The Risk of Acute Kidney Injury from Fluid Restriction and Hydroxyethyl Starch in Thoracic Surgery

Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary PeriOperative Quality Initiative

Fluid therapy is an integral component of perioperative management. In light of emerging evidence in this area, the Perioperative Quality Initiative (POQI) convened an international multiprofessional expert meeting to generate evidence-based consensus recommendations for fluid management in patients undergoing surgery. This article provides a summary of the recommendations for perioperative fluid management of surgical patients from the preoperative period until hospital discharge and for all types of elective and emergency surgery, apart from burn injuries and head and neck surgery. Where evidence was lacking, recommendations for future research were generated. Specific recommendations are made for fluid management in elective major noncardiac surgery, cardiopulmonary bypass, thoracic surgery, neurosurgery, minor noncardiac surgery under general anaesthesia, and critical illness. There are ongoing gaps in knowledge resulting in variation in practice and some disagreement with our consensus recommendations. Perioperative fluid management should be individualised, taking into account the type of surgery and important patient factors, including intravascular volume status and acute and chronic comorbidities. Recommendations are made for further research in perioperative fluid management to address important gaps.

The impact of goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing thoracic surgery: a systematic review and meta-analysis

BACKGROUND

Pulmonary complications after thoracic surgery are common and associated with significant morbidity and high cost of care. Goal-directed fluid therapy (GDFT) could reduce the incidence of postoperative pulmonary complications (PPCs) and facilitate recovery in patients undergoing major abdominal surgery. However, whether GDFT could reduce the incidence of PPCs in patients undergoing thoracic surgery was unclear. The present meta-analysis was designed to assess the impact of Goal-directed Fluid Therapy on PPCs in patients undergoing thoracic surgery.

METHODS

Randomized controlled trials (RCTs) comparing GDFT with other conventional fluid management strategies in adult patients undergoing thoracic surgery were identified. Databases searched included PubMed, Web of Science, Embase, and Cochrane Library databases. Review Manager 5.4 (The Cochrane Collaboration, Oxford, UK) software was used for statistical analysis. Heterogeneity was analyzed using I2 statistics, and a standardized mean difference with 95% CI and P value was used to calculate the treatment effect for outcome variables. The primary study outcomes were the incidence of PPCs. Secondary outcomes were the total volume infused, the length of hospitalization, the incidence of cardiac complications, and the incidence of renal dysfunction. Subgroup analysis was planned to verify the definite role of GDFT.

RESULTS

A total of 6 RCTs consisting of 680 patients were included in this meta-analysis, which revealed that GDFT did not reduce the incidence of PPCs in patients undergoing thoracic surgery (RR, 0.57; 95% CI 0.29-1.14). However, GDFT decreased the total intra-operative fluid input (MD, - 244.40 ml; 95% CI - 397.06 to - 91.74). There was no statistical difference in the duration of hospitalization (MD; - 1.31, 95% CI - 3.00 to 0.38), incidence of renal dysfunction (RR, 0.62; 95% CI 0.29-1.35), and incidence of cardiac complications (RR, 0.62; 95% CI 0.27-1.40).

CONCLUSIONS

The results of this meta-analysis indicate that GDFT did not reduce the postoperative incidence of pulmonary complications in individuals undergoing thoracic surgery. However, considering the small number of contributing studies, these results should be interpreted with caution.

The effect of intraoperative goal-directed fluid therapy combined with enhanced recovery after surgery program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection: a prospective randomized controlled study

BACKGROUND

To investigate the effect of intraoperative goal-directed fluid therapy (GDFT) combined with enhanced recovery after surgery (ERAS) program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection.

METHODS

Patients, more than 60 years old, undergoing thoracoscopic pulmonary resection for non-small cell lung cancer were randomly divided into GDFT group and restrictive fluid therapy (RFT) group. ERAS program was implemented in all patients. In GDFT group, the intraoperative fluid management was guided by stroke volume variation (SVV), cardiac index (CI), and mean arterial pressure (MAP) and maintained the SVV < 13%, CI > 2.5 L/min/m², and MAP > 65 mmHg. In RFT group, fluid maintenance with 2 ml/kg/h of balanced crystalloid solution, norepinephrine was used to maintain MAP > 65 mmHg. The incidence of postoperative acute kidney injury (AKI) and pulmonary and cardiac complications was compared.

RESULTS

Two-hundred seventy-six patients were enrolled and randomly divided into two groups (138 in each group). Compared to RFT group, the total intraoperative infusion volume, colloids infusion volume, and urine output were more; the dosage of norepinephrine was lower in GDFT group. Although there were no significant differences of postoperative AKI (GDFT vs RFT; 4.3% vs 8%; P = 0.317) and composite postoperative complications (GDFT vs RFT; 66 vs 70) between groups, but the postoperative increase degree of serum creatinine was lower in GDFT group than that in RFT group (GDFT vs RFT; 91.9 ± 25.2 μmol/L vs 97.1 ± 17.6 μmol/L; P = 0.048).

CONCLUSIONS

Under ERAS program, there was no significant difference of AKI incidence between GDFT and RFT in elderly patients undergoing thoracoscopic pulmonary resection. But postoperative increase degree of serum creatinine was lower in GDFT group.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov, NCT04302467 on 26 February 2020.

Acute Kidney Injury After General Thoracic Surgery: A Systematic Review and Meta-analysis

INTRODUCTION

The clinical importance of postoperative acute kidney injury (AKI) in patients undergoing general thoracic surgery is unclear. We aimed to systematically review the incidence, risk factors, and prognostic implications of AKI as a complication after general thoracic surgery.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library from January 2004 to September 2021. Observational or interventional studies that enrolled ≥50 patients undergoing general thoracic surgery and reported postoperative AKI defined using contemporary consensus criteria were included for meta-analysis.

RESULTS

Thirty-seven articles reporting 35 unique cohorts were eligible. In 29 studies that enrolled 58,140 consecutive patients, the pooled incidence of postoperative AKI was 8.0% (95% confidence interval [CI]: 6.2-10.0). The incidence was 3.8 (2.0-6.2) % after sublobar resection, 6.7 (4.1-9.9) % after lobectomy, 12.1 (8.1-16.6) % after bilobectomy/pneumonectomy, and 10.5 (5.6-16.7) % after esophagectomy. Considerable heterogeneity in reported incidences of AKI was observed across studies. Short-term mortality was higher (unadjusted risk ratio: 5.07, 95% CI: 2.99-8.60) and length of hospital stay was longer (weighted mean difference: 3.53, 95% CI: 2.56-4.49, d) in patients with postoperative AKI (11 studies, 28,480 patients). Several risk factors for AKI after thoracic surgery were identified.

CONCLUSIONS

AKI occurs frequently after general thoracic surgery and is associated with increased short-term mortality and length of hospital stay. For patients undergoing general thoracic surgery, AKI may be an important postoperative complication that needs early risk evaluation and mitigation.

Incidence and Associations of Acute Kidney Injury after General Thoracic Surgery: A System Review and Meta-Analysis

(1) Background: Acute kidney injury (AKI) is related to adverse outcomes in critical illness and cardiovascular surgery. In this study, a systematic literature review and meta-analysis was carried out to evaluate the incidence and associations of AKI as a postoperative complication of thoracic (including lung resection and esophageal) surgical procedures. (2) Methods: Adopting a systematic strategy, the electronic reference databases (PubMed, EMBASE, and Cochrane Library) were searched for articles researching postoperative renal outcomes that were diagnosed using RIFLE, AKIN or KDIGO consensus criteria in the context of a thoracic operation. A random-effects model was applied to estimate the incidence of AKI and, where reported, the pooled relative risk of mortality and non-renal complications after AKI. The meta-analysis is registered in PROSPERO under the number CRD42021274166. (3) Results: In total, 20 studies with information gathered from 34,826 patients after thoracic surgery were covered. Comprehensively, the incidence of AKI was estimated to be 8.8% (95% CI: 6.7−10.8%). A significant difference was found in the mortality of patients with and without AKI (RR = 2.93, 95% CI: 1.79−4.79, p < 0.001). Additionally, in patients experiencing AKI, cardiovascular and respiratory complications were more common (p = 0.01 and p < 0.001, respectively). (4) Conclusions: AKI is a common complication associated with adverse outcomes following general thoracic surgery. An important issue in perioperative care, AKI should be considered as a highly significant prognostic indicator and an attractive target for potential therapeutic interventions, especially in high-risk populations.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Should fluid management in thoracic surgery be goal directed?

PURPOSE OF REVIEW

To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed?

RECENT FINDINGS

'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks.

SUMMARY

Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

Restricted, optimized or liberal fluid strategy in thoracic surgery: A narrative review

Perioperative fluid balance has a major impact on clinical and functional outcome, regardless of the type of interventions. In thoracic surgery, patients are more vulnerable to intravenous fluid overload and to develop acute respiratory distress syndrome and other complications. New insight has been gained on the mechanisms causing pulmonary complications and the role of the endothelial glycocalix layer to control fluid transfer from the intravascular to the interstitial spaces and to promote tissue blood flow. With the implementation of standardized processes of care, the preoperative fasting period has become shorter, surgical approaches are less invasive and patients are allowed to resume oral intake shortly after surgery. Intraoperatively, body fluid homeostasis and adequate tissue oxygen delivery can be achieved using a normovolemic therapy targeting a “near-zero fluid balance” or a goal-directed hemodynamic therapy to maximize stroke volume and oxygen delivery according to the Franck–Starling relationship. In both fluid strategies, the use of cardiovascular drugs is advocated to counteract the anesthetic-induced vasorelaxation and maintain arterial pressure whereas fluid intake is limited to avoid cumulative fluid balance exceeding 1 liter and body weight gain (~1-1.5 kg). Modern hemodynamic monitors provide valuable physiological parameters to assess patient volume responsiveness and circulatory flow while guiding fluid administration and cardiovascular drug therapy. Given the lack of randomized clinical trials, controversial debate still surrounds the issues of the optimal fluid strategy and the type of fluids (crystalloids versus colloids). To avoid the risk of lung hydrostatic or inflammatory edema and to enhance the postoperative recovery process, fluid administration should be prescribed as any drug, adapted to the patient's requirement and the context of thoracic intervention.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Tailored anaesthesia for thoracoscopic surgery promoting enhanced recovery: The state of the art

PURPOSE OF THE REVIEW

The current review focuses on precise anaesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. The main aim of an enhanced recovery program after thoracic surgery is to reduce postoperative stress response, protect from postoperative pulmonary complications, give hospitals a better financial option and improve overall patient outcome. This can ultimately reduce hospital stay and increase patient satisfaction. With advances in endoscopic, robotic and endovascular techniques, video-assisted thoracoscopic surgery (VATS) can be performed in a minimally invasive way in managing most pulmonary, pleural and mediastinal diseases. As a minimally invasive technique, video-assisted thoracoscopic surgery (VATS) represents an important element of enhanced recovery program in thoracic surgery as it can achieve most of its goals. Anaesthetic management during preoperative, intraoperative and postoperative period is essential for the establishment of a successful enhanced recovery program. In the era of enhanced recovery protocols, non-intubated thoracoscopic procedures present a step forward. This article focuses on the key anaesthetic elements of the enhanced recovery program during all phases of thoracoscopic surgery. Having reviewed recent literature, a systematic review of literature will highlight successful ERAS protocols published for thoracoscopic surgery.

Minimizing postoperative pulmonary complications in thoracic surgery patients

PURPOSE OF REVIEW

Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery.

RECENT FINDINGS

There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy.

SUMMARY

The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy combined with enhanced recovery after surgery protocol on complications after thoracoscopic lobectomy in high-risk patients: study protocol for a prospective randomized controlled trial

BACKGROUND

Acute kidney injury (AKI) is a common complication after thoracoscopic lobectomy in high-risk patients due to insufficient intraoperative infusion. Goal-directed fluid therapy (GDFT) is an individualized fluid infusion strategy; the fluid infusion strategy is adjusted according to the patient's fluid response. GDFT during operation can reduce the incidence of AKI after major surgery. Enhanced recovery after surgery (ERAS) protocol optimizes perioperative interventions to decrease the postoperative complications after surgery. In ERAS protocol of lobectomy, intraoperative restrictive fluid therapy is recommended. In this study, we will compare the effects of intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients.

METHODS/DESIGN

This is a prospective single-center single-blind randomized controlled trial. Two hundred seventy-six patients scheduled for thoracoscopic lobectomy are randomly allocated to receive either GDFT or restrictive fluid therapy combined with an ERAS protocol at a 1:1 ratio. The primary outcome is the incidence of AKI after operation. The secondary outcomes include (1) the incidence of renal replacement therapy, (2) the length of intensive care unit stay after operation, (3) the length of hospital stay after operation, and (4) the incidence of other complications including infection, acute lung injury, pneumonia, arrhythmia, heart failure, myocardial injury after noncardiac surgery, and cardiac infarction.

DISCUSSION

This is the first study to compare intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients. The hypothesis is that the restrictive fluid therapy is noninferior to GDFT in reducing the incidence of AKI, but restrictive fluid therapy is simpler to apply than GDFT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04302467 . Registered on 26 February 2020.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Intraoperative Intravascular Effect of Lactated Ringer's Solution and Hyperoncotic Albumin During Hemorrhage in Cystectomy Patients

BACKGROUND

The intraoperative effect of 20% albumin on plasma volume during surgery involving major blood loss has not been explored extensively due to methodological difficulties. Crystalloids poorly expand the plasma volume, and using a colloid might then be a way to avoid fluid overload. As doubts have been raised about synthetic colloids, albumin solutions are currently used more extensively. This study presents a methodological development showing how plasma volume expansion can be studied in surgical settings with the coinfusion of 20% albumin and lactated Ringer's solution.

METHODS

In this single-arm, single-center feasibility study, an intravenous (i.v.) infusion of 3 mL·kg·BW-1 of 20% albumin was administered over 30 minutes to 23 cystectomy patients during the bleeding phase in addition to lactated Ringer's solution to correct blood loss. Blood samples were measured at regular intervals over a period of 300 minutes to estimate the blood volume expansion resulting from simultaneous infusions of lactated Ringer's and 20% albumin solutions, using a regression equation and the area under the volume-time curve method.

RESULTS

Mean hemorrhage was 974 mL (standard deviation [SD] ± 381). The regression method showed strong correlation (r2 = 0.58) between blood loss minus blood volume expansion and the independent effects of the infused volume of lactated Ringer's and 20% albumin solutions. The mean plasma volume expansion attributable to the infusion of lactated Ringer's solution amounted to 0.38 (95% confidence interval [CI], 0.31-0.49) of the infused volume; for the 20% albumin, it was 1.94 mL/mL (95% CI, 1.41-2.46 mL/mL) over 5 hours on average (regression method). The mean within-patient change was 0.20 mL/mL (± 0.06 mL/mL) for the lactated Ringer's solution and 2.20 mL/mL (±1.31 mL/mL) for the 20% albumin using the area under the volume-time curve method.

CONCLUSIONS

Blood volume expansion averaged 1.9-2.2 times the infused volume of 20% albumin during surgery associated with hemorrhage of around 1000 mL. This effect was long standing and approximately 5 times stronger than for the lactated Ringer's solution. Twenty percent albumin boosts the plasma volume expansion of lactated Ringer's solution to as high as 40% of the infused volume on the average, which is an effect that lasts at least 5 hours.

Intraoperative Anesthetic Management of the Thoracic Patient

The intraoperative anesthetic management for thoracic surgery can impact a patient's postoperative course, especially in patients with significant lung disease. One-lung ventilation poses an inherent risk to patients, including hypoxemia, acute lung injury, and right ventricular dysfunction. Patient-specific ventilator management strategies during one-lung ventilation can reduce postoperative morbidity.

Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study

Restrictive fluid management has been recommended for thoracic surgery. However, specific guidelines are lacking, and there is always concern regarding impairment of renal perfusion with a restrictive policy. The objective of this study was to find the net intraoperative fluid infusion rate which shows the lowest incidence of composite complications (either pulmonary complications or acute kidney injury) in open thoracotomy. We hypothesized that a certain range of infusion rate would decrease the composite complications within postoperative 30 days. All patients (n = 1,031) who underwent open thoracotomy at a tertiary care university hospital were included in this retrospective study. The time frame of fluid monitoring was from the start of operation to postoperative 24 hours. The cutoff value of the intraoperative net fluid amount was 4–5 ml.kg⁻¹.h⁻¹ according to the minimum p-value method, thus, patients were divided into Low (≤3 ml.kg⁻¹.h⁻¹), Cutoff (4–5 ml.kg⁻¹.h⁻¹) and High (≥6 ml.kg⁻¹.h⁻¹) groups. The Cutoff group showed the lowest composite complication rate (19%, 12%, and 13% in the Low, Cutoff, and High groups, respectively, P = 0.0283; Low vs. Cutoff, P = 0.0324, Bonferroni correction). Acute respiratory distress syndrome occurred least frequently in the Cutoff group (7%, 3%, and 6% for the Low, Cutoff, and High groups, respectively, P = 0.0467; Low vs. Cutoff, P = 0.0432, Bonferroni correction). In multivariable analysis, intraoperative net fluid infusion rate was associated with composite complications, and the Cutoff group decreased risk (odds ratio 0.54, 95% confidence interval: 0.35–0.81, P = 0.0035). In conclusion, maintaining intraoperative net fluid infusion at 4–5 ml.kg⁻¹.h⁻¹ was associated with better results in open thoracotomy, in terms of composite complications, compared to more restrictive fluid management.

lntraoperative administration of 6% hydroxyethyl starch 130/0.4 is not associated with acute kidney injury in elective non-cardiac surgery: A sequential and propensity-matched analysis

BACKGROUND

Intraoperative use of hydroxyethyl starch (HES) may increase the risk of postoperative acute kidney injury (AKI). Data from large populations are lacking. We aimed to assess whether intraoperative administration of 6% HES 130/0.4 is associated with AKI in non-cardiac surgery.

METHODS

This retrospective study used the electronic records concerning elective abdominal, urologic, thoracic and peripheral vascular surgeries from 2010 to 2015. HES and non-HES patients were compared using a propensity score matching. Postoperative AKI, defined by stage 3 of the Kidney Disease Improving Global Outcomes (KDIGO) score, was the primary outcome. Because the use of HES markedly decreased in 2013, additional analyses, restricted to the 2010-2012 period, were also performed.

RESULTS

In total, 23,045, and 11,691 patients were included in the whole, and restricted periods, respectively. The reduction in HES use was not accompanied by any change in the incidence of AKI. Unadjusted association between HES and KDIGO 3 AKI was significant (OR [95% CI] of 2.13 [1.67, 2.71]). For the whole period, 6460 patients were matched. Odd ratios for KDIGO 3 and all-stage AKI when using HES (10.3±4.7mL.kg^-1) were 1.20 (95% CI [0.74, 1.95]), and 1.21 (95% CI [0.95, 1.54]), respectively. There was no association with the initiation of renal replacement therapy or in-hospital mortality either. Similar results were found for the restricted period.

CONCLUSION

The intraoperative use of moderate doses of 6% HES 130/0.4 was not associated with increased risk of AKI. No conclusion can be drawn for higher doses of HES.

Epidural analgesia and avoidance of blood transfusion are associated with reduced mortality in patients with postoperative pulmonary complications following thoracotomic esophagectomy: a retrospective cohort study of 335 patients

Background

Postoperative pulmonary complications (PPCs) represent the most frequent complications after esophagectomy. The aim of this study was to identify modifiable risk factors for PPCs and 90-days mortality related to PPCs after esophagectomy in esophageal cancer patients.

Methods

This is a single center retrospective cohort study of 335 patients suffering from esophageal cancer who underwent esophagectomy between 1996 and 2014 at a university hospital center. Statistical processing was conducted using univariate and multivariate stepwise logistic regression analysis of patient-specific and procedural risk factors for PPCs and mortality.

Results

The incidence of PPCs was 52% (175/335) and the 90-days mortality rate of patients with PPCs was 8% (26/335) in this study cohort. The univariate and multivariate analysis revealed the following independent risk factors for PPCs and its associated mortality. ASA score ≥ 3 was the only independent patient-specific risk factor for the incidence of PPCs and 90-days mortality of patients with an odds ratio for PPCs being 1.7 (1.1–2.6 95% CI) and an odds ratio of 2.6 (1.1–6.2 95% CI) for 90-days mortality. The multivariate approach depicted two independent procedural risk factors including transfusion of packed red blood cells (PRBCs) odds ratio of 1.9 (1.2–3 95% CI) for PPCs and an odds ratio of 5.0 (2.0–12.6 95% CI) for 90-days mortality; absence of thoracic epidural anesthesia (TEA) revealed the highest odds ratio 2.0 (1.01–3.8 95% CI) for PPCs and an odds ratio of 3.9 (1.6–9.7 95% CI) for 90-days mortality.

Conclusion

In esophageal cancer patients undergoing esophagectomy via thoracotomy, epidural analgesia and the avoidance of intraoperative blood transfusion are significantly associated with a reduced 90-days mortality related to PPCs.

[Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study]

BACKGROUND AND OBJECTIVES

Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury.

METHODS

We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. Acute kidney injury was diagnosed within 48h of surgery based estabilished criteria for its diagnosis. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality.

RESULTS

The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery, but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89pg.mL^-1).

CONCLUSIONS

Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.

Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study

Background and objectives

Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury.

Methods

We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation periods. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. acute kidney injury was diagnosed within 48 h of surgery based on acute kidney injury criteria. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality.

Results

The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6 h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89 pg.mL⁻¹).

Conclusions

Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.

Application of standardized hemodynamic protocols within enhanced recovery after surgery programs to improve outcomes associated with anastomotic leak and conduit necrosis in patients undergoing esophagectomy

Esophagectomy for cancer is associated with high risk for postoperative morbidity. The most serious regularly encountered complication is anastomotic leak and the most feared individual complication is conduit necrosis. Both of these complications affect the length of stay, mortality, quality of life, and survival for patients undergoing esophageal resection. The maintenance of conduit viability is of primary importance in the perioperative care of patients following esophageal resection. It has been shown that restrictive fluid management may be associated with improved postoperative outcomes in abdominal and other types of surgery, but many factors can affect the incidence of anastomotic leak and the viability of the gastric conduit. We have performed a comprehensive review with the aim to give an overview of the available evidence for the use of standardized hemodynamic protocols (SHPs) for esophagectomy and review the hemodynamic protocol, which has been applied within a standardized clinical pathway (SCP) at the Department of Thoracic surgery at the Virginia Mason Medical Center between 2004-2018 where the anastomotic leak rate over the period has been 5.2% and the incidence of conduit necrosis requiring surgical management is zero. The literature review demonstrates that there are few high quality studies that provide scientific evidence for the use of a SHP. The evidence indicates that the use of goal-directed hemodynamic monitoring might be associated with a reduced risk for postoperative complications, shortened length of stay, and decreased need for intensive care unit stay. We propose that the routine application of a SHP can provide a uniform infrastructure to optimize conduit perfusion and decrease the incidence of anastomotic leak.

Understanding the Harms of HES: A Review of the Evidence to Date

Intravenous (IV) fluid resuscitation is one of the most common interventions in intensive care medicine. Despite clear guidelines, the choice of IV fluid is largely dependent on physician preference instead of high-quality evidence of efficacy and safety. This is particularly the case for synthetic colloids, such as hydroxyethyl starch (HES). The use of HES in critical care has been associated with increased rates of acute kidney injury (AKI), renal replacement therapy and mortality. In light of this, current guidelines and scientific and regulatory bodies do not recommend the use of HES for fluid therapy in critical illness and caution against its use in many other settings. Despite this, HES products are still debated and used. Awareness of the indications, contraindications, doses, benefits and adverse effects for IV fluids, as well as recommendations from scientific and regulatory bodies, is essential to guarantee patients' safety. Poor awareness of optimal IV fluid therapy has recently been revealed in some countries including Turkey. Therefore, we provide a review of fluids used for resuscitation, discuss safety data and adverse effects of HES, such as increased AKI and mortality, and discuss recent updates from scientific and regulatory bodies in order to raise awareness of fluid therapy. We conclude that given the lack of a clear benefit of HES in any clinical setting and the availability of safer alternatives, such as crystalloids and albumin, HES should be avoided.

Heated humidified high-flow nasal oxygen prevents intraoperative body temperature decrease in non-intubated thoracoscopy

PURPOSE

In patients receiving non-intubated video-assisted thoracic surgery (NIVATS), transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has been applied instead of oxygen mask for better oxygenation. However, the THRIVE effects on intraoperative temperature decrease have not been investigated.

METHODS

Pre- and postoperative temperatures, measured by an infrared tympanic ear thermometer, taken before sending patients to the operation room and immediately upon their arrival in the postoperative anesthesia unit, were collected from medical records of patients who received NIVATS either with oxygen mask or THRIVE. Intraoperative temperature decrease, calculated by preoperative temperature minus postoperative temperature, was compared between different groups. Multiple linear regression analysis was performed to determine factors associated with intraoperative temperature decrease.

RESULTS

Records of 256 adult patients with forced-air warming were retrospectively analyzed. 172 patients of them received THRIVE and 84 patients received oxygen mask. Preoperative temperatures were comparable between groups (THRIVE: 36.25 ± 0.46 °C; mask: 36.30 ± 0.39 °C, p = 0.43). Postoperative temperatures were significantly higher in patients using THRIVE than those using oxygen masks (36.05 ± 0.59 vs 35.87 ± 0.62 °C, p = 0.025). Significantly less intraoperative temperature decrease was shown in THRIVE group (THRIVE: 0.20 ± 0.69 °C; mask: 0.43 ± 0.69 °C, p = 0.04). According to the multiple linear regression analysis, significant temperature decrease was associated with the advanced age (β_age = 0.01) but not the anesthetic duration. Using THRIVE was correlated with significantly less body temperature decrease (β_TRIVE = - 0.24).

CONCLUSIONS

THRIVE effectively prevents intraoperative temperature decrease during NIVATS, especially in old patients.

Anaesthesia management for bronchoscopic and surgical lung volume reduction

Optimizing the patient's condition before the lung volume reduction (LVR) according to recommendations by American College of Cardiology/American Heart Association (ACC/AHA) guideline on perioperative cardiovascular evaluation is mandatory. Implementation of a multimodal analgesia concept and the use short-acting anaesthetics enhances recovery and avoids postoperative pulmonary complications. Normovolemia, normothermia, lung protective ventilation and an evidence-based concept of airway management (i.e., double-lumen tube, bronchus blocker) are suggested for intraoperative management of surgical lung volume reduction (SLVR). General anaesthesia (using remifentanil, propofol and mivacurium) with an i-gel^® supraglottic airway device should be used for bronchoscopic lung volume reduction (BLVR). Jet ventilation through rigid bronchoscopy or with a jet catheter may be an alternative concept. Experienced consultants should perform anaesthesia for LVR.

Update on perioperative acute kidney injury

PURPOSE OF REVIEW

In this review, we discuss the latest updates on perioperative acute kidney injury (AKI) and the specific considerations that are relevant to different surgeries and patient populations.

RECENT FINDINGS

AKI diagnosis is constantly evolving. New biomarkers detect AKI early and shed a light on the possible cause of AKI. Hypotension, even for a short duration, is associated with perioperative AKI. The debate on the deleterious effects of chloride-rich solutions is still far from conclusion. Remote ischemic preconditioning is showing promising results in the possible prevention of perioperative AKI. No definite data show a beneficiary effect of statins, fenoldepam, or sodium bicarbonate in preventing AKI.

SUMMARY

Perioperative AKI is prevalent and associated with significant morbidity and mortality. Considering the lack of effective preventive or therapeutic interventions, this review focuses on perioperative AKI: measures for early diagnosis, defining risks and possible mechanisms, and summarizing current knowledge for intraoperative fluid and hemodynamic management to reduce risk of AKI.

Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice

In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniques should be favored over intravenous analgesia: the thoracic epidural, the paravertebral block (PVB), the intercostal nerve block (ICNB), and the serratus anterior plane block (SAPB) are thoroughly reviewed and the most common dosages are reported. Fluid therapy needs to be administered critically, to avoid both overload and cardiovascular compromisation. All these practices are analyzed singularly with the aid of the most recent evidences aimed at the best patient care. Finally, a few notes on some of the latest trends in research are presented, such as non-intubated video-assisted thoracoscopic surgery (VATS) and intravenous lidocaine.

Association Between Elevated Echocardiographic Index of Left Ventricular Filling Pressure and Acute Kidney Injury After Off-Pump Coronary Artery Surgery

BACKGROUND

The ratio of the early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') is an echocardiographic index of mean left ventricular (LV) filling pressure. We investigated the association between the preoperative E/e' ratio and postoperative acute kidney injury (AKI) during off-pump coronary artery bypass surgery (OPCAB).

METHODS AND RESULTS

We reviewed 585 patients who underwent OPCAB and with preserved LV ejection fraction determined by preoperative echocardiography. AKI was determined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression analysis was performed. E/e' was also analyzed as 3 categories (E/e' <8, 8≤E/e'≤15, and E/e' >15) and as a continuous variable. A propensity score analysis was used to match the patients with E/e' >15 and E/e' ≤15. A preoperative E/e' >15 was an independent predictor for AKI (odds ratio 3.01, 95% confidence interval 1.40-6.17). E/e' >15 was also an independent predictor for AKI when E/e' was analyzed with 3 categories or as a continuous variable. In the matched sample, the incidence of AKI and 1-year mortality was significantly higher in patients with E/e' >15.

CONCLUSIONS

Among patients undergoing OPCAB with preserved LV systolic function, a preoperative E/e' ratio >15 was an independent predictor of postoperative AKI. Measurement of the preoperative E/e' ratio may help to assess the risk of postoperative AKI.

Enhanced Recovery in Thoracic Surgery: A Review

The main goal of enhanced recovery program after thoracic surgery is to minimize stress response, reduce postoperative pulmonary complications, and improve patient outcome, which will in addition decrease hospital stay and reduce hospital costs. As minimally invasive technique, video-assisted thoracoscopic surgery represents an important element of enhanced recovery program in thoracic surgery. Anesthetic management during preoperative, intraoperative and postoperative period is essential for the enhanced recovery. In the era of enhanced recovery protocols, non-intubated thoracoscopic procedures present a step forward. This article focuses on the key elements of the enhanced recovery program in thoracic surgery. Having reviewed recent literature, the authors highlight potential procedures and techniques that might be incorporated into the program.

Randomised trial comparing forced-air warming to the upper or lower body to prevent hypothermia during thoracoscopic surgery in the lateral decubitus position

BACKGROUND

In the supine position, forced-air warming is more effective on the lower body than on the upper body to prevent intraoperative hypothermia. However, it is unknown in the lateral decubitus position. We thus compared forced-air warming on the upper and lower bodies in the lateral position.

METHODS

Patients (n=123) were randomised to receive forced-air warming on the upper body or lower body during thoracoscopic surgery in the lateral position. We measured the nasopharyngeal temperature at 0, 30, 60, 90, and 120 min after lateral positioning during surgery and the infrared tympanic membrane temperature at 0, 30, 60, 90, and 120 min after surgery. Patients received both upper and lower body warming at a temperature of <35.5°C. The primary outcome was the incidence of intraoperative hypothermia with a temperature of <36.0°C.

RESULTS

Intraoperative hypothermia was less frequent with the upper body warming than with the lower body warming {21/62 vs 35/61, risk ratio [95% confidence interval (CI)] 0.6 (0.4-0.9), P=0.011}. The intraoperative temperature was higher with the upper body warming than with the lower body warming at 30 (P=0.002), 60 (P<0.001), and 90 (P<0.001) min after lateral positioning, and the postoperative temperature was higher at 0 (P<0.001) and 30 (P=0.001) min after surgery. Fewer patients received both upper and lower body warming in the upper body warming group than in the lower body warming group during surgery (1 vs 7, P=0.032).

CONCLUSIONS

Forced-air warming was more effective on the upper body than on the lower body to prevent hypothermia during thoracoscopic surgery in the lateral decubitus position.

CLINICAL TRIAL REGISTRATION

NCT02993666.

Postoperative Acute Kidney Injury and Blood Product Transfusion After Synthetic Colloid Use During Cardiac Surgery

OBJECTIVES

This study assessed the effect of 2 types of hydroxyethyl starches (HES) on renal integrity and blood transfusion in cardiac surgery patients.

DESIGN

Retrospective investigation.

SETTING

Patients from a single tertiary medical center.

PARTICIPANTS

Inclusion criteria included coronary artery bypass graft (CABG) and/or valve surgery that included cardiopulmonary bypass with aortic cross-clamping.

INTERVENTIONS

Intraoperative HES and blood product administration.

MEASUREMENTS AND MAIN RESULTS

The study comprised 1,265 patients who met inclusion criteria. Of these patients, 70% received HES, and of these, 47% received<1,000 mL and 53% received≥1,000 mL. There was no difference in the development of acute kidney injury between the 2 groups. A parsimonious propensity model for colloids showed that combined CABG and valve surgery were less likely to be associated with HES administration than was CABG alone (OR 0.68, confidence interval [CI] 0.46-0.97; p = 0.04). Intra-aortic balloon pump use was less likely to be associated with HES administration (OR 0.57, CI 0.38-0.86; p = 0.007). Patients with chronic kidney disease, stages 3 to 5, were less likely to receive HES, with an OR of 0.56 (CI 0.38-0.84; p = 0.004); 0.51 (CI 0.20-1.33; p = 0.170); and 0.23 (CI 0.12-0.44; p<0.0001), respectively, for each stage. No difference was noted in red blood cell transfusion. However, fresh frozen plasma, cryoprecipitate, and platelet transfusions were significantly higher with larger volumes of HES, with an OR of 2.03 (CI 1.64-2.52; p<0.001); 1.60 (CI 1.30-1.97; p<0.000); and 1.62 (CI 1.21-2.15; p = 0.006), respectively. No differences in surgical mortality were found between the colloid and noncolloid groups.

CONCLUSIONS

This study showed no association of postoperative acute kidney injury and red blood cell transfusion between the colloid and noncolloid groups. Although the complication rate was higher with HES administration, there was no difference in surgery mortality between the 2 groups.

Preoperative aspirin use and acute kidney injury after cardiac surgery: A propensity-score matched observational study

BACKGROUND

The association between preoperative aspirin use and postoperative acute kidney injury (AKI) in cardiovascular surgery is unclear. We sought to evaluate the effect of preoperative aspirin use on postoperative AKI in cardiac surgery.

METHODS

A total of 770 patients who underwent cardiovascular surgery under cardiopulmonary bypass were reviewed. Perioperative clinical parameters including preoperative aspirin administration were retrieved. We matched 108 patients who took preoperative aspirin continuously with patients who stopped aspirin more than 7 days or did not take aspirin for the month before surgery. The parameters used in the matching included variables related to surgery type, patient's demographics, underlying medical conditions and preoperative medications.

RESULTS

In the first seven postoperative days, 399 patients (51.8%) developed AKI, as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria and 128 patients (16.6%) required hemodialysis. Most patients took aspirin 100 mg once daily (n = 195, 96.5%) and the remaining 75 mg once daily. Multivariable analysis showed that preoperative maintenance of aspirin was independently associated with decreased incidence of postoperative AKI (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.98, P = 0.048; after propensity score matching: OR 0.39, 95% CI 0.22-0.67, P = 0.001). Preoperative maintenance of aspirin was associated with less incidence of AKI defined by KDIGO both in the entire and matched cohort (n = 44 [40.7%] vs. 69 [63.9%] in aspirin and non-aspirin group, respectively in matched sample, relative risk [RR] 0.64, 95% CI 0.49, 0.83, P = 0.001). Preoperative aspirin was associated with decreased postoperative hospital stay after matching (12 [9-18] days vs. 16 [10-25] in aspirin and non-aspirin group, respectively, P = 0.038). Intraoperative estimated or calculated blood loss using hematocrit difference and estimated total blood volume showed no difference according to aspirin administration in both entire and matched cohort.

CONCLUSIONS

Preoperative low dose aspirin administration without discontinuation was protective against postoperative AKI defined by KDIGO criteria independently in both entire and matched cohort. Preoperative aspirin was also associated with decreased hemodialysis requirements and decreased postoperative hospital stay without increasing bleeding. However, differences in AKI and hospital stay were not associated with in-hospital mortality.

Incidence and risk factors of acute kidney injury after esophageal cancer surgery: A nested case-control study

BACKGROUND

Acute kidney injury (AKI) has been increasingly recognized as a common and serious postoperative complication. Although many studies have been conducted to investigate postoperative AKI after thoracic surgery, little is known about AKI after esophageal surgery. Thus, we conducted this study to determine the incidence and identify risk factors of postoperative AKI after esophageal cancer surgery.

MATERIALS AND METHODS

A retrospective nested case-control study of patients undergoing elective esophageal cancer surgery between July 2013 and July 2016 in a single tertiary specialized cancer hospital was performed. The primary outcome was development of AKI. Conditional logistic regression analysis was performed to identify independent risk factors for AKI.

RESULTS

Of 2094 patients, 51 (2.4%) developed postoperative AKI after esophageal cancer surgery. In multivariate conditional logistic regression analysis, four risk factors for AKI after esophageal surgery for cancer were identified: preoperative serum creatinine level (OR 1.040; 95% CI 1.012-1.069), duration of surgery (OR 1.009; 95% CI 1.005-1.014), smoking history (OR 3.029; 95% CI 1.092-8.399) and hypertension (OR 6.422; 95% CI 2.736-15.070).

CONCLUSION

Postoperative AKI occurred in 2.4% of patients after esophageal surgery for cancer. Preoperative serum creatinine level, duration of surgery, smoking history and hypertension were independent risk factors for postoperative AKI.

Safety of gelatin solutions for the priming of cardiopulmonary bypass in cardiac surgery: a systematic review and meta-analysis

This systematic review and meta-analysis was conducted to evaluate the safety of gelatin versus hydroxyethyl starches (HES) and crystalloids when used for cardiopulmonary bypass (CPB)-priming in cardiac surgery. MEDLINE (Pubmed), Embase and CENTRAL were searched. We included only randomized, controlled trials comparing CPB-priming with gelatin with either crystalloids or HES-solutions of the newest generation. The primary endpoint was the blood loss during the first 24 hours. Secondary outcomes included perioperative transfusion requirements, postoperative kidney function, postoperative ventilation times and length of stay on the intensive care unit. Sixteen studies were identified, of which only ten met the inclusion criteria, representing a total of 824 adult patients: 4 studies compared gelatin with crystalloid, and 6 studies gelatin with HES priming. Only 2 of the studies comparing HES and gelatin reported postoperative blood loss after 24 hours. No significant difference in postoperative blood loss was found when results of both studies were pooled (SMD -0.12; 95% CI: -0.49, 0.25; P=0.52). Likewise, the pooled results of 3 studies comparing gelatin and crystalloids as a priming solution could not demonstrate significant differences in postoperative bleeding after 24 hours (SMD -0.07; 95% CI: -0.40, 0.26; P=0.68). No differences regarding any of the secondary outcomes could be identified. This systematic review suggests gelatins to have a safety profile which is non-inferior to modern-generation tetrastarches or crystalloids. However, the grade of evidence is rated low owing to the poor methodological quality of the included studies, due to inconsistent outcome reporting and lack of uniform endpoint definitions.