Crystalloid administration among patients undergoing liver surgery: Defining patient- and provider-level variation.
BACKGROUND
Fluid administration among patients undergoing liver resection is a key aspect of perioperative care. We sought to examine practice patterns of crystalloid administration, as well as potential factors associated with receipt of crystalloid fluids.


METHODS
Patients who underwent liver resection between 2010 and 2014 were identified. Data on clinicopathologic variables, operative details, and perioperative fluid administration were collected and analyzed using univariable and multivariable analyses; variation in practice of crystalloid administration was presented as coefficient of variation (COV).


RESULTS
Among 487 patients, median crystalloid administered at the time of surgery was 4,000 mL. After adjusting for body size and operative duration, median corrected crystalloid was 30.0 mL kg(-1) m(2) h(-1), corresponding with a COV of 35%. Patients who received <30 mL kg(-1) m(2) h(-1) crystalloids were more likely to be younger (58 vs 60 years), white (79% vs 74%), and have a higher body mass index (BMI; 28.2 vs 25.4 kg/m(2); all P < .001). On multivariable analysis, increasing Charlson comorbidity index, BMI, estimated blood loss, and each additional hour of surgery were all associated with increased crystalloid administration (all P < .05). Corrected crystalloid administration varied among providers with a corrected COV ranging from 14% to 61%. When overall variation in crystalloid administration was assessed, 80% of the variation occurred at the patient level, and 20% occurred at the provider level (surgeon, 3% vs anesthesiologist, 17%).


CONCLUSIONS
There was wide variability in crystalloid administration among patients undergoing liver resection. Although the majority of variation was attributable to patient factors, a large amount of residual variation was attributable to provider-level differences.
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Yuhree
Y
Kim
Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL.
Aslam
A
Ejaz
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Faiz
F
Gani
Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.
Jack O
JO
Wasey
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Li
L
Xu
Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.
Steven M
SM
Frank
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address: tpawlik1@jhmi.edu.
Timothy M
TM
Pawlik
D000328:Adult; D000368:Aged; D000077324:Crystalloid Solutions; D005260:Female; D005440:Fluid Therapy / Q000379:methods* / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006498:Hepatectomy; D006801:Humans; D007552:Isotonic Solutions / Q000627:therapeutic use*; D008297:Male; D008396:Maryland; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D015532:Rehydration Solutions / Q000627:therapeutic use*; D012189:Retrospective Studies
D000077324:Crystalloid Solutions; D007552:Isotonic Solutions; D015532:Rehydration Solutions