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Obradovic M, Luf F, Reiterer C, Schoppmann S, Kurz A, Fleischmann E, Kabon B. The effect of goal-directed crystalloid versus colloid administration on postoperative spirometry parameters: a substudy of a randomized controlled clinical trial. Perioper Med (Lond) 2024; 13:28. [PMID: 38622671 PMCID: PMC11020978 DOI: 10.1186/s13741-024-00381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/21/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Pulmonary function is impaired after major abdominal surgery and might be less impaired by restrictive fluid administration. Under the assumption of a fluid-sparing effect of colloids, we tested the hypothesis that an intraoperative colloid-based goal-directed fluid management strategy impairs postoperative pulmonary function parameters less compared to goal-directed crystalloid administration. METHODS We performed a preplanned, single-center substudy within a recently published trial evaluating the effect of goal-directed crystalloids versus colloids on a composite of major complications. Sixty patients undergoing major open abdominal surgery were randomized to Doppler-guided intraoperative fluid replacement therapy with lactated Ringer's solution (n = 31) or unbalanced 6% hydroxyethyl starch 130/0.4 (n = 29). A blinded investigator performed bedside spirometry (Spirobank-G, Medical International Research, Rome, Italy) preoperatively as well as 6, 24, and 48 h postoperatively. RESULTS Median total intraoperative fluid requirements were significantly higher during crystalloid administration compared to patients receiving colloids (4567 ml vs. 3044 ml, p = 0.01). Six hours after surgery, pulmonary function parameters did not differ significantly between the crystalloid - and the colloid group: forced vital capacity (FVC): 1.6 l (1.2-2 l) vs. 1.9 l (1.5-2.4 l), p = 0.15; forced expiratory volume in 1 second (FEV1): 1.1 l (0.9-1.6 l) vs. 1.4 l (1.2-1.7 l), p = 0.18; and peak expiratory flow (PEF): 2 l.sec-1 (1.5 - 3.6 l.sec -1) vs. 2.3 l.sec -1 (1.8 - 3.4 l.sec -1), p = 0.23. Moreover, postoperative longitudinal time × group interactions of FVC, FEV1, and PEF between 6 and 48 postoperative hours did not differ significantly. CONCLUSION Postoperative pulmonary function parameters were similarly impaired in patients receiving goal-directed crystalloid administration as compared to goal-directed colloid administration during open abdominal surgery. TRIAL REGISTRATION ClinicalTrials.gov ( NCT00517127 , registered on August 16, 2007) and EudraCT (2005-004602-86).
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Affiliation(s)
- Mina Obradovic
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Florian Luf
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
- Department of Anesthesiology and Intensive Care, Hanusch Hospital, Heinrich-Collin-Straße 30, 1140 Wien, Vienna, Austria
| | - Christian Reiterer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Sebastian Schoppmann
- Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Andrea Kurz
- Department of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Deslarzes P, Jurt J, Larson DW, Blanc C, Hübner M, Grass F. Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice. J Clin Med 2024; 13:801. [PMID: 38337495 PMCID: PMC10856154 DOI: 10.3390/jcm13030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.
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Affiliation(s)
- Philip Deslarzes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Jonas Jurt
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - David W. Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Catherine Blanc
- Department of Anesthesiology, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland;
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
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3
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Mahrose R, Kasem AA. Pulse Pressure Variation-Based Intraoperative Fluid Management Versus Traditional Fluid Management for Colon Cancer Patients Undergoing Open Mass Resection and Anastomosis: A Randomized Controlled Trial. Anesth Pain Med 2023; 13:e135659. [PMID: 38024002 PMCID: PMC10676660 DOI: 10.5812/aapm-135659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background Bowel edema leads to decreased perfusion and oxygenation of the intestine at the anastomotic site after colonic mass resection with failure of healing and leakage. Additionally, dehydration causes bowel hypoperfusion and difficulty healing with more complications. Fluid therapy guided by dynamic monitoring of fluid response can help avoid bowel dehydration and edema with fewer complications. Objectives The main goal of this study was to compare the effects of intraoperative fluid therapy based on pulse pressure variation (PPV) to traditional fluid therapy to maintain adequate hydration without intraoperative instability of hemodynamics and postoperative complications. Methods This randomized controlled study was conducted on 90 adult patients (age range: 18-70 years) undergoing elective open colonic mass resection and anastomosis at Eldemerdash Hospital, Ain Shams University, Cairo, Egypt. There were two groups of patients, namely group A (n = 45; conventional fluid management [CFM] group) and group B (n = 45; goal-guided fluid management [GGFM] group based on PPV), using randomly generated data from a computer. Intraoperative fluids and vasopressors were given using GGFM or routine care. The key tool for directing hemodynamic management in the GGFM algorithm was the fluid protocol and PPV. As a result, the outcomes were measured to include the volume of intraoperative fluid, water fraction, and postoperative complications. Results In this study, 90 patients underwent analysis. Both groups' demographics were similar (P > 0.05). Baseline characteristics and surgical procedures did not differ significantly between the two groups (P > 0.05). Both the amount of urine output and the intraoperative administration of crystalloids were statistically significantly higher in group A (P < 0.05). The two groups' heart rate, mean arterial pressure and intraoperative usage of colloids and ephedrine were not statistically different (P > 0.05). Water fraction, bowel recovery, anastomotic leak, and length of hospital stay were significantly higher in the CFM group (P < 0.05). Conclusions For patients with the American Society of Anesthesiologists physical status I - II undergoing elective open resection of colonic mass and anastomosis, PPV-based GGFM, a less invasive tool for intraoperative fluid management, might be a better option than CFM.
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Affiliation(s)
- Ramy Mahrose
- Anesthesia, Intensive Care and Pain Management, Ain Shams University, Cairo, Egypt
| | - Amr A. Kasem
- Anesthesia, Intensive Care and Pain Management, Ain Shams University, Cairo, Egypt
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4
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Trauzeddel RF, Leitner M, Dehé L, Nordine M, Piper SK, Habicher M, Sander M, Perka C, Treskatsch S. Goal-directed fluid therapy using uncalibrated pulse contour analysis and balanced crystalloid solutions during hip revision arthroplasty: a quality implementation project. J Orthop Surg Res 2023; 18:281. [PMID: 37024966 PMCID: PMC10078091 DOI: 10.1186/s13018-023-03738-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND To implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study. METHODS Adult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction. RESULTS Sixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54-74 ml; colloids: 67.5 (60-75.25 ml) and total volume infused (crystalloids: 2575 (2000-4210) ml; colloids: 2435 (1760-3480) ml; and controls: 2210 (1658-3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3-55.2%) for crystalloids and 49.2% (95%CI 40.4-58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1-74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6-42.9); colloids: 43% (95%CI 34.4-52.0); and controls: 62% (95%CI 52.6-69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay. CONCLUSIONS Perioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01753050.
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Affiliation(s)
- R F Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Leitner
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - L Dehé
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Nordine
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - S K Piper
- Institute of Medical Informatics, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - M Habicher
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - M Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte and Virchow-Klinikum, Charitéplatz 1, 10117, Berlin, Germany
| | - S Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Yang TX, Tan AY, Leung WH, Chong D, Chow YF. Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review. Cureus 2023; 15:e38238. [PMID: 37261162 PMCID: PMC10226838 DOI: 10.7759/cureus.38238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.
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Affiliation(s)
- Timothy Xianyi Yang
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Adrian Y Tan
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Wesley H Leung
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - David Chong
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Yu Fat Chow
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
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6
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Hoang TN, Musquiz BN, Tubog TD. Impact of Goal-Directed Fluid Therapy on Postoperative Outcomes in Colorectal Surgery: An Evidence-Based Review. J Perianesth Nurs 2023:S1089-9472(22)00596-2. [PMID: 36858859 DOI: 10.1016/j.jopan.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/26/2022] [Accepted: 11/06/2022] [Indexed: 03/03/2023]
Abstract
PURPOSE To investigate the effects of goal-directed fluid therapy (GDFT) or conventional fluid therapy (CFT) in improving postoperative outcomes in patients undergoing colorectal surgeries. DESIGN Evidence-Based Review. METHODS Following the guidelines outlined in the PRISMA statement, a comprehensive search was conducted using PubMed, Elsevier ScienceDirect, Oxford Academic, EBSCO, Google Scholar, Cochrane Library, and gray literature. Only randomized controlled studies and pre-appraised evidence such as systematic review with meta-analysis examining the effects of GDFT and CFT in colorectal surgery were included. The quality appraisal of the literature was conducted using the proposed algorithm described in the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide. FINDINGS Two systematic reviews with meta-analyses and four randomized controlled trials (RCT) involving 2018 patients were included in this review. Overall, the use of GDFT did not shorten the hospital length of stay (LOS), reduce 30-day mortality, lower overall morbidity rates, or decrease incidence of postoperative ileus. Additionally, the return of bowel function was not improved using GDFT or CFT. However, when GDFT was implemented within enhanced recovery after surgery (ERAS) programs, there was a significant reduction in hospital LOS. . When GDFT was used in a non-ERAS patient care setting, there was a significant reduction in overall morbidity rate and faster time to first flatus. All studies included in the review were categorized as Level I and rated Grade A, implying strong confidence in the true effects of GDFT on all outcome measures in the review. CONCLUSIONS The benefits of GDFT in colorectal surgery are still unclear. Considerable heterogeneity based on the types of GDFT devices, patient outcome parameters, and fluid protocols limit the application to clinical practice. Furthermore, there was limited data on the effects of GDFT in high-risk patients for colorectal surgery.
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Affiliation(s)
- Tuyet N Hoang
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Brittney N Musquiz
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Tito D Tubog
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX.
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Abbassi F, Müller SA, Steffen T, Schmied BM, Warschkow R, Beutner U, Tarantino I. Caffeine for intestinal transit after laparoscopic colectomy: randomized clinical trial (CaCo trial). Br J Surg 2022; 109:1216-1223. [PMID: 35909263 DOI: 10.1093/bjs/znac265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/23/2022] [Accepted: 07/13/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Coffee has been suggested to help postoperative gastrointestinal motility but the mechanism is not known. This trial assessed whether caffeine shortened time to bowel activity after laparoscopic colectomy. METHODS This was a single-centre, randomized, double-blinded, placebo-controlled superiority trial (October 2015 to August 2020). Patients aged at least 18 years undergoing elective laparoscopic colectomy were assigned randomly to receive 100 mg or 200 mg caffeine, or a placebo (250 mg corn starch) three times a day orally. The primary endpoint was the time to first bowel movement. Secondary endpoints included colonic transit time, time to tolerance of solid food, duration of hospital stay, and perioperative morbidity. RESULTS Sixty patients were assigned randomly to either the 200-mg caffeine group (20 patients), the 100-mg caffeine group (20) or the placebo group (20). In the intention-to-treat analysis, the mean(s.d.) time to first bowel movement was 67.9(19.2) h in the 200-mg caffeine group, 68.2(32.2) h in the 100-mg caffeine group, and 67.3(22.7) h in the placebo group (P = 0.887). The per-protocol analysis and measurement of colonic transit time confirmed no measurable difference with caffeine. CONCLUSION Caffeine was not associated with reduced time to first bowel movement. REGISTRATION NUMBER NCT02510911 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Fariba Abbassi
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St Gallen, St Gallen, Switzerland.,Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Sascha A Müller
- Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Campus SLB, Berne, Switzerland.,Department of Surgery, Clinic Beau-Site, Berne, Switzerland
| | - Thomas Steffen
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - René Warschkow
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Ulrich Beutner
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Ignazio Tarantino
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
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Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial. J Am Acad Orthop Surg 2022; 30:e833-e841. [PMID: 35312650 DOI: 10.5435/jaaos-d-21-00960] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/11/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study investigates the effects of preoperative carbohydrate-rich drinks on postoperative outcomes after primary total knee arthroplasty. METHODS We prospectively randomized 153 consecutive patients undergoing primary total knee arthroplasty at one institution. Patients were assigned to one of three groups: group A (50 patients) received a carbohydrate-rich drink; group B (51 patients) received a placebo drink; and group C (52 patients) did not receive a drink (control). All healthcare personnel and patients were blinded to group allocation. Controlling for demographics, we analyzed the rate of postoperative nausea and vomiting, length of stay, opiate consumption, pain scores, serum glucose, adverse events, and intraoperative and postoperative fluid intake. RESULTS Demographics and comorbidities were similar among the groups. There were no significant differences in surgical interventions or experience. Surgical fluid intake and total blood loss were similar among the three groups (P = 0.47, P = 0.23). Furthermore, acute postoperative outcomes (ie, pain, episodes of nausea, and length of stay) were similar across all three groups. There were no significant differences in adverse events between the three groups (P = 0.13). There was a significant difference in one-time postoperative bolus between the three groups (P = 0.02), but after multivariate analysis, it did not demonstrate significance. None of the intervention group were readmitted, whereas 5.9% and 11.5% were readmitted in the placebo and control groups, respectively (P = 0.047). The chance of 90-day readmission was reduced in group A compared with group C (odds ratio, 0.08; 95% confidence interval, 0.01 to 0.72; P = 0.02). There were no differences in other postoperative outcome measurements. CONCLUSION This randomized controlled trial demonstrated that preoperative carbohydrate loading does not improve immediate postoperative outcomes, such as nausea and vomiting; however, it demonstrated that consuming fluid preoperatively proved no increased risk of adverse outcomes and there was a trend toward decrease of one-time boluses postoperatively. CLINICAL TRIALS REGISTRY NCT03380754.
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Voldby AW, Aaen AA, Loprete R, Eskandarani HA, Boolsen AW, Jønck S, Ekeloef S, Burcharth J, Thygesen LC, Møller AM, Brandstrup B. Perioperative fluid administration and complications in emergency gastrointestinal surgery-an observational study. Perioper Med (Lond) 2022; 11:9. [PMID: 35189974 PMCID: PMC8862386 DOI: 10.1186/s13741-021-00235-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/11/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The fluid balance associated with a better outcome following emergency surgery is unknown. The aim of this study was to explore the association of the perioperative fluid balance and postoperative complications during emergency gastrointestinal surgery. METHODS We retrospectively included patients undergoing emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 2.5 L divided the cohort in a conservative and liberal group. Outcome was Clavien-Dindo graded complications registered 90 days postoperatively. We used logistic regression adjusted for age, sex, American Society of Anesthesiologists' classification, use of epidural analgesia, use of vasopressor, type of surgery, intraabdominal pathology, and hospital. Predicted risk of complications was demonstrated on a continuous scale of the fluid balance. RESULTS We included 342 patients operated between July 2014 and July 2015 from three centers. The perioperative fluid balance was 1.6 L IQR [1.0 to 2.0] in the conservative vs. 3.6 L IQR [3.0 to 5.3] in the liberal group. Odds ratio of overall 2.6 (95% CI 1.5 to 4.4), p < 0.001, and cardiopulmonary complications 3.2 (95% CI 1.9 to 5.7), p < 0.001, were increased in the liberal group. A perioperative fluid balance of 0-2 L was associated with minimal risk of cardiopulmonary complications compared to 1.5-3.5 L for renal complications. CONCLUSION We found a perioperative fluid balance above 2.5 L to be associated with an increased risk of overall and cardiopulmonary complications following emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 0-2 L was associated with the lowest risk of cardiopulmonary complications and 1.5-3.5 L for renal complications.
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Affiliation(s)
- Anders W Voldby
- Department of Surgery, Holbæk Hospital, part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Anne A Aaen
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | | | - Hassan A Eskandarani
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Anders W Boolsen
- Department of Surgery, Holbæk Hospital, part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Simon Jønck
- Department of Emergency Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Sarah Ekeloef
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Lau C Thygesen
- Department of Population Health and Morbidity, University of Southern Denmark, Odense, Denmark
| | - Ann M Møller
- Department of Anesthesiology and Intensive Care Medicine, Herlev Hospital, Herlev, Denmark.,Institute for Clinical Medicins, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Brandstrup
- Department of Surgery, Holbæk Hospital, part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark. .,Institute for Clinical Medicins, University of Copenhagen, Copenhagen, Denmark.
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10
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Major Abdominal Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Harbell MW, Kraus MB, Bucker-Petty SA, Harbell JW. Intraoperative fluid management and kidney transplantation outcomes: A retrospective cohort study. Clin Transplant 2021; 35:e14489. [PMID: 34546602 DOI: 10.1111/ctr.14489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients undergoing kidney transplantation traditionally receive liberal amounts of fluid during surgery. However, excessive fluids can lead to fluid overload and ileus. In this retrospective cohort study, we compared the effect of restrictive versus liberal fluid therapy on kidney transplantation outcomes. METHODS Patients who underwent deceased-donor kidney transplantation at Mayo Clinic from January 2014 to March 2019 were included. Those who received <3 L of intravenous fluids intraoperatively were categorized as "restrictive;" those who received ≥3 L were categorized as "liberal." The primary outcome was incidence of delayed graft function (DGF). Secondary outcomes included length of stay, readmission within 30 days, time to return of bowel function, and incidence of postoperative complications. RESULTS Of the 1171 patients included, 557 were in the restrictive group and 614 in the liberal group. The mean (SD) fluid intake was 2.17 (.54) L in the restrictive group and 3.67 (.68) L in the liberal group (P<.001). There was no difference in DGF (relative risk, 1.03; P = .56), length of stay (P = .34), readmission (P = .80), return of bowel function (P = .71), or other postoperative complications. CONCLUSIONS Intraoperative restrictive fluid therapy during kidney transplantation was not associated with DGF or worse outcomes when compared with liberal fluid therapy.
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Affiliation(s)
- Monica W Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Molly B Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Jack W Harbell
- Division of Transplant and Hepatobiliary Surgery, Mayo Clinic, Scottsdale, Arizona, USA.,Transplant Center, Mayo Clinic Hospital, Phoenix, Arizona, USA
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12
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Huepenbecker SP, Iniesta MD, Zorrilla-Vaca A, Ramirez PT, Cain KE, Vaughn M, Cata JP, Mena GE, Lasala J, Meyer LA. Incidence of acute kidney injury after open gynecologic surgery in an enhanced recovery after surgery pathway. Gynecol Oncol 2021; 163:191-198. [PMID: 34400005 DOI: 10.1016/j.ygyno.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the incidence of postoperative AKI after open gynecologic surgery within ERAS, compare AKI in pre-ERAS and ERAS cohorts, and identify factors associated with AKI. METHODS We compared postoperative AKI in patients who underwent open gynecologic surgery at one institution before and after ERAS implementation. AKI was defined as acute risk, injury, or failure by RIFLE criteria. Pre-ERAS and ERAS cohorts were matched using propensity score analysis in a 1:1 fashion using the nearest neighbor technique. Chi-squared, Fisher's Exact, and Wilcoxon rank-sum tests were used. RESULTS Among 1334 ERAS and 191 pre-ERAS patients, postoperative AKI incidence was higher in the ERAS cohort (13.1% vs 5.8%, p = .004). In 166 matched pairs, ERAS patients had higher incidence (16.9% vs 5.4%, p < .001) and odds (OR 3.54, 95% CI 1.61-7.76) of AKI. Within ERAS, AKI was associated with older age (median age 65 vs 57, p < .001), Charlson Comorbidity Index score ≥ 3 (71.4% vs 57.9%, p < .001), and higher intraoperative estimated blood loss (400 vs 225 mL, p < .001), fluid administration (net fluid balance +1535 vs 1261 mL, p < .001), and hypotension lasting >5 min (41.7% vs 30.7%, p < .001). ERAS patients with AKI had longer hospital stays (median 4 vs 3 days, p < .001) and more readmissions (19% vs. 10%, p < .001) and grade 3+ complications (26% vs. 7%, p < .001). CONCLUSIONS The incidence and odds of postoperative AKI was higher after gynecologic surgery within ERAS, and patients with AKI were more likely to have complications. Potential strategies to prevent postoperative AKI include perioperative fluid and blood pressure optimization.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrés Zorrilla-Vaca
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Micah Vaughn
- The University of Texas Medical Branch, Galveston, TX, USA
| | - Juan P Cata
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel E Mena
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javier Lasala
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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13
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Castellanos Garijo ME, Sepúlveda Blanco A, Tinoco Gonzalez J, Merinero Casado A, Medina de Moya JI, Yanes Vidal G, Forastero Rodriguez A, Martín García CÁ, Muñoz-Casares FC, Padillo Ruiz J. Fluid administration in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: neither too much nor too little. Braz J Anesthesiol 2021; 72:695-701. [PMID: 34371057 DOI: 10.1016/j.bjane.2021.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Intraoperative fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy plays an important role in postoperative morbidity. Studies have found an association between overload fluid therapy and increased postoperative complications, advising restrictive intraoperative fluid therapy. Our objective in this study was to compare the morbidity associated with restrictive versus non-restrictive intraoperative fluid therapy. METHODS Retrospective analysis of a database collected prospectively in the Anesthesiology Service of Virgen del Rocío Hospital, from December 2016 to April 2019. One hundred and six patients who underwent complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were divided into two cohorts according to Fluid Therapy received 1. Restrictive ≤ 9 mL.kg-1.h-1 (34 patients), 2. Non-restrictive ≥ 9 mL.kg-1.h-1 (72 patients). Percentage of major complications (Clavien-Dindo grade III-IV) and length hospital stay were the main outcomes variables. RESULTS Of the 106 enrolled patients, 68.9% were women; 46.2% had ovarian cancer, 35.84% colorectal cancer, and 7.5% peritoneal cancer. The average fluid administration rate was 11 ± 3.58 mL.kg-1.h-1. The restrictive group suffered a significantly higher percentage of Clavien-Dindo grade III-IV complications (35.29%) compared with the non-restrictive group (15.27%) (p = 0.02). The relative risk associated with restrictive therapy was 1.968 (95% confidence interval: 1.158-3.346). We also found a significant difference for hospital length of stay, 20.91 days in the restrictive group vs 16.19 days in the non-restrictive group (p = 0.038). CONCLUSIONS Intraoperative fluid therapy restriction below 9 mL.kg-1.h-1 in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was associated with a higher percentage of major postoperative complications.
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14
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Messina A, Robba C, Calabrò L, Zambelli D, Iannuzzi F, Molinari E, Scarano S, Battaglini D, Baggiani M, De Mattei G, Saderi L, Sotgiu G, Pelosi P, Cecconi M. Perioperative liberal versus restrictive fluid strategies and postoperative outcomes: a systematic review and metanalysis on randomised-controlled trials in major abdominal elective surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:205. [PMID: 34116707 PMCID: PMC8194047 DOI: 10.1186/s13054-021-03629-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/06/2021] [Indexed: 12/12/2022]
Abstract
Background Postoperative complications impact on early and long-term patients’ outcome. Appropriate perioperative fluid management is pivotal in this context; however, the most effective perioperative fluid management is still unclear. The enhanced recovery after surgery pathways recommend a perioperative zero-balance, whereas recent findings suggest a more liberal approach could be beneficial. We conducted this trial to address the impact of restrictive vs. liberal fluid approaches on overall postoperative complications and mortality. Methods Systematic review and meta-analysis, including randomised controlled trials (RCTs). We performed a systematic literature search using MEDLINE (via Ovid), EMBASE (via Ovid) and the Cochrane Controlled Clinical trials register databases, published from 1 January 2000 to 31 December 2019. We included RCTs enrolling adult patients undergoing elective abdominal surgery and comparing the use of restrictive/liberal approaches enrolling at least 15 patients in each subgroup. Studies involving cardiac, non-elective surgery, paediatric or obstetric surgeries were excluded. Results After full-text examination, the metanalysis finally included 18 studies and 5567 patients randomised to restrictive (2786 patients; 50.0%) or liberal approaches (2780 patients; 50.0%). We found no difference in the occurrence of severe postoperative complications between restrictive and liberal subgroups [risk difference (95% CI) = 0.009 (− 0.02; 0.04); p value = 0.62; I2 (95% CI) = 38.6% (0–66.9%)]. This result was confirmed also in the subgroup of five studies having a low overall risk of bias. The liberal approach was associated with lower overall renal major events, as compared to the restrictive [risk difference (95% CI) = 0.06 (0.02–0.09); p value = 0.001]. We found no difference in either early (p value = 0.33) or late (p value = 0.22) postoperative mortality between restrictive and liberal subgroups Conclusions In major abdominal elective surgery perioperative, the choice between liberal or restrictive approach did not affect overall major postoperative complications or mortality. In a subgroup analysis, a liberal as compared to a restrictive perioperative fluid policy was associated with lower overall complication renal major events, as compared to the restrictive. Trial Registration CRD42020218059; Registration: February 2020, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=218059. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03629-y.
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Affiliation(s)
- Antonio Messina
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
| | - Lorenzo Calabrò
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Daniel Zambelli
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Francesca Iannuzzi
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Edoardo Molinari
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Silvia Scarano
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
| | - Marta Baggiani
- Anesthesia and Intensive Care Medicine, Maggiore Della Carità University Hospital, Novara, Italy
| | - Giacomo De Mattei
- Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Integrata Udine, Udine, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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15
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Comparison of treatment to improve gastrointestinal functions after colorectal surgery within enhanced recovery programmes: a systematic review and meta-analysis. Sci Rep 2021; 11:7423. [PMID: 33795783 PMCID: PMC8016851 DOI: 10.1038/s41598-021-86699-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/10/2021] [Indexed: 02/01/2023] Open
Abstract
Despite a significant improvement with enhanced recovery programmes (ERP), gastro-intestinal (GI) functions that are impaired after colorectal resection and postoperative ileus (POI) remain a significant issue. In the literature, there is little evidence of the distinction between the treatment assessed within or outside ERP. The purpose was to evaluate the efficiency of treatments to reduce POI and improve GI function recovery within ERP. A search was performed in PubMed and Scopus on 20 September 2019. The studies were included if they compared the effect of the administration of a treatment aiming to treat or prevent POI or improve the early functional outcomes of colorectal surgery within an ERP. The main outcome measures were the occurrence of postoperative ileus, time to first flatus and time to first bowel movement. Treatments that were assessed at least three times were included in a meta-analysis. Among the analysed studies, 28 met the eligibility criteria. Six of them focused on chewing-gum and were only randomized controlled trials (RCT) and 8 of them focused on Alvimopan but none of them were RCT. The other measures were assessed in less than 3 studies over RCTs (n = 11) or retrospective studies (n = 2). In the meta-analysis, chewing gum had no significant effect on the endpoints and Alvimopan allowed a significant reduction of the occurrence of POI. Chewing-gum was not effective on GI function recovery in ERP but Alvimopan and the other measures were not sufficiently studies to draw conclusion. Randomised controlled trials are needed.Systematic review registration number CRD42020167339.
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16
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Alimian M, Mohseni M, Moradi Moghadam O, Seyed Siamdoust SA, Moazzami J. Effects of Liberal Versus Restrictive Fluid Therapy on Renal Function Indices in Laparoscopic Bariatric Surgery. Anesth Pain Med 2020; 10:e95378. [PMID: 34150556 PMCID: PMC8207848 DOI: 10.5812/aapm.95378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 08/16/2020] [Accepted: 09/07/2020] [Indexed: 02/05/2023] Open
Abstract
Background Earlier studies have suggested the liberal administration of fluids in favor of reducing the risk of rhabdomyolysis in obese patients, but the results are conflicting. Objectives The present study aimed at comparing the effects of liberal and restrictive fluid therapy on renal indices in laparoscopic gastric bypass surgery. Methods In a double-blinded randomized clinical trial, 72 candidates of bariatric surgery were randomly assigned into two groups of restrictive and liberal fluid therapy. Indices, including BUN, creatinine, creatine kinase, GFR, and urine output were measured before and 24 hours after the surgery. The clinical trial was registered at IRCT.ir under code IRCT20170109031852N3. Results There was no significant difference in BUN, creatinine, creatinine kinase, and GFR indices between the two groups of liberal and restrictive fluid therapy both before and 24 hours after surgery (P > 0.05). Intragroup comparisons before and after surgery revealed that BUN decreased in both groups after the surgery (P < 0.05). Also, creatinine and GFR values improved in patients who received a liberal fluid regimen, whereas these indices remained statistically unchanged in the restrictive group before and 24 hours after the surgery (P > 0.05). Conclusions Two methods of liberal and restrictive fluid therapy have comparable effects on traditional renal functional indices in laparoscopic bariatric surgery. The clinical significance of observed differences in outcomes should be investigated in further studies. The use of early biomarkers of acute kidney injury is warranted.
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Affiliation(s)
- Mahzad Alimian
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
| | - Masood Mohseni
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran.
| | | | | | - Javad Moazzami
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
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17
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2020; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.,Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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18
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Hammer M, Grabitz SD, Teja B, Wongtangman K, Serrano M, Neves S, Siddiqui S, Xu X, Eikermann M. A Tool to Predict Readmission to the Intensive Care Unit in Surgical Critical Care Patients-The RISC Score. J Intensive Care Med 2020; 36:1296-1304. [PMID: 32840427 DOI: 10.1177/0885066620949164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Readmission to the Intensive Care Unit (ICU) is associated with a high risk of in-hospital mortality and higher health care costs. Previously published tools to predict ICU readmission in surgical ICU patients have important limitations that restrict their clinical implementation. We sought to develop a clinically intuitive score that can be implemented to predict readmission to the ICU after surgery or trauma. We designed the score to emphasize modifiable predictors. METHODS In this retrospective cohort study, we included surgical patients requiring critical care between June 2015 and January 2019 at Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA. We used logistic regression to fit a prognostic model for ICU readmission from a priori defined, widely available candidate predictors. The score performance was compared with existing prediction instruments. RESULTS Of 7,126 patients, 168 (2.4%) were readmitted to the ICU during the same hospitalization. The final score included 8 variables addressing demographical factors, surgical factors, physiological parameters, ICU treatment and the acuity of illness. The maximum score achievable was 13 points. Potentially modifiable predictors included the inability to ambulate at ICU discharge, substantial positive fluid balance (>5 liters), severe anemia (hemoglobin <7 mg/dl), hyperglycemia (>180 mg/dl), and long ICU length of stay (>5 days). The score yielded an area under the receiver operating characteristic curve of 0.78 (95% CI 0.74-0.82) and significantly outperformed previously published scores. The performance of the underlying model was confirmed by leave-one-out cross-validation. CONCLUSION The RISC-score is a clinically intuitive prediction instrument that helps identify surgical ICU patients at high risk for ICU readmission. The simplicity of the score facilitates its clinical implementation across surgical divisions.
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Affiliation(s)
- Maximilian Hammer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Stephanie D Grabitz
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Bijan Teja
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Karuna Wongtangman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Marjorie Serrano
- Cardiovascular Intensive Care Unit, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Sara Neves
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
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19
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Shen Y, Cai G, Gong S, Yan J. Perioperative Fluid Restriction in Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2020; 43:2747-2755. [PMID: 31332489 DOI: 10.1007/s00268-019-05091-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Perioperative fluid management is a critical component in patients undergoing abdominal surgery. However, the benefit of restricted fluid regimen remains inconclusive. This systematic review aimed to explore potential factors causing these inconsistent findings. METHODS The literature searches were performed in three databases including PubMed, Embase, and the Cochrane library until August 30, 2018. Only randomized, controlled trials comparing the effect of restricted versus liberal regimen in abdominal surgery were included. The primary outcome was total postoperative complications. Subgroup analysis was performed according to between-group weight increase difference (≥ 2 kg and < 2 kg) and fluid intake ratio (≥ 1.8 and < 1.8). RESULTS Sixteen studies were finally included in this meta-analysis. The benefit of the restricted regimen in reducing postoperative complication was only significant in the subgroup with high weight increase difference (≥ 2 kg) (RR 0.67, 95% CI 0.57-0.79) and the subgroup with high fluid intake ratio (≥ 1.8) (RR 0.72, 95% CI 0.62-0.82). In the subgroup with low weight increase difference (< 2 kg) or low fluid intake ratio (< 1.8), the effect of the restricted regimen was not significant (RR 0.88, 95% CI 0.51-1.50, and RR 1.18, 95% CI 0.91-1.53, respectively). CONCLUSIONS The benefit of the restricted regimen was only significant in the subgroup with high weight increase difference (≥ 2 kg) or high fluid intake ratio (≥ 1.8).
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Affiliation(s)
- Yanfei Shen
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Guolong Cai
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China.
| | - Shijin Gong
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Jing Yan
- Department of Intensive Care Unit, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, 310000, Zhejiang, People's Republic of China
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20
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Kumar L, Kumar K, Sandhya S, Koshy DM, Ramamurthi KP, Rajan S. Effect of liberal versus restrictive fluid therapy on intraoperative lactate levels in robot- assisted colorectal surgery. Indian J Anaesth 2020; 64:599-604. [PMID: 32792736 PMCID: PMC7413354 DOI: 10.4103/ija.ija_401_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/27/2020] [Accepted: 05/09/2020] [Indexed: 12/22/2022] Open
Abstract
Background and Aims Minimally invasive and robotic surgeries need lesser fluid replacement but the role of restricted fluids in robotic surgeries other than prostatic surgeries has not been clearly defined. Our primary aim was to evaluate the effects of a restrictive fluid regimen versus a liberal policy on intra-operative lactate in robotic colorectal surgery. Secondary outcomes were need for vasopressors, extubation on table, post-operative renal functions and length of ICU (LOICU) stay. Methods American society of anaesthesiologists (ASA) physical status I-II patients scheduled for robot-assisted colorectal surgery were randomised into one of two groups, receiving either 2 mL/kg/h (Group R) or 4mL/kg/h, (group L). Fluid boluses of 250 ml were administered if mean arterial pressure (MAP) <65 mmHg or urine output <0.5 ml/kg/h. Norepinephrine was added for the blood pressure after 2 fluid boluses. Surgical field was assessed by modified Boezaart's scale and surgeon satisfaction by Likert scale. Results Demographics and baseline renal functions were comparable. Adjusted intra-operative lactate at 2 h, 4 h, and 6 h and need for noradrenaline and post-operative creatinine were similar. One patient in the group L was ventilated due to hypothermia. The field was better at the 4 h in group R and comparable at other time points. The LOICU stay was longer in Group L. Conclusion The use of restrictive fluid strategy of 2 mL/kg/h (group R) does not increase lactate levels or creatinine, improves surgical field at 4 h and shortens ICU stay in comparison to a liberal 4 mL/kg/h (group L) in robotic colorectal surgery.
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Affiliation(s)
- Lakshmi Kumar
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Kalyan Kumar
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sai Sandhya
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Deepa M Koshy
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Kruthika P Ramamurthi
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sunil Rajan
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Massoth C, Zarbock A, Meersch M. Risk Stratification for Targeted AKI Prevention After Surgery: Biomarkers and Bundled Interventions. Semin Nephrol 2020; 39:454-461. [PMID: 31514909 DOI: 10.1016/j.semnephrol.2019.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Perioperative acute kidney injury (AKI) is a surgery-associated complication with increasing incidence, not only because of enhanced awareness for the diagnosis, but also as a result of the aging society with a growing number of severe comorbidities undergoing major surgical procedures. The dilemma of AKI as a global health burden lies in the discrepancy between its importance as a significant risk factor for morbidity and mortality, and the unavailability of specific therapies to modify these adverse outcomes. Thus, it is all the more important to focus management on AKI prevention, and when AKI occurs to focus on early recognition and immediate adaption of individualized care. AKI is the result of an inter-relationship between patient susceptibility and determinants of perioperative exposures. Screening for constellations of risk factors along with measurement of novel biomarkers allows for early identification of patients who are susceptible to AKI and to initiate early targeted care. Targeted care involves implementation of a bundle of interventions adapted from a consensus management guideline, and is a strategy with growing evidence of a beneficial effect on patients' short- and long-term outcomes.
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Affiliation(s)
- Christina Massoth
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany.
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Impact of Age on Short- and Long-Term Outcomes after Pancreatoduodenectomy for Periampullary Neoplasms. Gastroenterol Res Pract 2020; 2020:1793051. [PMID: 32382261 PMCID: PMC7183022 DOI: 10.1155/2020/1793051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/24/2020] [Accepted: 03/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background Although mortality and morbidity of pancreatoduodenectomy (PD) have improved significantly over the past years, the impact of age for patients undergoing PD is still debated. This study is aimed at analyzing short- and long-term outcomes of PD in elderly patients. Methods 124 consecutive patients who have undergone PD for pancreas neoplasms in our center between 2012 and 2017 were analyzed. Patients were divided into two groups: group I (<75 years) and group II (≥75 years). Demographic features and intraoperative and clinical-pathological data were collected. Primary endpoints were perioperative morbidity and mortality; complications were classified according to the Clavien-Dindo Score. Secondary endpoints included feasibility of adjuvant treatment and overall survival rates. Results A total of 106 patients were included in this study. There were 73 (68.9%) patients in group I and 33 (31.1%) in group II. Perioperative deceases were 4 (3.6%), and postoperative pancreatic fistulas were 34 (32.1%). Significant difference between two groups was demonstrated for the ASA Score (p = 0.004), Karnofsky Score (p = 0.025), preoperative jaundice (p = 0.004), and pulmonary complications (p = 0.034). No significance was shown for diabetes, radicality of resection, stage of disease, operative time, length of stay, postoperative complications according to the Clavien-Dindo Score, postoperative mortality, pancreatic fistula, and reoperation rates. 69.9% of the patients in group I underwent adjuvant treatment vs. 39.4% of the older ones (p = 0.012). Mean overall survival was 28.5 months in group I vs. 22 months in group II (p = 0.909). Conclusion PD can be performed safely in elderly patients. Advanced age should not be an absolute contraindication for PD, even if greater frailty should be considered. The outcome of elderly patients who have undergone PD is similar to that of younger patients, even though adjuvant treatment administration is significantly lower, demonstrating that surgery remains the main therapeutic option.
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Odor PM, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe SR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ 2020; 368:m540. [PMID: 32161042 PMCID: PMC7190038 DOI: 10.1136/bmj.m540] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIA Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESIS Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS 117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONS Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGISTRATION Prospero CRD42016035662.
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Affiliation(s)
- Peter M Odor
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Sohail Bampoe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - David Gilhooly
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Benedict Creagh-Brown
- Surrey Perioperative Anaesthesia Critical care collaborative Research (SPACeR) Group, Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - S Ramani Moonesinghe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
- UCL/UCLH Surgical Outcomes Research Centre, UCL Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
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Perioperative Fluid Administration in Pancreatic Surgery: a Comparison of Three Regimens. J Gastrointest Surg 2020; 24:569-577. [PMID: 30945088 DOI: 10.1007/s11605-019-04166-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Optimization of perioperative fluid management is a controversial issue. Weight-adjusted, fixed fluid strategies do not take into account patient hemodynamic status, so that individualized strategies guided by relevant variables may be preferable. We studied this issue in patients undergoing pancreatic surgery within our institution. METHODS All patients who underwent a laparotomy for pancreatic cancer during a 5-month period at our hospital (AOUI of Verona, Italy) were eligible to be included in this prospective, observational study. According to the responsible anesthesiologist's free choice, patients received, during surgery, either liberal (12 ml/kg/h) or restricted (4 ml/kg/h) fixed-volume weight-guided replacement fluids or goal-directed (GD) fluid replacement using stroke volume variation (SVV) determined by the FloTrac Vigileo device. RESULTS Eighty-six patients were included: 29 in the liberal group, 23 in the restricted group, and 34 in the GD group. The mean duration of surgery was 6 [4-7] h. Patients in the liberal group received more perioperative fluid than those in the GD and restricted groups. Nearly one third of all patients had a major complication, including delayed enteral feeding, and presented a longer duration of hospital stay. Despite the biases related to our limited cohort, there were significantly fewer postoperative complications (such as postoperative fistula, abdominal collection, and hemorrhage) in the restricted and GD groups of patients than in the liberal one. CONCLUSION In patients undergoing pancreatic surgery, a restricted or individually guided GD strategy for management of perioperative fluids can result in fewer complications than a liberal fluid strategy. Larger and randomized investigations are warranted to confirm these data on this domain.
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Sander M, Schneck E, Habicher M. Management of perioperative volume therapy - monitoring and pitfalls. Korean J Anesthesiol 2020; 73:103-113. [PMID: 32106641 PMCID: PMC7113166 DOI: 10.4097/kja.20022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022] Open
Abstract
Over 300 million surgical procedures are performed every year worldwide. Anesthesiologists play an important role in the perioperative process by assessing the overall risk of surgery and aim to reduce the risk of complications. Perioperative hemodynamic and volume management can help to improve outcomes in perioperative patients. There has been ongoing discussion about goal-directed therapy. However, there is a consensus that fluid overload and severe fluid depletion in the perioperative period are harmful and can lead to adverse outcomes. This article provides an overview of how to evaluate the fluid responsiveness of patients, details which parameters could be used, and what limitations should be noted.
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Affiliation(s)
- Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
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Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis. ACTA ACUST UNITED AC 2020; 6:5-24. [PMID: 32104727 PMCID: PMC7029405 DOI: 10.2478/jccm-2020-0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
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.
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Goal-Directed vs Traditional Approach to Intraoperative Fluid Therapy during Open Major Bowel Surgery: Is There a Difference? Anesthesiol Res Pract 2019; 2019:3408940. [PMID: 31871449 PMCID: PMC6907038 DOI: 10.1155/2019/3408940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Optimum perioperative fluid therapy is important to improve the outcome of the surgical patient. This study prospectively compared goal-directed intraoperative fluid therapy with traditional fluid therapy in general surgical patients undergoing open major bowel surgery. Methodology Patients between 20 and 70 years of age, either gender, ASA I and II, and scheduled for elective open major bowel surgery were included in the study. Patients who underwent laparoscopic and other surgeries were excluded. After routine induction of general anaesthesia, the patients were randomised to either the control group (traditional fluid therapy), the FloTrac group (based on stroke volume variation), or the PVI group (based on pleth variability index). Fluid input and output, recovery characteristics, and complications were noted. Results 306 patients, with 102 in each group, were enrolled. Five patients (control (1), FloTrac (2), and PVI (2)) were inoperable and were excluded. Demographic data, ASA PS, anaesthetic technique, duration of surgery, and surgical procedures were comparable. The control group received significantly more crystalloids (3200 ml) than the FloTrac (2000 ml) and PVI groups (1875 ml), whereas infusion of colloids was higher in the FloTrac (400–700 ml) and PVI (200–500 ml) groups than in the control group (0–500 ml). The control group had significantly positive net fluid balance intraoperatively (2500 ml, 9 ml/kg/h) compared to the FloTrac (1515 ml, 5.4 ml/kg/h) and PVI (1420 ml, 6 ml/kg/h) groups. Days to ICU stay, HDU stay, return of bowel movement, oral intake, morbidity, duration of hospital stay, and survival rate were comparable. The total number of complications was not different between the three groups. Anastomotic leaks occurred more often in the Control group than in the others, but the numbers were small. Conclusions Use of goal-directed fluid management, either with FloTrac or pleth variability index results in a lower volume infusion and lower net fluid balance. However, the complication rate is similar to that of traditional fluid therapy. This trial is registered with CTRI/2018/04/013016.
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Preoperative Dehydration does not Increase the Risk of Complications Following Elective Lumbar Surgery. Spine (Phila Pa 1976) 2019; 44:E1336-E1341. [PMID: 31689256 DOI: 10.1097/brs.0000000000003149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to evaluate the effect of preoperative dehydration on hospital length of stay (LOS), rates of 30-day postoperative complications, related reoperations, and readmissions. SUMMARY OF BACKGROUND DATA Preoperative dehydration has long been associated with postoperative infection, deep vein thrombosis (DVT), acute renal failure, and an increased hospital LOS. To our knowledge, the effect of preoperative dehydration on complication rates for patients undergoing elective lumbar spine surgery has not been well described. METHODS An analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 2006 to 2013 was performed. Patients undergoing elective lumbar procedures were identified and exclusion criteria eliminated patients who underwent any emergency procedures, infections, tumor cases, or revision surgeries. Patient dehydration was defined as preoperative blood urea nitrogen/creatinine (BUN/Cr) ratio greater than 20. RESULTS Patients (4698; 34.5%) with preoperative dehydration based on BUN/Cr ratio were identified. Univariate analysis was suggestive of an association between preoperative dehydration and an increased risk of DVT (1.1% compared with 0.6%; P = 0.002), urinary tract infection (2.5% compared with 1.6%; P < 0.001), and need for transfusion postoperatively (17.6% compared with 14.4%; P < 0.001). However, on the basis of multivariate regression, no significant association between dehydration and increased odds of aforementioned outcomes was identified. CONCLUSION Preoperative dehydration does not appear to negatively affect perioperative outcomes or readmission in patients undergoing elective lumbar spine surgery. LEVEL OF EVIDENCE 3.
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Jewer JK, Wong MJ, Bird SJ, Habib AS, Parker R, George RB. Supplemental perioperative intravenous crystalloids for postoperative nausea and vomiting. Cochrane Database Syst Rev 2019; 3:CD012212. [PMID: 30925195 PMCID: PMC6440702 DOI: 10.1002/14651858.cd012212.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common complication following general anaesthesia. It may be associated with patient dissatisfaction, increased costs of treatment, and unintended admission to hospital.Supplemental intravenous crystalloid administration in the perioperative period may be a simple intervention to prevent PONV. OBJECTIVES To assess whether supplemental intravenous crystalloid administration prevents PONV in patients undergoing surgical procedures under general anaesthesia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE (1946 to August 2018), Embase (1947 to August 2018), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL; 1971 to August 2018). We searched clinical trials registers for ongoing or unpublished completed studies (August 2018), handsearched three major journals (British Journal of Anaesthesia, European Journal of Anaesthesiology, and Anesthesiology; August 2018), and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA We included randomized controlled trials of participants older than six months undergoing surgical procedures under general anaesthesia and given supplemental perioperative intravenous crystalloids, defined as a volume larger than that received by a comparator group, to prevent PONV. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures described by Cochrane. MAIN RESULTS We included 41 studies (4224 participants). Participants underwent ambulatory or short length of stay surgical procedures, and were predominantly American Society of Anesthesiology (ASA) class I or II. There is one study awaiting classification and three ongoing studies. All studies took place in surgical centres, and were conducted in geographically diverse settings. Risk of bias was generally unclear across all domains.Supplemental intravenous crystalloid administration probably reduces the cumulative risk of postoperative nausea (PON) (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.51 to 0.75; 18 studies; 1766 participants; moderate-certainty evidence). When the postoperative period was divided into early (first six hours postoperatively) and late (at the time point closest to or including 24 hours postoperatively) time points, the intervention reduced the risk of early PON (RR 0.67, 95% CI 0.58 to 0.78; 20 studies; 2310 participants; moderate-certainty evidence) and late PON (RR 0.47, 95% CI 0.32 to 0.69; 17 studies; 1682 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the risk of postoperative vomiting (POV) (RR 0.50, 95% CI 0.40 to 0.63; 20 studies; 1970 participants; moderate-certainty evidence). The intervention specifically reduced both early POV (RR 0.56, 95% CI 0.41 to 0.76; 19 studies; 1998 participants; moderate-certainty evidence) and late POV (RR 0.48, 95% CI 0.29 to 0.79; 15 studies; 1403 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the need for pharmacologic treatment of PONV (RR 0.62, 95% CI 0.51 to 0.76; 23 studies; 2416 participants; moderate-certainty evidence).The effect of supplemental intravenous crystalloid administration on the risk of unplanned postoperative admission to hospital is unclear (RR 1.05, 95% CI 0.77 to 1.43; 3 studies; 235 participants; low-certainty evidence).No studies reported serious adverse events that may occur following supplemental perioperative intravenous crystalloid administration (i.e. admission to high-dependency unit, postoperative cardiac or respiratory complication, or death). AUTHORS' CONCLUSIONS There is moderate-certainty evidence that supplemental perioperative intravenous crystalloid administration reduces PON and POV, in ASA class I to II patients receiving general anaesthesia for ambulatory or short length of stay surgical procedures. The intervention probably also reduces the risk of pharmacologic treatment for PONV. The effect of the intervention on the risk of unintended postoperative admission to hospital is unclear. The risk of serious adverse events resulting from supplemental perioperative intravenous crystalloid administration is unknown as no studies reported this outcome. The one study awaiting classification may alter the conclusions of the review once assessed.
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Affiliation(s)
- James K Jewer
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
| | - Michael J Wong
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
| | - Sally J Bird
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
- IWK Health CentreDepartment of Pediatric Anesthesia5850/5890 University AvenueHalifaxNSCanadaB3P 0B7
| | | | - Robin Parker
- Dalhousie UniversityW.K. Kellogg Health Sciences Library5850 College StPO Box 15000HalifaxNSCanadaB3H 4R2
| | - Ronald B George
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 378] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Pleth variability index versus pulse pressure variation for intraoperative goal-directed fluid therapy in patients undergoing low-to-moderate risk abdominal surgery: a randomized controlled trial. BMC Anesthesiol 2019; 19:34. [PMID: 30851740 PMCID: PMC6408844 DOI: 10.1186/s12871-019-0707-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/01/2019] [Indexed: 12/15/2022] Open
Abstract
Background Goal-directed fluid therapy (GDFT) based on dynamic indicators of fluid responsiveness has been shown to decrease postoperative complications and hospital length of stay (LOS) in patients undergoing major abdominal surgery. The usefulness of this approach still needs to be clarified in low-to-moderate risk abdominal surgery. Both pulse-pressure variation (PPV) and pleth variability index (PVI) can be used to guide GDFT strategies. The objective of this prospective randomized controlled trial was to determine if the use of PVI guided GDFT, when compared to PPV guided GDFT, would lead to similar hospital LOS in patients undergoing low-to-moderate risk surgery. Secondary outcomes included amount of fluid administered and incidence of postoperative complications. Methods Patients were randomized into either PVI or PPV guided GDFT groups. Both received a baseline 2 ml kg− 1 h− 1 Lactated Ringer infusion. Additional fluid boluses consisted of 250 mL of colloid that was infused over a 10 min period if PVI was > 15% or PPV was > 13% for at least five minutes. The primary outcome was to determine if hospital LOS, which was defined as the number of days from surgery up to the day the surgeon authorized hospital discharge, was equivalent between the two groups. Results A total of 76 patients were included and they were randomized into two groups of 38 patients. Baseline characteristics were similar in both groups. Both PVI and PPV guided GDFT strategies were equivalent for the primary outcome of LOS (median [interquartile range]) (days) 2.5 [2.0–3.3] vs. 3.0 [2.0–5.0], p = 0.230, respectively. Fluids infused, postoperative complications, and all other outcomes were not different between groups. Conclusion In patients undergoing low-to-moderate risk abdominal surgery, PVI seems to guide GDFT similarly to PPV in regards to hospital LOS, amount of fluid, and incidence of postoperative complications. However, in low-risk patients undergoing these surgical procedures optimizing stroke volume may have limited impact on outcome. Trial registration ClinicalTrials.gov Identifier: NCT02908256, September 2016, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12871-019-0707-9) contains supplementary material, which is available to authorized users.
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Kuo SC, Mu PF, Chang LY, Chou SS, Lee MY, Su JY, Shih CF, Curia M. Effectiveness of coffee for postoperative ileus in patients following abdominal surgery: a systematic review protocol. ACTA ACUST UNITED AC 2018; 16:2072-2079. [PMID: 30439742 DOI: 10.11124/jbisrir-2017-003686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The purpose of this systematic review is to critically appraise, synthesize and present the best available evidence concerning the effects of coffee on postoperative ileus following abdominal surgery. The review will consider the effect of coffee and decaffeinated coffee on recovering gastrointestinal function, time to first bowel movement, time to first flatus, time to tolerance of solid food, postoperative complications and length of hospital stay.
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Affiliation(s)
- Shu-Chen Kuo
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Nursing, School of Nursing, National Yang-Ming University, Taipei, Taiwan
| | - Pei-Fan Mu
- Institute of Clinical Nursing, National Yang-Ming University, Taipei, Taiwan.,Taiwan Evidence Based Practice Centre: a Joanna Briggs Centre of Excellence
| | - Li-Yin Chang
- Department of Nursing, China Medical University Hospital, Taichung City, Taiwan
| | - Shin-Shang Chou
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Nursing, School of Nursing, National Yang-Ming University, Taipei, Taiwan
| | - Mei-Yin Lee
- Department of Nursing, National Taipei University of Nursing and Health Science, Taipei, Taiwan
| | - Jui-Yuan Su
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chiung-Fen Shih
- Department of Nursing, Taichung Veterans General Hospital, Taichung City, Taiwan
| | - Marianne Curia
- Department of Nursing, School of Nursing, National Yang-Ming University, Taipei, Taiwan
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Hoaglund EL, Hess AM, Hassel DM. Retrospective evaluation of the effect of intravenous fluid administration on development of postoperative reflux in horses with colic (2004-2012): 194 horses. J Vet Emerg Crit Care (San Antonio) 2018; 28:566-572. [PMID: 30302921 DOI: 10.1111/vec.12776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 02/28/2017] [Accepted: 03/11/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the role of intravenous fluid volume and electrolyte supplementation on the development of postoperative reflux (POR) in horses undergoing celiotomy for colic. DESIGN Case-control study spanning 2004-2012 for horses undergoing celiotomy for colic. SETTING University teaching hospital. ANIMALS Sixty-seven client-owned horses >1 year of age with POR were each matched to 2 controls with similar surgical lesions that did not demonstrate POR. MEASUREMENTS AND MAIN RESULTS Survival was significantly lower in cases (65.7%) than controls (96.1%). Factors found to be associated with POR included decreased net fluid volume administered on day 1 postoperatively, increased age, and performing a resection and anastomosis. Mean time until onset of POR was 20.4 hours postoperatively. PCV was significantly higher immediately following surgery and at 24 hours postoperatively in horses that developed POR compared with matched controls. There was no association between electrolyte values at presentation or administration of potassium, calcium, or magnesium in the postoperative period and the subsequent development of reflux. CONCLUSIONS In the perioperative period, IV fluid volume overload and electrolyte abnormalities were not contributing factors in the development of POR in this population of surgical colic patients. Close postoperative monitoring with consideration and correction of pre- and postoperative fluid deficits is recommended.
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Affiliation(s)
- Elizabeth L Hoaglund
- Departments of Clinical Sciences, Colorado State University, Fort Collins, CO, 80525
| | - Ann M Hess
- Department of Statistics, Colorado State University, Fort Collins, CO, 80525
| | - Diana M Hassel
- Departments of Clinical Sciences, Colorado State University, Fort Collins, CO, 80525
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Early Diuresis After Colon and Rectal Surgery Does Not Reduce Length of Hospital Stay: Results of a Randomized Trial. Dis Colon Rectum 2018; 61:1187-1195. [PMID: 30192327 DOI: 10.1097/dcr.0000000000001183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Excessive perioperative fluid administration likely increases postoperative cardiovascular, infectious, and GI complications. Early administration of diuretics after elective surgery facilitates rapid mobilization of excess fluid, potentially leading to decreased bowel edema, more rapid return of bowel function, and reduced length of hospital stay. OBJECTIVE This study aimed to evaluate the benefit of early diuresis after elective colon and rectal surgery in the setting of an enhanced recovery after surgery practice. DESIGN This was a prospective study. SETTINGS The study was conducted at a quaternary referral center. PATIENTS A randomized, open-label, parallel-group trial was conducted in patients undergoing elective colon and rectal surgery at a single quaternary referral center. INTERVENTION The primary intervention was administration of intravenous furosemide plus enhanced recovery after surgery on postoperative day 1 and 2 versus enhanced recovery after surgery alone. MAIN OUTCOME MEASURES The primary outcome was length of hospital stay. Secondary outcomes included 30-day readmission rate, time to stool output during hospitalization after surgery, and incidence of various complications within the first 48 hours of hospital stay. RESULTS In total, 123 patients were randomly assigned to receive either furosemide plus enhanced recovery after surgery (n = 62) or enhanced recovery after surgery alone (n = 61). Groups were evenly matched at baseline. At interim analysis, length of hospital stay was not superior in the intervention group (80.6 vs 99.6 hours, p = 0.564). No significant difference was identified in the rates of nasogastric tube replacement (1.6% vs 9.7%, p = 0.125). Time to return of bowel function was significantly longer in the intervention group (45.4 vs 48.8 hours, p = 0.048). The decision was made to end the study early because the conditional power of the study favored futility. LIMITATIONS This was a single-center study. CONCLUSIONS Early administration of furosemide does not significantly reduce the length of hospital stay after elective colon and rectal surgery in the setting of enhanced recovery after surgery practice. See Video Abstract at http://links.lww.com/DCR/A714.
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Affiliation(s)
- Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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Cesur S, Çardaközü T, Kuş A, Türkyılmaz N, Yavuz Ö. Comparison of conventional fluid management with PVI-based goal-directed fluid management in elective colorectal surgery. J Clin Monit Comput 2018; 33:249-257. [PMID: 29948666 PMCID: PMC6420438 DOI: 10.1007/s10877-018-0163-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/26/2018] [Indexed: 02/07/2023]
Abstract
Intraoperative fluid management is quite important in terms of postoperative organ perfusion and complications. Different fluid management protocols are in use for this purpose. Our primary goal was to compare the effects of conventional fluid management (CFM) with the Pleth Variability Index (PVI) guided goal-directed fluid management (GDFM) protocols on the amount of crystalloids administered, blood lactate, and serum creatinine levels during the intraoperative period. The length of hospital stay was our secondary goal. Seventy ASA I–II elective colorectal surgery patients were randomly assigned to CFM or GDFM for fluid management. The hemodynamic data and the data obtained from ABG were recorded at the end of induction and during the follow-up period at 1 h intervals. In the preoperative period and at 24 h postoperatively, blood samples were taken for the measurement of hemoglobin, Na, K, Cl, serum creatinine, albumin and blood lactate. In the first 24 h after surgery, oliguria and the time of first bowel movement were recorded. Length of hospital stay was also recorded. Intraoperative crystalloid administration and urine output were statistically significantly higher in CFM group (p < 0.001, p: 0.018). The end-surgery fluid balance was significantly lower in Group GDFM. Preoperative and postoperative Na, K, Cl, serum albumin, serum creatinine, lactate and hemoglobin values were similar between the groups. The time to passage of stool was significantly short in Group-GDFM compared to Group-CFM (p = 0.016). The length of hospital stay was found to be similar in both group. PVI-guided GDFM might be an alternative to CFM in ASA I–II patients undergoing elective colorectal surgery. However, further studies need to be carried out to search the efficiency and safety of PVI.
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Affiliation(s)
- Sevim Cesur
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey.
| | - Tülay Çardaközü
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Alparslan Kuş
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Neşe Türkyılmaz
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Ömer Yavuz
- Department of General Surgery, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
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Simões CM, Carmona MJC, Hajjar LA, Vincent JL, Landoni G, Belletti A, Vieira JE, de Almeida JP, de Almeida EP, Ribeiro U, Kauling AL, Tutyia C, Tamaoki L, Fukushima JT, Auler JOC. Predictors of major complications after elective abdominal surgery in cancer patients. BMC Anesthesiol 2018; 18:49. [PMID: 29743022 PMCID: PMC5944034 DOI: 10.1186/s12871-018-0516-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/27/2018] [Indexed: 12/23/2022] Open
Abstract
Background Patients undergoing abdominal surgery for solid tumours frequently develop major postoperative complications, which negatively affect quality of life, costs of care and survival. Few studies have identified the determinants of perioperative complications in this group. Methods We performed a prospective observational study including all patients (age > 18) undergoing abdominal surgery for cancer at a single institution between June 2011 and August 2013. Patients undergoing emergency surgery, palliative procedures, or participating in other studies were excluded. Primary outcome was a composite of 30-day all-cause mortality and infectious, cardiovascular, respiratory, neurologic, renal and surgical complications. Univariate and multiple logistic regression analyses were performed to identify predictive factors for major perioperative adverse events. Results Of a total 308 included patients, 106 (34.4%) developed a major complication during the 30-day follow-up period. Independent predictors of postoperative major complications were: age (odds ratio [OR] 1.03 [95% CI 1.01–1.06], p = 0.012 per year), ASA (American Society of Anesthesiologists) physical status greater than or equal to 3 (OR 2.61 [95% CI 1.33–5.17], p = 0.003), a preoperative haemoglobin level lower than 12 g/dL (OR 2.13 [95% CI 1.21–4.07], p = 0.014), intraoperative use of colloids (OR 1.89, [95% CI 1.03–4.07], p = 0.047), total amount of intravenous fluids (OR 1.22 [95% CI 0.98–1.59], p = 0.106 per litre), intraoperative blood losses greater than 500 mL (2.07 [95% CI 1.00–4.31], p = 0.043), and hypotension needing vasopressor support (OR 4.68 [95% CI 1.55–27.72], p = 0.004). The model had good discrimination with the area under the ROC curve being 0.80 (95% CI 0.75–0.84, p < 0.001). Conclusions Our findings suggest that a perioperative strategy aimed at reducing perioperative complications in cancer surgery should include treatment of preoperative anaemia and an optimal fluid strategy, avoiding fluid overload and intraoperative use of colloids. Electronic supplementary material The online version of this article (10.1186/s12871-018-0516-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudia M Simões
- Anesthesia Department, Instituto do Câncer do Estado de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Maria J C Carmona
- Anesthesia Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ludhmila A Hajjar
- Anesthesia Department, Instituto do Câncer do Estado de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil.
| | | | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Joaquim E Vieira
- Anesthesia Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Juliano P de Almeida
- Anesthesia Department, Instituto do Câncer do Estado de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Elisangela P de Almeida
- Anesthesia Department, Instituto do Câncer do Estado de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Ulysses Ribeiro
- Anesthesia Department, Instituto do Câncer do Estado de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - Ana L Kauling
- Anesthesia Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Celso Tutyia
- Anesthesia Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lie Tamaoki
- Anesthesia Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Julia T Fukushima
- Anesthesia Department, Instituto do Câncer do Estado de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil
| | - José O C Auler
- Anesthesia Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Noel-Morgan J, Muir WW. Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Front Vet Sci 2018; 5:53. [PMID: 29616230 PMCID: PMC5864866 DOI: 10.3389/fvets.2018.00053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/02/2018] [Indexed: 12/14/2022] Open
Abstract
Although the utility and benefits of anesthesia and analgesia are irrefutable, their practice is not void of risks. Almost all drugs that produce anesthesia endanger cardiovascular stability by producing dose-dependent impairment of cardiac function, vascular reactivity, and compensatory autoregulatory responses. Whereas anesthesia-related depression of cardiac performance and arterial vasodilation are well recognized adverse effects contributing to anesthetic risk, far less emphasis has been placed on effects impacting venous physiology and venous return. The venous circulation, containing about 65–70% of the total blood volume, is a pivotal contributor to stroke volume and cardiac output. Vasodilation, particularly venodilation, is the primary cause of relative hypovolemia produced by anesthetic drugs and is often associated with increased venous compliance, decreased venous return, and reduced response to vasoactive substances. Depending on factors such as patient status and monitoring, a state of relative hypovolemia may remain clinically undetected, with impending consequences owing to impaired oxygen delivery and tissue perfusion. Concurrent processes related to comorbidities, hypothermia, inflammation, trauma, sepsis, or other causes of hemodynamic or metabolic compromise, may further exacerbate the condition. Despite scientific and technological advances, clinical monitoring and treatment of relative hypovolemia still pose relevant challenges to the anesthesiologist. This short perspective seeks to define relative hypovolemia, describe the venous system’s role in supporting normal cardiovascular function, characterize effects of anesthetic drugs on venous physiology, and address current considerations and challenges for monitoring and treatment of relative hypovolemia, with focus on insights for future therapies.
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Affiliation(s)
- Jessica Noel-Morgan
- Center for Cardiovascular & Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - William W Muir
- QTest Labs, Columbus, OH, United States.,College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
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Bazargani ST, Ghodoussipour S, Tse B, Miranda G, Cai J, Schuckman A, Daneshmand S, Djaladat H. The association between intraoperative fluid intake and postoperative complications in patients undergoing radical cystectomy with an enhanced recovery protocol. World J Urol 2018; 36:401-407. [PMID: 29299662 DOI: 10.1007/s00345-017-2164-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/26/2017] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To evaluate the association between intraoperative fluid intake and postoperative complications in patients who underwent radical cystectomy (RC) for bladder cancer with an enhanced recovery protocol. METHODS 287 patients underwent open RC with enhanced recovery protocol (ERAS) from 2012 to 2016. 107 were excluded; non-urothelial (30), palliative (37), had adjunct procedures or not-consented (40). We prospectively evaluated intraoperative fluid intake (crystalloid, colloid and blood) and correlated with length of stay, 30- and 90-day complications. RESULTS 180 patients enrolled into the study with median age of 70 years (78% male). 71% underwent orthotopic diversion. Median intraoperative crystalloid and colloid intake were 4000 and 500 cc, respectively. Nineteen percent of patients received blood transfusion. Median length of stay was 4 days. The overall 30- and 90-day complication rates were 59 and 75%, respectively. Multivariate logistic regressions controlling for a subset of clinically relevant variables showed no significant association between intraoperative fluid intake and complications at 30 or 90 days (p = 0.88 and 0.62, respectively). A multivariable linear regression similarly showed no association between total intraoperative fluid intake and length of stay (p = 0.099). CONCLUSION Higher intraoperative fluid intake was not found to independently increase the complication rate following radical cystectomy. Larger studies and prospective trials are needed to determine if fluid optimization may play a role in decreasing morbidity after this major surgery.
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Affiliation(s)
- Soroush T Bazargani
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Saum Ghodoussipour
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Beverly Tse
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Gus Miranda
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Jie Cai
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Anne Schuckman
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Siamak Daneshmand
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Hooman Djaladat
- Institute of Urology, USC/Norris Comprehensive Cancer Center, USC, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA.
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Eng OS, Dumitra S, O'Leary M, Raoof M, Wakabayashi M, Dellinger TH, Han ES, Lee SJ, Paz IB, Lee B. Association of Fluid Administration With Morbidity in Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy. JAMA Surg 2018; 152:1156-1160. [PMID: 28832866 DOI: 10.1001/jamasurg.2017.2865] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal cancers can be associated with significant complications. Randomized trials have demonstrated increased morbidity with liberal fluid regimens in abdominal surgery. Objective To investigate the association of intraoperative fluid administration and morbidity in patients undergoing CRS/HIPEC. Design, Setting, and Participants A retrospective analysis of information from a prospectively collected institutional database was conducted at a National Cancer Institute-designated comprehensive cancer center. A total of 133 patients from April 15, 2009, to June 23, 2016, with primary or secondary peritoneal cancers were included. Exposures Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Main Outcomes and Measures Morbidity associated with intraoperative fluid management calculated by the comprehensive complication index, which uses a formula combining all perioperative complications and their severities into a continuous variable from 0 to 100 in each patient. Results Of the 133 patients identified, 38% and 37% had diagnoses of metastatic appendiceal and colorectal cancers, respectively. Mean age was 54 (interquartile range [IQR], 47-64) years, and mean peritoneal cancer index was 13 (IQR, 7-18). Mitomycin and platinum-based chemotherapeutic agents were used in 96 (72.2%) and 37 (27.8%) of the patients, respectively. Mean intraoperative fluid (IOF) rate was 15.7 (IQR, 11.3-18.7) mL/kg/h. Mean comprehensive complication index (CCI) was 26.0 (IQR, 8.7-36.2). On multivariate analysis, age (coefficient, 0.32; 95% CI, 0.01-0.64; P = .04), IOF rate (coefficient, 0.97; 95% CI, 0.19-1.75; P = .02), and estimated blood loss (coefficient, 0.02; 95% CI, 0.01-0.03; P = .002) were independent predictors of increased CCI. In particular, patients who received greater than the mean IOF rate experienced a 43% increase in the CCI compared with patients who received less than the mean IOF rate (31.5 vs 22.0; P = .02). Conclusions and Relevance Intraoperative fluid administration is associated with a significant increase in perioperative morbidity in patients undergoing CRS/HIPEC. Fluid administration protocols that include standardized restrictive fluid rates can potentially help to mitigate morbidity in patients undergoing CRS/HIPEC.
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Affiliation(s)
- Oliver S Eng
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Sinziana Dumitra
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Michael O'Leary
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mark Wakabayashi
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Thanh H Dellinger
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Ernest S Han
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Stephen J Lee
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - I Benjamin Paz
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Byrne Lee
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Kurz A, Kopyeva T, Suliman I, Podolyak A, You J, Lewis B, Vlah C, Khatib R, Keebler A, Reigert R, Seuffert M, Muzie L, Drahuschak S, Gorgun E, Stocchi L, Turan A, Sessler D. Supplemental oxygen and surgical-site infections: an alternating intervention controlled trial. Br J Anaesth 2018; 120:117-126. [DOI: 10.1016/j.bja.2017.11.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/04/2017] [Accepted: 08/31/2017] [Indexed: 01/29/2023] Open
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Cohen B, Meilik B, Weiss-Meilik A, Tarrab A, Matot I. Intraoperative factors associated with postoperative complications in body contouring surgery. J Surg Res 2017; 221:24-29. [PMID: 29229135 DOI: 10.1016/j.jss.2017.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 07/01/2017] [Accepted: 08/01/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several preoperative factors have been shown to influence outcome of body contouring surgeries. The effect of intraoperative features, including fluid volume administered, hemodynamic and respiratory parameters, and body temperature on postoperative complication, has not been reported to date. MATERIALS AND METHODS All subsequent patients undergoing body contouring surgery in the Tel Aviv Medical Center between 2007 and 2012 were enrolled. Demographic and intraoperative data were collected and analyzed for possible associations with postoperative complications, including formation of seroma, hematoma/bleeding, other surgical site complications (infection, adhesiolysis, or need for debridement), formation of a hypertrophic scar, any documented, infection or a composite outcome of any of the previously mentioned. RESULTS Data of 218 patients were assessed. Mean (standard deviation) age of patients was 41(14) y. Intraoperative administration of higher volumes of fluids was significantly associated with formation of seroma (P = 0.01), hematoma/bleeding (P = 0.03), hypertrophic scar (P = 0.01), surgical site complications (P = 0.01), and a composite outcome (P < 0.001). Development of hematoma/bleeding was associated with longer periods of low (<35.6°C) intraoperative core temperature (72% versus 50% of surgery duration in patients who did not develop this complication, P < 0.05). Surgical site complications were associated with longer periods of intraoperative oxygen desaturation (saturation ≤92%, 4.2% versus 0.9% of surgery duration in patients who did not develop surgical site complications, P < 0.01). CONCLUSIONS Intraoperative moderate hypothermia, hypoxemia, and liberal fluid administration are associated with worse surgical outcome in patients undergoing body contouring surgery. Increased awareness of the potential adverse effects of these factors in body contouring surgery will enhance interventions aimed at avoiding and promptly treating such events.
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Affiliation(s)
- Barak Cohen
- Division of Anesthesia, Intensive Care and Pain Medicine, Tel Aviv Medical Center affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Benjamin Meilik
- Department of Plastic Surgery, Tel Aviv Medical Center affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Ahuva Weiss-Meilik
- Clinical Performances Research and Operational Unit, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Aviv Tarrab
- Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Idit Matot
- Division of Anesthesia, Intensive Care and Pain Medicine, Tel Aviv Medical Center affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.
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Fluid Management in the Elderly. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0243-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yao L, Wang Y, Du B, Song J, Ji F. Comparison of Postoperative Pain and Residual Gas Between Restrictive and Liberal Fluid Therapy in Patients Undergoing Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 2017; 27:346-350. [DOI: 10.1097/sle.0000000000000463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Objectives: To determine whether perioperative fluid restrictive administration can reduce specific postoperative complications in adults undergoing major abdominal surgery. Methods: We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, Google scholar, and article reference lists (up to December 2015) for studies that assessed fluid therapy and morbidity or mortality in patients undergoing major abdominal surgeries. The quality of the trials was assessed using the Jadad scoring system, and a meta-analysis of the included randomized, controlled trials was conducted using Review Manager software, version 5.2. Results: Ten studies with a total of 1160 patients undergoing major abdominal surgeries were included. We found that perioperative restrictive fluid therapy could reduce the risk of postoperative infectious complications (odds ratio [OR]=0.54, 95% confidence interval [CI]:0.39-0.74, p=0.0001, I2=37%), pulmonary complications (OR=0.49, 95% CI: 0.26-0.93, p=0.03, I2=50%), and cardiac complications (OR=0.45, 95% CI: 0.29-0.69, p=0.0003, I2=48%), but had no effect on the risk of gastrointestinal complications (OR=0.87, 95% CI: 0.51-1.46, p=0.59, I2=0%), renal complications (OR=0.76, 95% CI: 0.43-1.34, p=0.35, I2=0%), and postoperative mortality (OR=0.62, 95% CI: 0.25-1.50, p=0.29, I2=0%). Conclusion: Perioperative restrictive fluid administration was superior to liberal fluid administration in reducing the infectious, pulmonary and cardiac complications after major abdominal surgeries.
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Affiliation(s)
- Qianyun Pang
- Department of Anesthesia, Chongqing Cancer Institute/ Hospital/Cancer Center, Chongqing, China. E-mail.
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Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties. Ann Surg 2017; 265:930-940. [PMID: 28398962 DOI: 10.1097/sla.0000000000001745] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery. BACKGROUND Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices. METHODS Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS). RESULTS There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings. CONCLUSIONS Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function.
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Malbouisson LMS, Silva JM, Carmona MJC, Lopes MR, Assunção MS, Valiatti JLDS, Simões CM, Auler JOC. A pragmatic multi-center trial of goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery. BMC Anesthesiol 2017; 17:70. [PMID: 28558654 PMCID: PMC5450107 DOI: 10.1186/s12871-017-0356-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 05/08/2017] [Indexed: 11/24/2022] Open
Abstract
Background Intraoperative fluid therapy guided by mechanical ventilation-induced pulse-pressure variation (PPV) may improve outcomes after major surgery. We tested this hypothesis in a multi-center study. Methods The patients were included in two periods: a first control period (control group; n = 147) in which intraoperative fluids were given according to clinical judgment. After a training period, intraoperative fluid management was titrated to maintain PPV < 10% in 109 surgical patients (PPV group). We performed 1:1 propensity score matching to ensure the groups were comparable with regard to age, weight, duration of surgery, and type of operation. The primary endpoint was postoperative hospital length of stay. Results After matching, 84 patients remained in each group. Baseline characteristics, surgical procedure duration and physiological parameters evaluated at the start of surgery were similar between the groups. The volume of crystalloids (4500 mL [3200-6500 mL] versus 5000 mL [3750-8862 mL]; P = 0.01), the number of blood units infused during the surgery (1.7 U [0.9-2.0 U] versus 2.0 U [1.7-2.6 U]; P = 0.01), the fraction of patients transfused (13.1% versus 32.1%; P = 0.003) and the number of patients receiving mechanical ventilation at 24 h (3.2% versus 9.7%; P = 0.027) were smaller postoperatively in PPV group. Intraoperative PPV-based improved the composite outcome of postoperative complications OR 0.59 [95% CI 0.35-0.99] and reduced the postoperative hospital length of stay (8 days [6-14 days] versus 11 days [7-18 days]; P = 0.01). Conclusions In high-risk surgeries, PPV-directed volume loading improved postoperative outcomes and decreased the postoperative hospital length of stay. Trial Registration ClinicalTrials.gov Identifier; retrospectively registered- NCT03128190
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Affiliation(s)
- Luiz Marcelo Sá Malbouisson
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil.
| | - João Manoel Silva
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | - Maria José Carvalho Carmona
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | - Marcel Rezende Lopes
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | | | | | - Claudia Marques Simões
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | - José Otavio Costa Auler
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
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Prospective Randomized Controlled Trial of Liberal Vs Restricted Perioperative Fluid Management in Patients Undergoing Pancreatectomy. Ann Surg 2017; 264:591-8. [PMID: 27355261 DOI: 10.1097/sla.0000000000001846] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study is to examine, by a prospective randomized controlled trial, the influence of liberal (LIB) vs restricted (RES) perioperative fluid administration on morbidity following pancreatectomy. SUMMARY OF BACKGROUND DATA Randomized controlled trials in patients undergoing major intra-abdominal surgery have challenged the historical use of LIB fluid administration, suggesting that a more restricted regimen may be associated with fewer postoperative complications. METHODS Patients scheduled to undergo pancreatic resection were consented for randomization to a LIB (n = 164) or RES (n = 166) perioperative fluid regimen. Sample size was designed with 80% power to decrease Grade 3 complications from 35% to 21%. RESULTS Between July 2009 and July 2015, we randomized 330 patients undergoing pancreaticoduodenectomy (PD, n = 218), central (n = 16), or distal pancreatectomy (DP, n = 96). Patients were equally distributed for all demographic and intraoperative characteristics. Intraoperatively, LIB patients received crystalloid 12 mL/kg/h and RES patients 6 mL/kg/h. Cumulative crystalloid given (median, range, mL) days 0 to 3 was LIB: 12,252 (6600 to 21,365), RES 7808 (2700 to 16,274) P < 0.0001. Sixty-day mortality was 2 of 330 (0.6%). Median operative time for PD was 227 minutes (105 to 462) and DP 150 (44 to 323). Grade 3 complications occurred in 20% of LIB and 27% of RES patients (P = 0.6). Median length of stay was 7 and 5 days for PD and DP, respectively, in both arms. CONCLUSIONS In a high volume institution, major perioperative complications from pancreatic resection were not significantly influenced by fluid regimens that differed approximately 1.6-fold.
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