Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery

Fluid resuscitation for acute kidney injury: an empty promise

PURPOSE OF REVIEW

The past decade has seen more advances in our understanding of fluid therapy than the preceding decades combined. What was once thought to be a relatively benign panacea is increasingly being recognized as a potent pharmacological and physiological intervention that may pose as much harm as benefit.

RECENT FINDINGS

Recent studies have clearly indicated that the amount, type, and timing of fluid administration have profound effects on patient morbidity and outcomes. The practice of aggressive volume resuscitation for 'renal protection' and 'hemodynamic support' may in fact be contributing to end organ dysfunction. The practice of early goal-directed therapy for patients suffering from critical illness or undergoing surgery appears to offer no benefit over conventional therapy and may in fact be harmful. A new conceptual model for fluid resuscitation of critically ill patients has recently been developed and is explored here.

SUMMARY

The practice of giving more fluid early and often is being replaced with new conceptual models of fluid resuscitation that suggest fluid therapy be 'personalized' to individual patient pathophysiology.

Preoperative fluid restriction for trauma patients with hemorrhagic shock decreases ventilator days

Aim

In recent years, with the concept of damage control resuscitation, hemostasis and preoperative fluid restriction have been carried out, but there is controversy regarding the effectiveness of fluid restriction.

Methods

From April 2007 to March 2013, 101 trauma patients presented with hemorrhagic shock (systolic blood pressure ≤90 mmHg) at the prehospital or emergency department and were admitted to Hyogo Emergency Medical Center (Hyogo, Japan). They underwent emergency hemostasis by surgery and transcatheter arterial embolization. We compared two groups in a historical cohort study, the aggressive fluid resuscitation (AR) group, which included 59 cases treated in the period April 2007-March 2010, and the fluid restriction (FR) group, which included 42 cases treated in the period April 2010-March 2013.

Results

There was no difference between both groups in patient background (heart rate, 110 b.p.m.; systolic blood pressure, 70 mmHg). The Injury Severity Score was 34 (AR) versus 38 (FR) (not significant). Preoperative infusion volume of crystalloid significantly decreased, from 2310 mL (AR) to 1025 mL (FR) (P ≤ 0.01). There was no difference in mortality (36% [AR] versus 41% [FR]). Ventilator days significantly decreased, from 8.5 days (AR) to 5.5 days (FR) (P = 0.02).

Conclusions

Preoperative fluid restriction for trauma patients with hemorrhagic shock did not improve mortality, but it decreased ventilator days by reducing the perioperative plus water balance and it might contribute to perioperative intensive care.

Impact of a Novel Multiparameter Decision Support System on Intraoperative Processes of Care and Postoperative Outcomes

Background

The authors hypothesized that a multiparameter intraoperative decision support system with real-time visualizations may improve processes of care and outcomes.

Methods

Electronic health record data were retrospectively compared over a 6-yr period across three groups: experimental cases, in which the decision support system was used for 75% or more of the case at sole discretion of the providers; parallel controls (system used 74% or less); and historical controls before system implementation. Inclusion criteria were adults under general anesthesia, advanced medical disease, case duration of 60 min or longer, and length of stay of two days or more. The process measures were avoidance of intraoperative hypotension, ventilator tidal volume greater than 10 ml/kg, and crystalloid administration (ml · kg–1 · h–1). The secondary outcome measures were myocardial injury, acute kidney injury, mortality, length of hospital stay, and encounter charges.

Results

A total of 26,769 patients were evaluated: 7,954 experimental cases, 10,933 parallel controls, and 7,882 historical controls. Comparing experimental cases to parallel controls with propensity score adjustment, the data demonstrated the following medians, interquartile ranges, and effect sizes: hypotension 1 (0 to 5) versus 1 (0 to 5) min, P < 0.001, beta = –0.19; crystalloid administration 5.88 ml · kg–1 · h–1 (4.18 to 8.18) versus 6.17 (4.32 to 8.79), P < 0.001, beta = –0.03; tidal volume greater than 10 ml/kg 28% versus 37%, P < 0.001, adjusted odds ratio 0.65 (0.53 to 0.80); encounter charges $65,770 ($41,237 to $123,869) versus $69,373 ($42,101 to $132,817), P < 0.001, beta = –0.003. The secondary clinical outcome measures were not significantly affected.

Conclusions

The use of an intraoperative decision support system was associated with improved process measures, but not postoperative clinical outcomes.

Association of Fluid Administration With Morbidity in Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

Importance

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal cancers can be associated with significant complications. Randomized trials have demonstrated increased morbidity with liberal fluid regimens in abdominal surgery.

Objective

To investigate the association of intraoperative fluid administration and morbidity in patients undergoing CRS/HIPEC.

Design, Setting, and Participants

A retrospective analysis of information from a prospectively collected institutional database was conducted at a National Cancer Institute-designated comprehensive cancer center. A total of 133 patients from April 15, 2009, to June 23, 2016, with primary or secondary peritoneal cancers were included.

Exposures

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Main Outcomes and Measures

Morbidity associated with intraoperative fluid management calculated by the comprehensive complication index, which uses a formula combining all perioperative complications and their severities into a continuous variable from 0 to 100 in each patient.

Results

Of the 133 patients identified, 38% and 37% had diagnoses of metastatic appendiceal and colorectal cancers, respectively. Mean age was 54 (interquartile range [IQR], 47-64) years, and mean peritoneal cancer index was 13 (IQR, 7-18). Mitomycin and platinum-based chemotherapeutic agents were used in 96 (72.2%) and 37 (27.8%) of the patients, respectively. Mean intraoperative fluid (IOF) rate was 15.7 (IQR, 11.3-18.7) mL/kg/h. Mean comprehensive complication index (CCI) was 26.0 (IQR, 8.7-36.2). On multivariate analysis, age (coefficient, 0.32; 95% CI, 0.01-0.64; P = .04), IOF rate (coefficient, 0.97; 95% CI, 0.19-1.75; P = .02), and estimated blood loss (coefficient, 0.02; 95% CI, 0.01-0.03; P = .002) were independent predictors of increased CCI. In particular, patients who received greater than the mean IOF rate experienced a 43% increase in the CCI compared with patients who received less than the mean IOF rate (31.5 vs 22.0; P = .02).

Conclusions and Relevance

Intraoperative fluid administration is associated with a significant increase in perioperative morbidity in patients undergoing CRS/HIPEC. Fluid administration protocols that include standardized restrictive fluid rates can potentially help to mitigate morbidity in patients undergoing CRS/HIPEC.

Research progress of fast track surgery

The purpose of surgical treatment is to remove the lesions, repair tissue, and reconstruct organ function, but the process will inevitably cause certain degrees of trauma and stress. As a traumatic treatment, surgical treatment can produce a series of pathophysiological changes while achieving the therapeutic effect. Surgical complications are significantly associated with perioperative stress. Therefore, controlling operation-related stress can effectively improve prognosis. In order to reduce the incidence of surgical stress and postoperative complications and promote the rehabilitation of patients as soon as possible, the concept of fast track surgery has been put forward in recent years. It is supported by evidence-based medicine and subverts the traditional concept of surgery, optimizing the multidisciplinary cooperation in the perioperative treatment and rehabilitation process. Moreover, it accelerates the recovery of postoperative patients. Since the concept was put forward, it has been widely applied in European and American countries in the fields of gastroenterology, cardiothoracic surgery, orthopedics, urology, and gynecology. This paper briefly reviews the advances of fast track surgery in recent years.

Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomized controlled trial

AIM

Individualized, goal-directed fluid therapy (GDFT), based on Doppler measurements of stroke volume, has been proposed as a treatment strategy in terms of reducing complications, mortality and length of hospital stay in major bowel surgery. We studied the effect of Doppler-guided GDFT on intestinal damage as compared with standard postoperative fluid replacement.

METHOD

Patients undergoing elective colorectal resection for malignancy were randomized either to standard intra- and postoperative fluid therapy or to standard fluid therapy with additional Doppler-guided GDFT. The primary outcome was intestinal epithelial cell damage measured by plasma levels of intestinal fatty acid-binding protein (I-FABP). Global gastrointestinal perfusion was measured by gastric tonometry, expressed as regional (gastric) minus arterial CO₂ -gap (P_r-a CO₂ -gap).

RESULTS

I-FABP levels were not significantly different between the intervention group and the control group (respectively, 440.8 (251.6) pg/ml and 522.4 (759.9) pg/ml, P = 0.67). Mean areas under the curve (AUCs) of intra-operative P_r-a CO₂ -gaps were significantly lower in the intervention group than in the control group (P = 0.01), indicating better global gastrointestinal perfusion in the intervention group. Moreover, the mean intra-operative P_r-a CO₂ -gap peak in the intervention group was 0.5 (1.0) kPa, which was significantly lower than the mean peak in the control group, of 1.4 (1.4) kPa (P = 0.03).

CONCLUSION

Doppler-guided GDFT during and in the first hours after elective colorectal surgery for malignancy increases global gastrointestinal perfusion, as measured by P_r-a CO₂ -gap.

Contemporary Approaches to Perioperative IV Fluid Therapy

BACKGROUND

Intravenous fluid therapy is required for most surgical patients, but inappropriate regimens are commonly prescribed. The aim of this narrative review was to provide evidence-based guidance on appropriate perioperative fluid management.

METHOD

We did a systematic literature search of the literature to identify relevant studies and meta-analyses to develop recommendations.

RESULTS

Of 275 retrieved articles, we identified 25 articles to inform this review. "Normal" saline (0.9% sodium chloride) is not physiological and can result in sodium overload and hyperchloremic acidosis. Starch colloid solutions are not recommended in surgical patients at-risk of sepsis or renal failure. Most surgical patients can have clear fluids and/or administration of carbohydrate-rich drinks up to 2 h before surgery. An intraoperative goal-directed fluid strategy may reduce postoperative complications and reduce hospital length of stay. Regular postoperative assessment of the patient's fluid status and requirements should include looking for physical signs of dehydration or hypovolemia, or fluid overload. Both hypovolemia and salt and water overload lead to adverse events, complications and prolonged hospital stay. Urine output can be an unreliable indicator of hydration status in the postoperative surgical patient. Excess fluid administration has been linked to acute kidney injury, gastrointestinal dysfunction, and cardiac and pulmonary complications.

CONCLUSION

There is good evidence supporting the avoidance of unnecessary fasting and the value of an individualized perioperative IV fluid regimen, with transition to oral fluids as soon as possible, to help patients recover from major surgery.

Restrictive and liberal fluid administration in major abdominal surgery

Objectives:

To determine whether perioperative fluid restrictive administration can reduce specific postoperative complications in adults undergoing major abdominal surgery.

Methods:

We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, Google scholar, and article reference lists (up to December 2015) for studies that assessed fluid therapy and morbidity or mortality in patients undergoing major abdominal surgeries. The quality of the trials was assessed using the Jadad scoring system, and a meta-analysis of the included randomized, controlled trials was conducted using Review Manager software, version 5.2.

Results:

Ten studies with a total of 1160 patients undergoing major abdominal surgeries were included. We found that perioperative restrictive fluid therapy could reduce the risk of postoperative infectious complications (odds ratio [OR]=0.54, 95% confidence interval [CI]:0.39-0.74, p=0.0001, I²=37%), pulmonary complications (OR=0.49, 95% CI: 0.26-0.93, p=0.03, I²=50%), and cardiac complications (OR=0.45, 95% CI: 0.29-0.69, p=0.0003, I²=48%), but had no effect on the risk of gastrointestinal complications (OR=0.87, 95% CI: 0.51-1.46, p=0.59, I²=0%), renal complications (OR=0.76, 95% CI: 0.43-1.34, p=0.35, I²=0%), and postoperative mortality (OR=0.62, 95% CI: 0.25-1.50, p=0.29, I²=0%).

Conclusion:

Perioperative restrictive fluid administration was superior to liberal fluid administration in reducing the infectious, pulmonary and cardiac complications after major abdominal surgeries.

Effect of gum chewing on ameliorating ileus following colorectal surgery: A meta-analysis of 18 randomized controlled trials

BACKGROUND AND OBJECTIVE

Chewing gum, as an alternative to sham feeding, had been shown to hasten the recovery of gut function following abdominal surgery. However, conclusions remained contradictory. We sought to conduct an updated meta-analysis to evaluate the efficacy of gum chewing in alleviating ileus following colorectal surgery.

METHODS

We searched PubMed, EMBASE, and Cochrane Library Databases through February 2017 to identify randomized controlled trials (RCTs) evaluating the efficacy of the additional use of chewing gum following colorectal surgery. After screening for inclusion, data extraction, and quality assessment, meta-analysis was conducted by the Review Manager 5.3 software. The outcomes of interest were the time to first flatus, time to first bowel movement, length of hospital stay, and some clinically relevant parameters. We also performed subgroup analyses according to the type of surgical approaches or on trials that adopted enhanced recovery after surgery (ERAS) protocol or sugared gum.

RESULTS

A total of 18 RCTs, involving 1736 patients, were included. Compared with standardized postoperative care, Chewing gum resulted in a shorter passage to first flatus [WMD = -8.81, 95%CI: (-13.45, -4.17), P = 0.0002], earlier recovery of bowel movement [WMD = -16.43, 95%CI: (-22.68, -10.19), P < 0.00001], and a reduction in length of hospital stay [WMD = -0.89, 95%CI: (-1.72, -0.07), P = 0.03]. Chewing gum was also associated with a lower risk of postoperative ileus [OR = 0.41, 95%CI: (0.23, 0.73), P = 0.003]. No evidence of significant advantages in overall postoperative complication, nausea, vomiting, bloating, readmission and reoperation towards the addition of chewing gum was observed. Subgroup analyses all favored gum chewing. However, the findings are hampered by the significant heterogeneity between trials.

CONCLUSIONS

Based on current evidence, chewing gum offers an inexpensive, well-tolerated, safe and effective method to ameliorate ileus following colorectal surgery. However, tightly controlled, randomized and considerably larger multicenter trials are warranted to further validate our findings.

Goal-directed Fluid Therapy Does Not Reduce Primary Postoperative Ileus after Elective Laparoscopic Colorectal Surgery: A Randomized Controlled Trial

BACKGROUND

Inadequate perioperative fluid therapy impairs gastrointestinal function. Studies primarily evaluating the impact of goal-directed fluid therapy on primary postoperative ileus are missing. The objective of this study was to determine whether goal-directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program.

METHODS

Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Patients were assigned randomly to receive intraoperative goal-directed fluid therapy (goal-directed fluid therapy group) or fluid therapy based on traditional principles (control group). Primary postoperative ileus was the primary outcome.

RESULTS

One hundred twenty-eight patients were included and analyzed (goal-directed fluid therapy group: n = 64; control group: n = 64). The incidence of primary postoperative ileus was 22% in the goal-directed fluid therapy and 22% in the control group (relative risk, 1; 95% CI, 0.5 to 1.9; P = 1.00). Intraoperatively, patients in the goal-directed fluid therapy group received less intravenous fluids (mainly less crystalloids) but a greater volume of colloids. The increase of stroke volume and cardiac output was more pronounced and sustained in the goal-directed fluid therapy group. Length of hospital stay, 30-day postoperative morbidity, and mortality were not different.

CONCLUSIONS

Intraoperative goal-directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program. Its previously demonstrated benefits might have been offset by advancements in perioperative care.

Does coffee affect the bowel function after caesarean section?

OBJECTIVES

Postoperative ileus is a common consequence of abdominal surgery, which tends to prolong the duration of hospital stay and imposes considerable economic costs on healthcare system. Coffee is proved to have positive effects on gastrointestinal motility index in healthy young adults. Thus, the present study aims to examine effects of coffee on bowel function after caesarean section.

MATERIAL AND METHOD

A total number 100 patients after elective caesarean section were randomly assigned before surgery into control and intervention groups. The intervention group received 100cc coffee at 8, 12 and 20h after the surgery, while the control group received 100cc hot water at the same intervals. First bowel sound, first passage of flatus, first defecation, and length of stay after surgery were compared in the two groups.

FINDINGS

Mean time to first flatus passage was recorded in the control (22.54±5.09h) and intervention (17.28±4.44h) groups and showed to be statistically significant (p=-0.000). However, average time of first defecation (intervention 37.22±16.31h; control 36.82±16.5h; p=0.647) and mean time of hospital stay of patients (intervention 30.08±9.50h; control 32.16±11.82h; p=0.518) and first bowel sound (intervention 5.84±1.41h; control 6.16±1.33h; p=-0.326) were not statistically significant.

DISCUSSION

Drinking coffee after a caesarean section reduces time to first flatus in patients. Nevertheless, further studies are needed to examine effects of coffee on ileus after elective caesarean section.

A Comparison of Multimodal Analgesic Approaches in Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery: Pharmacological Agents

INTRODUCTION

Enhanced Recovery After Surgery (ERAS^®) protocols are the cornerstone of improved recovery after colorectal surgery. Their implementation leads to reduced morbidity and shorter hospital stays while attenuating the surgical stress response. Multimodal analgesia is an important part of ERAS protocols. We compared and contrasted protocols from 15 institutions to test our hypothesis that there is a fundamental consensus among them.

MATERIALS AND METHODS

ERAS protocols for open and laparoscopic colorectal surgery were compared from 15 different healthcare facilities. We examined each institution's approach to multimodal analgesia related to the use of oral and intravenous analgesics. Preoperative, intraoperative, and postoperative management was examined.

RESULTS

All but three protocols used preoperative multimodal analgesics, with acetaminophen, celecoxib, and gabapentin being the most common. Intraoperative recommendations included the use of ketamine, lidocaine, magnesium, and ketorolac. Some protocols advocated for the use of opiates, while others aimed to minimize total opioid dose. In the postoperative period, the three most utilized agents were acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids.

CONCLUSIONS

There were many similarities and some significant differences among ERAS protocols examined. Acetaminophen was the most widely used nonopioid agent and along with NSAIDs offers a benefit with respect to postoperative analgesia, opioid-sparing effects, earlier ambulation, and reduction in postoperative ileus. Gabapentin was widely used as it may reduce opioid consumption within the first 24 hours postoperatively. Lidocaine infusion was recommended if there were contraindications to or failure of epidural anesthesia. Ketamine is frequently recommended due to its analgesic, antihyperalgesic, antiallodynic, and antitolerance properties. Differences in approaches may be due to both institutional- and provider-level factors.

Excess intraoperative fluid volume administration is associated with pancreatic fistula after pancreaticoduodenectomy: A retrospective multicenter study

Recent studies on perioperative fluid administration in patients undergoing pancreaticoduodenectomy (PD) have suggested that increased fluid loads are associated with worse perioperative outcomes. The purpose of this study was to investigate the relationship between intraoperative fluid (IOF) administration and postoperative pancreatic fistula (POPF), and to determine additional risk factors affecting pancreatic fistula in patients undergoing PD.From 2005 to 2014, a total of 182 patients with various periampullary diseases after PD were reviewed retrospectively at Dongguk University Ilsan Hospital, Chung-Ang University Hospital, and Dongnam Institute of Radiological and Medical Sciences. Patients were assigned to high or low IOF groups based on more or less fluid administration for supplementation of estimated blood loss and maintenance volume (12.5 mL/kg/h) than planned, respectively. The associations between IOF administration, pancreatic fistula development, and perioperative outcomes were evaluated.A total of 98 patients were assigned to the high-IOF group, and 84 to the low-IOF group. Risk factors for pancreatic fistula after univariate analysis were assignment to the high-IOF group, higher preoperative serum hemoglobin level, ampullary or bile duct cancer, pylorus preserving PD, small pancreatic duct, duct-to-mucosa pancreatojejunostomy, use of a stent, and mesh application to pancreatojejunal anastomosis. Among these, assignment to the high-IOF group (hazard ratio [HR] = 5.501, 95% CI 1.624-18.632, P = .006) and a small (<4 mm) pancreatic duct (HR = 4.129, 95% CI 1.569-14.658, P = .035) were identified as independent risk factors for the development of pancreatic fistula after multivariate analysis. However, long-term survival rate did not differ according to IOF group or duct size.Excessive IOF volume administration is associated with an increased incidence of pancreatic fistula after pancreaticoduodenectomy.

Restrictive versus liberal fluid therapy in major abdominal surgery (RELIEF): rationale and design for a multicentre randomised trial

INTRODUCTION

The optimal intravenous fluid regimen for patients undergoing major abdominal surgery is unclear. However, results from many small studies suggest a restrictive regimen may lead to better outcomes. A large, definitive clinical trial evaluating perioperative fluid replacement in major abdominal surgery, therefore, is required.

METHODS/ANALYSIS

We designed a pragmatic, multicentre, randomised, controlled trial (the RELIEF trial). A total of 3000 patients were enrolled in this study and randomly allocated to a restrictive or liberal fluid regimen in a 1:1 ratio, stratified by centre and planned critical care admission. The expected fluid volumes in the first 24 hour from the start of surgery in restrictive and liberal groups were ≤3.0 L and ≥5.4 L, respectively. Patient enrolment is complete, and follow-up for the primary end point is ongoing. The primary outcome is disability-free survival at 1 year after surgery, with disability defined as a persistent (at least 6 months) reduction in functional status using the 12-item version of the World Health Organisation Disability Assessment Schedule.

ETHICS/DISSEMINATION

The RELIEF trial has been approved by the responsible ethics committees of all participating sites. Participant recruitment began in March 2013 and was completed in August 2016, and 1-year follow-up will conclude in August 2017. Publication of the results of the RELIEF trial is anticipated in early 2018.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT01424150.

Pancreatoduodenectomy and the risk of complications from perioperative fluid administration

BACKGROUND

The dogma of administering sufficient intravenous fluids aggressively to avoid under-resuscitation has recently been challenged. Evidence suggests that excessive perioperative fluid administration may be associated with negative clinical outcomes in gastrointestinal surgery. This study examines the impact of fluid administration on perioperative outcomes in patients undergoing pancreatoduodenectomy (PD).

METHODS

A retrospective analysis of 202 patients undergoing PD between January 2004 and August 2015 was performed. A cut-off value of 10 mL/kg/h was applied (low fluid group: <10 mL/kg/h versus high fluid group: ≥10 mL/kg/h).

RESULTS

There were 76 patients in the low fluid group and 126 patients in the high fluid group. Both groups had comparable age, American Society of Anesthesiologists score and preoperative morbidity rates. Patients in the high fluid group received significantly more total fluids, crystalloids and colloids intraoperatively (P < 0.0001, P < 0.0001 and P = 0.013, respectively) without a significant difference in estimated blood loss (P = 0.586). The net fluid balance on post-operative day 0 was also significantly higher in the high fluid group (P < 0.0001). The mortality rate was 0% in the cohort. Major morbidity rate was 46.1% and 44.4% in low and high fluid groups, respectively (P = 0.836). Reoperation rate was 5.3% for the low fluid group and 1.6% for the high fluid group (P = 0.136). There were no significant differences between the groups for any of the individual complications.

CONCLUSION

This study did not identify a difference in post-operative outcomes between the low and high fluid regime in patients undergoing PD.

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

Increased incidence of prolonged ileus after colectomy for inflammatory bowel diseases under ERAS protocol: a cohort analysis

BACKGROUND

Postoperative ileus is a common problem after colorectal surgery. The aim of the study was to investigate the incidence and risk factors for prolonged postoperative ileus (POI) after colectomy for inflammatory bowel diseases (IBDs).

METHODS

Consecutive patients who underwent colorectal resection for IBD versus colorectal cancer (CRC) patients under enhanced recovery after surgery protocol were retrospectively analyzed. Primary assessment end point is the incidence of prolonged POI (>4 days); secondary end points were GI-2 recovery (time to first toleration of solid food and first bowel movement), nasogastric tube reinsertion, and postoperative length of stay. Risk factors for prolonged POI in IBD patients were assessed by multiple logistic regression analysis with P score matching.

RESULTS

The incidence of prolonged POI was higher in IBD versus CRC group (28.8% versus 14.8%, P < 0.001). Patients with IBD had a longer time to GI-2 recovery (4.8 ± 2.1 versus 3.7 ± 1.4 d, P < 0.001), postoperative length of stay (10.7 ± 6.2 versus 7.9 ± 5.3 d, P < 0.001), higher incidence of nasogastric tube reinsertion (9.8% versus 4.0%, P = 0.02). After propensity-score matching analysis, the differences were still significant. Preoperative steroid use >20 mg/d (odds ratio, [OR] = 2.19, P = 0.048), hypoalbuminemia (<35 g/L; OR 2.72, P = 0.03), systemic inflammatory response syndrome status (OR 4.91, P = 0.03), and postoperative intraabdominal sepsis (OR 9.31, P = 0.001) were independent risk factors for prolonged POI in IBD patients.

CONCLUSIONS

In the setting of enhanced recovery after surgery, colectomy for IBD is associated with delayed gastrointestinal function recovery and higher incidence of prolonged POI compared to CRC patients. Normalizing preoperative albumin level, weaning off steroids, reducing preoperative systemic inflammatory response syndrome, and early management of postoperative intraabdominal sepsis may reduce POI in IBD population.

The importance of albumin infusion rate for plasma volume expansion following major abdominal surgery - AIR: study protocol for a randomised controlled trial

BACKGROUND

Administration of fluids to restore normovolaemia is one of the most common therapeutic interventions performed peri-operatively and in the critically ill, but no study has evaluated the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid. The present study is designed to test the hypothesis that a slow infusion of resuscitation fluid results in better plasma volume expansion than a rapid infusion.

METHODS/DESIGN

The study is a single-centre, assessor-blinded, parallel-group, randomised prospective study. Patients over 40 years of age admitted to the post-operative care unit after a Whipple procedure or major gynaecological surgery and presenting with signs of hypovolaemia are eligible for inclusion. Patients are randomised in a 1:1 fashion with no stratification to either rapid (30 minutes) or slow (180 minutes) infusion of 5% albumin at a dose of 10 ml/kg ideal body weight. Plasma volume is measured using 125I human serum albumin at baseline (prior to albumin infusion) as well as at 30 minutes and 180 minutes after infusion start. The primary endpoint is change in plasma volume from baseline to 180 minutes after the start of 5% albumin infusion. Secondary endpoints include the integral of plasma volume over time from baseline to 180 minutes after the start of the infusion and transcapillary escape rate of albumin (%/h) from 180 minutes to 240 minutes after the start of albumin infusion. In addition, diuresis, change in central venous oxygen saturation, lactate and blood pressure will be evaluated. A total of 70 patients will be included in the study, and the study has 80% power to detect a difference of 4 ml/kg in plasma volume expansion between the two groups.

DISCUSSION

The present study is the first clinical investigation of the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid.

TRIAL REGISTRATION

EudraCT identifier: 2013-004446-42 . Registration date: 20 December 2013. ClinicalTrials.gov identifier: NCT02728921 . Registration date: 31 March 2016.

Life-threatening complications after postoperative intermediate care unit discharge: A retrospective, observational study

BACKGROUND

Postoperative patients who require intensive monitoring, intervention with an arterial line, vasoactive drugs and prolonged ventilator weaning are admitted to the postoperative intermediate care unit (IMCU).

OBJECTIVES

The aim of this study was to estimate the prevalence of life-threatening complications within 7 days after IMCU discharge. Furthermore, we searched for associations between perioperative risk factors and these life-threatening complications.

DESIGN

A retrospective observational study.

SETTING

The postoperative IMCU of a university hospital in Tokyo, Japan, between 2010 and 2012.

PATIENTS

All adult patients who stayed in the postoperative IMCU and who were discharged to general wards without being transferred to the ICU were included.

MAIN OUTCOME MEASURES

A composite outcome of life-threatening complications needing unplanned ICU admission within 7 days after IMCU stay, or death within 7 days after IMCU stay.

RESULTS

Forty out of 3093 patients (1.3%) presented a life-threatening complication; all had an unplanned ICU admission, and none died. Patients with life-threatening complications had a longer length of hospital stay [median 38.0 (interquartile range, IQR 21.3 to 56.8) days vs. 12.0 (IQR 8.0 to 23.0), P < 0.001] and a higher in-hospital mortality (12.5 vs. 0.7%, P < 0.001). Independent risk factors were an emergency operation before IMCU admission [vs. elective; odds ratio (OR) 20.5; 95% confidence interval (95% CI) 12.2 to 36.0, P < 0.001], higher cumulative perioperative fluid load during the surgical operation and IMCU stay (3000 to 4999 vs. <1000 ml; OR 5.7; 95% CI 1.6 to 23.7, P = 0.009; ≥5000 vs. <1000 ml; OR 7.2; 95% CI 1.3 to 39.6, P = 0.021), mechanical ventilation during IMCU stay less than 6 h (vs. no use; OR 3.6; 95% CI 1.4 to 9.2, P = 0.007).

CONCLUSION

More than 1% of patients had a life-threatening complication within 7 days after IMCU discharge, but with no deaths. Risk factors were an emergency operation before IMCU admission, higher cumulative perioperative fluid load and a short period of mechanical ventilation during the IMCU stay.

Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology

IMPORTANCE

Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology.

OBJECTIVE

The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology.

EVIDENCE ACQUISITION

Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed.

RESULTS

Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life.

CONCLUSIONS AND RELEVANCE

High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.

Impact of perioperative care on the post-operative recovery of women undergoing surgery for gynaecological tumours

To assess perioperative care in patients undergoing abdominal surgery for gynaecological tumours and how it relates to post-operative (PO) complications and oral PO feeding. Ninety-one women undergoing major abdominal surgery for gynaecological tumours were enrolled. Data included mechanical bowel preparation (MBP), prescribed diet, length of fast, start date of oral diet and progression of food consistency, anaesthetic technique, use of opioids and intravenous hydration (IH). Outcomes evaluated were nausea, vomiting and abdominal distension. The median pre-operative length of fast was 11.4 h. PO digestive complications occurred in 46.2% of the patients. Median intraoperative total IH and crystalloids were significantly higher in patients with abdominal distension during the first and second PO day. MBP with mannitol implied greater intraoperative IH and was significantly associated with a higher incidence of immediate PO nausea. Post-operative IH was also associated with gastrointestinal complications. The best cut-off point for the cumulative fluid load PO for determining a longer PO hospital stay was 4 L. Performing MBP before surgery and excessive IH are factors related to major digestive complications in our study population. Changes in pre-operative fasting time and PO refeeding should be considered to reduce the gastrointestinal complications and PO recovery time.

Targeting Oliguria Reversal in Goal-Directed Hemodynamic Management Does Not Reduce Renal Dysfunction in Perioperative and Critically Ill Patients: A Systematic Review and Meta-Analysis

BACKGROUND

We investigated whether resuscitation protocols to achieve and maintain urine output above a predefined threshold-including oliguria reversal as a target--prevent acute renal failure (ARF).

METHODS

We performed a systematic review and meta-analysis using studies found by searching MEDLINE, EMBASE, and references in relevant reviews and articles. We included all studies that compared "conventional fluid management" (CFM) with "goal-directed therapy" (GDT) using cardiac output, urine output, or oxygen delivery parameters and reported the occurrence of ARF in critically ill or surgical patients. We divided studies into groups with and without oliguria reversal as a target for hemodynamic optimization. We calculated the combined odds ratio (OR) and 95% confidence intervals (CIs) using random-effects meta-analysis.

RESULTS

We based our analyses on 28 studies. In the overall analysis, GDT resulted in less ARF than CFM (OR, 0.58; 95% CI, 0.44-0.76; P < 0.001; I = 34.3%; n = 28). GDT without oliguria reversal as a target resulted in less ARF (OR, 0.45; 95% CI, 0.34-0.61; P < 0.001; I = 7.1%; n = 7) when compared with CFM with oliguria reversal as a target. The studies comparing GDT with CFM in which the reversal of oliguria was targeted in both or in neither group did not provide enough evidence to conclude a superiority of GDT (targeting oliguria reversal in both protocols: OR, 0.63; 95% CI, 0.36-1.10; P = 0.09; I = 48.6%; n = 9, and in neither protocol: OR, 0.66; 95% CI, 0.37-1.16; P = 0.14; I = 20.2%; n = 12).

CONCLUSIONS

Current literature favors targeting circulatory optimization by GDT without targeting oliguria reversal to prevent ARF. Future studies are needed to investigate the hypothesis that targeting oliguria reversal does not prevent ARF in critically ill and surgical patients.

Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients

PURPOSE

The objective of our study was to assess the reliability of the distensibility index of the inferior vena cava (dIVC) as a predictor of fluid responsiveness in postoperative, mechanically ventilated patients and compare its accuracy with that of the pulse pressure variation (PPV) measurement.

MATERIALS AND METHODS

We included postoperative mechanically ventilated and sedated patients who underwent volume expansion with 500mL of crystalloids over 15minutes. A response to fluid infusion was defined as a 15% increase in the left ventricular outflow tract velocity time integral according to transthoracic echocardiography. The inferior vena cava diameters were recorded by a subcostal view using the M-mode and the PPV by automatic calculation. The receiver operating characteristic (ROC) curves were generated for the baseline dIVC and PPV.

RESULTS

Twenty patients were included. The area under the ROC curve for dIVC was 0.84 (95% confidence interval, 0.63-1.0), and the best cutoff value was 16% (sensitivity, 67%; specificity, 100%). The area under the ROC curve for PPV was 0.92 (95% confidence interval, 0.76-1.0), and the best cutoff was 12.4% (sensitivity, 89%; specificity, 100%). A noninferiority test showed that dIVC cannot replace PPV to predict fluid responsiveness (P=.28).

CONCLUSION

The individual PPV discriminative properties for predicting fluid responsiveness in postoperative patients seemed superior to those of dIVC.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Background

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

Methods

Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

Results

This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

Conclusions

Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ^®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

Intraoperative volume restriction in esophageal cancer surgery: an exploratory randomized clinical trial

Aim

To investigate whether the fluid volume administered during esophageal cancer surgery affects pulmonary gas exchange and tissue perfusion.

Methods

An exploratory single-center randomized clinical trial was performed. Patients with esophageal cancer who underwent Lewis-Tanner procedure between June 2011 and August 2012 at the Department of Thoracic surgery “Jordanovac”, Zagreb were analyzed. Patients were randomized (1:1) to receive a restrictive volume of intraoperative fluid (≤8 mL/kg/h) or a liberal volume (>8 mL/kg/h). Changes in oxygen partial pressure (Pao₂), inspired oxygen fraction (FiO₂), creatinine, and lactate were measured during and after surgery.

Results

Overall 16 patients were randomized and they all were analyzed (restrictive group n = 8, liberal group n = 8). The baseline value Pao₂/FiO₂ ratio (restrictive) was 345.01 ± 35.31 and the value six hours after extubation was 315.51 ± 32.91; the baseline Pao₂/FiO₂ ratio (liberal) was 330.11 ± 34.71 and the value six hours after extubation was 307.11 ± 30.31. The baseline creatinine value (restrictive) was 91.91 ± 12.67 and the value six hours after extubation was 100.88 ± 18.33; the baseline creatinine value (liberal) was 90.88 ± 14.99 and the value six hours after extubation was 93.51 ± 16.37. The baseline lactate value (restrictive) was 3.93 ± 1.33 and the value six hours after extubation was 2.69 ± 0.91. The baseline lactate value (liberal) was 3.26 ± 1.25 and the value six hours after extubation was 2.40 ± 1.08. The two groups showed no significant differences in Pao₂/FiO₂ ratio (P = 0.410), creatinine (P = 0.410), or lactate (P = 0.574).

Conclusions

Restriction of intraoperative applied volume does not significantly affect pulmonary exchange function or tissue perfusion in patients undergoing surgical treatment for esophageal cancer.

Trial registration number: Clinical Trials NCT 02033213.

The effect of a postoperative quality improvement program on outcomes in colorectal surgery in a community hospital

PURPOSE

The aim of this study was to evaluate whether implementation of a comprehensive quality improvement program was associated with improved outcomes in patients undergoing oncological colorectal surgery in a non-academic, non-referral community hospital.

METHODS

The quality improvement program (QIP) was introduced in January 2011 and consisted of the following interventions: (1) avoidance of postoperative nonsteriodal anti-inflammatory drugs; (2) normovolemia was pursued pre- and postoperatively; (3) non-resectional surgery if possible, in patients over 80 with ASA 3 or 4 classification; and (4) a standardized, postoperative surveillance protocol was introduced, with CRP determination day 2 and 4, and if necessary subsequent abdominal CT with rectal contrast to reduce delay in diagnosis of complications. From a prospectively maintained database of 488 patients undergoing colorectal surgery between 2009 and 2014, postoperative outcomes of patients operated before and after implementation of the program were compared.

RESULTS

The severe complication rate (Clavien-Dindo >3b) decreased significantly (25.0 vs. 13.7 %; p < .001) after implementation of the QIP program. The mortality rate dropped from 8.7 to 2.6 % (p = .003). The percentage of anastomotic leakage was 9.6% before QIP implementation and 4.2% after (p = .013). Median length of hospital stay decreased from 9 (IQR 5-19) to 7 days (IQR 4-12) (p < .001). Multivariate analyses showed that surgery after implementation of the program was a strong independent predictor for less major complications (OR 0.54, 95 % CI 0.32-0.88).

CONCLUSIONS

A significant decrease in major complications and mortality was observed after introduction of a relative simple quality improvement program.

Fluid balance and mortality in critically ill patients with acute kidney injury: a multicenter prospective epidemiological study

Introduction

Early and aggressive volume resuscitation is fundamental in the treatment of hemodynamic instability in critically ill patients and improves patient survival. However, one important consequence of fluid administration is the risk of developing fluid overload (FO), which is associated with increased mortality in patients with acute kidney injury (AKI). We evaluated the impact of fluid balance on mortality in intensive care unit (ICU) patients with AKI.

Methods

The data were extracted from the Beijing Acute Kidney Injury Trial. This trial was a prospective, observational, multicenter study conducted in 30 ICUs among 28 tertiary hospitals in Beijing, China, from 1 March to 31 August 2012. In total, 3107 patients were admitted consecutively, and 2526 patients were included in this study. The data from the first 3 sequential days were analyzed. The AKI severity was classified according to the Kidney Disease: Improving Global Outcomes guidelines. The daily fluid balance was recorded, and the cumulative fluid balance was registered at 24, 48, and 72 h. A multivariate analysis was performed with Cox regression to determine the impact of fluid balance on mortality in patients with AKI.

Results

Among the 2526 patients included, 1172 developed AKI during the first 3 days. The mortality was 25.7 % in the AKI group and 10.1 % in the non-AKI group (P < 0.001). The daily fluid balance was higher, and the cumulative fluid balance was significantly greater, in the AKI group than in the non-AKI group. FO was an independent risk factor for the incidence of AKI (odds ratio 4.508, 95 % confidence interval 2.900 to 7.008, P < 0.001) and increased the severity of AKI. Non-surviving patients with AKI had higher cumulative fluid balance during the first 3 days (2.77 [0.86–5.01] L versus 0.93 [−0.80 to 2.93] L, P < 0.001) than survivors did. Multivariate analysis revealed that the cumulative fluid balance during the first 3 days was an independent risk factor for 28-day mortality.

Conclusions

In this multicenter ICU study, the fluid balance was greater in patients with AKI than in patients without AKI. FO was an independent risk factor for the incidence of AKI and increased the severity of AKI. A higher cumulative fluid balance was an important factor associated with 28-day mortality following AKI.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1085-4) contains supplementary material, which is available to authorized users.

Closing the audit cycle: improving short-term outcomes of oesophagectomy in a provincial hospital

A previously published study regarding the outcomes of oesophagectomy at a provincial hospital identified issues with perioperative care (Al-Herz et al 2012). The aim of this study was to evaluate the effect of changes in management at the institution concerned. This was a cohort study which compared the outcomes of 30 patients undergoing oesophagectomy before the unit audit and 30 patients after it. Demographics, operative details, recovery parameters, and oncological data were collected retrospectively. There was a significant reduction in the use of intravenous fluid, both intraoperatively (6.6 vs 3.3L, P < 0.0001) and during the first 24 hours (9.2 vs 5.5L, P < 0.0001). Patients were extubated three days earlier (P < 0.001) after the audit, and the percentage of patients requiring tracheostomy was smaller (26.7% vs 0%, P = 0.003). The length of total hospital stay was shorter (15 vs 13 days, P = 0.035). We conclude that the publication of a unit audit changed perioperative practice and resulted in a significant improvement in the short term outcomes after oesophagectomy.

Dynamic muscle O2 saturation response is impaired during major non-cardiac surgery despite goal-directed haemodynamic therapy

BACKGROUND

Near-infrared spectroscopy combined with a vascular occlusion test (VOT) could indicate an impairment of microvascular reactivity (MVR) in septic patients by detecting changes in dynamic variables of muscle O2 saturation (StO2). However, in the perioperative context the consequences of surgical trauma on dynamic variables of muscle StO2 as indicators of MVR are still unknown.

METHODS

This study is a sub-analysis of a randomised controlled trial in patients with metastatic primary ovarian cancer undergoing debulking surgery, during which a goal-directed haemodynamic algorithm was applied using oesophageal Doppler. During a 3 min VOT, near-infrared spectroscopy was used to assess dynamic variables arising from changes in muscle StO2.

RESULTS

At the beginning of surgery, values of desaturation and recovery slope were comparable to values obtained in healthy volunteers. During the course of surgery, both desaturation and recovery slope showed a gradual decrease. Concomitantly, the study population underwent a transition to a surgically induced systemic inflammatory response state shown by a gradual increase in norepinephrine administration, heart rate, and Interleukin-6, with a peak immediately after the end of surgery. Higher rates of norepinephrine and a higher heart rate were related to a faster decline in StO2 during vascular occlusion.

CONCLUSIONS

Using near-infrared spectroscopy combined with a VOT during surgery showed a gradual deterioration of MVR in patients treated with optimal haemodynamic care. The deterioration of MVR was accompanied by the transition to a surgically induced systemic inflammatory response state.

Postoperative fluid management

Postoperative care units are run by an anesthesiologist or a surgeon, or a team formed of both. Management of postoperative fluid therapy should be done considering both patients’ status and intraoperative events. Types of the fluids, amount of the fluid given and timing of the administration are the main topics that determine the fluid management strategy. The main goal of fluid resuscitation is to provide adequate tissue perfusion without harming the patient. The endothelial glycocalyx dysfunction and fluid shift to extracellular compartment should be considered wisely. Fluid management must be done based on patient’s body fluid status. Patients who are responsive to fluids can benefit from fluid resuscitation, whereas patients who are not fluid responsive are more likely to suffer complications of over-hydration. Therefore, common use of central venous pressure measurement, which is proved to be inefficient to predict fluid responsiveness, should be avoided. Goal directed strategy is the most rational approach to assess the patient and maintain optimum fluid balance. However, accessible and applicable monitoring tools for determining patient’s actual fluid need should be further studied and universalized. The debate around colloids and crystalloids should also be considered with goal directed therapies. Advantages and disadvantages of each solution must be evaluated with the patient’s specific condition.

Fluid Overload

Most critically ill patients experience external or internal fluid shifts and hemodynamic instability. In response to these changes, intravenous fluids are frequently administered. However, rapid losses of administered fluids from circulation and the indirect link between the short-lived plasma volume expansion and end points frequently result in transient responses to fluid therapy. Therefore, fluid overload is a common finding in intensive care units. The authors consider the evidence of harm associated with fluid overload and the physiologic processes that lead to fluid accumulation in critical illness. The authors then consider methods to prevent fluid accumulation and/or manage its resolution.

Defining goals of resuscitation in the critically ill patient

There is still no "universal" consensus on an optimal endpoint for goal directed therapy (GDT) in the critically ill patient. As in other areas of medicine, this should help providers to focus on a more "individualized approach" rather than a protocolized approach to ensure proper patient care. Hemodynamic optimization needs more than simply blood pressure, heart rate, central venous pressure and urine output monitoring. It is essential to also monitor flow variables (cardiac output/stroke volume) and dynamic parameters of fluid responsiveness whenever available. This article will provide a review of current and trending approaches of the goals of resuscitation in the critically ill patient.