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Bennett VA, Cecconi M. Perioperative fluid management: From physiology to improving clinical outcomes. Indian J Anaesth 2017; 61:614-621. [PMID: 28890555 PMCID: PMC5579850 DOI: 10.4103/ija.ija_456_17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Perioperative fluid management is a key component in the care of the surgical patient. It is an area that has seen significant changes and developments, however there remains a wide disparity in practice between clinicians. Historically, patients received large volumes of intravenous fluids perioperatively. The concept of goal directed therapy was then introduced, with the early studies showing significant improvements in morbidity and mortality. The current focus is on fluid therapy guided by an individual patient's physiology. A fluid challenge is commonly performed as part of an assessment of a patient's fluid responsiveness. There remains wide variation in how clinicians perform a fluid challenge and this review explores the evidence for how to administer an effective challenge that is both reliable and reproducible. The methods for monitoring cardiac output have evolved from the pulmonary artery catheter to a range of less invasive techniques. The different options that are available for perioperative use are considered. Fluid status can also be assessed by examining the microcirculation and the importance of recognising the possibility of a lack of coherence between the macro and microcirculation is discussed. Fluid therapy needs to be targeted to specific end points and individualised. Not all patients who respond to a fluid challenge will necessarily require additional fluid administration and care should be aimed at identifying those who do. This review aims to explain the underlying physiology and describe the evidence base and the changes that have been seen in the approach to perioperative fluid therapy.
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Affiliation(s)
- Victoria A Bennett
- Department of Intensive Care Medicine, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, United Kingdom
| | - Maurizio Cecconi
- Department of Intensive Care Medicine, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, United Kingdom
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Krömker M, Lauscher P, Kertscho H, Zacharowski K, Rosenberger P, Meier J. Anemia tolerance during normo-, hypo-, and hypervolemia. Transfusion 2016; 57:613-621. [PMID: 27990642 DOI: 10.1111/trf.13942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Restrictive intraoperative fluid management has been demonstrated to improve outcome of visceral and lung surgery in several studies. However, subsequent hypovolemia (HOV) may be accompanied by a decrease of anemia tolerance, resulting in increased transfusion needs. We therefore investigated the effect of volume status on anemia tolerance. STUDY DESIGN AND METHODS Eighteen domestic pigs of either sex (mean weight, 23.5 ± 4.8 kg) were anesthetized, ventilated, and randomized into three experimental groups: normovolemia (no intervention), HOV (blood loss of 40% of blood volume), and hypervolemia (HEV; volume infusion of 40% of blood volume). The animals were then hemodiluted until their individual critical hemoglobin concentrations (Hbcrit ) were reached by the exchange of whole blood for hydroxyethyl starch (HES; 130:0.4). Subsequently, organ-specific hypoxia was assessed using pimonidazole tissue staining in relevant organs. Hemodynamic and metabolic variables were also investigated. RESULTS Despite significant differences in exchangeable blood volume, Hbcrit was the same in all groups (2.3 g/dL, NS). During HOV, tissue hypoxia was aggravated in the myocardium, brain, and kidneys, whereas tissue oxygenation of the liver and intestine was not influenced by volume status. HEV increased tissue hypoxia in the lungs, but did not impact tissue oxygenation of other organs. CONCLUSIONS The combination of hemorrhagic HOV with subsequent anemia leads to accentuated tissue hypoxia, revealed by a significant increase in pimonidazole binding at Hbcrit , in heart, lungs, brain, and kidney. The lungs were the only organ that showed increased tissue hypoxia after pretreatment of HES infusion and subsequent anemia by normovolemic hemodilution.
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Affiliation(s)
- Malte Krömker
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Sana Klinikum Offenbach, Offenbach, Germany
| | - Patrick Lauscher
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Sana Klinikum Offenbach, Offenbach, Germany
| | - Harry Kertscho
- Department of Anesthesiology and Critical Care Medicine, University Hospital Mannheim, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Peter Rosenberger
- Clinic for Anesthesiology and Intensive Care Medicine, Eberhard Karls University, Tübingen, Germany
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine of the Kepler University, Linz, Austria
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Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, Gomes SM, Gans S, Wallert ED, Wu X, Abbas M, Boermeester MA, Dellinger EP, Egger M, Gastmeier P, Guirao X, Ren J, Pittet D, Solomkin JS. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. THE LANCET. INFECTIOUS DISEASES 2016; 16:e288-e303. [PMID: 27816414 DOI: 10.1016/s1473-3099(16)30402-9] [Citation(s) in RCA: 476] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/28/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
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Affiliation(s)
- Benedetta Allegranzi
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland.
| | - Bassim Zayed
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Peter Bischoff
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | - N Zeynep Kubilay
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Stijn de Jonge
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Fleur de Vries
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Sarah Gans
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Elon D Wallert
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Xiuwen Wu
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Mohamed Abbas
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | | | - Jianan Ren
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; WHO Collaborating Centre on Patient Safety (Infection Control and Improving Practices), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Joseph S Solomkin
- OASIS Global, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
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van Rooijen SJ, Huisman D, Stuijvenberg M, Stens J, Roumen RMH, Daams F, Slooter GD. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36:183-200. [PMID: 27756644 DOI: 10.1016/j.ijsu.2016.09.098] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation. METHODS Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies). RESULTS The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL. CONCLUSION Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.
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Affiliation(s)
- S J van Rooijen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands.
| | - D Huisman
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - M Stuijvenberg
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - J Stens
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - R M H Roumen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - F Daams
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - G D Slooter
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
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Liberal versus restrictive fluid management in abdominal surgery: a meta-analysis. Surg Today 2016; 47:344-356. [DOI: 10.1007/s00595-016-1393-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/14/2016] [Indexed: 01/26/2023]
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Schol PBB, Terink IM, Lancé MD, Scheepers HCJ. Liberal or restrictive fluid management during elective surgery: a systematic review and meta-analysis. J Clin Anesth 2016; 35:26-39. [PMID: 27871539 DOI: 10.1016/j.jclinane.2016.07.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 06/20/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
Abstract
This article reviews if a restrictive fluid management policy reduces the complication rate if compared to liberal fluid management policy during elective surgery. The PubMed database was explored by 2 independent researchers. We used the following search terms: "Blood transfusion (MESH); transfusion need; fluid therapy (MESH); permissive hypotension; fluid management; resuscitation; restrictive fluid management; liberal fluid management; elective surgery; damage control resuscitation; surgical procedures, operative (MESH); wounds (MESH); injuries (MESH); surgery; trauma patients." A secondary search in the Medline, EMBASE, Web of Science, and Cochrane library revealed no additional results. We selected randomized controlled trials performed during elective surgeries. Patients were randomly assigned to a restrictive fluid management policy or to a liberal fluid management policy during elective surgery. The patient characteristics and the type of surgery varied. All but 3 studies reported American Society of Anaesthesiologists groups 1 to 3 as the inclusion criterion. The primary outcome of interest is total number of patients with a complication and the complication rate. Secondary outcome measures are infection rate, transfusion need, postoperative rebleeding, hospital stay, and renal function. In total, 1397 patients were analyzed (693 restrictive protocol, 704 liberal protocol). Meta-analysis showed that in the restrictive group as compared with the liberal group, fewer patients experienced a complication (relative risk [RR], 0.65; 95% confidence interval [CI], 0.55-0.78). The total complication rate (RR, 0.57; 95% CI, 0.52-0.64), risk of infection (RR, 0.62; 95% CI, 0.48-0.79), and transfusion rate (RR, 0.81; 95% CI, 0.66-0.99) were also lower. The postoperative rebleeding did not differ in both groups: RR, 0.76 (95% CI, 0.28-2.06). We conclude that compared with a liberal fluid policy, a restrictive fluid policy in elective surgery results in a 35% reduction in patients with a complication and should be advised as the preferred fluid management policy.
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Affiliation(s)
- Pim B B Schol
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, PO 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Ivon M Terink
- Maastricht University, PO 616, 6200 MD Maastricht, The Netherlands.
| | - Marcus D Lancé
- Department of Anaesthesia and Pain Treatment, Maastricht University Medical Centre, PO 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, PO 5800, 6202 AZ, Maastricht, The Netherlands.
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Enomoto LM, Blackham A, Woo Y, Yamamoto M, Pimiento J, Gusani NJ, Wong J. Ratio of intra-operative fluid to anesthesia time and its impact on short term perioperative outcomes following gastrectomy for cancer: A retrospective cohort study. Int J Surg 2016; 33 Pt A:13-7. [PMID: 27394407 DOI: 10.1016/j.ijsu.2016.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 06/17/2016] [Accepted: 07/05/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study evaluates the short-term impact of fluid administration during gastrectomy for cancer. METHODS A multi-institutional database of patients undergoing gastrectomy for cancer from three tertiary centers was reviewed. Logistic and linear regression analyses were performed. RESULTS 205 patients were included. The majority of patients (n = 116, 57%) underwent proximal or total gastrectomy. Median anesthesia time was 280 min (range 95-691 min). Median intraoperative crystalloid administration was 2901 ml (range 500-10,700 ml). Median colloid administration was 0 (range 0-3835 ml), although only 66 patients (32%) received colloid. On multivariate analysis, patients who received <10.0 ml total fluid per minute of anesthesia had a significantly higher risk of complications (OR 4.12, p = 0.010). Crystalloid and total fluid administration ratios did not significantly affect LOS or discharge disposition. CONCLUSIONS Restricting intra-operative fluid resuscitation to <10 ml total fluid per minute anesthesia is associated with an increased risk of complications in patients undergoing gastrectomy for cancer.
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Affiliation(s)
- Laura M Enomoto
- The Pennsylvania State University, College of Medicine, Department of Surgery, 500 University Drive, MC-H159, Hershey, PA 17033-0850, USA.
| | - Aaron Blackham
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
| | - Yanghee Woo
- Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA.
| | - Maki Yamamoto
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
| | - Jose Pimiento
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
| | - Niraj J Gusani
- Program for Liver, Pancreas, & Foregut Tumors, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA 17033, USA.
| | - Joyce Wong
- Program for Liver, Pancreas, & Foregut Tumors, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA 17033, USA.
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Targeting oliguria reversal in perioperative restrictive fluid management does not influence the occurrence of renal dysfunction. Eur J Anaesthesiol 2016; 33:425-35. [DOI: 10.1097/eja.0000000000000416] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Patel K, Hadian F, Ali A, Broadley G, Evans K, Horder C, Johnstone M, Langlands F, Matthews J, Narayan P, Rallon P, Roberts C, Shah S, Vohra R. Postoperative pulmonary complications following major elective abdominal surgery: a cohort study. Perioper Med (Lond) 2016; 5:10. [PMID: 27222707 PMCID: PMC4877761 DOI: 10.1186/s13741-016-0037-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/09/2016] [Indexed: 12/27/2022] Open
Abstract
Background Postoperative pulmonary complications (PPC) are an under-reported but major cause of perioperative morbidity and mortality. The aim of this prospective, contemporary, multicentre cohort study of unselected patients undergoing major elective abdominal surgery was to determine the incidence and effects of PPC. Methods Data on all major elective abdominal operations performed over a 2-week period in December 2014 were collected in six hospitals. The primary outcome measure of PPC at 7 days was used. Univariate and multivariate analyses were performed to investigate how different factors were associated with PPC and the effects of such complications. Results Two hundred sixty-eight major elective abdominal operations were performed, and the internal validation showed that the data set was 99 % accurate. Thirty-two (11.9 %) PPC were reported at 7 days. PPC was more common in patients with a history of chronic obstructive pulmonary disease compared to those with no history (26.7 vs. 10.2 %, p < 0.001). PPC was not associated with other patient factors (e.g. age, gender, body mass index or other comorbidities), type/method of operation or postoperative analgesia. The risk of PPC appeared to increase with every additional minute of operating time independent of other factors (odds ratio 1.01 (95 % confidence intervals 1.00–1.02), p = 0.007). PPC significantly increase the length of hospital stay (10 vs. 3 days). Attendance to the emergency department within 30 days (27.3 vs. 10.6 %), 30-day readmission (21.7 vs. 9.9 %) and 30-day mortality (12.5 vs. 0.0 %) was higher in those with PPC. Conclusions PPC are common and have profound effects on outcomes. Strategies need to be considered to reduce PPC. Electronic supplementary material The online version of this article (doi:10.1186/s13741-016-0037-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kamlesh Patel
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Fatemeh Hadian
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Aysha Ali
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Graham Broadley
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Kate Evans
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Claire Horder
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Marianne Johnstone
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Fiona Langlands
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Jake Matthews
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Prithish Narayan
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Priya Rallon
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Charlotte Roberts
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Sonali Shah
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK
| | - Ravinder Vohra
- West Midlands Research Collaborative, Academic Department of Surgery, School of Cancer Sciences, University of Birmingham, Birmingham, B15 2TH UK ; Nottingham Oesophago-Gastric Unit, Nottingham University Hospitals, Nottingham, UK
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Lam T, Singh M, Yadollahi A, Chung F. Is Perioperative Fluid and Salt Balance a Contributing Factor in Postoperative Worsening of Obstructive Sleep Apnea? Anesth Analg 2016; 122:1335-9. [DOI: 10.1213/ane.0000000000001169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Fluid Management, Volume Overload, and Gastrointestinal Tolerance in the Perioperative Period. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0135-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 375] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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Karaman Ilić M, Madžarac G, Kogler J, Stančić-Rokotov D, Hodoba N. Intraoperative volume restriction in esophageal cancer surgery: an exploratory randomized clinical trial. Croat Med J 2016; 56:290-6. [PMID: 26088854 PMCID: PMC4500974 DOI: 10.3325/cmj.2015.56.290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Maja Karaman Ilić
- Maja Karaman Ilić, University Hospital Centre Zagreb, Department of Anesthesiology, Jordanovac 104, 10000 Zagreb, Croatia,
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Malfroy S, Wallet F, Maucort-Boulch D, Chardonnal L, Sens N, Friggeri A, Passot G, Glehen O, Piriou V. Complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis: Risk factors for ICU admission and morbidity prognostic score. Surg Oncol 2015; 25:6-15. [PMID: 26979635 DOI: 10.1016/j.suronc.2015.11.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 11/03/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES For patients suffering from peritoneal carcinomatosis, cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is the only curative option. We focused on severe complications in the postoperative course of HIPEC. METHODS We studied perioperative data from patients who underwent HIPEC between January 2010 and August 2011. Our primary objective was to identify perioperative risk factors for ICU admission. Our secondary objective was to identify patient that may be re-admitted to the ICU thanks to a prognostic score. RESULTS 122 patients underwent HIPEC. 32 presented severe adverse events (26.2%) and 7 died (5.7%). Reasons for ICU admission were septic shock in 28.1% of patients, hemorrhagic shock for 21.9%, hemodynamic instability for 15.6%, respiratory causes for 6.2% and post-operative acidosis for 6.2%. Vasopressors were required for 34% and 40.6% were mechanically ventilated. CONCLUSION Peritoneal cancer index, diaphragmatic peritonectomy, the need of vasopressive therapy, total volume of fluid leakage collected in drains and total volume of fluid therapy administered at day 1 reported on ideal body weight were the 5 significant variables that we combined to build a morbidity prognostic score. One patient over 4 is likely to present severe complications. A predictive morbidity score provide informative data for clinicians.
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Affiliation(s)
- Sylvain Malfroy
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France.
| | - Florent Wallet
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Delphine Maucort-Boulch
- Biostatistic Unit, Hospices Civils de Lyon, F-69003, Lyon, France; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, F-69100, Villeurbanne, France
| | - Laurent Chardonnal
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Nicolas Sens
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Arnaud Friggeri
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
| | - Guillaume Passot
- Department of Surgical Oncology, CHU Lyon Sud, Lyon 1 University, EMR 3738, Pierre Benite, France
| | - Olivier Glehen
- Department of Surgical Oncology, CHU Lyon Sud, Lyon 1 University, EMR 3738, Pierre Benite, France
| | - Vincent Piriou
- Anesthesiology and Critical Care Department, CHU Lyon Sud, Université Lyon 1, Pierre Benite, France
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Effect of Coffee on the Length of Postoperative Ileus After Elective Laparoscopic Left-Sided Colectomy: A Randomized, Prospective Single-Center Study. Dis Colon Rectum 2015; 58:1064-9. [PMID: 26445179 DOI: 10.1097/dcr.0000000000000449] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative ileus is common problem after colorectal surgery. A positive effect of coffee to bowel movement has been described. It is still unclear whether coffee decreases the risk of postoperative ileus. OBJECTIVE The purpose of this study was to determine whether consuming a 100-mL cup of coffee is effective in preventing or reducing postoperative ileus. DESIGN This was a prospective, single-center, randomized controlled study. SETTINGS The study was conducted at a university teaching hospital. PATIENTS All of the patients who were scheduled for elective laparoscopic left-sided colectomy at our hospital after the detection of malignant disease in a preoperative biopsy between January 2013 and December 2014 entered the study. The patients were assigned randomly before surgery to receive coffee with caffeine (first group), coffee without caffeine (second group), or water (third group) after the procedure (100 mL 3 times daily). MAIN OUTCOME MEASURES The primary end point was time to first bowel movement; secondary end points were time to first flatus and time to tolerance of solid food. RESULTS A total of 105 patients were randomly assigned, 35 to each group. Fifteen patients were excluded. Patient demographic characteristics were similar in the groups. The time until the first bowel movement (measured in days) was significantly (p < 0.05) shorter in the decaffeinated coffee group (3.00 ± 1.50) versus the coffee with caffeine (3.75 ± 1.53) and water groups (4.14 ± 1.14). The time until tolerance of solid food was significantly shorter in decaffeinated group versus coffee with caffeine and water groups (1.85 versus 2.60 and 2.80; p < 0.05). Time until the first flatus (1.47 versus 1.57 and 1.77 for decaffeinated coffee versus coffee with caffeine and water; p > 0.05) did not show statistical significance. Postoperative hospital stay was similar in all 3 of the groups. LIMITATIONS This is a single-center study with a relatively small sample size. CONCLUSIONS Coffee consumption after colectomy was safe and in the decaffeinated group associated with a reduced time to first bowel action. Caffeine is not a main ingredient affecting the length of postoperative ileus.
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Feldheiser A, Pavlova V, Weimann K, Hunsicker O, Stockmann M, Koch M, Giebels A, Wernecke KD, Spies CD. Haemodynamic Optimization by Oesophageal Doppler and Pulse Power Wave Analysis in Liver Surgery: A Randomised Controlled Trial. PLoS One 2015; 10:e0132715. [PMID: 26186702 PMCID: PMC4505861 DOI: 10.1371/journal.pone.0132715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 06/04/2015] [Indexed: 11/18/2022] Open
Abstract
Liver surgery is still associated with a high rate of morbidity and mortality. We aimed to compare different haemodynamic treatments in liver surgery. In a prospective, blinded, randomised, controlled pilot trial patients undergoing liver resection were randomised to receive haemodynamic management guided by conventional haemodynamic parameters or by oesophageal Doppler monitor (ODM, CardioQ-ODM) or by pulse power wave analysis (PPA, LiDCOrapid) within a goal-directed algorithm adapted for liver surgery. The primary endpoint was stroke volume index before intra-operative start of liver resection. Secondary endpoints were the haemodynamic course during surgery and postoperative pain levels. Due to an unbalance in the extension of the surgical procedures with a high rate of only minor procedures the conventional group was dropped from the analysis. Eleven patients in the ODM group and 10 patients in the PPA group were eligible for statistical analysis. Stroke volume index before start of liver resection was 49 (37; 53) ml/m2 and 48 (41; 56) ml/m2 in the ODM and PPA group, respectively (p=0.397). The ODM guided group was haemodynamically stable as shown by ODM and PPA measurements. However, the PPA guided group showed a significant increase of pulse-pressure-variability (p=0.002) that was not accompanied by a decline of stroke volume index displayed by the PPA (p=0.556) but indicated by a decline of stroke volume index by the ODM (p<0.001). The PPA group had significantly higher postoperative pain levels than the ODM group (p=0.036). In conclusion, goal-directed optimization by ODM and PPA showed differences in intraoperative cardiovascular parameters indicating that haemodynamic optimization is not consistent between the two monitors.
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Affiliation(s)
- Aarne Feldheiser
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - University Medicine Berlin, Berlin, Germany
| | - Velizara Pavlova
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - University Medicine Berlin, Berlin, Germany
| | - Karin Weimann
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - University Medicine Berlin, Berlin, Germany
| | - Oliver Hunsicker
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - University Medicine Berlin, Berlin, Germany
| | - Martin Stockmann
- Department of General-, Visceral- and Transplantation Surgery, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Mandy Koch
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - University Medicine Berlin, Berlin, Germany
| | - Alexander Giebels
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - University Medicine Berlin, Berlin, Germany
| | | | - Claudia D. Spies
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - University Medicine Berlin, Berlin, Germany
- * E-mail:
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67
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[Rational fluid and volume replacement therapy: wishful dream or realistic future option]. Anaesthesist 2015; 63:727-9. [PMID: 25300661 DOI: 10.1007/s00101-014-2378-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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68
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Time to readiness for discharge is a valid and reliable measure of short-term recovery after colorectal surgery. World J Surg 2015; 37:2927-34. [PMID: 24101012 DOI: 10.1007/s00268-013-2208-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Short-term recovery after colorectal surgery has been traditionally investigated through length of stay (LOS). However, this measure is influenced by several confounding factors. This study aimed to investigate the construct validity and reliability of assessing the time to achieve standardized discharge criteria (time to readiness for discharge, or TRD) as a measure of short-term recovery. In a secondary analysis, we compared sample size requirements for randomized controlled trials (RCTs) using TRD or LOS as outcome measures. METHODS Seventy patients participated in the construct validity study and 21 patients participated in the reliability study. TRD was defined as the number of days to achieve discharge criteria previously defined by consensus. Construct validity was investigated by testing six hypothesis based on the assumption that TRD measures short-term recovery. Reliability was calculated by comparing measures of TRD by two independent assessors. Variability estimates (standard deviations) of LOS and TRD were used for sample size calculations. RESULTS Five of the six hypotheses were supported by the data (p < 0.05). Interobserver reliability was excellent (ICC2.1 = 0.99). Sample size estimations showed that RCTs using TRD as an outcome measure require approximately 23 % less participants compared to RCTs using LOS. CONCLUSIONS The results of this research support the construct-validity and reliability of TRD as a measure of short-term recovery. Using TRD as an alternative to LOS may reduce sample size requirements in future RCTs.
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69
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Drautz J, Anschütz M, Kafka-Ritsch R. Amount and influence of perioperative fluid administration on outcome in routine elective colorectal surgery according to an ERAS protocol. Eur Surg 2015. [DOI: 10.1007/s10353-015-0301-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Minto G, Scott MJ, Miller TE. Monitoring needs and goal-directed fluid therapy within an enhanced recovery program. Anesthesiol Clin 2015; 33:35-49. [PMID: 25701927 DOI: 10.1016/j.anclin.2014.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Patients having major abdominal surgery need perioperative fluid supplementation; however, enhanced recovery principles mitigate against many of the factors that traditionally led to relative hypovolemia in the perioperative period. An estimate of fluid requirements for abdominal surgery can be made but individualization of fluid prescription requires consideration of clinical signs and hemodynamic variables. The literature supports goal-directed fluid therapy. Application of this evidence to justify stroke volume optimization in the setting of major surgery within an enhanced recovery program is controversial. This article places the evidence in context, reviews controversies, and suggests implications for current practice and future research.
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Affiliation(s)
- Gary Minto
- Department of Anaesthesia & Perioperative Medicine, Plymouth Hospitals NHS Trust, Plymouth University Peninsula School of Medicine, Plymouth PL6 8DH, UK.
| | - Michael J Scott
- Department of Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital, University of Surrey, Guildford GU1 7XX, UK
| | - Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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71
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McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 2015; 102:462-79. [PMID: 25703524 DOI: 10.1002/bjs.9697] [Citation(s) in RCA: 516] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/09/2014] [Accepted: 10/08/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1-19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs. METHODS A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment. RESULTS Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3-5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented. CONCLUSION Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.
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Affiliation(s)
- F D McDermott
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
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The HYSLAR trial: a prospective randomized controlled trial of the use of a restrictive fluid regimen with 3% hypertonic saline versus lactated Ringers in patients undergoing pancreaticoduodenectomy. Ann Surg 2015; 260:445-53; discussion 453-5. [PMID: 25115420 DOI: 10.1097/sla.0000000000000872] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study was designed to determine whether the volume and type of fluid administered for pancreaticoduodenectomy impacts postoperative outcomes. BACKGROUND Three percent hypertonic saline (HYS) has been suggested as a means of reducing the volume of fluid required to sustain tissue perfusion in the perioperative period. METHODS Between May 2011 and November 2013, patients undergoing pancreaticoduodenectomy were enrolled in an institutional review board-approved, single-center, prospective, parallel, randomized controlled trial (NCT 01428050), comparing lactated Ringers (LAR) (15 mL/kg/hr LAR intraoperation, 2 mL/kg/hr LAR postoperation) with HYS (9 mL/kg/hr LAR and 1 mL/kg/hr HYS intraoperation, 1 mL/kg/hr HYS postoperation). RESULTS A total of 264 patients were randomized. Demographic variables between groups were similar. The HYS patients had a significantly reduced net fluid balance (65 vs 91 mL/kg, P = 0.02). The overall complication rate was reduced in the HYS group (43% vs 54%), with a relative risk of 0.79 [95% confidence interval (CI), 0.62-1.02; P = 0.073], factoring stratification for pancreas texture. After adjustment for age and weight, the relative risk was 0.75 [95% CI (0.58-0.96); P = 0.023]. The total number of complications was significantly reduced in the HYS group (93 vs 123), with an incidence rate ratio of 0.74 [95% CI (0.56-0.97); P = 0.027]. After adjustment for age and weight, the incidence rate ratio was 0.69 [95% CI (0.52-0.90); P = 0.0068]. Reoperations, length of stay, readmissions, and 90-day mortality were similar between groups. CONCLUSIONS A moderately restrictive fluid regimen with HYS resulted in a statistically significant 25% reduction in complications when adjusted for age, weight, and pancreatic texture.
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Eng OS, Melstrom LG, Carpizo DR. The relationship of perioperative fluid administration to outcomes in colorectal and pancreatic surgery: a review of the literature. J Surg Oncol 2015; 111:472-7. [PMID: 25643938 DOI: 10.1002/jso.23857] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/08/2014] [Indexed: 12/11/2022]
Abstract
Optimal perioperative fluid administration in major gastrointestinal surgery remains a challenging clinical problem. Traditional dogma of a liberal approach to fluid administration in order to counteract potential hypovolemia and decreased end-organ perfusion can often result in fluid overload, perhaps negatively impacting perioperative outcomes. This hypothesis has been investigated in several types of gastrointestinal surgery. We discuss the current literature on perioperative fluid administration in colorectal and pancreatic surgery and highlight the controversies that still exist.
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Affiliation(s)
- Oliver S Eng
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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74
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Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 2015; 38:1531-41. [PMID: 24368573 DOI: 10.1007/s00268-013-2416-8] [Citation(s) in RCA: 584] [Impact Index Per Article: 64.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Meta-analyses in the literature show that enhanced recovery after surgery (ERAS) is associated with lower morbidity rate and shorter hospital stay after elective colorectal surgery. However, a recent Cochrane review did not indicate the ERAS pathway as being the new standard of care due to the limited number of published trials, together with their poor quality. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the impact of the ERAS pathway on overall morbidity, single postoperative complications, length of hospital stay, and readmission rate following colorectal surgery. METHODS We searched BioMedCentral, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) for RCTs comparing the ERAS pathway to conventional perioperative care. No language restrictions were considered. A quality score was calculated for each trial included. RESULTS A total of 2,376 patients in 16 RCTs were included in the analysis. The ERAS pathway was associated with a reduction of overall morbidity [relative ratio (RR) = 0.60, (95 % CI 0.46-0.76)], particularly with respect to nonsurgical complications [RR = 0.40, (95 % CI 0.27-0.61)]. The reduction of surgical complications was not significant [RR = 0.76, (95 % CI 0.54-1.08)]. The ERAS pathway shortened hospital stay (WMD = -2.28 days [95 % CI -3.09 to -1.47]), without increasing readmission rate. CONCLUSIONS The ERAS pathway reduced overall morbidity rates and shortened the length of hospital stay, without increasing readmission rates. A significant reduction in nonsurgical complications was evident, while no significant reduction was found for surgical complications.
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Affiliation(s)
- Massimiliano Greco
- Department of Anesthesiology, San Raffaele Hospital, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy,
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Fluid management in the cardiothoracic intensive care unit: diuresis--diuretics and hemofiltration. Curr Opin Anaesthesiol 2014; 27:133-9. [PMID: 24514030 DOI: 10.1097/aco.0000000000000055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The present review discusses the current concepts of fluid management in cardiothoracic surgery, and its clinical implications with special reference to organ-related complications and their prevention. RECENT FINDINGS Current strategies in fluid management for cardiothoracic patients, various fluid formulation, and the preventive strategies for minimizing fluid-related complications are described, with particular reference to new discoveries and controversies that have arisen from recent literature. SUMMARY The optimal fluid management in cardiothoracic patients has not been settled. Results of recent clinical published trials highlight the need for minimizing fluid administration and attempting to use diuretics to achieve a negative fluid, although hypovolemia and hypoperfusion should be carefully considered. An individualized optimization of fluid status, using goal-directed therapy, has emerged as a possible preferable approach. The old debate between crystalloid and colloid solutions has been partially solved, as some colloids have demonstrated deleterious effect on renal function and coagulation system. Various preventive strategies have also emerged for minimizing fluid-related complications.
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76
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Phan TD, An V, D'Souza B, Rattray MJ, Johnston MJ, Cowie BS. A Randomised Controlled Trial of Fluid Restriction Compared to Oesophageal Doppler-Guided Goal-Directed Fluid Therapy in Elective Major Colorectal Surgery within an Enhanced Recovery after Surgery Program. Anaesth Intensive Care 2014; 42:752-60. [DOI: 10.1177/0310057x1404200611] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
There is continued controversy regarding the benefits of goal-directed fluid therapy, with earlier studies showing marked improvement in morbidity and length-of-stay that have not been replicated more recently. The aim of this study was to compare patient outcomes in elective colorectal surgery patients having goal-directed versus restrictive fluid therapy. Inclusion criteria included suitability for an Enhanced Recovery After Surgery care pathway and patients with an American Society of Anesthesiologists Physical Status score of 1 to 3. Patients were intraoperatively randomised to either restrictive or Doppler-guided goal-directed fluid therapy. The primary outcome was length-of-stay; secondary outcomes included complication rate, change in haemodynamic variables and fluid volumes. One hundred patients, 50 in each group, were included in the analysis. Compared to restrictive therapy, goal-directed therapy resulted in a greater volume of intraoperative fluid, 2115 (interquartile range 1350 to 2560) ml versus 1500 (1200 to 2000) ml, P=0.008, and was associated with an increase in Doppler-derived stroke volume index from beginning to end of surgery, 43.7 (16.3) to 54.2 (21.1) ml/m2, P <0.001, in the latter group. Length-of-stay was similar, P=0.421. The number of patients with any complication (minor or major) was similar; 60% (30) versus 52% (26), P=0.42, or major complications, 1 (2%) versus 4 (8%), P=0.36, respectively. The increased perioperative fluid volumes and increased stroke volumes at the end of surgery in patients receiving goal-directed therapy did not translate to a significant difference in length-of-stay and we did not observe a difference in the number of patients experiencing minor or major complications.
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Affiliation(s)
- T. D. Phan
- Department of Anaesthesia, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria
| | - V. An
- Department of Anaesthesia, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria
- Department of Colorectal Surgery, St Vincent's Hospital, Fitzroy, Victoria
| | - B. D'Souza
- Department of Anaesthesia, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria
- Department of Colorectal Surgery, St Vincent's Hospital, Fitzroy, Victoria
| | - M. J. Rattray
- Department of Anaesthesia, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria
| | - M. J. Johnston
- Department of Anaesthesia, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria
- Department of Colorectal Surgery, St Vincent's Hospital, Melbourne, Victoria
| | - B. S. Cowie
- Department of Anaesthesia, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria
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Yates DRA, Davies SJ, Warnakulasuriya SR, Wilson RJT. Volume Management and Resuscitation in Colorectal Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0078-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Della Rocca G, Vetrugno L, Tripi G, Deana C, Barbariol F, Pompei L. Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperative approach? BMC Anesthesiol 2014; 14:62. [PMID: 25104915 PMCID: PMC4124502 DOI: 10.1186/1471-2253-14-62] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/14/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Fluid management in the perioperative period has been extensively studied but, despite that, "the right amount" still remains uncertain. The purpose of this paper is to summarize the state of the art of intraoperative fluid approach today. DISCUSSION In the current medical literature there are only heterogeneous viewpoints that gives the idea of how confusing the situation is. The approach to the intraoperative fluid management is complex and it should be based on human physiology and the current evidence. SUMMARY An intraoperative restrictive fluid approach in major surgery may be beneficial while Goal-directed Therapy should be superior to the liberal fluid strategy. Finally, we propose a rational approach currently used at our institution.
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Affiliation(s)
- Giorgio Della Rocca
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Luigi Vetrugno
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Gabriella Tripi
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Cristian Deana
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Federico Barbariol
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Livia Pompei
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
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Piegeler T, Dreessen P, Graber SM, Haile SR, Schmid DM, Beck-Schimmer B. Impact of intraoperative fluid administration on outcome in patients undergoing robotic-assisted laparoscopic prostatectomy--a retrospective analysis. BMC Anesthesiol 2014; 14:61. [PMID: 25100922 PMCID: PMC4123305 DOI: 10.1186/1471-2253-14-61] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/22/2014] [Indexed: 11/16/2022] Open
Abstract
Background Robotic-assisted laparoscopic prostatectomy (RALP) gained much popularity during the last decade. Although the influence of intraoperative fluid management on patients’ outcome has been largely discussed in general, its impact on perioperative complications and length of hospitalization in patients undergoing RALP has not been examined so far. We hypothesized that a more restrictive fluid management might lead to a shortened length of hospitalization and a decreased rate of complications in our patients. Methods Retrospective analysis of data of 182 patients undergoing RALP at an University Hospital (first series of RALP performed at the center). Results The amount of fluid administered was initially normalized for body mass index of the patient and the duration of the operation and additionally corrected for age and the interaction of these variables. The application of crystalloids (multiple linear regression model, estimate = -0.044, p = 0.734) had no effect on the length of hospitalization, whereas a negative effect was found for colloids (estimate = -8.317, p = 0.021). Additionally, a significant interaction term between age and the amount of colloid applied (estimate = 0.129, p = 0.028) was calculated. Evaluation of the influence of intraoperative fluid administration using multiple logistic regression models corrected for body mass index, duration of the surgery and additionally for age revealed a negative effect of crystalloids on the incidence of an anastomotic leak between bladder and urethra (estimate = -23.860, p = 0.017), with a significant interaction term between age and the amount of crystalloids (estimate = 0.396, p = 0.0134). Colloids had no significant effect on this particular complication (estimate = 1.887, p = 0.524). Intraoperative blood loss did not alter the incidence of an anastomotic leak (estimate = 0.001, p = 0.086), nor did it affect the length of hospitalization (estimate = 0.0001, p = 0.351). Conclusions In accordance to the findings of our study, we suggest that a standardized, more restrictive fluid management might be beneficial in patients undergoing RALP. In older patients this measure would be able to shorten the length of hospitalization and to decrease the incidence of anastomosis leakage as a major complication.
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Affiliation(s)
- Tobias Piegeler
- Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Pamela Dreessen
- Surgical Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Sereina M Graber
- Institute of Physiology and Center for Integrative Human Physiology, University of Zurich, Winterthurerstrasse 190, 8057 Zurich, Switzerland
| | - Sarah R Haile
- Institute for Social and Preventive Medicine, Division of Biostatistics, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland
| | - Daniel Max Schmid
- Department of Urology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Beatrice Beck-Schimmer
- Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland ; Institute of Physiology and Center for Integrative Human Physiology, University of Zurich, Winterthurerstrasse 190, 8057 Zurich, Switzerland
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Abstract
Perioperative fluid management of the colorectal surgical patient has evolved significantly over the last five decades. Older notions espousing aggressive hydration have been shown to be associated with increased complications. Newer data regarding fluid restriction has shown an association with improved outcomes. Management of perioperative fluid administration can be considered in three primary phases: In the preoperative phase, data suggests that avoidance of preoperative bowel preparation and avoidance of undue preoperative dehydration can improve outcomes. Although the type of intraoperative fluid given does not have a significant effect on outcome, data do suggest that a restrictive fluid regimen results in improved outcomes. Finally, in the postoperative phase of fluid management, a fluid-restrictive regimen, coupled with early enteral feeding also seems to result in improved outcomes.
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Affiliation(s)
- Joshua I S Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Cary B Aarons
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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81
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Schootman M, Lian M, Pruitt SL, Hendren S, Mutch M, Deshpande AD, Jeffe DB, Davidson NO. Hospital and geographic variability in two colorectal cancer surgery outcomes: complications and mortality after complications. Ann Surg Oncol 2014; 21:2659-66. [PMID: 24748161 DOI: 10.1245/s10434-013-3472-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The purpose of this study was to describe hospital and geographic variation in 30-day risk of surgical complications and death among colorectal cancer (CRC) patients and the extent to which patient-, hospital-, and census-tract-level characteristics increased risk of these outcomes. METHODS We included patients at least 66 years old with first primary stage I-III CRC from the 2000-2005 National Cancer Institute's Surveillance, Epidemiology, and End Results data linked with 1999-2005 Medicare claims. A multilevel, cross-classified logistic model was used to account for nesting of patients within hospitals and within residential census tracts. Outcomes were risk of complications and death after a complication within 30 days of surgery. RESULTS Data were analyzed for 35,946 patients undergoing surgery at 1,222 hospitals and residing in 12,187 census tracts; 27.2 % of patients developed complications, and of these 13.4 % died. Risk-adjusted variability in complications across hospitals and census tracts was similar. Variability in mortality was larger than variability in complications, across hospitals and across census tracts. Specific characteristics increased risk of complications (e.g., census-tract-poverty rate, emergency surgery, and being African-American). No hospital characteristics increased complication risk. Specific characteristics increased risk of death (e.g. census-tract-poverty rate, being diagnosed with colon (versus rectal) cancer, and emergency surgery), while hospitals with at least 500 beds showed reduced death risk. CONCLUSIONS Large, unexplained variations exist in mortality after surgical complications in CRC across hospitals and geographic areas. The potential exists for quality improvement efforts targeted at the hospital and/or census-tract levels to prevent complications and augment hospitals' ability to reduce mortality risk.
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Affiliation(s)
- M Schootman
- Department of Epidemiology, Saint Louis University, Saint Louis, MO, USA,
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82
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Pietri LD, Montalti R, Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol 2014; 20:2304-20. [PMID: 24605028 PMCID: PMC3942834 DOI: 10.3748/wjg.v20.i9.2304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer remains a significant and unresolved therapeutic challenge. Currently, the only curative treatment for pancreatic cancer is surgical resection. Pancreatic surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and mortality. Systemic, rather than surgical complications, cause the majority of deaths. Because patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex, anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical intervention. The anaesthetist plays a key role in perioperative management and can significantly influence patient outcome. To optimise overall care, patients should be appropriately referred to tertiary centres, where multidisciplinary teams (surgical, medical, radiation oncologists, gastroenterologists, interventional radiologists and anaesthetists) work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality rates. In this review, we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.
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83
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Arulkumaran N, Corredor C, Hamilton MA, Ball J, Grounds RM, Rhodes A, Cecconi M. Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Br J Anaesth 2014; 112:648-59. [PMID: 24413429 DOI: 10.1093/bja/aet466] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Patients with limited cardiopulmonary reserve are at risk of mortality and morbidity after major surgery. Augmentation of oxygen delivery index (DO2I) with i.v. fluids and inotropes (goal-directed therapy, GDT) has been shown to reduce postoperative mortality and morbidity in high-risk patients. Concerns regarding cardiac complications associated with fluid challenges and inotropes may prevent clinicians from performing GDT in patients who need it most. We hypothesized that GDT is not associated with an increased risk of cardiac complications in high-risk, non-cardiac surgical patients. We performed a systematic search of Medline, Embase, and CENTRAL databases for randomized controlled trials (RCTs) of GDT in high-risk surgical patients. Studies including cardiac surgery, trauma, and paediatric surgery were excluded. We reviewed the rates of all cardiac complications, arrhythmias, myocardial ischaemia, and acute pulmonary oedema. Meta-analyses were performed using RevMan software. Data are presented as odds ratios (ORs), [95% confidence intervals (CIs)], and P-values. Twenty-two RCTs including 2129 patients reported cardiac complications. GDT was associated with a reduction in total cardiovascular (CVS) complications [OR=0.54, (0.38-0.76), P=0.0005] and arrhythmias [OR=0.54, (0.35-0.85), P=0.007]. GDT was not associated with an increase in acute pulmonary oedema [OR=0.69, (0.43-1.10), P=0.12] or myocardial ischaemia [OR=0.70, (0.38-1.28), P=0.25]. Subgroup analysis revealed the benefit is most pronounced in patients receiving fluid and inotrope therapy to achieve a supranormal DO2I, with the use of minimally invasive cardiac output monitors. Treatment of high-risk surgical patients GDT is not associated with an increased risk of cardiac complications; GDT with fluids and inotropes to optimize DO2I during early GDT reduces postoperative CVS complications.
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Affiliation(s)
- N Arulkumaran
- Department of Intensive Care Medicine, St George's Hospital, London SW17 0QT, UK
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84
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Perioperative fluid restriction in major abdominal surgery: systematic review and meta-analysis of randomized, clinical trials. World J Surg 2014; 37:1193-202. [PMID: 23463399 DOI: 10.1007/s00268-013-1987-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fluid management is a fundamental component of surgical care. Recently, there has been considerable interest in perioperative fluid restriction as a method of facilitating recovery following elective major surgery. A number of randomized trials have addressed the issue in various surgical specialities, and a recent meta-analysis proposed uniform definitions regarding fluid amount as well as examining fluid restriction in patients undergoing colonic resection. METHODS Medline, Embase, trial registries, conference proceedings, and article reference lists were searched to identify randomized, controlled trials of perioperative fluid restriction versus "standard" perioperative fluid management, as per definitions formulated previously. All of the studies involved patients undergoing colonic resection. The primary outcome measure was postoperative morbidity. Secondary endpoints included mortality, renal failure, time to first flatus, and length of hospital stay. A random effects model was applied. RESULTS Seven randomized, controlled trials with a total of 856 patients investigating standard versus restrictive fluid regimes, as denoted by the definitions, were included. Perioperative fluid restriction had no effect on the risk of postoperative complications (OR 0.49 (95 % confidence interval (CI) 0.2-1.18; P = 0.101). There was no detectable effect on death and fluid restriction did not reduce hospital stay (Pooled weighted mean difference -0.25; 95 % CI 0.72-0.21; P = 0.29). CONCLUSIONS Perioperative fluid restriction does not significantly reduce the risk of complications following major abdominal surgery. Furthermore, it does not appear to reduce length of hospital stay.
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85
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Kalyan JP, Rosbergen M, Pal N, Sargen K, Fletcher SJ, Nunn DL, Clark A, Williams MR, Lewis MPN. Randomized clinical trial of fluid and salt restriction compared with a controlled liberal regimen in elective gastrointestinal surgery. Br J Surg 2014; 100:1739-46. [PMID: 24227358 PMCID: PMC4312881 DOI: 10.1002/bjs.9301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2013] [Indexed: 12/14/2022]
Abstract
Background Excessive intravenous fluid prescription may play a causal role in postoperative complications following major gastrointestinal resectional surgery. The aim of this study was to investigate whether fluid and salt restriction would decrease postoperative complications compared with a more modern controlled liberal regimen. Methods In this observer-blinded single-site randomized clinical trial consecutive patients undergoing major gastrointestinal resectional surgery were randomized to receive either a liberal control fluid regimen or a restricted fluid and salt regimen. The primary outcome was postoperative complications of grade II and above (moderate to severe). Results Some 240 patients (194 colorectal resections and 46 oesophagogastric resections) were enrolled in the study; 121 patients were randomized to the restricted regimen and 119 to the control (liberal) regimen. During surgery the control group received a median (interquartile range) fluid volume of 2033 (1576–2500) ml and sodium input of 282 (213–339) mmol, compared with 1000 (690–1500) ml and 142 (93–218) mmol respectively in the restricted group. There was no significant difference in major complication rate between groups (38·0 and 39·0 per cent respectively). Median (range) hospital stay was 8 (3–101) days in the controls and 8 (range 3–76) days among those who received restricted fluids. There were four in-hospital deaths in the control group and two in the restricted group. Substantial differences in weight change, serum sodium, osmolality and urine : serum osmolality ratio were observed between the groups. Conclusion There were no significant differences in major complication rates, length of stay and in-hospital deaths when fluid restriction was used compared with a more liberal regimen. Registration number: ISRCTN39295230 (http://www.controlled-trials.com).
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Affiliation(s)
- J P Kalyan
- Department of Surgery, Norfolk and Norwich University HospitalNorwich, UK
- Correspondence to: Mr J. P. Kalyan, Department of General Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK (e-mail: )
| | - M Rosbergen
- Department of Surgery, Norfolk and Norwich University HospitalNorwich, UK
| | - N Pal
- Department of Surgery, Norfolk and Norwich University HospitalNorwich, UK
| | - K Sargen
- Department of Surgery, Norfolk and Norwich University HospitalNorwich, UK
| | - S J Fletcher
- Department of Anaesthetics and Intensive Care, Norfolk and Norwich University HospitalNorwich, UK
| | - D L Nunn
- Department of Anaesthetics and Intensive Care, Norfolk and Norwich University HospitalNorwich, UK
| | - A Clark
- School of Medicine (Biostatistics), University of East AngliaNorwich, UK
| | - M R Williams
- Department of Biology, University of East AngliaNorwich, UK
| | - M P N Lewis
- Department of Surgery, Norfolk and Norwich University HospitalNorwich, UK
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86
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Straub BD, Aslani A, Enohumah K, Rahore R, Conrick-Martin I, Kumar D, Campbell M, Dicker P, Mocanu E, Loughrey JP, Hayes NE, McCaul CL. Evaluation of the effect of intra-operative intravenous fluid on post-operative pain and pulmonary function: a randomized trial comparing 10 and 30 ml kg(-1) of crystalloid. Ir J Med Sci 2013; 183:549-56. [PMID: 24323549 DOI: 10.1007/s11845-013-1049-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 11/25/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Existing evidence suggests that administration of intravenous fluids has been shown to improve outcomes including pain in gynecological laparoscopic surgery but the optimum fluid dose has not been determined. AIMS To determine the effect of administration of intravenous fluids on post-operative pain and pulmonary function after gynecological laparoscopy. METHODS In a prospective randomized double-blinded study 100 ASA 1 and 2 elective patients undergoing gynecological laparoscopy were randomized to receive intravenous compound sodium lactate 10 ml kg(-1) (CSL10-restrictive) or 30 ml kg(-1) (CSL30-liberal) administered intra-operatively. The primary outcome measure was the post-operative pain score at 24, 48 and 72 h, assessed by 0-10 verbal rating scale (VRS). Pulmonary function (FEV1, FVC, PEFR) and oxygen saturation were also measured. RESULTS Patients who received CSL 30 had lower post-operative pain scores than CSL 10 (ANCOVA-mean difference = 0.47, 95 % CI 0.11-0.83, P = 0.01). Post-operative pain VRS was lower in CSL30 than CSL10 at 48 h (mean difference 0.56, 95 % CI 0.04-1.09, P = 0.036). Patients in CSL30 reported shoulder tip pain less frequently than those in CSL10 (30.4 vs. 43.9 % of assessments, P = 0.03, OR 0.58) but reported wound pain more frequently 39.0 vs. 24.2 %, P = 0.01, OR 2.0). Indices of pulmonary function did not differ between groups at any time. CONCLUSIONS Liberal compared to restrictive administration of i.v. crystalloid is associated with a clinical modest reduction in pain. Pulmonary dysfunction was not increased with liberal fluid administration.
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Affiliation(s)
- B D Straub
- Department of Anesthesia, The Rotunda Hospital, Parnell Square, Dublin 1, Ireland
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87
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The impact of old age on surgical outcomes of totally laparoscopic gastrectomy for gastric cancer. Surg Endosc 2013; 27:3990-7. [PMID: 23877760 DOI: 10.1007/s00464-013-3073-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 06/14/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Old age is regarded as the risk factor of major abdominal surgery due to the lack of functional reserve and the increased presence of comorbidities. This study aimed to evaluate the impact of old age on the surgical outcomes of totally laparoscopic gastrectomy for gastric cancer. METHODS This study enrolled 389 gastric cancer patients who underwent totally laparoscopic gastrectomy at Hanyang University Guri Hospital and ASAN Medical Center. The patients were classified into two groups according to age as those older than 70 years and those younger than 70 years. Early surgical outcomes such as operation time, postoperative complications, time to first flatus, days until soft diet began, and hospital stay were evaluated. RESULTS No patient was converted to open surgery. The two groups differed significantly in terms of overall postoperative complication rate, time to first flatus, days until soft diet began, and hospital stay. The patients who underwent Roux-en-Y gastrojejunostomy differed in incidence of postoperative ileus but not in severe postoperative complication rate. CONCLUSIONS The results of this study demonstrated that old age can have an effect on the surgical outcomes of totally laparoscopic gastrectomy. This study especially showed that elderly patients are affected by the return of bowel movement after totally laparoscopic gastrectomy. On the other hand, however, it is presumed that old age has not had a serious impact on surgical outcomes in totally laparoscopic gastrectomy because no difference in the severe postoperative complication rate was observed.
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88
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Zakhaleva J, Tam J, Denoya PI, Bishawi M, Bergamaschi R. The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: a randomized controlled trial. Colorectal Dis 2013; 15:892-9. [PMID: 23905554 DOI: 10.1111/codi.12180] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 11/26/2012] [Indexed: 02/08/2023]
Abstract
AIM A randomized controlled trial was conducted to test the hypothesis that there is no difference in complications in patients receiving intravenous (iv) water and electrolyte, based on either stroke volume or clinical indicators at bowel surgery. METHOD Eligible patients were randomized either to intra-operative iv administration of fluid boluses based on stroke volume measured by oesophageal Doppler (probe arm) or to iv fluid based on clinical indicators (no-probe arm). The end-point was the complication rate, defined as deviation from an uneventful postoperative course. Surgery was defined as elective bowel resection with primary anastomosis. All patients were on an enhanced recovery protocol. A randomized controlled trial suggested a sample size of 91 patients. RESULTS Ninety-one patients were randomized. Seventeen were excluded because of withdrawal of consent, failure of the procedure or cancellation of surgery. Patients were comparable for age (P = 0.89), gender (P = 0.14), body mass index (BMI) (P = 0.7), American Society of Anesthesiology (ASA) score (P > 0.9), race (P = 0.55), colorectal POSSUM score (P = 0.11), comorbidity (P = 0.4), previous operations (P = 0.45) and diagnosis (P = 0.50). Physiological and Operative Severity Score for the Enumeration of Morbidity and Mortality (POSSUM)-predicted mortality was higher in the test (probe) arm (P = 0.011). No differences were observed in epidural analgesia (P = 0.16), type of resection (P = 0.43), incision length (P = 0.40), type of incision (P = 0.47), operation time (P = 0.92), estimated blood loss (EBL) (P = 0.56), time to ambulation (P = 0.95), flatus (P = 0.37), diet (P = 0.17), removal of the epidural anaesthesia (P = 0.26) and length of hospital stay (LOS) (P = 0.575). Intra-operative fluids administered were 3.1 (0.7-77) vs 4 (0.9-6.2) liters (P = 0.53). Postoperative fluids administered were 12.5 (5.5-84.6) vs 11.3 (3.4-49.8) (P = 0.42). Overall and septic complication rates were significantly decreased in the test arm (7/32 (22%) vs 19/40 (49%) (P = 0.022) and 2/32 (6.2%) vs 12/40 (30%) (P = 0.05), respectively). CONCLUSION Intra-operative administration of iv water and electrolyte during bowel surgery, based on stroke volume measured using oesophageal Doppler, was associated with decreased complication rates.
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Affiliation(s)
- J Zakhaleva
- Division of Colon & Rectal Surgery, State University of New York, Stony Brook, NY 11794-8191, USA
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89
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Wallström Å, Frisman GH. Facilitating early recovery of bowel motility after colorectal surgery: a systematic review. J Clin Nurs 2013; 23:24-44. [DOI: 10.1111/jocn.12258] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2013] [Indexed: 12/15/2022]
Affiliation(s)
- Åsa Wallström
- Department of Surgery; County Council of Östergötland; Linköping Sweden
| | - Gunilla Hollman Frisman
- Division of Nursing Science; Department of Medicine and Health; Faculty of Health Science; Linköping Sweden
- Anaesthetics, Operations and Speciality Surgery Centre; County Council of Östergötland; Linköping Sweden
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90
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Iijima T, Brandstrup B, Rodhe P, Andrijauskas A, Svensen CH. The maintenance and monitoring of perioperative blood volume. Perioper Med (Lond) 2013; 2:9. [PMID: 24472160 PMCID: PMC3964327 DOI: 10.1186/2047-0525-2-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 03/11/2013] [Indexed: 11/18/2022] Open
Abstract
The assessment and maintenance of perioperative blood volume is important because fluid therapy is a routine part of intraoperative care. In the past, patients undergoing major surgery were given large amounts of fluids because health-care providers were concerned about preoperative dehydration and intraoperative losses to a third space. In the last decade it has become clear that fluid therapy has to be more individualized. Because the exact determination of blood volume is not clinically possible at every timepoint, there have been different approaches to assess fluid requirements, such as goal-directed protocols guided by invasive and less invasive devices. This article focuses on laboratory volume determination, capillary dynamics, aspects of different fluids and how to clinically assess and monitor perioperative blood volume.
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Affiliation(s)
| | | | | | | | - Christer H Svensen
- Karolinska Institutet, Department of Clinical Science and Education, Section of Anesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden.
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91
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Kim JW, Kim WS, Cheong JH, Hyung WJ, Choi SH, Noh SH. Safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy for gastric cancer: a randomized clinical trial. World J Surg 2013; 36:2879-87. [PMID: 22941233 DOI: 10.1007/s00268-012-1741-7] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fast-track surgery has been shown to enhance postoperative recovery in several surgical fields. This study aimed to evaluate the safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy. METHODS The present study was designed as a single-center, randomized, unblinded, parallel-group trial. Patients were eligible if they had gastric cancer for which laparoscopic distal gastrectomy was indicated. The fast-track surgery protocol included intensive preoperative education, a short duration of fasting, a preoperative carbohydrate load, early postoperative ambulation, early feeding, and sufficient pain control using local anesthetics perfused via a local anesthesia pump device, with limited use of opioids. The primary endpoint was the duration of possible and actual postoperative hospital stay. RESULTS We randomized 47 patients into a fast-track group (n=22) and a conventional pathway group (n=22), with three patients withdrawn. The possible and actual postoperative hospital stays were shorter in the fast-track group than in the conventional group (4.68±0.65 vs. 7.05±0.65; P<0.001 and 5.36±1.46 vs. 7.95±1.98; P<0.001). The time to first flatus and pain intensity were not different between groups; however, a greater frequency of additional pain control was needed in the conventional group (3.64±3.66 vs. 1.64±1.33; P=0.023). The fast-track group was superior to the conventional group in several factors of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, including: fatigue, appetite loss, financial problems, and anxiety. The complication and readmission rates were similar between groups. CONCLUSIONS Fast-track surgery could enhance postoperative recovery, improve immediate postoperative quality of life, and be safely applied in laparoscopic distal gastrectomy.
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Affiliation(s)
- Jong Won Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 712 Eonjuro, Gangnam-gu, Seoul, 135-720, Korea.
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92
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Hübner M, Lovely JK, Huebner M, Slettedahl SW, Jacob AK, Larson DW. Intrathecal analgesia and restrictive perioperative fluid management within enhanced recovery pathway: hemodynamic implications. J Am Coll Surg 2013; 216:1124-34. [PMID: 23623218 DOI: 10.1016/j.jamcollsurg.2013.02.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Revised: 02/10/2013] [Accepted: 02/15/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intrathecal analgesia and avoidance of perioperative fluid overload are key items within enhanced recovery pathways. Potential side effects include hypotension and renal dysfunction. STUDY DESIGN From January 2010 until May 2010, all patients undergoing colorectal surgery within enhanced recovery pathways were included in this retrospective cohort study and were analyzed by intrathecal analgesia (IT) vs none (noIT). Primary outcomes measures were systolic and diastolic blood pressure, mean arterial pressure, and heart rate for 48 hours after surgery. Renal function was assessed by urine output and creatinine values. RESULTS One hundred and sixty-three consecutive colorectal patients (127 IT and 36 noIT) were included in the analysis. Both patient groups showed low blood pressure values within the first 4 to 12 hours and a steady increase thereafter before return to baseline values after about 24 hours. Systolic and diastolic blood pressure and mean arterial pressure were significantly lower until 16 hours after surgery in patients having IT compared with the noIT group. Low urine output (<0.5 mL/kg/h) was reported in 11% vs 29% (IT vs noIT; p = 0.010) intraoperatively, 20% vs 11% (p = 0.387), 33% vs 22% (p = 0.304), and 31% vs 21% (p = 0.478) for postanesthesia care unit and postoperative days 1 and 2, respectively. Only 3 of 127 (2.4%) IT and 1 of 36 (2.8%) noIT patients had a transitory creatinine increase >50%; no patients required dialysis. CONCLUSIONS Postoperative hypotension affects approximately 10% of patients within an enhanced recovery pathway and is slightly more pronounced in patients with IT. Hemodynamic depression persists for <20 hours after surgery; it has no measurable negative impact and therefore cannot justify detrimental postoperative fluid overload.
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Affiliation(s)
- Martin Hübner
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Cecconi M, Corredor C, Arulkumaran N, Abuella G, Ball J, Grounds RM, Hamilton M, Rhodes A. Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:209. [PMID: 23672779 PMCID: PMC3679445 DOI: 10.1186/cc11823] [Citation(s) in RCA: 221] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with limited cardiac reserve are less likely to survive and develop more complications following major surgery. By augmenting oxygen delivery index (DO2I) with a combination of intravenous fluids and inotropes (goal directed therapy (GDT)), postoperative mortality and morbidity of high-risk patients may be reduced. However, although most studies suggest that GDT may improve outcome in high-risk surgical patients, it is still not widely practiced. We set out to test the hypothesis that GDT results in greatest benefit in terms of mortality and morbidity in patients with the highest risk of mortality and have undertaken a systematic review of the current literature to see if this is correct. We performed a systematic search of Medline, Embase and CENTRAL databases for randomized controlled trials (RCTs) and reviews of GDT in surgical patients. To minimize heterogeneity we excluded studies involving cardiac, trauma, and paediatric surgery. Extremely high risk, high risk and intermediate risks of mortality were defined as >20%, 5 to 20% and <5% mortality rates in the control arms of the trials, respectively. Meta analyses were performed and Forest plots drawn using RevMan software. Data are presented as odd ratios (OR; 95% confidence intervals (CI), and P-values). A total of 32 RCTs including 2,808 patients were reviewed. All studies reported mortality. Five studies (including 300 patients) were excluded from assessment of complication rates as the number of patients with complications was not reported. The mortality benefit of GDT was confined to the extremely high-risk group (OR = 0.20, 95% CI 0.09 to 0.41; P < 0.0001). Complication rates were reduced in all subgroups (OR = 0.45, 95% CI 0.34 to 0.60; P < 0.00001). The morbidity benefit was greatest amongst patients in the extremely high-risk subgroup (OR = 0.27, 95% CI 0.15 to 0.51; P < 0.0001), followed by the intermediate risk subgroup (OR = 0.43, 95% CI 0.27 to 0.67; P = 0.0002), and the high-risk subgroup (OR 0.56, 95% CI 0.36 to 0.89; P = 0.01). Despite heterogeneity in trial quality and design, we found GDT to be beneficial in all high-risk patients undergoing major surgery. The mortality benefit of GDT was confined to the subgroup of patients at extremely high risk of death. The reduction of complication rates was seen across all subgroups of GDT patients.
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94
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Vather R, Bissett I. Management of prolonged post-operative ileus: evidence-based recommendations. ANZ J Surg 2013; 83:319-24. [PMID: 23418987 DOI: 10.1111/ans.12102] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Prolonged post-operative ileus (PPOI) occurs in up to 25% of patients following major elective abdominal surgery. It is associated with a higher risk of developing post-operative complications, prolongs hospital stay and confers a significant financial load on health-care institutions. Literature outlining best-practice management strategies for PPOI is nebulous. The aim of this text was to review the literature and provide concise evidence-based recommendations for its management. METHODS A literature search through the Ovid MEDLINE, EMBASE, Google Scholar and Cochrane databases was performed from inception to July 2012 using a combination of keywords and MeSH terms. Review of the literature was followed by synthesis of concise recommendations for management accompanied by Strength of Recommendation Taxonomy (either A, B or C). RESULTS Recommendations for management include regular evaluation and correction of electrolytes (B); review of analgesic prescription with weaning of narcotics and substitution with regular paracetamol, regular non-steroidal anti-inflammatory drugs if not contraindicated, and regular or as-required Tramadol (A); nasogastric decompression for those with nausea or vomiting as prominent features (C); isotonic dextrose-saline crystalloid maintenance fluids administered within a restrictive regimen (B); balanced isotonic crystalloid replacement fluids containing supplemental potassium, in equivalent volume to losses (C); regular ambulation (C); parenteral nutrition if unable to tolerate an adequate oral intake for more than 7 days post-operatively (A) and exclusion of precipitating pathology or alternate diagnoses if clinically suspected (C). CONCLUSIONS Recommendations have a variable and frequently inconsistent evidence base. Further research is required to validate many of the outlined recommendations and to investigate novel interventions that may be used to shorten duration of PPOI.
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Affiliation(s)
- Ryash Vather
- Department of Surgery, The University of Auckland, Auckland, New Zealand
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Feldheiser A, Conroy P, Bonomo T, Cox B, Garces TR, Spies C. Development and feasibility study of an algorithm for intraoperative goaldirected haemodynamic management in noncardiac surgery. J Int Med Res 2013; 40:1227-41. [PMID: 22971475 DOI: 10.1177/147323001204000402] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study developed an evidence-based, goal-directed haemodynamic management algorithm to standardize intraoperative haemodynamic therapy. A systematic literature search identified three haemodynamic management goals: stroke volume optimization by fluid therapy; maintenance of a target mean arterial pressure by vasopressor therapy; maintenance of a target cardiac index≥2.5 l/min per m2 by inotropic therapy. The algorithm was adapted to international standards and consensus was reached through a modified Delphi method at international meetings. Implementation of the algorithm into routine intraoperative management in noncardiac surgery was shown to be feasible. Compared with conventional haemodynamic management, use of the algorithm significantly reduced length of hospital stay, requirement for ventilation and incidence of prolonged hospital stay, thereby resulting in reduced hospital costs.
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Affiliation(s)
- A Feldheiser
- Department of Anaesthesia and Intensive Care Medicine, Charité-Universitätsmedizin Berlin Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
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Perez d'Empaire PA, Kajdacsy-Balla Amaral AC. Year in review 2011: Critical Care--Resource management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:244. [PMID: 23256851 PMCID: PMC3672572 DOI: 10.1186/cc11821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Increasing complexity and costs are a fundamental problem in critical care medicine, leading researchers to study opportunities and threats to continue to provide high-quality care in a more efficient health system. Over the past decades, we have learned from industrial methods that quality improvement and resource management can help achieve these results. Last year, Critical Care published a number of papers that highlight key points of critical care resource management. Each of these is grouped into one of three broad categories, based on domains of quality: (a) outcomes, in which we review long-term outcome data with an emphasis on the aging population, strategies to help mitigate the psychological burden of critical care, adverse events, and the appropriate use of resources, such as prolonged mechanical ventilation and intensive care unit (ICU) beds; (b) processes of care, in which we review variability in the provision of critical care, owing to gender, insurance status, and delays in ICU admission; knowledge translation studies in critical care; goal-directed therapy for postoperative patients and decision-making in the ICU; and (c) structure, in which we review strategies to improve quality through changes in design and the structural limitations to provide care in resource-limited settings.
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97
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Gray LD, Morris C. The principles and conduct of anaesthesia for emergency surgery. Anaesthesia 2012; 68 Suppl 1:14-29. [DOI: 10.1111/anae.12057] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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98
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Predictive factors of hospital stay in patients undergoing minimally invasive transforaminal lumbar interbody fusion and instrumentation. Spine (Phila Pa 1976) 2012; 37:2046-54. [PMID: 22576071 DOI: 10.1097/brs.0b013e31825c6688] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A single-center retrospective study. OBJECTIVE To identify predictors of length of stay (LOS) days in patients undergoing 1 level minimally invasive (MIS) transforaminal lumbar interbody fusions (TLIF). SUMMARY OF BACKGROUND DATA Recent studies suggest intraoperative fluid administration, and colloid and crystalloid administration among other intraoperative variables may prolong LOS days and increase complications. Therefore, an understanding of which preoperative, intraoperative, and immediate postoperative parameters best predict immediate LOS days will help risk stratify patients and guide decision making. METHODS We retrospectively reviewed 104 patients undergoing a MIS TLIF at 1 institution between 2008 and 2010. Two groups were selected on the basis of the time of discharge. Group 1 consisted of patients discharged within 24 hours after surgery and group 2 consisted of patients discharged more than 24 hours after surgery. Multiple regression analysis was performed to determine which preoperative, intraoperative, and postoperative variables were independent predictors of LOS days. RESULTS Seventy-eight patients (75%) with a LOS greater than 24 hours had significantly higher estimated blood loss, received more crystalloids, had higher total fluids, longer surgical time, lower end of case temperature, lower hemoglobin during hospitalization, and a lower preoperative narcotic use. Multiple regression analysis showed that significant predictors of increased LOS were postoperative creatinine, visual analogue scale score, intraoperative colloids, fluids input at the end of surgical case, crystalloid to colloid ratio, fluid balance, oxycodone (Oxycontin) use, mean percentage of fraction of inspired oxygen, and preoperative hemoglobin. CONCLUSION Patients undergoing 1 level MIS TLIF for degenerative conditions can overall expect a short LOS postoperatively. Multiple preoperative, intraoperative, and immediate postoperative factors can prolong the LOS in this group. This information should help the surgical team in optimizing their intraoperative patient management.
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Zhang J, Qiao H, He Z, Wang Y, Che X, Liang W. Intraoperative fluid management in open gastrointestinal surgery: goal-directed versus restrictive. Clinics (Sao Paulo) 2012; 67:1149-55. [PMID: 23070341 PMCID: PMC3460017 DOI: 10.6061/clinics/2012(10)06] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/28/2012] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE The optimal strategy for fluid management during gastrointestinal surgery remains unclear. Minimizing the variation in arterial pulse pressure, which is induced by mechanical ventilation, is a potential strategy to improve postoperative outcomes. We tested this hypothesis in a prospective, randomized study with lactated Ringer's solution and 6% hydroxyethyl starch solution. METHOD A total of 60 patients who were undergoing gastrointestinal surgery were randomized into a restrictive lactated Ringer's group (n = 20), a goal-directed lactated Ringer's group (n = 20) and a goal-directed hydroxyethyl starch group (n = 20). The goal-directed fluid treatment was guided by pulse pressure variation, which was recorded during surgery using a simple manual method with a Datex Ohmeda S/5 Monitor and minimized to 11% or less by volume loading with either lactated Ringer's solution or 6% hydroxyethyl starch solution (130/0.4). The postoperative flatus time, the length of hospital stay and the incidence of complications were recorded as endpoints. RESULTS The goal-directed lactated Ringer's group received the greatest amount of total operative fluid compared with the two other groups. The flatus time and the length of hospital stay in the goal-directed hydroxyethyl starch group were shorter than those in the goal-directed lactated Ringer's group and the restrictive lactated Ringer's group. No significant differences were found in the postoperative complications among the three groups. CONCLUSION Monitoring and minimizing pulse pressure variation by 6% hydroxyethyl starch solution (130/0.4) loading during gastrointestinal surgery improves postoperative outcomes and decreases the discharge time of patients who are graded American Society of Anesthesiologists physical status I/II.
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Affiliation(s)
- Jun Zhang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China.
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Klein M, Gögenur I, Rosenberg J. Postoperative use of non-steroidal anti-inflammatory drugs in patients with anastomotic leakage requiring reoperation after colorectal resection: cohort study based on prospective data. BMJ 2012; 345:e6166. [PMID: 23015299 PMCID: PMC3458793 DOI: 10.1136/bmj.e6166] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the effect of postoperative use of non-steroidal anti-inflammatory drugs (NSAIDs) on anastomotic leakage requiring reoperation after colorectal resection. DESIGN Cohort study based on data from a prospective clinical database and electronically registered medical records. SETTING Six major colorectal centres in eastern Denmark. PARTICIPANTS 2766 patients (1441 (52%) men) undergoing elective operation for colorectal cancer with colonic or rectal resection and primary anastomosis between 1 January 2006 and 31 December 2009. Median age was 70 years (interquartile range 62-77). INTERVENTION Postoperative use of NSAID (defined as at least two days of NSAID treatment in the first seven days after surgery). MAIN OUTCOME MEASURES Frequency of clinical anastomotic leakage verified at reoperation; mortality at 30 days. RESULTS Of 2756 patients with available data and included in the final analysis, 1871 (68%) did not receive postoperative NSAID treatment (controls) and 885 (32%) did. In the NSAID group, 655 (74%) patients received ibuprofen and 226 (26%) received diclofenac. Anastomotic leakage verified at reoperation was significantly increased among patients receiving diclofenac and ibuprofen treatment, compared with controls (12.8% and 8.2% v 5.1%; P<0.001). After unadjusted analyses and when compared with controls, more patients had anastomotic leakage after treatment with diclofenac (7.8% (95% confidence interval 3.9% to 12.8%)) and ibuprofen (3.2% (1.0% to 5.7%)). But after multivariate logistic regression analysis, only diclofenac treatment was a risk factor for leakage (odds ratio 7.2 (95% confidence interval 3.8 to 13.4), P<0.001; ibuprofen 1.5 (0.8 to 2.9), P=0.18). Other risk factors for anastomotic leakage were male sex, rectal (v colonic) anastomosis, and blood transfusion. 30 day mortality was comparable in the three groups (diclofenac 1.8% v ibuprofen 4.1% v controls 3.2%; P=0.20). CONCLUSIONS Diclofenac treatment could result in an increased proportion of patients with anastomotic leakage after colorectal surgery. Cyclo-oxygenase-2 selective NSAIDs should be used with caution after colorectal resections with primary anastomosis. Large scale, randomised controlled trials are urgently needed.
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Affiliation(s)
- Mads Klein
- Department of Surgery, Herlev Hospital, University of Copenhagen, 2730 Herlev, Denmark.
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