The effect of an intraoperative patient-specific, surgery-specific haemodynamic algorithm in improving textbook outcomes for hepatobiliary-pancreatic surgery: a multicentre retrospective study

Background

The concept of a "textbook outcome" is emerging as a metric for ideal surgical outcomes. We aimed to evaluate the impact of an advanced haemodynamic monitoring (AHDM) algorithm on achieving a textbook outcome in patients undergoing hepatobiliary-pancreatic surgery.

Methods

This retrospective, multicentre observational study was conducted across private and public teaching sectors in Victoria, Australia. We studied patients managed by a patient-specific, surgery-specific haemodynamic algorithm or via usual care. The primary outcome was the effect of using a patient-specific, surgery-specific AHDM algorithm for achieving a textbook outcome, with adjustment using propensity score matching. The textbook outcome criteria were defined according to the International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery and Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery.

Results

Of the 780 weighted cases, 477 (61.2%, 95% CI: 57.7%-64.6%) achieved the textbook outcome. Patients in the AHDM group had a higher rate of textbook outcomes [n = 259 (67.8%)] than those in the Usual care group [n = 218 (54.8%); p < 0.001, estimated odds ratio (95% CI) 1.74 (1.30-2.33)]. The AHDM group had a lower rate of surgery-specific complications, severe complications, and a shorter hospital length of stay (LOS) [OR 2.34 (95% CI: 1.30-4.21), 1.79 (95% CI: 1.12-2.85), and 1.83 (95% CI: 1.35-2.46), respectively]. There was no significant difference between the groups for hospital readmission and mortality.

Conclusions

AHDM use was associated with improved outcomes, supporting its integration in hepatobiliary-pancreatic surgery. Prospective trials are warranted to further evaluate the impact of this AHDM algorithm on achieving a textbook impact on long-term outcomes.

Effect of cardiac output - guided hemodynamic management on acute lung injury in pediatric living donor liver transplantation

BACKGROUND

Acute lung injury (ALI) after liver transplantation (LT) may lead to acute respiratory distress syndrome, which is associated with adverse postoperative outcomes, such as prolonged hospital stay, high morbidity, and mortality. Therefore, it is vital to maintain hemodynamic stability and optimize fluid management. However, few studies have reported cardiac output-guided (CO-G) management in pediatric LT.

AIM

To investigate the effect of CO-G hemodynamic management on early postoperative ALI and hemodynamic stability during pediatric living donor LT.

METHODS

A total of 130 pediatric patients scheduled for elective living donor LT were enrolled as study participants and were assigned to the control group (65 cases) and CO-G group (65 cases). In the CO-G group, CO was considered the target for hemodynamic management. In the control group, hemodynamic management was based on usual perioperative care guided by central venous pressure, continuous invasive arterial pressure, urinary volume, etc. The primary outcome was early postoperative ALI. Secondary outcomes included other early postoperative pulmonary complications, readmission to the intense care unit (ICU) for pulmonary complications, ICU stay, hospital stay, and in-hospital mortality.

RESULTS

The incidence of early postoperative ALI was 27.7% in the CO-G group, which was significantly lower than that in the control group (44.6%) (P < 0.05). During the surgery, the incidence of postreperfusion syndrome was lower in the CO-G group (P < 0.05). The level of intraoperative positive fluid transfusions was lower and the rate of dobutamine use before portal vein opening was higher, while the usage and dosage of epinephrine during portal vein opening and vasoactive inotropic score after portal vein opening were lower in the CO-G group (P < 0.05). Compared to the control group, serum inflammatory factors (interleukin-6 and tumor necrosis factor-α), cardiac troponin I, and N-terminal pro-brain natriuretic peptide were lower in the CO-G group after the operation (P < 0.05).

CONCLUSION

CO-G hemodynamic management in pediatric living-donor LT decreases the incidence of early postoperative ALI due to hemodynamic stability through optimized fluid management and appropriate administration of vasopressors and inotropes.

MEasuring the impact of Anesthetist-administered medications volumeS on intraoperative flUid balance duRing prolonged abdominal surgEry (MEASURE Study)

BACKGROUND

The contribution of intraoperative anesthetist-administered medications (IAAMs) to the total volume of intraoperative intravenous (IV) fluid therapy and their association with postoperative outcomes has never been formally investigated.

METHODS

We performed a retrospective study of adult patients undergoing pancreaticoduodenectomy. The volume of IAAMs, crystalloids and colloids, blood and blood products, blood loss, urine output and intraoperative fluid balance were collected. The contribution of IAAMs to the total intraoperative IV fluid volume and postoperative complications was evaluated.

RESULTS

A total of 152 consecutive patients were included. The median volume of IAAMs was 363.8 mL (interquartile range [IQR], (241.0-492.5) delivered at a median rate of 0.61 mL kg hr^-1 (0.40-0.87) over a median duration of surgery of 489 minutes (416.3-605.3). This increased the total administered fluid volume by 5.2% (95% confidence intervals [CI]: 4.6, 5.9%) (Cohen's d=1.33, P<0.001). The volume of IAAMs was comparable to the intraoperative colloid volume administered (median colloid volume, 400 mL). Overall, fluid volumes correlated significantly with the severity of complications (P=0.011), and the correlation strength increased when the IAAMs volume was included (P=0.005). On addition of IAAMs, the area under the receiver operator characteristic curve for prediction of postoperative complications increased from 0.580 (95%CI: 0.458, 0.701) to 0.603 (95%CI: 0.483, 0.723), P=0.041).

CONCLUSIONS

IAAMs significantly increased the total administered fluid volume during pancreaticoduodenectomy. Their inclusion increases the accuracy of postoperative complications predictions. These findings support their inclusion in fluid volumes and balances in future interventional studies.

Effect of the Type of Intraoperative Restrictive Fluid Management on the Outcome of Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Background. The perioperative management of pancreaticoduodenectomy is complicated, and the significant morbidity and mortality may be influenced by the method of intraoperative fluid management. Whether intraoperative restrictive fluid therapy can affect the outcomes of pancreaticoduodenectomy or not is controversial. Methods. PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov were searched for prospective and retrospective studies comparing restrictive and liberal intraoperative fluids in patients undergoing pancreaticoduodenectomy. Following study identification, a systematic review and meta-analysis were performed. Results. Fourteen studies, including six prospective trials and eight retrospective studies, involving 2,596 patients, were included. Intraoperative restrictive fluid regimens had no effect on the mortality compared to liberal fluid regimens in the overall cohort (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 0.82–2.35, $p=0.773$ ). Liberal fluid regimens could increase the risk of pulmonary adverse events (OR: 1.66; 95% CI: 1.10–2.50, $p=0.131$ ) and prolong the length of hospital stay (SMD -0.10; 95% CI -0.19– -0.01, $p=0.375$ ). There were no significant differences in the incidence of pancreatic fistulas. Conclusions. Restrictive fluid regimens have a slight effect on the outcomes of pancreaticoduodenectomy. The clinical relevance of this finding needs to be interpreted. The existing evidence may not be adequate; therefore, further studies are warranted.

Persistent severe post-operative hypotension after pancreaticoduodenectomy is related to increased inflammatory response

BACKGROUND

Hypotension during major surgery is frequent, resulting in increased need for observation in the post-anaesthesia care unit and treatment including vasopressors and fluids. However, although severe hypotension in the immediate post-operative recovery phase after major surgery is suggested to be related to increased morbidity and mortality, the underlying risk factors are not well described, hindering advancements in prevention and treatment.

METHODS

We performed a retrospective study assessing factors (age, gender, body-mass index, cardiac co-morbidity, haemoglobin, absolute and increase in c-reactive protein on the first post-operative day, bleeding, fluid balance at the end of surgery and the first post-operative day) related to severe persistent hypotension (SPH) (SPH: need for noradrenaline to maintain a mean arterial blood pressure (MAP) >65.0 mm Hg on the morning after surgery) and occurrence of other early (24 hours) complications. One hundred patients undergoing pancreaticoduodenectomy (PD) with pre-operative high-dose glucocorticoid and goal-directed fluid therapy were enrolled and perioperative data collected from anaesthetic and medical records.

RESULTS

Forty-five patients had SPH, who had a significantly higher increase in CRP levels the morning after surgery (median 50 mg L^-1 vs 41 mg L^-1 , SPH vs non-SPH, respectively, P = .028), and a significantly more positive fluid balance at discharge (median 1457 ml vs 1031 ml, respectively, P = .027) vs patients without SPH.

CONCLUSIONS

Severe persistent hypotension after PD was associated with significantly increased inflammatory response and increased need for fluids. Future studies should investigate the effect of further inflammatory control in PD to improve haemodynamics and morbidity.

Goal-Directed Fluid Therapy Does Not Improve Early Glomerular Filtration Rate in a Porcine Renal Transplantation Model

BACKGROUND:

Insufficient fluid administration intra- and postoperatively may lead to delayed renal graft function (DGF), while fluid overload increases the risk of heart failure, infection, and obstipation. Several different fluid protocols have been suggested to ensure optimal fluid state. However, there is a lack of evidence of the clinical impact of these regimens. This study aimed to determine whether individualized goal-directed fluid therapy (IGDT) positively affects the initial renal function compared to a high-volume fluid therapy (HVFT) and to examine the effects on renal endothelial glycocalyx, inflammatory and oxidative stress markers, and medullary tissue oxygenation. The hypothesis was that IGDT improves early glomerular filtration rate (GFR) in pigs subjected to renal transplantation.

METHODS:

This was an experimental randomized study. Using a porcine renal transplantation model, animals were randomly assigned to receive IGDT or HVFT during and until 1 hour after transplantation from brain-dead donors. The kidneys were exposed to 18 hours of cold ischemia. The recipients were observed until 10 hours after reperfusion, which included GFR measured as clearance of chrom-51-ethylendiamintetraacetat (⁵¹Cr-EDTA), animal weight, and renal tissue oxygenation by fiber optic probes. The renal expression of inflammatory and oxidative stress markers as well as glomerular endothelial glycocalyx were analyzed in the graft using polymerase chain reaction (PCR) technique and immunofluorescence.

RESULTS:

Twenty-eight recipient pigs were included for analysis. We found no evidence that IGDT improved early GFR compared to HVFT (P = .45), while animal weight increased more in the HVFT group (a mean difference of 3.4 kg [1.96–4.90]; P < .0001). A better, however nonsignificant, preservation of glomerular glycocalyx (P = .098) and significantly lower levels of the inflammatory marker cyclooxygenase 2 (COX-2) was observed in the IGDT group when compared to HVFT. COX-2 was 1.94 (1.50–2.39; P = .012) times greater in the HVFT group when compared to the IGDT group. No differences were observed in outer medullary tissue oxygenation or oxidative stress markers.

CONCLUSIONS:

IGDT did not improve early GFR; however, it may reduce tissue inflammation and could possibly lead to preservation of the glycocalyx compared to HVFT.

Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: a single centre retrospective observational study

Background

Right hepatectomy is a complex procedure that carries inherent risks of perioperative morbidity. To evaluate outcome differences between a low central venous pressure fluid intervention strategy and a goal directed fluid therapy (GDFT) cardiac output algorithm we performed a retrospective observational study. We hypothesized that a GDFT protocol would result in less intraoperative fluid administration, reduced complications and a shorter length of hospital stay.

Methods

Patients undergoing hepatectomy using an established enhanced recovery after surgery (ERAS) programme between 2010 and 2017 were extracted from a prospectively managed electronic hospital database. Inclusion criteria included adult patients, undergoing open right (segments V-VIII) or extended right (segments IV-VIII) hepatectomy. Primary outcome: amount of intraoperative fluid administration used between the two groups. Secondary outcomes: type and amount of vasoactive medications used, the development of predefined postoperative complications, hospital length of stay, and 30-day mortality. Complications were defined by the European Perioperative Clinical Outcome definitions and graded according to Clavien-Dindo classification. The association between GDFT and the amount of fluid and vasoactive medication used was investigated using logistic and linear regression models.

Results

Fifty-eight consecutive patients were identified. 26 patients received GDFT and 32 received Usual care. There were no significant differences in baseline patient characteristics. Less intraoperative fluid was used in the GDFT group: median (IQR) 2000 ml (1175 to 2700) vs. 2750 ml (2000 to 4000) in the Usual care group; p = 0.03. There were no significant differences in the use of vasoactive medications. Postoperative complications were similar: 9 patients (35%) in the GDFT group vs. 18 patients (56%) in the Usual care group; p = 0.10, OR: 0.41; (95%CI: 0.14 to 1.20). Median (IQR) length of stay for patients in the GDFT group was 7 days (6:8) vs. 9 days (7:13) in the Usual care group; incident rate ratio 0.72 (95%CI: 0.56 to 0.93); p = 0.012. There was no difference in perioperative mortality.

Conclusions

In patients undergoing open right hepatectomy with an established ERAS programme, use of GDFT was associated with less intraoperative fluid administration and reduced hospital length of stay when compared to Usual care. There were no significant differences in postoperative complications or mortality.

Trial registration

Australian New Zealand Clinical Trials Registry: no12619000558123 on 10/4/19.

Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial

Background

The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown.

Methods

We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications.

Results

Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45–1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed.

Conclusion

In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified.

•

Major liver resection is a complex procedure with up to 40% patients experiencing complications.

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Optimisation of perfusion and oxygen delivery to all organs remain the cornerstone of best hemodynamic care.

•

Traditionally, a low central venous pressure strategy during major liver resection has been used to reduce venous bleeding.

•

The impact of a restrictive cardiac output fluid optimisation algorithm during major liver surgery is unknown.

•

After major hepatobiliary surgery, a fluid restrictive algorithm did not reduce length of hospital stay or complications.

Health economic implications of complications associated with pancreaticoduodenectomy at a University Hospital: a retrospective cohort cost study

BACKGROUND

A cost analyses of complications following pancreaticoduodenectomy (PD) was performed in a high volume hepato-biliary-pancreatic service. We hypothesised that costs are increased with both severity and number of complications; we investigated the relationship between complications and specific cost centres.

METHODS

100 patients from 2011 to 2016 were included. Data relating to their perioperative course were collected. Complications were documented by the Clavien-Dindo classification and costs were inflated and converted to 2017 USD.

RESULTS

Mean hospital costs in complicated patients more than doubled those of uncomplicated patients ($28 330 vs. $57 150, p < 0.0001). Total hospital costs significantly increased with both severity and number of complications. This cost increase was influenced by medical consult, pathology, pharmacy, radiology, ward, intensive care, and allied health costs, but not operating theatre or anaesthesia costs. Postoperative pancreatic fistula, postoperative haemorrhage, delayed gastric emptying and infection were associated with cost differentials of $65 438, $74 079, $35 620 and $46 316 respectively over uncomplicated patients.

CONCLUSION

The development of complications following PD is common, costly and associated with increased length of stay. Costs increased with greater complication severity, and specific complications. The in-depth breakdown of hospital costs suggests specific targets for cost containment.

Intraoperative fluid management: Past and future, where is the evidence?

Currently, there is no consensus about the optimum intraoperative fluid therapy strategy. There is growing body of evidence supports the beneficial effects of adopting “Goal-directed therapy” over either the “liberal” or “restrictive” fluid therapy strategies. In this narrative review, we have presented the evidence to support the optimum strategy for intraoperative therapy. In conclusion, whatever the intravenous fluid replacement strategy used, the anesthesiologist must be prepared to adjust the composition and rate of the fluids administered to provide sufficient intravascular fluid volume for adequate perfusion of vital organs without overwhelming the glycocalyx function with fluid overloads.