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intraoperative management to prevent induction-induced hypotension (references are shown in the UMIN-CTR supplement at www.umin.ac.jp/ctr/index.htm) [1,2]. Oral rehydration and infusion management during the perioperative period have been recommended for earlier recovery; however, preoperative management with more than 4 h of oral fluid restriction is not realistic [3]. The relationship between the duration of fluid intake restriction and the volume deficit is not fully understood. The stroke volume variation (SVV) is an index of circulating blood volume [4]. We hypothesized that the preoperative volume deficit associated with a 2 h oral intake restriction is smaller than that associated with a 4 h restriction. We tested this hypothesis using the SVV following anesthetic induction. After approval of the study protocol and registration (UMIN5696), we conducted an assessor-blinded randomized controlled trial from June 2011 to November 2012. All patients with American Society of Anesthesiologists physical status I or II undergoing elective otolaryngological or breast surgery were enrolled. Written informed consent was obtained from all patients. Using an envelope method, the patients were randomly assigned to restriction of clear liquid intake for either 2 h (short-period group [SG]) or 4 h (long-period group [LG]). Exclusion criteria are shown in the UMIN-CTR supplement. Intake of solid foods was discontinued 6 h before anesthesia. Until 2 or 4 h before anesthetic induction, all patients were allowed unlimited oral fluids. Anesthesia management is described in the UMIN-CTR supplement. Anesthesia was maintained with propofol and remifentanil. The inspiratory pressure was adjusted to 12–15 cmH2O, with tidal volume 6–10 ml/kg to maintain an arterial carbon dioxide partial pressure of 35–40 mmHg. An arterial catheter was inserted and connected to a FloTrac sensor version 3.02 (Edwards Lifesciences, USA). When the SVV had stabilized, the patients received an infusion of 6% hydroxyl starch solution (Hespander; Fresenius Kabi, Japan) at a constant rate of 1,000 ml per 60 min using an infusion pump (Terufusion TE-161S; Terumo Corp., Japan). We chose a starch for fluid resuscitation in this study because of the volume remaining in the intravascular space. The cardiac index, stroke volume index, and SVV were recorded automatically until the end of anesthesia. The next day, a blinded investigator estimated the required duration needed to decrease the SVV to < 13% with the collected data and calculated the required infusion amount. If the Letter to the Editor

korean journal of anesthesiology

Effect of two- or four-hour oral intake restriction on intraoperative intravascular volume optimization using stroke volume variation analysis: a single-blinded randomized controlled trial