Arterial Pressure Variation in Elective Noncardiac Surgery: Identifying Reference Distributions and Modifying Factors

Liver Resection for Hepatocellular Carcinoma: Recent Advances

Hepatocellular carcinoma (HCC) represents a significant global health burden. Surgery remains a cornerstone in the curative treatment of HCC, and recent years have witnessed notable advancements aimed at refining surgical techniques and improving patient outcomes. This review presents a detailed examination of the recent innovations in HCC surgery, highlighting key developments in both surgical approaches and adjunctive therapies. Advanced imaging technologies have revolutionized preoperative assessment, enabling precise tumour localization and delineation of vascular anatomy. The use of three-dimensional rendering has significantly augmented surgical planning, facilitating more accurate and margin-free resections. The advent of laparoscopic and robotic-assisted surgical techniques has ushered in an era of minimal access surgery, offering patients the benefits of shorter hospital stays and faster recovery times, while enabling equivalent oncological outcomes. Intraoperative innovations such as intraoperative ultrasound (IOUS) and fluorescence-guided surgery have emerged as valuable adjuncts, allowing real-time assessment of tumour extent and aiding in parenchyma preservation. The integration of multimodal therapies, including neoadjuvant and adjuvant strategies, has allowed for 'bio-selection' and shown the potential to optimize patient outcomes. With the advent of augmented reality and artificial intelligence (AI), the future holds immense potential and may represent significant strides towards optimizing patient outcomes and refining the standard of care.

Comparison of Dynamic Measures in Intraoperative Goal-Directed Fluid Therapy of Patients with Morbid Obesity Undergoing Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Obesity increases the risk of morbidity and mortality during surgical procedures. Goal-directed fluid therapy (GDFT) is a new concept for perioperative fluid management that has been shown to improve patient prognosis. This study aimed to investigate the role of the Pleth Variability Index (PVI), systolic pressure variation (SPV), and pulse pressure variation (PPV) in maintaining tissue perfusion and renal function during GDFT management in patients undergoing laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

Two hundred ten patients were enrolled in our prospective randomized controlled clinical trial. Demographic data, hemodynamic parameters, biochemical parameters, the amount of crystalloid and colloid fluid administered intraoperatively, and the technique of goal-directed fluid management used were recorded. Patients were randomly divided into three groups: PVI (n = 70), PPV (n = 70), and SPV (n = 70), according to the technique of goal-directed fluid management. Postoperative nausea and vomiting, time of return of bowel movement, and hospital stay duration were recorded.

RESULTS

There was no statistically significant difference between the number of crystalloids administered in all three groups. However, the amount of colloid administered was statistically significantly lower in the SPV group than in the PVI group, and there was no significant difference in the other groups. Statistically, there was no significant difference between the groups in plasma lactate, blood urea, and creatinine levels.

CONCLUSION

In LSG, dynamic measurement techniques such as PVI, SPV, and PPV can be used in patients with morbid obesity without causing intraoperative and postoperative complications. PVI may be preferred over other invasive methods because it is noninvasive.

Perioperative Fluid Management and Volume Assessment

Fluid therapy is an integral component of perioperative care and helps maintain or restore effective circulating blood volume. The principal goal of fluid management is to optimize cardiac preload, maximize stroke volume, and maintain adequate organ perfusion. Accurate assessment of volume status and volume responsiveness is necessary for appropriate and judicious utilization of fluid therapy. To accomplish this, static and dynamic indicators of fluid responsiveness have been widely studied. This review discusses the overarching goals of perioperative fluid management, reviews the physiology and parameters used to assess fluid responsiveness, and provides evidence-based recommendations on intraoperative fluid management.

Right ventricular and pulmonary artery pulse pressure variation and systolic pressure variation for the prediction of fluid responsiveness: an interventional study in coronary artery bypass surgery patients

PURPOSE

Predicting fluid responsiveness is essential when treating surgical or critically ill patients. When using a pulmonary artery catheter, pulse pressure variation and systolic pressure variation can be calculated from right ventricular and pulmonary artery pressure waveforms.

METHODS

We conducted a prospective interventional study investigating the ability of right ventricular pulse pressure variation (PPV_RV) and systolic pressure variation (SPV_RV) as well as pulmonary artery pulse pressure variation (PPV_PA) and systolic pressure variation (SPV_PA) to predict fluid responsiveness in coronary artery bypass (CABG) surgery patients. Additionally, radial artery pulse pressure variation (PPV_ART) and systolic pressure variation (SPV_ART) were calculated. The area under the receiver operating characteristics (AUROC) curve with 95%-confidence interval (95%-CI) was used to assess the capability to predict fluid responsiveness (defined as an increase in cardiac index of > 15%) after a 500 mL crystalloid fluid challenge.

RESULTS

Thirty-three patients were included in the final analysis. Thirteen patients (39%) were fluid-responders with a mean increase in cardiac index of 25.3%. The AUROC was 0.60 (95%-CI 0.38 to 0.81) for PPV_RV, 0.63 (95%-CI 0.43 to 0.83) for SPV_RV, 0.58 (95%-CI 0.38 to 0.78) for PPV_PA, and 0.71 (95%-CI 0.52 to 0.89) for SPV_PA. The AUROC for PPV_ART was 0.71 (95%-CI 0.53 to 0.89) and for SPV_ART 0.78 (95%-CI 0.62 to 0.94). The correlation between pulse pressure variation and systolic pressure variation measurements derived from the different waveforms was weak.

CONCLUSIONS

Right ventricular and pulmonary artery pulse pressure variation and systolic pressure variation seem to be weak predictors of fluid responsiveness in CABG surgery patients.

The Potential of Arterial Pulse Wave Analysis in Burn Resuscitation: A Pilot In Vivo Study

While urinary output (UOP) remains the primary endpoint for titration of intravenous fluid resuscitation, it is an insufficient indicator of fluid responsiveness. Although advanced hemodynamic monitoring (including arterial pulse wave analysis (PWA)) is of recent interest, the validity of PWA-derived indices in burn resuscitation extremes has not been established. The goal of this paper is to test the hypothesis that PWA-derived cardiac output (CO) and stroke volume (SV) indices as well as pulse pressure variation (PPV) and systolic pressure variation (SPV) can play a complementary role to UOP in burn resuscitation. Swine were instrumented with a Swan-Ganz catheter for reference CO and underwent a 40% total body surface area burns with varying resuscitation paradigms, and were monitored for 24 hours in an ICU setting under mechanical ventilation. The longitudinal changes in PWA-derived indices were investigated, and resuscitation adequacy was compared as determined by UOP versus PWA indices. The results indicated that PWA-derived indices exhibited trends consistent with reference CO and SV measurements: CO and SV indices were proportional to reference CO and SV, respectively (CO: post-calibration limits of agreement (LoA)=+/-24.7 [ml/min/kg], SV: post-calibration LoA=+/-0.30 [ml/kg]) while PPV and SPV were inversely proportional to reference SV (PPV: post-calibration LoA=+/-0.32 [ml/kg], SPV: post-calibration LoA=+/-0.31 [ml/kg]). The results also indicated that PWA-derived indices exhibited notable discrepancies from UOP in determining adequate burn resuscitation. Hence, it was concluded that the PWA-derived indices may have complementary value to UOP in assessing and guiding burn resuscitation.

Effect of prone position without volume expansion on pulse pressure variation in spinal surgery : a prospective observational study

Background : Pulse pressure variation (PPV) is a predictor of fluid responsiveness in supine patients under mechanical ventilation. Its use has also been validated in the prone position. The aim of this study was to assess changes in PPV induced by prone position in patients undergoing spinal surgery. Methods : Ninety-six patients aged 12 to 75 years, scheduled for elective spinal surgery were included. Patients were excluded if they had clinical signs related to any organ failure, or if they required vasoactive drugs and/or volume expansion during the early stages of anesthesia. Patients received a standardized anesthesia protocol. Fluid expansion was not allowed from induction until 10 minutes after positioning. Hemodynamic measurements recorded before the induction of anesthesia (T0) included : arterial pressure (systolic (SAP) diastolic (DAP) and mean (MAP)) and heart rate (HR). Radial artery was cannulated after intubation and measurements, as well as PPV, were noted in supine position (T1). Patients were then placed in prone position hemodynamics and PPV measurements were repeated (T2). Results : Forty-eight patients completed the study. Anesthesia induction induced a significant decrease in SAP, DAP, and MAP with no effect on HR. Prone position did not induce any significant changes in SAP, MAP, DAP, and HR. A significant difference was found between PPV values in supine (Mean=10.5, SD=4.5) and prone positions (Mean=15.2, SD=7.1) ; t=-4.15 (p<0.001). The mean increase in PPV was 4.7%. Conclusion : Prone position without prior volume expansion induces a significant increase in PPV prior to any modification in arterial blood pressure and heart rate.

A randomized comparison between pulse pressure variation and central venous pressure in patients undergoing renal transplantation

Background and Aims:

Intraoperative fluid management is important in renal transplant recipients with end-stage renal disease. Conventionally, central venous pressure (CVP) has been used to guide perioperative fluid administration but with high incidence of poor graft outcome. There is a requirement of reliable parameter to guide the fluid therapy in these patients so as to minimize the perioperative complications and improve the outcome. Hence, this study was conducted.

Material and Methods:

This prospective study included 75 patients of chronic kidney disease undergoing renal transplantation. Patients were divided into two groups. Group A (control group): Intraoperative fluids were guided by CVP; Group B: Intraoperative fluids were guided by pulse pressure variation (PPV). Primary outcome measure of this study was incidence of delayed graft functioning, i.e., need of hemodialysis within 7 days of renal transplant. Secondary outcome measures were incidence of perioperative hypotension, post-transplant pulmonary edema, tissue edema, and lactic acidosis.

Results:

Total amount of fluid before reperfusion was significantly greater in the control group (P = 0.005). However, the total amount of fluid required at the end of surgery was comparable. Delayed graft functioning was seen only in CVP group, although it was not statistically significant. The postoperative tissue edema was more in CVP group (P = 0.03). The postoperative nausea and vomiting, pulmonary edema, and mechanical ventilation were more in CVP group but not statistically significant. Increase in lactate value was more in CVP group.

Conclusion:

Perioperative fluid guidance by PPV is better than central venous pressure in renal transplant patients.

Fluid management concepts for severe neurological illness: an overview

PURPOSE OF REVIEW

The acute care of a patient with severe neurological injury is organized around one relatively straightforward goal: avoid brain ischemia. A coherent strategy for fluid management in these patients has been particularly elusive, and a well considered fluid management strategy is essential for patients with critical neurological illness.

RECENT FINDINGS

In this review, several gaps in our collective knowledge are summarized, including a rigorous definition of volume status that can be practically measured; an understanding of how electrolyte derangements interact with therapy; a measurable endpoint against which we can titrate our patients' fluid balance; and agreement on the composition of fluid we should give in various clinical contexts.

SUMMARY

As the possibility grows closer that we can monitor the physiological parameters with direct relevance for neurological outcomes and the various complications associated with neurocritical illness, we may finally move away from static therapy recommendations, and toward individualized, precise therapy. Although we believe therapy should ultimately be individualized rather than standardized, it is clear that the monitoring tools and analytical methods used ought to be standardized to facilitate appropriately powered, prospective clinical outcome trials.

Design of a Novel Multifunction Decision Support Display for Anesthesia Care: AlertWatch® OR

BACKGROUND

This paper describes the design of a multifunction alerting display for intraoperative anesthetic care. The design was inspired by the multifunction primary flight display used in modern aviation.

RESULTS

The display retrieves live data from multiple sources; the physiologic monitors, the anesthesia information management system, the laboratory values and comorbidities from patient's problem summary list, medical history or history & physical. This information is integrated into a display composed of readily identifiable icons of organ systems, which are color coded to signify normal range, marginal range, abnormal range (by green, yellow, red respectively) and orange outlines for comorbidities/risk factors. There are dozens of text alerts, which can be presented as black text (informational), red text (important information) and red scrolling text (highest importance information). The alerts are derived from current standards in the literature and some involve complex calculations being conducted in the background.

CONCLUSIONS

The goal of such a system is to improve the quality and safety of anesthetic care by providing enhanced situational awareness in a fashion analogous to the "glass cockpit" and its primary flight display which has improved aviation safety.

Journal of clinical monitoring and computing 2016 end of year summary: monitoring cerebral oxygenation and autoregulation

In the perioperative and critical care setting, monitoring of cerebral oxygenation (ScO₂) and cerebral autoregulation enjoy increasing popularity in recent years, particularly in patients undergoing cardiac surgery. Monitoring ScO₂ is based on near infrared spectroscopy, and attempts to early detect cerebral hypoperfusion and thereby prevent cerebral dysfunction and postoperative neurologic complications. Autoregulation of cerebral blood flow provides a steady flow of blood towards the brain despite variations in mean arterial blood pressure (MAP) and cerebral perfusion pressure, and is effective in a MAP range between approximately 50–150 mmHg. This range of intact autoregulation may, however, vary considerably between individuals, and shifts to higher thresholds have been observed in elderly and hypertensive patients. As a consequence, intraoperative hypotension will be poorly tolerated, and might cause ischemic events and postoperative neurological complications. This article summarizes research investigating technologies for the assessment of ScO₂ and cerebral autoregulation published in the Journal of Clinical Monitoring and Computing in 2016.