by
(Tables 3 and 4, Fig. 1).
using low tidal volumes [20, 21]. Since use of lung-protective
No difference was detected between groups in terms of
ventilation may interfere with dynamic parameters in predicting
preoperative and postoperative serum creatinine levels
fluid volumes in obese patients undergoing laparoscopic surgery,
(Table 5, Fig. 2) and mean arterial pressure. Five patients in
we did not include those patients with low pulmonary
PVI group and three patients in the control group received
compliance.
norepinephrine infusion intraoperatively (p > 0.05).
Compared to standard fluid protocols, GDFT protocols were
reported to allow for less fluid infusion intraoperatively [22], and
shorten length of hospital stay, reduce the incidence of surgical
Discussion site infections, and accelerate restoration of bowel movements
and perfusion [23, 24]. In our study, patients who were managed
GDFT protocols were recently developed to avoid excessive with GDFT protocol needed significantly less fluid compared to
fluid loading and improve postoperative patient outcomes. those receiving standard fluid therapy protocol. This was found
Various hemodynamic parameters are utilized to guide these to be consistent with the literature [25].

Fig. 2 Creatinine levels

362
Despite less volume of fluid administered intraoperatively
in GDFT group, renal functions measured at hours 24 and 48
were not different between the groups. This may originate
from improved renal perfusion by colloidal solution adminis-
tered to both groups during laparoscopy. In physiological per-
spective, hemodynamic stabilization with colloids results in
lower volume of fluid in a short period of time in the clinical
setting of tissue hypoperfusion and relative hypovolemia. In
addition, recent reports in the literature regarding GDFT sug-
gested no significant differences between intraoperative use of
colloids and crystalloids in terms of complication rates [26,
27].
Finding of no significant difference in terms of lactate
levels may be questioned considering small number of the
subjects in our study. However, it may also be explained by
distinctively designed fluid management in each group (4–
8 ml/kg/h in the control group, whereas 2 ml/kg/h in the PVI
group). We believe that this may further be influenced by
different practices used when mean arterial pressure decreases
below 65 mmHg: administration of norepinephrine alone in
the PVI group vs. bolus colloid and norepinephrine in the
control group. Detection of no difference in terms of lactate
levels in the PVI group subjects although they received less
crystalloid may be attributed to the individualized fluid man-
agement in this group.
Most of the bariatric interventions are performed with a
laparoscopic approach. Laparoscopy requires abdominal
insufflation of CO2 for intra-abdominal pressures up to
15 mmHg. As long as the intra-abdominal pressure ele-
vates, venous stasis increases, intraoperative portal venous
blood flow, intraoperative urinary output, and respiratory
compliance are reduced, airway pressure increases, and car-
diac function is impaired [28]. Intraoperative management
to minimize adverse effects of pneumoperitoneum includes
appropriate ventilator support to avoid hypercapnia and ac-
idosis, and optimization of intravascular volume to mini-
mize effects of elevated intra-abdominal pressure on renal
and cardiac functions. Apart from direct effects of the lap-
aroscopy, morbidly obese patients that would undergo sur-
gical procedure are also at risk of muscle injury, which, in
turn, may result in rhabdomyolysis, serious electrolyte dis-
turbance, cardiac arrhythmias, and acute renal failure.
Though aggressive fluid replacement is the mainstay for
the management of rhabdomyolysis, it is still contradictory
whether or not liberal perioperative fluid therapy will pre-
vent rhabdomyolysis. No difference was reported in the
incidence of rhabdomyolysis between bariatric surgery pa-
tients receiving either liberal or conservative crystalloid
fluid therapy [29].
Administration of each liter of extra fluid added on the given
fluids intraoperatively was reported to increase the risk of post-
operative symptoms and complications by 16 and 32%, respec-
tively [30]. Therefore, appropriateness of fluid responsiveness
OBES SURG (2018) 28:358–363
was studied for many years, and it was reported that dynamic
measurements based on the cardiopulmonary interactions in me-
chanically ventilated patients were one of the best predictors of
the fluid response [31, 32]. This suggests that there is a need for
investigating and developing of automatized and continuous
dynamic measurements [33].
Conclusion
In conclusion, utilization of GDFT protocols based on PVI
may prevent excessive intraoperative infusion of fluids in lap-
aroscopic bariatric surgery. This method when intending to
prevent intraoperative excessive fluid loading in RYGB sur-
gery appears to have no effect on either renal functions or
lactate levels. While this study shows the adequacy of PVI
for fluid therapy in mechanically ventilated patients undergo-
ing bariatric surgery, further research is warranted to assess
adequacy of optimization of PVI.
Compliance with Ethical Standards The study was approved by the
local ethics prior to conduction of the study. The study was approved by
the Ethics Committee for Non-Interventional Trials of Firat University.
Conflict of Interest The authors declare that they have no conflict of
interest.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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