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Alves MRD, Saturnino SF, Zen AB, de Albuquerque DGS, Diegoli H. Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis. CRITICAL CARE SCIENCE 2024; 36:e20240196en. [PMID: 38775544 PMCID: PMC11098079 DOI: 10.62675/2965-2774.20240196-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/08/2023] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE. RESULTS We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%). CONCLUSION Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.
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Affiliation(s)
| | - Saulo Fernandes Saturnino
- Universidade Federal de Minas GeraisBelo HorizonteMGBrazilUniversidade Federal de Minas Gerais - Belo Horizonte (MG), Brazil.
| | - Ana Beatriz Zen
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
| | | | - Henrique Diegoli
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
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Kim M, Tsouris N, Lung BE, Miskiewicz M, Wang KE, Komatsu DE, Wang ED. Cumulative effect of chronic dehydration and age on postoperative complications after total shoulder arthroplasty. JSES Int 2024; 8:491-499. [PMID: 38707563 PMCID: PMC11064703 DOI: 10.1016/j.jseint.2023.12.007] [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] [Indexed: 05/07/2024] Open
Abstract
Background Dehydration is a modifiable risk factor that should be optimized prior to all surgical procedures. The aim of this study was to determine the effects of dehydration on postoperative complications following total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019 and a total of 16,993 patients were included in this study. The study population was subsequently classified into 3 categories: 8498 (50.0%) nondehydrated patients with blood urea nitrogen/creatinine (BUN/Cr) < 20, 4908 (28.9%) moderately dehydrated patients with 20 ≤ BUN/Cr ≤ 25, and 3587 (21.1%) severely dehydrated patients with 25 < BUN/Cr. A subgroup analysis involving only elderly patients aged > 65 years and normalized gender-adjusted Cr values was also performed. Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to explore the correlation between dehydration and postoperative complications. Results Adjusted multivariate logistic regression analysis showed that the severely dehydrated cohort had a greater risk of postoperative transfusion, mortality, nonhome discharge, and increased length of stay (all P < .05). The moderately dehydrated cohort had a greater risk of wound dehiscence (P = .044). Among the elderly, severely dehydrated patients had a greater risk of cardiac complications, postoperative transfusion, mortality, nonhome discharge, and increased length of stay (all P < .05). Finally, the elderly moderately dehydrated cohort had a greater risk of postoperative transfusion and nonhome discharge (all P < .05). Conclusion BUN/Cr ratio is an important preoperative diagnostic tool to identify at-risk dehydrated patients. Providers should optimize dehydration to prevent complications, decrease costs, and improve discharge planning.
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Affiliation(s)
- Matthew Kim
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Nicholas Tsouris
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | | | - Michael Miskiewicz
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Katherine E. Wang
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - David E. Komatsu
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
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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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Singh S. Complete airway obstruction with inflammation of sternocleidomastoid muscle after prolonged posterior fossa surgery. Med J Armed Forces India 2024; 80:119-120. [PMID: 38261811 PMCID: PMC10793214 DOI: 10.1016/j.mjafi.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/24/2023] [Indexed: 01/25/2024] Open
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Khaled D, Fathy I, Elhalafawy YM, Zakaria D, Rasmy I. Comparison of ultrasound-based measures of inferior vena cava and internal jugular vein for prediction of hypotension during induction of general anesthesia. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2171548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Dalia Khaled
- Anesthesia, Surgical ICU and Pain Management, Faculty of Medicine, Cairo University
| | - Ismail Fathy
- Anesthesia, Surgical ICU and Pain Management, Faculty of Medicine, Cairo University
| | - Yasser M. Elhalafawy
- Anesthesia, Surgical ICU and Pain Management, Faculty of Medicine, Cairo University
| | - Dina Zakaria
- Anesthesia, Surgical ICU and Pain Management, Faculty of Medicine, Cairo University
| | - Islam Rasmy
- Anesthesia, Surgical ICU and Pain Management, Faculty of Medicine, Cairo University
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Soriano Hervás M, Robles-Hernández D, Serra A, Játiva-Porcar R, Gómez Quiles L, Maiocchi K, Llorca S, Climent MT, Llueca A. Analysis of Intraoperative Variables Responsible for the Increase in Lactic Acid in Patients Undergoing Debulking Surgery. J Pers Med 2023; 13:1540. [PMID: 38003855 PMCID: PMC10672096 DOI: 10.3390/jpm13111540] [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: 09/17/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
Background: Cytoreductive surgery (CRS) is a complex procedure with a high incidence of perioperative complications. Elevated lactacidaemia levels have been associated with complications and perioperative morbidity and mortality. This study aims to analyse the intraoperative variables of patients undergoing CRS and their relationship with lactacidaemia levels. Methods: This retrospective, observational study included 51 patients with peritoneal carcinomatosis who underwent CRS between 2014 and 2016 at the Abdomino-Pelvic Oncological Surgery Reference Unit (URCOAP) of the General University Hospital of Castellón (HGUCS). The main variable of interest was the level of lactic acid at the end of surgery. Intraoperative variables, including preoperative haemoglobin, duration of surgery, intraoperative bleeding, fluid therapy administered, administration of blood products, and intraoperative peritoneal cancer index (PCI), were analysed. Results: Positive correlations were found between lactic acid levels and PCI, duration of intervention, fluid therapy, intraoperative bleeding, and transfusion of blood products. Additionally, a negative correlation was observed between haemoglobin levels and lactic acid levels. Notably, the strongest correlations were found with operative PCI (ρ = 0.532; p-value < 0.001) and duration of surgery (ρ = 0.518; p-value < 0.001). Conclusions: PCI and duration of surgery are decisive variables in determining the prognosis of patients undergoing debulking surgery. This study suggests that, for each minute of surgery, lactic acid levels increase by 0.005 mmol/L, and for each unit increase in PCI, lactic acid levels increase by 0.060 mmol/L.
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Affiliation(s)
- Marta Soriano Hervás
- Department of Anaesthesiology, University General Hospital of Castellon, 12004 Castellon, Spain;
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
| | - Daniel Robles-Hernández
- Department of Anaesthesiology, University La Plana Hospital, Road from Vila-Real to Burriana, km 0.5, 12540 Castellón, Spain
| | - Anna Serra
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
- Department of Obstetrics and Gynaecology, University General Hospital of Castellon, 12004 Castellon, Spain
| | - Rosa Játiva-Porcar
- Department of Anaesthesiology, University General Hospital of Castellon, 12004 Castellon, Spain;
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
| | - Luis Gómez Quiles
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
- Department of General Surgery, University General Hospital of Castellon, 12004 Castellon, Spain
| | - Karina Maiocchi
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
- Department of General Surgery, University General Hospital of Castellon, 12004 Castellon, Spain
| | - Sara Llorca
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
- Department of General Surgery, University General Hospital of Castellon, 12004 Castellon, Spain
| | - María Teresa Climent
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
- Department of Obstetrics and Gynaecology, University General Hospital of Castellon, 12004 Castellon, Spain
| | - Antoni Llueca
- MUAPOS (Multidisciplinary Unit of Abdomino-Pelvic Oncology Surgery), University General Hospital of Castellon, 12004 Castellon, Spain; (A.S.)
- Department of Obstetrics and Gynaecology, University General Hospital of Castellon, 12004 Castellon, Spain
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Zhang Y, Ding Y, Zhang J, Huang T, Gao J. Tidal volume challenge-induced hemodynamic changes can predict fluid responsiveness during one-lung ventilation: an observational study. Front Med (Lausanne) 2023; 10:1169912. [PMID: 37636561 PMCID: PMC10447224 DOI: 10.3389/fmed.2023.1169912] [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] [Received: 02/20/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Background To evaluate the ability of tidal volume challenge (VTC)-induced hemodynamic changes to predict fluid responsiveness in patients during one-lung ventilation (OLV). Methods 80 patients scheduled for elective thoracoscopic surgery with OLV were enrolled. The inclusion criteria were: age ≥ 18 years, American Society of Anesthesiologists physical status I-III, normal right ventricular function, normal left ventricular systolic function (ejection fraction ≥55%), and normal or slightly impaired diastolic function. The study protocol was implemented 15 min after starting OLV. Simultaneous recordings were performed for hemodynamic variables of diameter of left ventricular outflow tract, velocity time integral (VTI) of aortic valve, and stroke volume (SV), and ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC were calculated at four time points: with VT 5 mL/kg (T1); after VT increased from 5 mL/kg to 8 mL/kg and maintained at this level for 2 min (T2); after VT was adjusted back to 5 mL/kg for 2 min (T3); and after volume expansion (250 mL of 0.9% saline infused over 10-15 min) (T4). Patients were considered as responders to fluid administration if SV increased by ≥10%. Receiver operating characteristic (ROC) curves for percent decrease in SV, VTI, and MAP by VTC were generated to evaluate their ability to discriminate fluid responders from nonresponders. Results Of the 58 patients analyzed, there were 32 responders (55%) and 26 nonresponders (45%). The basic characteristics were comparable between the two groups (p > 0.05). The area under the curve (AUC) for ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC to discriminate responders from nonresponders were 0.81 (95% CI: 0.68-0.90), 0.79 (95% CI: 0.66-0.89), and 0.56 (95% CI: 0.42-0.69). The best threshold for ΔSV-VTC was -16.1% (sensitivity, 78.1%; specificity, 84.6%); the best threshold for ΔVTI-VTC was -14.5% (sensitivity, 78.1%; specificity, 80.8%). Conclusion Tidal volume challenge-induced relative change of stroke volume and velocity time integral can predict fluid responsiveness in patients during one-lung ventilation.Clinical Trial Registration: Chinese Clinical Trial Registry, No: chictr210051310.
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Affiliation(s)
| | | | | | | | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou, China
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Hoeter K, Heinrich S, Wollschläger D, Melchior F, Noack A, Tripke V, Lang H, Thal SC, Bremerich DH. The Optimal Fluid Strategy Matters in Liver Surgery: A Retrospective Single Centre Analysis of 666 Consecutive Liver Resections. J Clin Med 2023; 12:3962. [PMID: 37373656 DOI: 10.3390/jcm12123962] [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: 03/19/2023] [Revised: 05/11/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
As optimal intraoperative fluid management in liver surgery has not been established, we retrospectively analyzed our fluid strategy in a high-volume liver surgery center in 666 liver resections. Intraoperative fluid management was divided into very restrictive (<10 m kg-1 h-1) and normal (≥10 mL kg-1 h-1) groups for study group characterization. The primary endpoint was morbidity as assessed by the Clavien-Dindo (CD) score and the comprehensive complication index (CCI). Logistic regression models identified factors most predictive of postoperative morbidity. No association was found between postoperative morbidity and fluid management in the overall study population (p = 0.89). However, the normal fluid management group had shorter postoperative hospital stays (p = <0.001), shorter ICU stays (p = 0.035), and lower in-hospital mortality (p = 0.02). Elevated lactate levels (p < 0.001), duration (p < 0.001), and extent of surgery (p < 0.001) were the most predictive factors for postoperative morbidity. In the subgroup of major/extreme liver resection, very low total (p = 0.028) and normalized fluid balance (p = 0.025) (NFB) were associated with morbidity. Moreover, fluid management was not associated with morbidity in patients with normal lactate levels (<2.5 mmol/L). In conclusion, fluid management in liver surgery is multifaceted and must be applied judiciously as a therapeutic measure. While a restrictive strategy appears attractive, hypovolemia should be avoided.
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Affiliation(s)
- Katharina Hoeter
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Felix Melchior
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Anna Noack
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Verena Tripke
- Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Serge C Thal
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Dorothee H Bremerich
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
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Diaphragm Neurostimulation Mitigates Ventilation-Associated Brain Injury in a Preclinical Acute Respiratory Distress Syndrome Model. Crit Care Explor 2022; 4:e0820. [PMID: 36601565 PMCID: PMC9788975 DOI: 10.1097/cce.0000000000000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In a porcine healthy lung model, temporary transvenous diaphragm neurostimulation (TTDN) for 50 hours mitigated hippocampal apoptosis and inflammation associated with mechanical ventilation (MV). HYPOTHESIS Explore whether TTDN in combination with MV for 12 hours mitigates hippocampal apoptosis and inflammation in an acute respiratory distress syndrome (ARDS) preclinical model. METHODS AND MODELS Compare hippocampal apoptosis, inflammatory markers, and serum markers of neurologic injury between never ventilated subjects and three groups of mechanically ventilated subjects with injured lungs: MV only (LI-MV), MV plus TTDN every other breath, and MV plus TTDN every breath. MV settings in volume control were tidal volume 8 mL/kg and positive end-expiratory pressure 5 cm H2O. Lung injury, equivalent to moderate ARDS, was achieved by infusing oleic acid into the pulmonary artery. RESULTS Hippocampal apoptosis, microglia, and reactive-astrocyte percentages were similar between the TTDN-every-breath and never ventilated groups. The LI-MV group had a higher percentage of these measures than all other groups (p < 0.05). Transpulmonary driving pressure at study end was lower in the TTDN-every-breath group than in the LI-MV group; systemic inflammation and lung injury scores were not significantly different. The TTDN-every-breath group had considerably lower serum concentration of homovanillic acid (cerebral dopamine production surrogate) at study end than the LI-MV group (p < 0.05). Heart rate variability declined in the LI-MV group and increased in both TTDN groups (p < 0.05). INTERPRETATIONS AND CONCLUSIONS In a moderate-ARDS porcine model, MV is associated with hippocampal apoptosis and inflammation, and TTDN mitigates that hippocampal apoptosis and inflammation.
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Siegel JB, O'Leary R, DeChamplain B, Lancaster WP. The Effect of Goal-Directed Fluid Administration on Outcomes After Pancreatic Surgery. World J Surg 2022; 46:2760-2768. [PMID: 35896759 DOI: 10.1007/s00268-022-06676-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND We evaluated the effect of an Enhanced Recovery After Surgery protocol on intraoperative fluid administration and postoperative outcomes in pancreatic surgery. METHODS Pancreatic cancer resections at our institution from 2012 to 2018 were grouped according to pre- or post-protocol initiation. Preoperative characteristics and postoperative outcomes were compared with Fisher's exact test and chi-square for categorical variables, and Mann-Whitney U test for continuous variables. Further analysis separated patients that had a Whipple from those who had distal pancreatectomy. RESULTS A total of 263 patients underwent pancreatic cancer resection during the study period (169 Whipples, 84 DPs, 92 pre-ERAS and 171 post-ERAS). Intraoperative fluid administration significantly decreased after protocol implementation (mean 6,277 ml vs. 3870 ml, p < 0.001). This held true when separating patients that had a Whipple procedure from those that had a DP (6,929 ml vs. 4,513 ml, p < 0.001, 5,060 ml vs. 2,833 cc, p = 0.002, respectively). Intensive care unit (ICU) admission (41.3% vs. 20.5%, p < 0.001) and length of stay (9.4 vs. 8.1 days, p < 0.01) were significantly reduced after ERAS implementation for all patients and in Whipple patients alone (47.5% vs. 23.6%, p = 0.002 and 10.7 vs. 6.6 days, p = 0.004). DP patients also had significantly decreased ICU admissions (41.3% vs. 20.5%, p = 0.045). All other postoperative outcomes were not significantly different. CONCLUSION For patients undergoing pancreatic cancer resection, goal-directed fluid management is associated with decreased intraoperative fluid administration, decreased ICU admission, and decreased length of stay without an increase in postoperative complications or readmission.
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Affiliation(s)
- Julie B Siegel
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.
| | - Ryan O'Leary
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Bryce DeChamplain
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - William P Lancaster
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
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Vézina-Audette R, Kantyka M, Gianotti G, Silverstein DC. Comparison of Mean Arterial Blood Pressure and Heart Rate Changes in Response to Three Different Randomized Isotonic Crystalloid Boluses in Hypotensive Anesthetized Dogs. Animals (Basel) 2022; 12:ani12141781. [PMID: 35883328 PMCID: PMC9312031 DOI: 10.3390/ani12141781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/23/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this prospective, randomized, nonblinded, controlled clinical trial was to compare mean arterial blood pressure (MAP) and heart rate (HR) during an intravenous bolus of three different balanced isotonic crystalloid solutions in euvolemic, anesthetized dogs with hypotension. Thirty healthy dogs (American Society of Anesthesiologists Physical Status I–II) weighing at least 15 kg that presented for elective orthopedic or dental surgical procedures at the Ryan Veterinary Hospital for Small Animals of the University of Pennsylvania were included in this study. Anesthetized hypotensive patients (defined as a MAP ≤ 65 mmHg), were administered an infusion of Lactated Ringer’s solution (LRS), Plasma-Lyte (PLYTE) or Canadian Plasma-Lyte (PLYTECA), selected at random. The infusion was administered over 15 min via a volumetric fluid pump. Differences in oscillometric MAP and HR between time points and across treatments were evaluated by mANOVA. Intravenous isotonic crystalloid infusions over 15 min did not significantly change MAP or HR in hypotensive dogs under general anesthesia. Neither LRS, PLYTE nor PLYTECA exacerbated hypotension or caused tachycardia.
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Affiliation(s)
- Raphaël Vézina-Audette
- Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, 3900 Delancey Street, University of Pennsylvania, Philadelphia, PA 19104, USA; (G.G.); (D.C.S.)
- Correspondence:
| | - Marta Kantyka
- Section of Anaesthesiology and Pain Therapy, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, 3012 Bern, Switzerland;
| | - Giacomo Gianotti
- Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, 3900 Delancey Street, University of Pennsylvania, Philadelphia, PA 19104, USA; (G.G.); (D.C.S.)
| | - Deborah C. Silverstein
- Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital, 3900 Delancey Street, University of Pennsylvania, Philadelphia, PA 19104, USA; (G.G.); (D.C.S.)
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Obermeier KT, Kraus M, Smolka W, Henkel J, Saller T, Otto S, Liokatis P. Postoperative Delirium in Patients with Oral Cancer: Is Intraoperative Fluid Administration a Neglected Risk Factor? Cancers (Basel) 2022; 14:cancers14133176. [PMID: 35804948 PMCID: PMC9265071 DOI: 10.3390/cancers14133176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Squamous cell carcinoma is the most typical malignant tumor of the oral cavity (OSCC) and surgery, including tumor resection and neck dissection with an appropriate reconstruction, remains the first line of treatment. Postoperative complications delay the healing process, and can have negative consequences for the patient. This study aimed to evaluate the impact of intraoperative fluid administration on developing postoperative delirium, and to identify other parameters leading to an increased risk of delirium. Abstract Squamous cell carcinoma (SCC) is a malignant tumor derived from squamous cells and can be found in different localizations. In the oral cavity especially, it represents the most common type of malignant tumor. First-line therapy for oral squamous cell carcinoma (OSCC) is surgery, including tumor resection, neck dissection, and maybe reconstruction. Although perioperative mortality is low, complications such as delirium are very common, and may have long-lasting consequences on the patient’s quality of life. This study examines if excessive fluid administration, among other parameters, is an aggravating factor for the development of postoperative delirium. A total of 198 patients were divided into groups concerning the reconstruction technique used: group A for primary wound closure or reconstruction with a local flap, and group B for microsurgical reconstruction. The patients with and without delirium in both groups were compared regarding intraoperative fluid administration, fluid balance, and other parameters, such as blood loss, duration of surgery and overall ventilation, alcohol consumption, and creatinine, albumin, natrium, and hematocrit levels. The logistic regression for group A shows that fluid intake (p = 0.02, OR = 5.27, 95% CI 1.27–21.8) and albumin levels (p = 0.036, OR = 0.22, CI 0.054–0.908) are independent predictors for the development of delirium. For group B, gender (p = 0.026, OR = 0.34, CI 0.133–0.879) with a protective effect for females, fluid intake (p = 0.003, OR = 3.975, CI 1.606–9.839), and duration of ventilation (p = 0.025, OR = 1.178, CI 1.021–1.359) are also independent predictors for delirium. An intake of more than 3000 mL for group A, and 4150 mL for group B, increases the risk of delirium by approximately five and four times, respectively. Fluid management should be considered carefully in patients with OSCC, in order to reduce the occurrence of postoperative delirium. Different factors may become significant for the development of delirium regarding different surgical procedures.
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Affiliation(s)
- Katharina Theresa Obermeier
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
- Correspondence:
| | - Moritz Kraus
- Musculoskeletal University Center Munich, Department of Orthopaedics and Trauma Surgery, University Hospital, LMU Munich, 80539 Munich, Germany;
| | - Wenko Smolka
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
| | - Jochen Henkel
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.H.); (T.S.)
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.H.); (T.S.)
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
| | - Paris Liokatis
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, 80337 Munich, Germany; (W.S.); (S.O.); (P.L.)
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13
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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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14
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Granell-Gil M, Murcia-Anaya M, Sevilla S, Martínez-Plumed R, Biosca-Pérez E, Cózar-Bernal F, Garutti I, Gallart L, Ubierna-Ferreras B, Sukia-Zilbeti I, Gálvez-Muñoz C, Delgado-Roel M, Mínguez L, Bermejo S, Valencia O, Real M, Unzueta C, Ferrando C, Sánchez F, González S, Ruiz-Villén C, Lluch A, Hernández A, Hernández-Beslmeisl J, Vives M, Vicente R. Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:266-301. [PMID: 35610172 DOI: 10.1016/j.redare.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/19/2021] [Indexed: 06/15/2023]
Abstract
The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.
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Affiliation(s)
- M Granell-Gil
- Sección en Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Profesor Contratado Doctor en Anestesiología, Universitat de València, Valencia, Spain
| | - M Murcia-Anaya
- Anestesiología, Reanimación y T. Dolor, Unidad de Cuidados Intensivos, Hospital IMED Valencia, Valencia, Spain.
| | - S Sevilla
- Sociedad de Cirugía Torácica, Complejo Hospitalario Universitario de Jaén, Jaén, Spain
| | - R Martínez-Plumed
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - E Biosca-Pérez
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - F Cózar-Bernal
- Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - I Garutti
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - L Gallart
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - I Sukia-Zilbeti
- Fisioterapia, Hospital Universitario Donostia de San Sebastián, Spain
| | - C Gálvez-Muñoz
- Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, Spain
| | - M Delgado-Roel
- Cirugía Torácica, Complejo Hospitalario Universitario La Coruña, La Coruña, Spain
| | - L Mínguez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - S Bermejo
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - O Valencia
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Doce de Octubre de Madrid, Madrid, Spain
| | - M Real
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Doce de Octubre de Madrid, Madrid, Spain
| | - C Unzueta
- Anestesiología, Reanimación y T. Dolor, Hospital Sant Pau de Barcelona, Barcelona, Spain
| | - C Ferrando
- Anestesiología, Reanimación y T. Dolor, Hospital Clínic Universitari de Barcelona, Barcelona, Spain
| | - F Sánchez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario de la Ribera de Alzira, Valencia, Spain
| | - S González
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Donostia de San Sebastián, Spain
| | - C Ruiz-Villén
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | - A Lluch
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - A Hernández
- Anestesiología, Reanimación y T. Dolor, Grupo Policlínica de Ibiza, Ibiza, Spain
| | - J Hernández-Beslmeisl
- Anestesiología, Reanimación y T. Dolor, Complejo Hospitalario Universitario de Canarias, Canarias, Spain
| | - M Vives
- Anestesiología, Reanimación y T. Dolor, Hospital Universitari Dr. Josep Trueta de Girona, Girona, Spain
| | - R Vicente
- Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR, Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Universitat de València, Valencia, Spain
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Roy S, Kothari N, Goyal S, Sharma A, Kumar R, Kaloria N, Bhatia P. Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022:S0104-0014(22)00051-3. [PMID: 35430190 PMCID: PMC10362455 DOI: 10.1016/j.bjane.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/25/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. METHODS One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. RESULTS Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p = 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p = 0.615). CONCLUSIONS Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.
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Affiliation(s)
- Shayak Roy
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Nikhil Kothari
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Shilpa Goyal
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Ankur Sharma
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India.
| | - Rakesh Kumar
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Narender Kaloria
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Pradeep Bhatia
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
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16
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Tang W, Qiu Y, Lu H, Xu M, Wu J. Stroke Volume Variation-Guided Goal-Directed Fluid Therapy Did Not Significantly Reduce the Incidence of Early Postoperative Complications in Elderly Patients Undergoing Minimally Invasive Esophagectomy: A Randomized Controlled Trial. Front Surg 2021; 8:794272. [PMID: 34938769 PMCID: PMC8685214 DOI: 10.3389/fsurg.2021.794272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/12/2021] [Indexed: 01/29/2023] Open
Abstract
Study Objective: This study aimed to investigate whether stroke volume variation (SVV)-guided goal-directed therapy (GDT) can improve postoperative outcomes in elderly patients undergoing minimally invasive esophagectomy (MIE) compared with conventional care. Design: A prospective, randomized, controlled study. Setting: A single tertiary care center with a study period from November 2017 to December 2018. Patients: Patients over 65 years old who were scheduled for elective MIE. Interventions: The GDT protocol included a baseline fluid supplement of 7 ml/kg/h Ringer's lactate solution and SVV optimization using colloid boluses assessed by pulse-contour analysis (PiCCO™). When SVV exceeded 11%, colloid was infused at a rate of 50 ml per minute; if SVV returned below 9% for at least 2 minutes, then colloid was stopped. Measurements: The primary outcome was the incidence of postoperative complications before discharge, as assessed using a predefined list, including postoperative anastomotic leakage, postoperative hoarseness, postoperative pulmonary complications, chylothorax, myocardial injury, and all-cause mortality. Main Results: Sixty-five patients were included in the analysis. The incidence of postoperative complications between groups was similar (GDT 36.4% vs. control 37.5%, P = 0.92). The total fluid volume was not significantly different between the two groups (2,192 ± 469 vs. 2,201 ± 337 ml, P = 0.92). Compared with those in the control group (n = 32), patients in the GDT group (n = 33) received more colloids intraoperatively (874 ± 369 vs. 270 ± 67 ml, P <0.05) and less crystalloid fluid (1,318 ± 386 vs. 1,937 ± 334 ml, P <0.05). Conclusion: The colloid-based SVV optimization during GDT did not significantly reduce the incidence of early postoperative complications after minimally invasive esophagectomy in elderly patients. Clinical Trial Number and Registry URL: ChiCTR-INR-17013352; http://www.chictr.org.cn/showproj.aspx?proj=22883
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Affiliation(s)
- Wei Tang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yuwei Qiu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Outcomes Research Consortium, Cleveland, OH, United States
| | - Huijie Lu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Meiying Xu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Outcomes Research Consortium, Cleveland, OH, United States
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17
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Furlan D, Deana C, Orso D, Licari M, Cappelletto B, DE Monte A, Vetrugno L, Bove T. Perioperative management of spinal cord injury: the anesthesiologist's point of view. Minerva Anestesiol 2021; 87:1347-1358. [PMID: 34874136 DOI: 10.23736/s0375-9393.21.15753-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is one of the most devastating events a person can experience. It may be life-threatening or result in long-term disability. This narrative review aims to delineate a systematic step-wise airways, breathing, circulation and disability (ABCD) approach to perioperative patient management during spinal cord surgery in order to fill some of the gaps in our current knowledge. METHODS We performed a comprehensive review of the literature regarding the perioperative management of traumatic spinal injuries from May 15, 2020, to December 13, 2020. We consulted the PubMed and Embase database libraries. RESULTS Videolaryngoscopy supplements the armamentarium available for airway management. Optical fiberscope use should be evaluated when intubating awake patients. Respiratory complications are frequent in the acute phase of traumatic spinal injury, with an estimated incidence of 36-83%. Early tracheostomy can be considered for expected difficult weaning from mechanical ventilation. Careful intraoperative management of administered fluids should be pursued to avoid complications from volume overload. Neuromonitoring requires investments in staff training and cooperation, but better outcomes have been obtained in centers where it is routinely applied. The prone position can cause rare but devastating complications, such as ischemic optic neuropathy; thus, the anesthetist should take the utmost care in positioning the patient. CONCLUSIONS A one-size fit all approach to spinal surgery patients is not applicable due to patient heterogeneity and the complexity of the procedures involved. The neurologic outcome of spinal surgery can be improved, and the incidence of complications reduced with better knowledge of patient-specific aspects and individualized perioperative management.
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Affiliation(s)
- Davide Furlan
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Daniele Orso
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Maurizia Licari
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Barbara Cappelletto
- Section of Spine and Spinal Cord Surgery, Department of Neurological Sciences, ASUFC University Hospital of Udine, Udine, Italy
| | - Amato DE Monte
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Medicine (DAME), University of Udine, Udine, Italy - .,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Medicine (DAME), University of Udine, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
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18
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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He Y, Liu C, Han Y, Huang Y, Zhou J, Xie Q. The impact of oral carbohydrate-rich supplement taken two hours before caesarean delivery on maternal and neonatal perioperative outcomes -- a randomized clinical trial. BMC Pregnancy Childbirth 2021; 21:682. [PMID: 34620123 PMCID: PMC8495981 DOI: 10.1186/s12884-021-04155-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/28/2021] [Indexed: 12/17/2022] Open
Abstract
Background To evaluate the impact of oral carbohydrate-rich (Ch-R) supplement taken 2 hours before an elective caesarean delivery (CD) on maternal and neonatal perioperative outcomes. Methods Ninety pregnant women undergoing elective CD were randomized into the Ch-R group, placebo group and fasting group equally. Participants’ blood was drawn at three time points, before intervention, immediately after and 1 day after the surgery to measure maternal and neonatal biochemical indices. Meanwhile women’s perioperative symptoms and signs were recorded. Results Eighty-eight pregnant women were finally included in the study. Women who had drunk Ch-R supplement had lower postoperative insulin level (β = − 3.50, 95% CI − 5.45 to − 1.56), as well as postoperative HOMA-IR index (β = − 0.74, 95% CI − 1.15 to − 0.34), compared with women who had fasted. Additionally, neonates of mothers who were allocated in the Ch-R group also had a higher glucose level, compared with neonates of mothers in the fasting group (β = 0.40, CI 0.17 to 0.62). Conclusion Oral Ch-R solution administered 2 hours before an elective CD may not only alleviate maternal postoperative insulin resistance, but also comfort women’s preoperative thirst and hunger, compared to fasting. Additionally, it may increase neonatal glucose level as well. Trial registration Chinese Clinical Trial Registry, ChiCTR2000033163. Data of Registration: 2020-5-22. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04155-z.
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Affiliation(s)
- Yuanying He
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Chunhong Liu
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Ying Han
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Yun Huang
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Jianhong Zhou
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Qigui Xie
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China.
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Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3830. [PMID: 34549012 PMCID: PMC8447987 DOI: 10.1097/gox.0000000000003830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/28/2021] [Indexed: 11/27/2022]
Abstract
Background: The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions. Methods: This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay. Results: Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome. Conclusions: The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.
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21
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Elsonbaty M, Abdullah S, Elsonbaty A. Lung Ultrasound Assisted Comparison of Volume Effects of Fluid Replacement Regimens in Pediatric Patients Undergoing Penile Hypospadias Repair: A Randomized Controlled Trial. Anesth Pain Med 2021; 11:e115152. [PMID: 34540641 PMCID: PMC8438712 DOI: 10.5812/aapm.115152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background Effective perioperative fluid therapy is a great consideration. Objectives Using lung ultrasound (LUS), this study evaluated the preference of the conventional and restrictive fluid replacement regimens for their volume impact in pediatric patients undergoing a relatively long procedure with limited volume loss (hypospadias repair). Methods Eighty pediatric patients scheduled for hypospadias repair surgery were enrolled for conventional (CG) or restrictive fluid management groups (RG). The CG obtained Ringer's lactate at the conventional calculated doses, while the RG obtained infusion of Ringer's lactate at a rate of 3 mL/kg/h. B-line numbers in the LUS, recovery score, urine output, blood pressure (BP), heart rate HR, and oxygen saturation (SpO2) were recorded. Results As evidenced by the LUS, RG showed a higher incidence of normal lung morphology with a mean and SD of 1.3 ± 2.2 for B-line numbers, whereas, in CG, they were 3.1 ± 2.2 with a P-value < 0.001. Urine output was 3.2 ± 0.8 and 2.9 ± 0.7 for CG and RG, respectively, with a P-value equal to 0.07. HR, BP, and SpO2 differences between groups were statistically insignificant. The recovery score was higher in RG (5.8 ± 0.4) than in CG (5.1 ± 0.8) at the first postoperative 20 minutes, with a P-value < 0.001. Conclusions In lengthy procedures with limited volume loss, using a moderately restrictive regimen is preferred over the conventional intraoperative fluid regimen considering both respiratory dysfunctions and recovery score.
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Affiliation(s)
- Mohamed Elsonbaty
- Anesthesiology Department, Faculty of Medicine of Cairo University, Cairo, Egypt
| | - Sherif Abdullah
- Lecturer of Anesthesia, Anesthesiology Department, Faculty of Medicine of Cairo University, Cairo, Egypt
- Corresponding Author: Lecturer of Anesthesia, Anesthesiology Department, Faculty of Medicine of Cairo University, 12511, Cairo, Egypt.
| | - Ahmed Elsonbaty
- Lecturer of Anesthesia, Anesthesiology Department, Faculty of Medicine of Cairo University, Cairo, Egypt
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Pharmacodynamic analysis of a fluid challenge with 4 ml kg -1 over 10 or 20 min: a multicenter cross-over randomized clinical trial. J Clin Monit Comput 2021; 36:1193-1203. [PMID: 34494204 PMCID: PMC8423602 DOI: 10.1007/s10877-021-00756-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/01/2021] [Indexed: 12/25/2022]
Abstract
Purpose A number of studies performed in the operating room evaluated the hemodynamic effects of the fluid challenge (FC), solely considering the effect before and after the infusion. Few studies have investigated the pharmacodynamic effect of the FC on hemodynamic flow and pressure variables. We designed this trial aiming at describing the pharmacodynamic profile of two different FC infusion times, of a fixed dose of 4 ml kg−1. Methods
Forty-nine elective neurosurgical patients received two consecutive FCs of 4 ml kg−1 of crystalloids in 10 (FC10) or 20 (FC20) minutes, in a random order. Fluid responsiveness was defined as stroke volume index increase ≥ 10%. We assessed the net area under the curve (AUC), the maximal percentage difference from baseline (dmax), time when the dmax was observed (tmax), change from baseline at 1-min (d1) and 5-min (d5) after FC end. Results After FC10 and FC20, 25 (51%) and 14 (29%) of 49 patients were classified as fluid responders (p = 0.001). With the exception of the AUCs of SAP and MAP, the AUCs of all the considered hemodynamic variables were comparable. The dmax and the tmax were overall comparable. In both groups, the hemodynamic effects on flow variables were dissipated within 5 min after FC end. Conclusions The infusion time of FC administration affects fluid responsiveness, being higher for FC10 as compared to FC20. The effect on flow variables of either FCs fades 5 min after the end of infusion. Supplementary Information The online version contains supplementary material available at 10.1007/s10877-021-00756-3.
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Bassi TG, Rohrs EC, Fernandez KC, Ornoswska M, Nicholas M, Gani M, Evans D, Reynolds SC. Transvenous Diaphragm Neurostimulation Mitigates Ventilation-associated Brain Injury. Am J Respir Crit Care Med 2021; 204:1391-1402. [PMID: 34491883 PMCID: PMC8865722 DOI: 10.1164/rccm.202101-0076oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Mechanical ventilation (MV) is associated with hippocampal apoptosis and inflammation, and it is important to study strategies to mitigate them. OBJECTIVES Explore whether temporary transvenous diaphragm neurostimulation (TTDN) in association with MV mitigates hippocampal apoptosis and inflammation after 50 hours of MV. METHODS Normal-lung porcine study comparing apoptotic index, inflammatory markers, and neurological-damage serum markers between never-ventilated subjects, subjects undergoing 50 hours of MV plus either TTDN every other breath or every breath, and subjects undergoing 50 hours of MV (MV group). MV settings in volume control were tidal volume of 8 ml/kg, and positive end-expiratory pressure of 5 cmH2O. MEASUREMENTS AND MAIN RESULTS Apoptotic indices, microglia percentages, and reactive astrocyte percentages were greater in the MV group in comparison to the other groups (p<0.05). Transpulmonary pressure at baseline and at study end were both lower in the group receiving TTDN every breath, but lung injury scores and systemic inflammatory markers were not different between the groups. Serum concentrations of four neurological-damage markers were lower in the group receiving TTDN every breath than in the MV group (p<0.05). Heart rate variability declined significantly in the MV group and increased significantly in both TTDN groups over the course of the experiments. CONCLUSION Our study found that mechanical ventilation is associated with hippocampal apoptosis and inflammation, independent of lung injury and systemic inflammation. Also, in a porcine model, TTDN results in neuroprotection after 50 hours, and the degree of neuroprotection increases with greater exposure to TTDN. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Affiliation(s)
- Thiago G Bassi
- Simon Fraser University, 1763, Biomedicine and Physiology, Burnaby, British Columbia, Canada;
| | | | - Karl C Fernandez
- Simon Fraser University, 1763, Burnaby, British Columbia, Canada
| | | | | | - Matt Gani
- Lungpacer Medical, Vancouver, British Columbia, Canada
| | - Doug Evans
- Lungpacer Medical, Vancouver, British Columbia, Canada
| | - Steven C Reynolds
- Royal Columbian Hospital, University of British Columbia, Department of Medicine and Critical Care Medicine, New Westminster, British Columbia, Canada
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24
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Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review. Br J Anaesth 2021; 127:845-861. [PMID: 34392972 DOI: 10.1016/j.bja.2021.06.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.
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Granell-Gil M, Murcia-Anaya M, Sevilla S, Martínez-Plumed R, Biosca-Pérez E, Cózar-Bernal F, Garutti I, Gallart L, Ubierna-Ferreras B, Sukia-Zilbeti I, Gálvez-Muñoz C, Delgado-Roel M, Mínguez L, Bermejo S, Valencia O, Real M, Unzueta C, Ferrando C, Sánchez F, González S, Ruiz-Villén C, Lluch A, Hernández A, Hernández-Beslmeisl J, Vives M, Vicente R. Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00129-8. [PMID: 34330548 DOI: 10.1016/j.redar.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/09/2021] [Accepted: 03/19/2021] [Indexed: 10/20/2022]
Abstract
The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.
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Affiliation(s)
- M Granell-Gil
- Sección en Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Profesor Contratado Doctor en Anestesiología, Universitat de València, Valencia, España
| | - M Murcia-Anaya
- Anestesiología, Reanimación y T. Dolor, Unidad de Cuidados Intensivos, Hospital IMED Valencia, Valencia, España.
| | - S Sevilla
- Sociedad de Cirugía Torácica, Complejo Hospitalario Universitario de Jaén, Jaén, España
| | - R Martínez-Plumed
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - E Biosca-Pérez
- Anestesiología, Reanimación y T. Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - F Cózar-Bernal
- Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, España
| | - I Garutti
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Gregorio Marañón, Madrid, España
| | - L Gallart
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | | | - I Sukia-Zilbeti
- Fisioterapia, Hospital Universitario Donostia, San Sebastián, España
| | - C Gálvez-Muñoz
- Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, España
| | - M Delgado-Roel
- Cirugía Torácica, Complejo Hospitalario Universitario La Coruña, La Coruña, España
| | - L Mínguez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, España
| | - S Bermejo
- Anestesiología, Reanimación y T. Dolor, Hospital del Mar de Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | - O Valencia
- Anestesiología, Reanimación y T. Dolor. Hospital Universitario Doce de Octubre de Madrid, Madrid, España
| | - M Real
- Anestesiología, Reanimación y T. Dolor. Hospital Universitario Doce de Octubre de Madrid, Madrid, España
| | - C Unzueta
- Anestesiología, Reanimación y T. Dolor. Hospital Sant Pau de Barcelona, Barcelona, España
| | - C Ferrando
- Anestesiología, Reanimación y T. Dolor. Hospital Clínic Universitari de Barcelona, Barcelona, España
| | - F Sánchez
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario de la Ribera de Alzira, Valencia, España
| | - S González
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Donostia de San Sebastián, España
| | - C Ruiz-Villén
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario Reina Sofía de Córdoba, Córdoba, España
| | - A Lluch
- Anestesiología, Reanimación y T. Dolor, Hospital Universitario La Fe de Valencia, Valencia, España
| | - A Hernández
- Anestesiología, Reanimación y T. Dolor, Grupo Policlínica de Ibiza, Ibiza, España
| | - J Hernández-Beslmeisl
- Anestesiología, Reanimación y T. Dolor, Complejo Hospitalario Universitario de Canarias, Canarias, España
| | - M Vives
- Anestesiología, Reanimación y T. Dolor, Hospital Universitari Dr. Josep Trueta de Girona, Girona, España
| | - R Vicente
- Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR, Anestesiología, Reanimación y T. Dolor. Hospital Universitario La Fe de Valencia, Universitat de València, Valencia, España
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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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Grünewald M, Heringlake M. [Solutions for Fluid Treatment and Outcome - an Update]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:261-275. [PMID: 33890258 DOI: 10.1055/a-1118-7488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Fluid therapy is one of the most frequently used medical interventions with the aim of normalizing the fluid balance. A decisive criterion for the efficiency of fluid or volume replacement is the functionality of the glycocalyx, a thin endothelial glycoprotein layer. Its solidity is an essential factor for fluid exchange and transport from the vascular system to the tissue. The recently described revised Starling principle extends the understanding considerably. From a clinical point of view, fluid treatment should aim for timely euvolemia without inducing relevant side effects. Both crystalloid and natural or synthetic colloidal solutions are available. In the case of crystalloid solutions, the so-called balanced solutions seem to be associated with fewer side effects. If the vascular barrier is intact, colloid solutions have a higher volume effect, but may have significant side effects limiting their use. At least in Europe, some synthetic colloids shall therefore no longer be used in critically ill patients. In contrast, treatment with albumin 20% in hypalbuminemic patients with cardiovascular disease leads to a reduced incidence of acute kidney injury and has also been associated with other clinical benefits. To what extent future, individualized therapeutic approaches employing colloids will influence the outcome is currently speculative.
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Tapia B, Garrido E, Cebrian JL, Del Castillo JL, Gonzalez J, Losantos I, Gilsanz F. Impact of Goal Directed Therapy in Head and Neck Oncological Surgery with Microsurgical Reconstruction: Free Flap Viability and Complications. Cancers (Basel) 2021; 13:cancers13071545. [PMID: 33801607 PMCID: PMC8037950 DOI: 10.3390/cancers13071545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/18/2021] [Accepted: 03/25/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Based on the proven benefits of goal directed therapy (GDT) in the perioperative management of different surgical procedures and in high-risk patients, we hypothesised that this approach would also be beneficial in microvascular free flap reconstruction in head and neck cancer. In this study, we investigated whether GDT would directly benefit flap viability in addition to improving morbidity and mortality. As this reconstructive technique is gradually being introduced in more specialist fields, particularly radical oncological surgery, the benefits of GDT in this context could be extended to numerous procedures. Abstract (1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years; however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p < 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p < 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p > 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.
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Affiliation(s)
- Blanca Tapia
- Anesthesia and Intensive Care Department, University Hospital La Paz, Universidad Autónoma de Madrid, 28046 Madrid, Spain;
- Correspondence: or ; Tel.: +34-678-787-670
| | - Elena Garrido
- Anesthesia and Intensive Care Department, Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210, USA;
| | - Jose Luis Cebrian
- Oral and Maxillofacial Surgery Department, University Hospital La Paz, Universidad Autónoma de Madrid, 28046 Madrid, Spain; (J.L.C.); (J.L.D.C.); (J.G.)
| | - Jose Luis Del Castillo
- Oral and Maxillofacial Surgery Department, University Hospital La Paz, Universidad Autónoma de Madrid, 28046 Madrid, Spain; (J.L.C.); (J.L.D.C.); (J.G.)
| | - Javier Gonzalez
- Oral and Maxillofacial Surgery Department, University Hospital La Paz, Universidad Autónoma de Madrid, 28046 Madrid, Spain; (J.L.C.); (J.L.D.C.); (J.G.)
| | - Itsaso Losantos
- Statistics Department, Hospital La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain;
| | - Fernando Gilsanz
- Anesthesia and Intensive Care Department, University Hospital La Paz, Universidad Autónoma de Madrid, 28046 Madrid, Spain;
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Hasselgren E, Hertzberg D, Camderman T, Björne H, Salehi S. Perioperative fluid balance and major postoperative complications in surgery for advanced epithelial ovarian cancer. Gynecol Oncol 2021; 161:402-407. [PMID: 33715894 DOI: 10.1016/j.ygyno.2021.02.034] [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: 01/03/2021] [Accepted: 02/25/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Appropriate fluid balance in the perioperative period is important as both hypo- and hypervolemia are associated with increased risk of complications. Women undergoing cytoreductive surgery (CRS) for advanced epithelial ovarian cancer (EOC) may have major fluid shifts. The optimal perioperative fluid balance in these women is yet to be determined. Our objective was to investigate the association between perioperative fluid balance and major postoperative complications. METHODS Women with advanced stage EOC who underwent surgery at Karolinska University Hospital, Stockholm, Sweden were identified from the institutional database. Women subjected to surgery with curative intent were included in the analysis. Additional data were retrieved from medical records. The association between perioperative fluid balance and major postoperative complications was investigated by multivariable regression and adjusted for predefined confounders. RESULTS Of the 270 women identified in the institutional database during 2014-2017, 184 women were included in the analyses. Of these women, 22% (n = 40) experienced a major postoperative complication. The fully adjusted odds of major postoperative complications increased when perioperative fluid balance exceeded >3000 mL, (Odds Ratio (OR) 4.85, 95% Confidence Interval (CI) 1.23-19.2, p = 0.02) and > 5000 mL (OR 33.7, 95% CI 4.13-275, p < 0.01). There was no association between negative fluid balance and major postoperative complications (OR 3.33, 95% CI 0.25-44.1, p = 0.36). CONCLUSIONS Fluid balance >3000 mL perioperatively during surgery for advanced EOC increased the odds of major postoperative complications. Management of perioperative fluid balance in advanced EOC surgery remains a challenge.
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Affiliation(s)
- Emma Hasselgren
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Daniel Hertzberg
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Tina Camderman
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Björne
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Sahar Salehi
- Department of Women's and Children's Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
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30
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Jabbour H, Abou Haidar M, Jabbour K, Abi Lutfallah A, Abou Zeid H, Ghanem I, Naccache N, Ayoub E. Effect of prone position without volume expansion on pulse pressure variation in spinal surgery : a prospective observational study. ACTA ANAESTHESIOLOGICA BELGICA 2021. [DOI: 10.56126/72.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Mendes RDS, Suassuna J. Perioperative oliguria: adequate physiological response or risk for acute kidney injury? J Bras Nefrol 2021; 43:1-2. [PMID: 33617624 PMCID: PMC8061957 DOI: 10.1590/2175-8239-jbn-2020-e001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Renata de Souza Mendes
- Universidade do Estado do Rio de Janeiro, Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brasil.,Universidade Federal do Rio de janeiro, Hospital Universitário Clementino Fraga Filho, RJ, Brasil
| | - José Suassuna
- Universidade do Estado do Rio de Janeiro, Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brasil
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32
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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. Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:43. [PMID: 33522953 PMCID: PMC7849093 DOI: 10.1186/s13054-021-03464-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/07/2021] [Indexed: 01/07/2023]
Abstract
Background Appropriate perioperative fluid management is of pivotal importance to reduce postoperative complications, which impact on early and long-term patient outcome. The so-called perioperative goal-directed therapy (GDT) approach aims at customizing perioperative fluid management on the individual patients’ hemodynamic response. Whether or not the overall amount of perioperative volume infused in the context of GDT could influence postoperative surgical outcomes is unclear.
Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of GDT approach between study population and control group in reducing postoperative complications and perioperative mortality, using MEDLINE, EMBASE and the Cochrane Controlled Clinical trials register. The enrolled studies were grouped considering the amount infused intraoperatively and during the first 24 h after the admission in the critical care unit (perioperative fluid). Results The metanalysis included 21 RCTs enrolling 2729 patients with a median amount of perioperative fluid infusion of 4500 ml. In the studies reporting an overall amount below or above this threshold, the differences in postoperative complications were not statically significant between controls and GDT subgroup [43.4% vs. 34.2%, p value = 0.23 and 54.8% vs. 39.8%; p value = 0.09, respectively]. Overall, GDT reduced the overall rate of postoperative complications, as compared to controls [pooled risk difference (95% CI) = − 0.10 (− 0.14, − 0.07); Chi2 = 30.97; p value < 0.0001], but not to a reduction of perioperative mortality [pooled risk difference (95%CI) = − 0.016 (− 0.0334; 0.0014); p value = 0.07]. Considering the rate of organ-related postoperative events, GDT did not reduce neither renal (p value = 0.52) nor cardiovascular (p value = 0.86) or pulmonary (p value = 0.14) or neurological (p value = 0.44) or infective (p value = 0.12) complications. Conclusions Irrespectively to the amount of perioperative fluid administered, GDT strategy reduces postoperative complications, but not perioperative mortality. Trial Registration CRD42020168866; Registration: February 2020 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866
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Affiliation(s)
- Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Lorenzo Calabrò
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy
| | - Daniel Zambelli
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Edoardo Molinari
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Silvia Scarano
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, 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
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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Petrolo M, Rangelova E, Toilou M, Hammarqvist F. Body composition, muscle function and biochemical values in patients after pancreatic surgery: An observational study. Clin Nutr 2021; 40:4284-4289. [PMID: 33583661 DOI: 10.1016/j.clnu.2021.01.021] [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: 03/23/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND & AIMS The complex nature of pancreatic operation makes it a high-risk and technically demanding major abdominal procedure, resulting in early pathophysiological alterations. This study aims to observe changes in body composition, muscle function and biochemical values in patients during the early postoperative days (PODs) following pancreaticoduodenectomy or total pancreatectomy. METHODS Assessment of body composition by bioimpedance spectroscopy, muscle function by peak expiratory flow rate (PEFR) and maximum handgrip strength (HGS), and biochemical values were measured in patients the day before surgery and on PODs 3, 6 and 9. RESULTS Significant changes occurred among 34 patients on POD 3 in body weight +2.3 (0.8-3.6) kg, total body water +2.8 (1.1-5.9) L, extracellular water +2.5 (1.2-3.7) L, intracellular water +1.1 (-0.4-1.9) L, phase angle -1.0 (-1.2 to -0.7)°, PEFR -250.0 (-407.5 to -125.0) L/m and HGS -4.8 (-7.3 to -3.0) kg, C-reactive protein +78.0 (41.0-102.8) mg/L, haemoglobin -34.5 (-45.8 to -26.0) g/L, albumin -12 (-16.5 to -10.0) g/L. CONCLUSIONS Changes in water distribution, phase angle, initial reduced muscle function and altered biochemical values were observed during the first 9 PODs.
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Affiliation(s)
- Martina Petrolo
- Clinical Nutrition, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
| | - Elena Rangelova
- Clinical Investigation and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden; Department of Upper Abdominal Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Toilou
- Clinical Nutrition, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Folke Hammarqvist
- Department of Trauma and Acute Reparative Medicine, Karolinska University Hospital, CLINTEC, Karolinska Institute, Stockholm, Sweden
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Wood C. Fluid management: An update for perioperative practitioners. J Perioper Pract 2021; 31:71-79. [PMID: 33472531 DOI: 10.1177/1750458920964174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An interprofessional team approach is required to achieve optimum fluid balance for patients during the perioperative period. Incorrect management of fluid assessment and monitoring is associated with adverse outcomes. The scientific understanding of perioperative fluid balance has improved over recent years leading to changes in clinical practice with regard to volume and choice of intravenous fluid. It is important that perioperative practitioners have an understanding of intravenous fluid, fluid compartmentalisation, fluid mechanics and intravascular fluid control mechanisms. Optimum fluid status not only shortens hospital stay but also reduces the incidence of postoperative nausea and vomiting and complication profiles. This article aims to provide perioperative practitioners with a comprehensive overview of fluid management. It will cover important issues surrounding physiological control of fluid balance, choice of intravenous fluid therapy, methods to monitor intravascular volume and factors which influence delivery.
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35
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Chow RS. Terms, Definitions, Nomenclature, and Routes of Fluid Administration. Front Vet Sci 2021; 7:591218. [PMID: 33521077 PMCID: PMC7844884 DOI: 10.3389/fvets.2020.591218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/02/2020] [Indexed: 12/14/2022] Open
Abstract
Fluid therapy is administered to veterinary patients in order to improve hemodynamics, replace deficits, and maintain hydration. The gradual expansion of medical knowledge and research in this field has led to a proliferation of terms related to fluid products, fluid delivery and body fluid distribution. Consistency in the use of terminology enables precise and effective communication in clinical and research settings. This article provides an alphabetical glossary of important terms and common definitions in the human and veterinary literature. It also summarizes the common routes of fluid administration in small and large animal species.
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Affiliation(s)
- Rosalind S Chow
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MI, United States
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36
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Diaper J, Schiffer E, Barcelos GK, Luise S, Schorer R, Ellenberger C, Licker M. Goal-directed hemodynamic therapy versus restrictive normovolemic therapy in major open abdominal surgery: A randomized controlled trial. Surgery 2020; 169:1164-1174. [PMID: 33143931 DOI: 10.1016/j.surg.2020.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this study was to compare the occurrence of postoperative complications in patients undergoing elective open abdominal surgery and receiving intraoperative goal-directed hemodynamic therapy or restrictive normovolemic therapy. METHODS A total of 401 patients were randomized in the goal-directed hemodynamic therapy or restrictive normovolemic therapy groups. A cardiac output monitor was used in all goal-directed hemodynamic therapy patients and was left at the discretion of anesthetists in charge of patients in the restrictive normovolemic therapy group. The primary outcome was a composite morbidity endpoint (30-day mortality and complications grade 2-4 according to Dindo-Clavien classification). Secondary outcomes were the hospital duration of stay, the incidence of pulmonary, cardiovascular, and renal complications up to 30 days after surgery, and midterm survival. RESULTS Intraoperatively, the goal-directed hemodynamic therapy group received higher intravenous fluid volumes (mean of 10.8 mL/kg/h and standard deviation of 4.0) compared with the restrictive normovolemic therapy group (mean of 7.2 mL/kg/h and standard deviation of 2.0; P < .001). On the first postoperative day, similar fluid volumes were infused in the 2 groups. The primary outcome occurred in 57.7% of goal-directed hemodynamic therapy and 53.0% of restrictive normovolemic therapy (relative risk, 1.09 [95% confidence interval, 0.91-1.30]), and there was no significant difference between groups for any secondary outcomes. CONCLUSION Among patients undergoing major open abdominal surgery, the goal-directed hemodynamic therapy and the restrictive normovolemic therapy were associated with similar incidence of moderate-to-severe postoperative complications and hospital resource use.
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Affiliation(s)
- John Diaper
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Eduardo Schiffer
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Gleicy Keli Barcelos
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Stéphane Luise
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland.
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Xie X, Guo S, Deng C, Guo C. Postoperative outcomes based on crystalloid administration in pediatric patients with necrotizing enterocolitis undergoing laparotomy. Medicine (Baltimore) 2020; 99:e21987. [PMID: 33019391 PMCID: PMC7535651 DOI: 10.1097/md.0000000000021987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Intravenous fluid prescription is an essential part of postoperative care and may play a causal role in postoperative complications. The objective of the present study was to evaluate the relationship between intraoperative fluid administration and postoperative outcomes in a large cohort of pediatric patients.This analysis included a retrospective review of 172 patients who underwent gastroenterological surgery from January 2012 to September 2018 at an academic tertiary care hospital. Patients were evaluated based on the median amount of corrected crystalloids and subsequently dichotomized as low (<25.89 mL/kg h) versus high (>25.89 mL/kg h). The primary outcome measure was the postoperative length of hospital stay (pLOS). Secondary outcome measures included the postoperative time to restore gastroenterological functions and postoperative complications.Patients who received larger amounts of crystalloids were more likely to have a lower intraoperative level of hemoglobin (P = .78) and an intraoperative blood transfusion (P = .27). There were trends toward lower incidence rates of hyperchloremic acidosis (P = .375) and metabolic acidosis (P = .54) in the high crystalloid administration cohort. The incidence of postoperative complications increased as the amount of administered fluid decreased (P = .046). The total length of hospital stay was shorter in patients who received high volumes of crystalloid fluid (19.5 [15.75-32.25] days) than in patients who received low volumes (22 [16-29.5] days, P = .283).Significant and multifaceted variability in crystalloid administration was noted among pediatric patients undergoing major surgery. High fluid administration was associated with favorable postoperative outcomes; these findings could be applied to improve patient safety and facilitate better quality of care.
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Affiliation(s)
- Xin Xie
- Ministry of Education Key Laboratory of Child Development and Disorders
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Siyuan Guo
- Ministry of Education Key Laboratory of Child Development and Disorders
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chun Deng
- Ministry of Education Key Laboratory of Child Development and Disorders
| | - Chunbao Guo
- Ministry of Education Key Laboratory of Child Development and Disorders
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
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Bossy M, Nyman M, Madhuri TK, Tailor A, Chatterjee J, Butler-Manuel S, Ellis P, Feldheiser A, Creagh-Brown B. The need for post-operative vasopressor infusions after major gynae-oncologic surgery within an ERAS (Enhanced Recovery After Surgery) pathway. Perioper Med (Lond) 2020; 9:26. [PMID: 32939254 PMCID: PMC7487584 DOI: 10.1186/s13741-020-00158-0] [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: 01/13/2020] [Accepted: 08/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension following major abdominal surgery is common, and once hypovolaemia has been optimally treated, is often due to vasodilation which can be treated with vasopressor infusions. There is unpredictability in the dose and duration of post-operative vasopressor infusions, and factors associated with this have not been determined. METHODS We present a case series of consecutive patients who received major gynae-oncology surgery delivered within an Enhanced Recovery After Surgery (ERAS) pathway at a single institution. Patients were electively admitted from theatre directly to the intensive care unit (ICU). Data was collected prospectively into electronic databases (Philips ICCA, Wardwatcher) and then retrospectively collated and appropriate statistical analyses were performed. In the absence of a consensus definition of vasoplegia, we, necessarily arbitrarily, chose a noradrenaline dose of > 0.1 mcg/kg/min at 08:00 on the first post-operative day. The rationale is that this would be more than would typically be expected to counteract the vasodilatory effects of epidural analgesia, which is commonly used at our institution. RESULTS Data was collected from 324 patients, all treated between February 2014 and July 2016. The average age was 67 years and 39% received neoadjuvant chemotherapy. The commonest tumour type was ovarian (58%). The median estimated blood loss was 800 ml and epidural analgesia was used in 71%. Fifty per cent received post-operative vasopressor infusions: factors associated with this included epidural use and estimated blood loss. Nineteen per cent met our criteria for vasoplegia: factors associated with this included CRP on post-operative day 1 and P-POSSUM morbidity score. Hospital and ICU length of stay was prolonged in those who had vasoplegia. CONCLUSIONS Patients commonly receive vasopressors following major gynae-oncologic surgery, and this can be at relatively high doses. Clinical factors only accounted for a minority of the variability in vasopressor usage-suggesting considerable biological variability. Optimal care of patients having major abdomino-pelvic surgery may include advanced haemodynamic monitoring and ready availability of infused vasopressors, in a suitable environment.
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Affiliation(s)
- Michèle Bossy
- Department of Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX UK
| | - Molly Nyman
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Thumuluru Kavitha Madhuri
- Department of Gynae-oncology Surgery, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - Anil Tailor
- Department of Gynae-oncology Surgery, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX UK
| | - Jayanta Chatterjee
- Department of Gynae-oncology Surgery, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - Simon Butler-Manuel
- Department of Gynae-oncology Surgery, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX UK
| | - Patricia Ellis
- Department of Gynae-oncology Surgery, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX UK
| | - Aarne Feldheiser
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Evang. Kliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, Essen, Germany
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Charité Campus Mitte, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ben Creagh-Brown
- Department of Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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Shim JW, Kwak J, Roh K, Ro H, Lee CS, Han SR, Lee YS, Lee IK, Park J, Lee HM, Chae MS, Lee HJ, Hong SH. Impact of intraoperative zero-balance fluid therapy on the occurrence of acute kidney injury in patients who had undergone colorectal cancer resection within an enhanced recovery after surgery protocol: a propensity score matching analysis. Int J Colorectal Dis 2020; 35:1537-1548. [PMID: 32385595 DOI: 10.1007/s00384-020-03616-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE An enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection encourages perioperative euvolemic status, and zero-balance fluid therapy is recommended for low-risk patients. Recently, several studies have reported concerns of increased acute kidney injury (AKI) in patients within an ERAS protocol. In the present study, we investigated the impact of intraoperative zero-balance fluid therapy within an ERAS protocol on postoperative AKI. METHODS Patients who underwent elective surgery for primary colorectal cancer were divided into zero-balance and non-zero-balance fluid therapy groups according to intraoperative fluid amount and balance. After propensity score (PS) matching, 210 patients from each group were selected. Incidences of AKI were compared between the two groups according to the Kidney Disease Improving Global Outcomes criteria. Postoperative kidney functions and surgical outcomes were also compared. RESULTS AKI was significantly higher in the zero-balance fluid therapy group compared to the non-zero-balance fluid therapy group (21.4% vs. 13.8%, p = 0.040) in PS-matched patients. The decrease in the estimated glomerular filtration rate on the day of surgery was significantly higher in the zero-balance fluid therapy group (- 5.9 mL/min/1.73 m2 vs. - 1.4 mL/min/1.73 m2, p = 0.005). There were no differences in general morbidity or mortality rate, although surgery-related complications were more common in the zero-balance group. CONCLUSIONS Despite the proven benefits of zero-balance fluid therapy in colorectal ERAS protocols, care should be taken to monitor for postoperative AKI. Further studies regarding the clinical significance of postoperative AKI occurrence and optimised intraoperative fluid therapy are needed in a colorectal ERAS setting.
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Affiliation(s)
- Jung-Woo Shim
- Department of Anaesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jueun Kwak
- Department of Anaesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungmoon Roh
- Department of Anaesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hojun Ro
- Department of Anaesthesiology and Pain Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Seung Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Rim Han
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon Suk Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Kyu Lee
- Department of Anaesthesiology and Pain Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaesik Park
- Department of Anaesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung Mook Lee
- Department of Anaesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anaesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hae-Jin Lee
- Department of Anaesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anaesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Peng H, Zhang Q, Qian J, Ruan F, Mai H, Wang Z, Liu M, Wang Z, Chen H, Li J, Zhu B, Li C, Wang K, Zhou J. Electrolyte disorders are ERAS-associated in patients undergoing hepato-pancreato-biliary surgery. Langenbecks Arch Surg 2020; 405:603-611. [PMID: 32710380 DOI: 10.1007/s00423-020-01922-y] [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: 04/29/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Emerging evidences have raised concerns about electrolyte disorders caused by restrictive fluid management in the enhanced recovery after surgery (ERAS) protocol. This study aims to investigate the morbidity and treatment of electrolyte disorders associated with ERAS in patients undergoing hepato-pancreato-biliary (HPB) surgery. METHODS Clinical data from 157 patients under the ERAS program and 166 patients under the traditional (Non-ERAS) program after HPB surgery were retrospectively analyzed. Risk factors and predictive factors of postoperative electrolyte disorders were analyzed by logistic regression analysis and receiver operator characteristic (ROC) curve analysis, respectively. RESULTS The average of intravenous fluid, sodium, chloride, and potassium supplementation after surgery were significantly lower in the ERAS group. Hypokalemia was the most common type of electrolyte disorders in the ERAS group, whose incidence was substantially increased compared to that in the Non-ERAS group [28.77% vs. 8.97%, p < 0.001, on postoperative (POD) 5]. Logistic regression analysis identified the ERAS program and age as independent risk factors of hypokalemia. ROC curve analysis identified serum potassium levels below 3.76 mmol/L on POD 3 (area under curve 0.731, sensitivity 58.54%, specificity 82.69%) as a predictive factor for postoperative hypokalemia in ERAS patients. Oral supplementation at an average of 35.41 mmol potassium per day was effective in restoring the ERAS-associated hypokalemia. CONCLUSIONS ERAS procedures were particularly associated with a lower supplementation of potassium and a higher incidence of hypokalemia in patients after HPB surgery. Oral potassium supplementation could be an adopted ERAS program for the elderly undergoing HPB surgery.
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Affiliation(s)
- Hongxian Peng
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Qifan Zhang
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jianping Qian
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Fangyi Ruan
- The First Clinical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Hanwen Mai
- The First Clinical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Zehao Wang
- The First Clinical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Meiqi Liu
- The First Clinical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Zihuan Wang
- The First Clinical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Hao Chen
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jieyuan Li
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Bili Zhu
- Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Chuanjiang Li
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
| | - Kai Wang
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
| | - Jie Zhou
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
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Bongers BC, Dejong CHC, den Dulk M. Enhanced recovery after surgery programmes in older patients undergoing hepatopancreatobiliary surgery: what benefits might prehabilitation have? Eur J Surg Oncol 2020; 47:551-559. [PMID: 32253075 DOI: 10.1016/j.ejso.2020.03.211] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/05/2020] [Accepted: 03/21/2020] [Indexed: 12/14/2022] Open
Abstract
Due to an aging population and the related growing number of less physically fit patients with multiple comorbidities, adequate perioperative care is a new and rapidly developing clinical science that is becoming increasingly important. This narrative review focuses on enhanced recovery after surgery (ERAS®) programmes and the growing interest in prehabilitation programmes to improve patient- and treatment-related outcomes in older patients undergoing hepatopancreatobiliary (HPB) surgery. Future steps required in the further development of optimal perioperative care in HPB surgery are also discussed. Multidisciplinary preoperative risk assessment in multiple domains should be performed to identify, discuss, and reduce risks for optimal outcomes, or to consider alternative treatment options. Prehabilitation should focus on high-risk patients based on evidence-based cut-off values and should aim for (partly) supervised multimodal prehabilitation tailored to the individual patient's risk factors. The program should be executed in the living context of these high-risk patients to improve the participation rate and adherence, as well as to involve the patient's informal support system. Developing tailored (multimodal) prehabilitation programmes for the right patients, in the right context, and using the right outcome measures is important to demonstrate its potential to further improve patient- and treatment-related outcomes following HPB surgery.
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Affiliation(s)
- Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Uniklinikum RWTH-Aachen, Aachen, Germany.
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Uniklinikum RWTH-Aachen, Aachen, Germany.
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Messina A, Montagnini C, Cammarota G, Giuliani F, Muratore L, Baggiani M, Bennett V, Della Corte F, Navalesi P, Cecconi M. Assessment of Fluid Responsiveness in Prone Neurosurgical Patients Undergoing Protective Ventilation. Anesth Analg 2020; 130:752-761. [DOI: 10.1213/ane.0000000000004494] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Grass F, Hübner M, Mathis KL, Hahnloser D, Dozois EJ, Kelley SR, Demartines N, Larson DW. Challenges to accomplish stringent fluid management standards 7 years after enhanced recovery after surgery implementation-The surgeon's perspective. Surgery 2020; 168:313-319. [PMID: 32122658 DOI: 10.1016/j.surg.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/13/2020] [Accepted: 01/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study aimed to analyze fluid management standards in 2 high-volume, enhanced recovery after surgery institutions 7 years after implementation. METHODS Retrospective analysis of consecutive patients undergoing elective, segmental colonic and extensive colorectal resections for benign and malignant pathology (2011-2017). Administration and composition of intravenous fluids, postoperative weight gain, and factors impeding compliance to preidentified fluid thresholds (3L fluid administration, 2.5 kg weight gain) were assessed. Multivariable logistic regression was performed to identify risk factors for postoperative adverse events. RESULTS A total of 5,155 patients were included. Among them, 2,320 patients (45.1%) received >3 L intravenous fluids at postoperative day 0. Fluid totals remained unchanged over the 7-year observation period. Fluid overload was independently associated with postoperative weight gain ≥2.5 kg at postoperative day 2 (odds ratio 1.34, P < .001). Patients with high American Society of Anesthesiologists score (≥3) undergoing open and longer (≥180 minutes) procedures were more likely to exceed both thresholds according to multivariable analysis (all P < .001). Other than open surgery, American Society of Anesthesiologists score ≥3, contamination class ≥3, and malignancy, both thresholds (≥3 L: odds ratio 1.76, 95% confidence interval 1.44-2.15, ≥ 2.5 kg: odds ratio 1.62, 95% confidence interval 1.33-1.97) were independent risk factors for postoperative adverse outcomes (occurring in 28.1% of patients). CONCLUSION Compliance with fluid thresholds appears to be challenging in patients with comorbidities undergoing open and long procedures. Efforts are encouraged because both thresholds are linked to adverse outcomes and appear to be potentially modifiable in selected patients.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN; Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN.
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Abstract
The older population is expected to nearly double across the globe by 2050, and the baby boom cohort is expected to represent at least 20% of the US population by 2030. Geriatric patients will increasingly utilize the health-care system, and therefore surgical and perioperative care must be tailored to this sensitive group given the increased risk for perioperative complications. The literature was reviewed to highlight fundamental components of the preoperative evaluation as well as cardiac, pulmonary, and renal complications. Frailty is a multidimensional process that can lead to the physiologic effects of aging and estimates the risk of perioperative morbidity and mortality better than chronologic age alone. Health-care providers should assess a geriatric patient's cognitive status, decision-making capacity, frailty, advance care planning, medications, and anesthetic approach in a multidisciplinary fashion to ensure optimal care. The risks of postoperative cardiac, pulmonary, and renal complications should be evaluated and optimized preoperatively to reduce the potential for adverse outcomes.
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Affiliation(s)
- Aditya P Devalapalli
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deanne T Kashiwagi
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Rabozzi R, Oricco S, Meneghini C, Bucci M, Franci P. Evaluation of the caudal vena cava diameter to abdominal aortic diameter ratio and the caudal vena cava respiratory collapsibility for predicting fluid responsiveness in a heterogeneous population of hospitalized conscious dogs. J Vet Med Sci 2020; 82:337-344. [PMID: 31932519 PMCID: PMC7118484 DOI: 10.1292/jvms.19-0028] [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] [Indexed: 12/14/2022] Open
Abstract
Fluid responsiveness, defined as the response of stroke volume to fluid loading, is a tool to individualize fluid administration in order to avoid the deleterious effects of hypovolemia or hypervolemia in hospitalized patients. To evaluate the accuracy of two ultrasound indices, the caudal vena cava to abdominal aorta ratio (CVC/Ao) and the respiratory collapsibility of the caudal vena cava (cCVC), as independent predictors of fluid responsiveness in a heterogeneous population of spontaneously breathing, conscious, hospitalized dogs. A prospective, multicenter, observational, cross-sectional study was designed in twenty-five dogs. The accuracy of CVC/Ao and cCVC in predicting fluid responsiveness was evaluated by the area under the receiver operating characteristic curve (AUROC) in a group of hospitalized dogs after receiving a mini-fluid bolus of 4 ml/kg of Hartmann's solution. Dogs with an increased aortic velocity time integral >15% were classified as fluid responders. Twenty-two dogs were finally included. Ten were classified as responders and 12 as non-responders. The AUROC curves were 0.88 for the CVC/Ao ratio (95% confidence interval, CI, 0.67-0.98; P=0.0001) and 0.54 for cCVC (95% CI 0.32-0.75; P=0.75). The CVC/Ao threshold optimized for best sensitivity (SE) and specificity (SP) values was 0.83 (SE 100%; SP 75%). In spontaneously breathing hospitalized dogs, the CVC/Ao measurement predicted stroke volume increase after a fluid bolus, while the respiratory variations in the cCVC did not discriminate between fluid responders and non-responders.
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Affiliation(s)
- Roberto Rabozzi
- CVRS-Policlinico Veterinario Roma Sud, 00173 Rome (RM), Italy
| | | | | | - Massimo Bucci
- Department of Animal Medicine, Production and Health School of Agriculture and Veterinary Medicine, Padua University, 35020 Legnaro (PD), Italy
| | - Paolo Franci
- Department of Veterinary Science, University of Turin, 10095 Grugliasco (TO), Italy
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Zheng C, Guo C. Intraoperative Urine Output Is Associated with Postoperative Outcome in Pediatric Population Undergone Major Abdominal Operations. Ther Clin Risk Manag 2020; 15:1453-1460. [PMID: 31908465 PMCID: PMC6927263 DOI: 10.2147/tcrm.s228528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/05/2019] [Indexed: 11/23/2022] Open
Abstract
Aim Few data support the advantage of confirming a low urine output target during Roux-en-Y hepaticojejunostomy, which was widely used as an indication for fluid administration. We aimed at evaluating postoperative outcomes in terms of urine output in pediatric patients undergoing elective Roux-en-Y hepaticojejunostomy. Methods We retrospectively reviewed 689 patients who had undergone Roux-en-Y hepaticojejunostomy between January 2007 and August 2014 at the Children’s Hospital of the Chongqing Medical University. Patients were dichotomized according to the average amount of corrected urine output (6.01 mL/kg*h) as a cut-off point. The primary endpoint was the occurrence of renal complications. The secondary endpoints included prompt postoperative gastrointestinal function recovery, postoperative complications and hospital length of stay. Results The lower urine output had a proportional association with lesser amounts of crystalloid fluids (12.99±6.52 and 17.36±7.74 mL/kg*h for low and high urine output, respectively, p=0.006). For patients with a lower urine output, there were trends toward lower incidence rates of grade II postoperative complications (OR, 0.68; 95CI, 0.45–1.03; p=0.041) and accelerated recovery of gastrointestinal function, as indicated by the first flatus (p=0.015) and first bowel movement (p=0.008); however, the occurrence of renal complications did not show significant differences between the groups. The total length of hospital stay was shorter in patients with low urine output (7.59±1.24 days) than that in patients with a high urine output (8.01±2.31 days, p = 0.016). Conclusion Lower urine output is associated with a lower incidence rate II postoperative complications and accelerated recovery of gastrointestinal function, without increasing the occurrence of renal complications in pediatric patient undergone hepaticojejunostomy. The optimal amount of urine output and associated fluid administration should be further investigated.
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Affiliation(s)
- Chao Zheng
- Department of Orthopedics, Children's Hospital, Chongqing Medical University, Chongqing 400014, People's Republic of China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chunbao Guo
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China
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47
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Shim JW, Moon HK, Park YH, Park M, Park J, Lee HM, Kim YS, Moon YE, Hong SH, Chae MS. Intraoperative changes in whole-blood viscosity in patients undergoing robot-assisted laparoscopic prostatectomy in the steep Trendelenburg position with pneumoperitoneum: a prospective nonrandomized observational cohort study. BMC Anesthesiol 2020; 20:7. [PMID: 31910810 PMCID: PMC6947909 DOI: 10.1186/s12871-019-0919-z] [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: 08/09/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022] Open
Abstract
Background The aim of this study was to investigate the effect of the steep Trendelenburg position (STP) with pneumoperitoneum on whole-blood viscosity (WBV) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). The study also analyzed the associations of clinical patient-specific and time-dependent variables with WBV and recorded postoperative outcomes. Methods Fifty-eight adult male patients (ASA physical status of I or II) undergoing elective RALP were prospectively analyzed in this study. WBV was intraoperatively measured three times: at the beginning of surgery in the supine position without pneumoperitoneum; after 30 min in the STP with pneumoperitoneum; and at the end of surgery in the supine position without pneumoperitoneum. The WBV at a high shear rate (300 s− 1) was recorded as systolic blood viscosity (SBV) and that at a low shear rate (5 s− 1) was recorded as diastolic blood viscosity (DBV). Systolic blood hyperviscosity was defined as > 13.0 cP at 300 s− 1 and diastolic blood hyperviscosity was defined as > 4.1 cP at 5 s− 1. Results The WBV and incidences of systolic and diastolic blood hyperviscosity significantly increased from the supine position without pneumoperitoneum to the STP with pneumoperitoneum. When RALP was performed in the STP with pneumoperitoneum, 12 patients (27.3%) who had normal SBV at the beginning of surgery and 11 patients (26.8%) who had normal DBV at the beginning of surgery developed new systolic and diastolic blood hyperviscosity, respectively. The degree of increase in WBV after positioning with the STP and pneumoperitoneum was higher in the patients with hyperviscosity than in those without hyperviscosity at the beginning of surgery. Higher preoperative body mass index (BMI) and hematocrit level were associated with the development of both systolic and diastolic blood hyperviscosity in the STP with pneumoperitoneum. All patients were postoperatively discharged without fatal complications. Conclusions Changes in surgical position may influence WBV, and higher preoperative BMI and hematocrit level are independent factors associated with the risk of hyperviscosity during RALP in the STP with pneumoperitoneum. Trial registration Clinical Research Information Service, Republic of Korea, approval number: KCT0003295 on October 25, 2018.
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Affiliation(s)
- Jung-Woo Shim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Hyun Kyung Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Yong Hyun Park
- Department of Urology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Misun Park
- Department of Biostatistics, Clinical Research Coordinating Center, Catholic Medical Center, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Hyung Mook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Yong-Suk Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Wrzosek A, Jakowicka‐Wordliczek J, Zajaczkowska R, Serednicki WT, Jankowski M, Bala MM, Swierz MJ, Polak M, Wordliczek J. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery. Cochrane Database Syst Rev 2019; 12:CD012767. [PMID: 31829446 PMCID: PMC6953415 DOI: 10.1002/14651858.cd012767.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization. OBJECTIVES To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery. SEARCH METHODS We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person. MAIN RESULTS From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment. AUTHORS' CONCLUSIONS Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.
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Affiliation(s)
- Anna Wrzosek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
- University HospitalDepartment of Anaethesiology and Intensive CareKrakowPoland
| | | | - Renata Zajaczkowska
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Wojciech T Serednicki
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Milosz Jankowski
- University HospitalDepartment of Anaesthesiology and Intensive CareKrakowPoland
- Jagiellonian University Medical CollegeDepartment of Internal Medicine; Systematic Reviews UnitKrakowPoland
| | - Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics; Systematic Reviews UnitKopernika 7KrakowPoland31‐034
| | - Mateusz J Swierz
- Jagiellonian University Medical CollegeDepartment of Hygiene and Dietetics; Systematic Reviews UnitKrakowPoland
| | - Maciej Polak
- Jagiellonian University Medical CollegeDepartment of Epidemiology and Population Studies in the Institute of Public HealthKrakowPoland
| | - Jerzy Wordliczek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
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Åkerberg D, Ansari D, Bergenfeldt M, Andersson R, Tingstedt B. Early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy. HPB (Oxford) 2019; 21:1784-1789. [PMID: 31164275 DOI: 10.1016/j.hpb.2019.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/29/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative fluid overload has been reported to increase complications after a variety of operative procedures. This study was conducted to investigate the incidence of fluid retention after pancreatic resection and its association with postoperative complications. METHODS Data from 1174 patients undergoing pancreatoduodenectomy between 2010 and 2016 were collected from the Swedish National Pancreatic and Periampullary Cancer Registry. Early postoperative fluid retention was defined as a weight gain ≥2 kg on postoperative day 1. Outcome measures were overall complications, as well as procedure-specific complications. RESULTS The weight change on postoperative day 1 ranged from -1 kg to +9 kg. A total of 782 patients (66.6%) were considered to have early fluid retention. Patients with fluid retention had significantly higher rates of total complications (p = 0.002), surgical complications (p = 0.001), pancreatic anastomotic leakage (p = 0.018) and wound infection (p = 0.023). Multivariable logistic regression confirmed early fluid retention as an independent risk factor for total complications (OR 1.46; p = 0.003), surgical complications (OR 1.49; p = 0.002), pancreatic anastomotic leakage (OR 1.48; p = 0.027) and wound infection (OR 1.84; p = 0.023). CONCLUSIONS Fluid retention is common after elective pancreatic resection, and its associated with an increased rate of postoperative complications.
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Affiliation(s)
- Daniel Åkerberg
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Magnus Bergenfeldt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden.
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Tang J, Liu X, Ma T, Lv X, Jiang W, Zhang J, Lu C, Chen H, Li W, Li H, Xie H, Du C, Geng Q, Feng J, Tang W. Application of enhanced recovery after surgery during the perioperative period in infants with Hirschsprung's disease - A multi-center randomized clinical trial. Clin Nutr 2019; 39:2062-2069. [PMID: 31676258 DOI: 10.1016/j.clnu.2019.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND & AIMS Various enhanced recovery after surgery (ERAS) guidelines have been established for several kinds of adult surgeries. While the guidelines for pediatric surgeries remained to be explored. The aim of the study was to prospectively evaluate the safety and efficacy of an ERAS protocol for Hirschsprung's disease (HSCR) infants undergoing pull-through procedures. METHODS An infant-specific ERAS protocol was developed and implemented at multiple centers from June 1, 2016 to December 31, 2017. The study included 145 consecutive patients who underwent pull-through surgery for HSCR in three Children's hospitals. Patients were primarily divided into three groups based on the clinical classification and surgical methods. Group I included patients with the short segment type who received transanal endorectal pull-through (TEPT) surgery. Group II comprised of patients with the classical type and long segment type who received laparoscopic-assisted pull-through (LAPT) surgery. Group III involved patients with the long segment type (who had received ileostomy or colostomy during the neonatal period) and total colonic aganglionosis who received open pull-through (OPPT) surgery. Patients in the three groups mentioned above were randomly and equally assigned into the ERAS group and traditional (TRAD) group with random number table row randomization. The primary outcome was the length of postoperative hospital stay (LOS). Secondary outcomes of interest included white blood cell (WBC) and C-reactive protein (CRP) on postoperative day 1 (POD 1), the blood glucose at the time of anesthesia and 24 h after surgery, time to first defecation, time to regular diet, plasma markers of nutrition status on POD 5, plasma natrium on POD 5, the mean intraoperative fluid volume, time to discontinuation of intravenous infusion, incidence of postoperative complications, re-admission within 30 days, hospitalization costs, parental satisfaction, and growth from admission to 6 months after surgery. RESULTS 73 and 75 patients were assigned to the TRAD and ERAS groups, respectively. There were no significant differences in demographic data. The LOS decreased from 9.5 days in the TRAD group to 7.9 days (P < 0.001) in the ERAS group. WBC count on POD 1 showed no significant difference between the two groups. CRP on POD 1 in the ERAS group was significantly lower (P < 0.001). In the ERAS group, the blood glucose was higher at anesthesia compared to the TRAD group (P < 0.001). On the contrary, the blood glucose at 24 h after surgery was significantly lower in the ERAS group (P < 0.001). Intraoperative fluid volume was lower in the EARS group (P < 0.001). ERAS could also reduce the time to first defecation (P < 0.001), discontinuation of intravenous infusion (P < 0.001) and regular diet (P < 0.001). In the ERAS group, the concentrations of prealbumin and retinol conjugated protein on POD 5 were higher than those in the TRAD group (P < 0.001, P < 0.001, respectively). The plasma natrium had no difference in the two groups on POD 5 (P > 0.05). The rate of complications (P > 0.05) and 30-day re-admission (P > 0.05) were not significantly different between the two groups. Hospitalization costs were also reduced (P < 0.001). ERAS group has a higher parental satisfaction rate, although there was no statistical difference (96% vs 89%). There was no difference in growth between the ERAS and the TRAD groups from admission to 6 months after the surgery (weight for age z score: P > 0.05, weight for length z score: P > 0.05). We also found that the shortening of LOS by the application of ERAS protocol was more obvious in the OPPT group (-2.5 ± 1.0) than that in the TEPT (-1.9 ± 1.3) and LAPT (-1.3 ± 0.4) groups. CONCLUSIONS Implementation of the ERAS protocol in infants undergoing HSCR pull-through operations is safe and efficient. The ERAS protocol is worthy of recommendation. TRIAL REGISTRATION Clinical Trials.gov identifier: NCT02776176.
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Affiliation(s)
- Jie Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Xiang Liu
- Department of Pediatric Surgery, Anhui Provincial Children's Hospital, Hefei 230000, China
| | - Tongshen Ma
- Department of Pediatric Surgery, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Xiaofeng Lv
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Weiwei Jiang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Jie Zhang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Changgui Lu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Huan Chen
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Wei Li
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Hongxing Li
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Hua Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Chunxia Du
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Qiming Geng
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210000, China.
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