Crystalloid versus colloid fluids for reduction of postoperative ileus after abdominal operation under combined general and epidural anesthesia

A Critical Reassessment of the Kidney Risk Caused by Tetrastarch Products in the Perioperative and Intensive Care Environments

Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship, the AKI-inducing property of 6% HES 130/0.4 or 0.42 should not be considered as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusions: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Additionally, conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.

Effect of acupuncture on postoperative ileus after laparoscopic elective colorectal surgery: A prospective, randomised, controlled trial

BACKGROUND

Postoperative ileus after colorectal surgery is a frequent problem that significantly delays recovery, increases perioperative costs, and negatively impacts on daily life, physical and psychosocial functioning, and wellbeing. We investigated the effect of acupuncture at different single acupoint combined with standard care on postoperative ileus.

METHODS

In this single-centre, three-arm, prospective, randomised trial, we enrolled patients with primary colorectal cancer undergoing elective colorectal resection at Cancer Hospital Chinese Academy of Medical Science in Beijing, China. Patients were randomly assigned (1:1:1) to receive either electroacupuncture (EA) at ST36 or ST25 combined with standard care (two EA groups) once daily from post-operative days 1-4, or standard care alone (standard care group). The co-primary outcomes were time to first flatus and time to defecation assessed in the intention-to-treat population. This study is registered with Chictr.org.cn, ChiCTR1900027466.

FINDING

Between Nov 15, 2019, and Sep 30, 2020, 129 patients were assessed for eligibility, 105 patients (35 patients per group) were enrolled and included in the intention-to-treat analysis. After receiving EA at ST36, the time to first flatus and defecation were shorter (between-group difference -10.98 [97.5% CI -21.41 to -0.56], p = 0·02 for flatus; -25.41 [-47.89 to -2.93], p = 0·02 for defecation). However, we did not observe a significant difference in time to first flatus and defecation between the EA at ST25 group and standard care group (between-group difference -5.54 [97.5% CI -15.78 to 4.70], p = 0·26 for flatus; -17.69 [-40.33 to 4.95], p = 0·08 for defecation). There were no serious adverse events.

INTERPRETATION

Compared with standard care alone, standard care combined with EA at ST36, but not ST25, significantly enhances bowel function recovery in a postoperative setting to patients with colorectal cancer with laparoscopic elective colorectal resection.

FUNDING

The National Key R&D Program of China (No: 2019YFC1712100) and the National Science Fund for Distinguished Young Scholars (No:81825024).

Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis

BACKGROUND

In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement.

METHODS

In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome (P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P value <.01 was considered statistically significant).

RESULTS

Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94-1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10-2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57-1.02; P = .02).

CONCLUSIONS

In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.

Safety and efficacy of tetrastarches in surgery and trauma: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Hydroxyethyl starch (HES) 130 is a frequently used fluid to replace intravascular losses during surgery or trauma. In the past years, several trials performed in critically ill patients have raised questions regarding the safety of this product. Our aim in this meta-analysis was to evaluate the safety and efficacy of 6% HES during surgery and in trauma.

METHODS

This systematic review and meta-analysis was registered at PROSPERO (CRD42018100379). We included 85 fully published articles from 1980 to June 2018 according to the protocol and three additional recent articles up to June 2020 in English, French, German, and Spanish reporting on prospective, randomised, and controlled clinical trials applying volume therapy with HES 130/0.4 or HES 130/0.42, including combinations with crystalloids, to patients undergoing surgery. Comparators were albumin, gelatin, and crystalloids only. A meta-analysis could not be performed for the two trauma studies as there was only one study that reported data on endpoints of interest.

RESULTS

Surgical patients treated with HES had lower postoperative serum creatinine (P<0.001) and showed no differences in renal dysfunction, renal failure, or renal replacement therapy. Although there was practically no further difference in the colloids albumin or gelatin, the use of HES improved haemodynamic stability, reduced need for vasopressors (P<0.001), and decreased length of hospital stay (P<0.001) compared with the use of crystalloids alone.

CONCLUSIONS

HES was shown to be safe and efficacious in the perioperative setting. Results of the present meta-analysis suggest that when used with adequate indication, a combination of intravenous fluid therapy with crystalloids and volume replacement with HES as colloid has clinically beneficial effects over using crystalloids only.

Hydroxyethyl starch 130/0.4 for volume replacement therapy in surgical patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The safety of perioperative intravenous hydroxyethyl starch (HES) products, specifically HES 130/0.4, continues to be the source of much debate. The aim of this meta-analysis was to update the existing evidence and gain further insight into the clinical effects of HES 130/0.4 on postoperative outcomes for volume replacement therapy in surgical patients.

METHODS

MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to March 2020 for relevant randomized controlled trials (RCTs) on perioperative use of HES 130/0.4 in adult surgical patients. The primary outcome was postoperative mortality and secondary outcomes were the incidence of acute kidney injury (AKI) and requirement for renal replacement therapy (RRT). The analysis was performed using the random-effects method and the risk ratio (RR) with a 95% confidence interval (CI). We performed the risk-of-bias assessment of eligible studies and assessed the overall quality of evidence for each outcome.

RESULTS

Twenty-five RCTs with 4111 participants were finally included. There were no statistical differences between HES 130/0.4 and other fluids in mortality at 30 days (RR 1.28, 95% CI 0.88 to 1.86, p = 0.20), the incidence of AKI (RR 1.23, 95% CI 0.99 to 1.53, p = 0.07), or requirement for RRT (RR 0.75, 95% CI 0.37 to 1.53, p = 0.43). Overall, there was a moderate certainty of evidence for all the outcomes. There was no subgroup difference related to the type of surgery (p = 0.17) in the incidence of AKI. As for the type of comparator fluids, however, there was a trend that was not statistically significant (p = 0.06) towards the increased incidence of AKI in the HES 130/0.4 group (RR 1.22, 95% CI 0.97 to 1.54) compared with the crystalloid group (RR 1.21, 95% CI 0.27 to 3.91). Subgroup analyses according to the type of surgery demonstrated consistent findings.

CONCLUSIONS

This systematic review and meta-analysis suggests that the use of HES 130/0.4 for volume replacement therapy compared with other fluids resulted in no significant difference in postoperative mortality or kidney dysfunction among surgical patients. Given the absent evidence of confirmed benefit and the potential trend of increased kidney injury, we cannot recommend the routine clinical use of HES 130/0.4 for volume replacement therapy in surgical patients from the perspective of benefit/risk profile. However, the results need to be interpreted with caution due to the limited sample size, and further well-powered RCTs are warranted.

TRIAL REGISTRATION

PROSPERO registry reference: CRD42020173058.

Goal-directed therapy with bolus albumin 5% is not superior to bolus ringer acetate in maintaining systemic and mesenteric oxygen delivery in major upper abdominal surgery: A randomised controlled trial

BACKGROUND

Goal-directed therapy (GDT) is increasingly used in abdominal surgery. Whether crystalloids can exert the same effect as colloid, and how this may affect perfusion, is still unclear. The effect of GDT on the systemic oxygen delivery index (sDO2I) and the mesenteric oxygen delivery index (mDO2I) can be quantified by measuring cardiac index and flow in the superior mesenteric artery, respectively.

OBJECTIVE

The aim of this study was to test the hypothesis that intra-operative GDT with bolus human albumin 5% is superior to GDT with bolus ringer acetate in maintaining sDO2I and mDO2I in elective major upper gastrointestinal cancer surgery.

DESIGN

Randomised controlled double blinded trial.

SETTING

Odense University Hospital, Denmark, from May 2014 to June 2015.

PATIENTS

A total of 89 adults scheduled for elective major upper gastrointestinal cancer surgery were randomised and data from 60 were analysed.

EXCLUSION CRITERIA

contraindications for using the LiDCOplus system, known allergy to albumin, pre-operative renal failure, pancreatic cancer and pre-operative down staging using chemotherapy and/or radiation therapy, pregnancy.

INTERVENTIONS

Patients were randomised to intra-operative GDT with either bolus human albumin or ringer acetate 250 ml, guided by pulse pressure variation and stroke volume.

MAIN OUTCOME MEASURES

Changes in sDO2I and mDO2I. Secondary outcomes were changes in other haemodynamic variables, fluid balance, blood transfusions, fluid-related complications and length of stay (LOS) in ICU and hospital.

RESULTS

Median [IQR] sDO2I was 522 [420 to 665] ml min m in the ringer acetate group and 490 [363 to 676] ml min m in the human albumin group, P = 0.36. Median [IQR] mDO2I was 12.1 [5.8 to 28.7] ml min m in the ringer acetate group and 17.0 [7.6 to 27.5] ml min m in the human albumin group, P = 0.17. Other haemodynamic comparisons did not differ significantly. More trial fluid was administered in the ringer acetate group. We found no significant difference in transfusions, complications or LOS.

CONCLUSION

Bolus human albumin 5% was not superior to bolus ringer acetate in maintaining systemic or mesenteric oxygen delivery in elective major upper gastrointestinal cancer surgery, despite the administration of larger volumes of trial fluid in the ringer acetate group. No significant difference was seen in fluid-related complications or LOS.

TRIAL REGISTRATION

https://eudract.ema.europa.eu/ Identifier: 2013-002217-36.

Intravenous Fluid of Choice in Major Abdominal Surgery: A Systematic Review

Background

Intravenous fluid therapy plays a role in maintaining the hemodynamic status for tissue perfusion and electrolyte hemostasis during surgery. Recent trials in critically ill patients reported serious side effects of some types of fluids. Since the most suitable type of fluid is debatable, a consensus in perioperative patients has not been reached.

Method

We performed a systematic review of randomized control trials (RCTs) that compared two or more types of fluids in major abdominal surgery. The outcomes were related to bleeding, hemodynamic status, length of hospital stay, and complications, such as kidney injury, electrolyte abnormality, major cardiac adverse event, nausea, vomiting, and mortality. A literature search was performed using Medline and EMBASE up to December 2019. The data were pooled to investigate the effect of fluid on macrocirculation and intravascular volume effect.

Results

Forty-three RCTs were included. Eighteen fluids were compared: nine were crystalloids and nine were colloids. The results were categorized into macrocirculation and intravascular volume effect, microcirculation, anti-inflammatory parameters, vascular permeability, renal function (colloids), renal function and electrolytes (crystalloids), coagulation and bleeding, return of bowel function, and postoperative nausea vomiting (PONV). We found that no specific type of fluid led to mortality and every type of colloid was equivalent in volume expansion and did not cause kidney injury. However, hydroxyethyl starch and dextran may lead to increased bleeding. Normal saline can cause kidney injury which can lead to renal replacement therapy, and dextrose fluid can decrease PONV.

Conclusion

In our opinion, it is safe to give a balanced crystalloid as the maintenance fluid and give a colloid, such as HES130/0.4, 4% gelatin, or human albumin, as a volume expander.

Acute Colonic Pseudo-Obstruction After Posterior Spinal Fusion: A Case Report and Literature Review

BACKGROUND

Acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome occurs in 0.22%-7% of patients undergoing surgery, with a mortality of up to 46%. ACPO increased median hospital days versus control in spinal surgery (14 vs. 6 days; P < 0.001). If defined as postoperative ileus, the incidence was 7%-13.4%. Postoperative ileus is associated with 2.9 additional hospital days and an $80,000 increase in cost per patient. We present a case of ACPO in an adult patient undergoing spinal fusion for correction of scoliosis and review the available literature to outline clinical characteristics and surgical outcomes.

CASE DESCRIPTION

The patient was a 31-year-old woman with untreated advanced scoliosis with no history of neurologic issues. T2-L3 spinal instrumentation and fusion was completed. Plain abdominal radiography showed of dilated cecum 11 cm and the department of general surgery was consulted. Neostigmine administration was planned after conservative treatment failure after transfer to the intensive care unit. The patient was discharged home with no recurrence >60 days. Thirty cases were found in our literature review using PubMed and Embase databases and summarized.

CONCLUSIONS

Of 30 cases reviewed, only 3 cases of ACPO were specific to patients undergoing spinal fusion for scoliosis. According to the literature, 20% of patients had resolution with conservative treatment, 40% with neostigmine, and 30% with surgical intervention. Other noninvasive treatments may have similar efficacy in preventing complications leading to surgical invention. Sixty clinical trials and 9 systematic reviews were summarized with an updated management algorithm.

Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Introduction

Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.

Aim

To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.

Methods

Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.

Results

Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.

Conclusions

There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

Is perioperative colloid infusion more effective than crystalloid in preventing postoperative nausea and vomiting?: A systematic review and meta-analysis

BACKGROUND

Adequate intravenous fluid replacement is recommended as an effective nonpharmacologic strategy for reducing postoperative nausea and vomiting (PONV), one of the most common and stressful complications of general anesthesia. We aimed to evaluate the effect of hydration, according to the type of fluid, on PONV as previous studies have reported inconsistent results.

METHODS

We performed a systemic review and meta-analysis of randomized controlled trials (RCTs) comparing infusion of colloid with that of crystalloid in terms of PONV incidence and the need for rescue antiemetic therapies for 24 hours after surgery under general anesthesia. The effect of fluid infusion according to the duration of anesthesia was also examined. A literature search was performed, using MEDLINE, Excerpta Medica Database, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus, up to February 2018.

RESULTS

We included 8 RCTs. Compared with the crystalloid infusion, perioperative colloid infusion did not reduce PONV incidence, with a relative risk of 0.87 (95% confidence interval [CI], 0.60-1.25). However, subgroup analysis by duration of anesthesia showed a statistically significant subgroup effect (P = .04, I = 77.4%), suggesting that the effect of colloid differed from that of crystalloid depending on the duration of anesthesia. In the subgroup that underwent anesthesia for more than 3 hours, in which the patients had mostly undergone abdominal surgeries, colloid infusion significantly reduced the incidence of PONV compared with crystalloid infusion (RR, 0.69; 95% CI, 0.53-0.89). In the subgroup that underwent anesthesia for <3 hours, colloid infusion did not reduce the incidence of PONV compared with crystalloid infusion (RR, 1.32; 95% CI, 0.76-2.27). The requirement for antiemetics was comparable between colloid and crystalloid infusions, with an RR of 0.93 (95% CI, 0.55-1.58).

CONCLUSION

Colloid administration had a more preventive effect on PONV than crystalloid administration in patients undergoing abdominal surgery under general anesthesia for more than 3 hours but did not show a preventive effect in patients undergoing anesthesia for <3 hours.

Choice of fluids in critically ill patients

Background

Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia.

Main text

Until recently, because of their excellent safety profile, fluids were not considered “medications”. However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions.

Conclusions

The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma).

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0669-3) contains supplementary material, which is available to authorized users.