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Forbes CM, Chehroudi AC, Mannas M, Bisaillon A, Hong T, So AI, Mayson K, Black PC. Defining postoperative ileus and associated risk factors in patients undergoing radical cystectomy with an Enhanced Recovery After Surgery (ERAS) program. Can Urol Assoc J 2020; 15:33-39. [PMID: 32745002 DOI: 10.5489/cuaj.6546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Postoperative ileus (POI) is a common complication of radical cystectomy (RC), occurring in 1.6-23.5% of cases. It is defined heterogeneously in the literature. POI increases hospital length of stay and postoperative morbidity. Factors such as age, epidural use, length of procedure, and blood loss may impact POI. In this study, we aimed to evaluate risk factors that contribute to POI in a cohort of patients managed with a comprehensive Enhanced Recovery After Surgery (ERAS) protocol. METHODS A retrospective review of consecutive patients who underwent RC from March 2015 to December 2016 at Vancouver General Hospital was performed. POI was defined a priori as insertion of nasogastric tube for nausea or vomiting, or failure to advance to a solid diet by the seventh postoperative day. To illustrate heterogeneity in previous studies, we also evaluated POI using other previously reported definitions in the RC literature. The influence of potential risk factors for POI, including patient comorbidities, American Society of Anesthesiologists score, gender, age, prior abdominal surgery or radiation, length of operation, diversion type, extent of lymph node dissection, removal date of analgesic catheter, blood loss, and fluid administration volume was analyzed. RESULTS Thirty-six (27%) of 136 patients developed POI. Using other previously reported definitions for POI, the incidence ranged from <1-51%. Node-positive status and age at surgery were associated with POI on univariate analysis but not multivariable analysis. CONCLUSIONS A large range of POI incidence was observed using previously published definitions of POI. We advocate for a standardized definition of POI when evaluating RC outcomes. POI occurs frequently even with a comprehensive ERAS protocol, suggesting that additional measures are needed to reduce the rate of POI.
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Affiliation(s)
- Connor M Forbes
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Ali Cyrus Chehroudi
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Miles Mannas
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Bisaillon
- Department of Surgical Services, University of British Columbia, Vancouver, BC, Canada
| | - Tracey Hong
- Department of Surgical Services, University of British Columbia, Vancouver, BC, Canada
| | - Alan I So
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Kelly Mayson
- Department of Anesthesiology University of British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
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Bradley CR, Bragg DD, Cox EF, El-Sharkawy AM, Buchanan CE, Chowdhury AH, Macdonald IA, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of isoeffective and isovolumetric intravenous crystalloid and gelatin on blood volume, and renal and cardiac hemodynamics. Clin Nutr 2020; 39:2070-2079. [PMID: 31668721 PMCID: PMC7359406 DOI: 10.1016/j.clnu.2019.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/09/2019] [Accepted: 09/30/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND & AIMS Blood volume expanding properties of colloids are superior to crystalloids. In addition to oncotic/osmotic properties, the electrolyte composition of infusions may have important effects on visceral perfusion, with infusions containing supraphysiological chloride causing hyperchloremic acidosis and decreased renal blood flow. In this non-inferiority study, a validated healthy human subject model was used to compare effects of colloid (4% succinylated gelatin) and crystalloid fluid regimens on blood volume, renal function, and cardiac output. METHODS Healthy male participants were given infusions over 60 min > 7 days apart in a randomized, crossover manner. Reference arm (A): 1.5 L of Sterofundin ISO, isoeffective arm (B): 0.5 L of 4% Gelaspan®, isovolumetric arm (C): 0.5 L of 4% Gelaspan® and 1 L of Sterofundin ISO (all B. Braun, Melsungen, Germany). Participants were studied over 240 min. Changes in blood volume were calculated from changes in weight and hematocrit. Renal volume, renal artery blood flow (RABF), renal cortex perfusion and diffusion, and cardiac index were measured with magnetic resonance imaging. RESULTS Ten of 12 males [mean (SE) age 23.9 (0.8) years] recruited, completed the study. Increase in body weight and extracellular fluid volume were significantly less after infusion B than infusions A and C, but changes in blood volume did not significantly differ between infusions. All infusions increased renal volume, with no significant differences between infusions. There was no significant difference in RABF across the infusion time course or between infusion types. Renal cortex perfusion decreased during the infusion (mean 18% decrease from baseline), with no significant difference between infusions. There was a trend for increased renal cortex diffusion (4.2% increase from baseline) for the crystalloid infusion. All infusions led to significant increases in cardiac index. CONCLUSIONS A smaller volume of colloid (4% succinylated gelatin) was as effective as a larger volume of crystalloid at expanding blood volume, increasing cardiac output and changing renal function. Significantly less interstitial space expansion occurred with the colloid. TRIAL REGISTRATION The protocol was registered with the European Union Drug Regulating Authorities Clinical Trials Database (https://eudract.ema.europa.eu) (EudraCT No. 2013-003260-32).
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Affiliation(s)
- Christopher R Bradley
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Sir Peter Mansfield Imaging Centre, University Park, University of Nottingham, NG7 2RD, UK
| | - Damian D Bragg
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Eleanor F Cox
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Sir Peter Mansfield Imaging Centre, University Park, University of Nottingham, NG7 2RD, UK
| | - Ahmed M El-Sharkawy
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Charlotte E Buchanan
- Sir Peter Mansfield Imaging Centre, University Park, University of Nottingham, NG7 2RD, UK
| | - Abeed H Chowdhury
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Ian A Macdonald
- School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Susan T Francis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Sir Peter Mansfield Imaging Centre, University Park, University of Nottingham, NG7 2RD, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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Jennings JM, Mejia M, Williams MA, Johnson RM, Yang CC, Dennis DA. The James A. Rand Young Investigator's Award: Traditional Intravenous Fluid vs. Oral Fluid Administration in Primary Total Knee Arthroplasty: A Randomized Trial. J Arthroplasty 2020; 35:S3-S9. [PMID: 32037213 DOI: 10.1016/j.arth.2020.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/07/2020] [Accepted: 01/14/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Optimal perioperative fluid management has not been established in patients undergoing orthopedic surgical procedures. Our purpose was to investigate the effects of perioperative fluid management (ie, preoperative, intraoperative, and postoperative) on patients undergoing total knee arthroplasty (TKA). METHODS One hundred thirty patients who met inclusion criteria undergoing primary unilateral TKA were prospectively randomized into traditional (TFG) vs oral (OFG) perioperative fluid management groups. The primary outcome was change in body weight (BW). Secondary outcome measures included knee motion, leg girth, bioelectrical impendence, quadriceps activation, functional outcomes testing, Knee injury and Osteoarthritis Outcome Score JR, VR-12, laboratory values, vital signs, patient satisfaction, pain scores, and adverse events. RESULTS The TFG had increased BW the evening of surgery (7.0 ± 4.3 vs 3.0 ± 3.9, P < .0001), postoperative day (POD) #1 (9.1 ± 4.3 vs 4.7 ± 3.9, P < .0001), and POD #2 (6.2 ± 5.0 vs 4.4 ± 4.0, P = .032). Bioelectrical impedance showed less limb edema in the OFG (4.2 ± 29.7 vs 17.8 ± 30.3, P < .0001) on POD #1. Urine specific gravity differences were seen preoperatively between groups (OFG, more hydrated, P = .002). Systolic blood pressure decrease from the baseline was greater in the OFG on arrival to the floor (19.4 ± 13.5 vs 10.6 ± 12.8, P < .0001) and 8 (23.4 ± 13.3 vs 17.0 ± 12.9, P = .006) and 16 (25.8 ± 13.8 vs 25.8 ± 13.8, P = .046) hours after floor arrival. The TFG had more urine output on POD #1 (3369 mL ± 1343 mL vs 2435 mL ± 1151 mL, P < .0001). The OFG were more likely to go home on POD #1 than the TFG (63 vs 56, P = .02). CONCLUSION Oral fluid intake with IVF restriction in the perioperative period after TKA may offer short-term benefits with swelling and BW fluctuations. The authors continue to limit perioperative IVFs and encourage patient initiated fluid intake.
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Affiliation(s)
- Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO
| | | | | | | | - Charlie C Yang
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO
| | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN
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Fischer MO, Fiant AL, Debroczi S, Boutros M, Pasqualini L, Demonchy M, Flais F, Alves A, Gérard JL, Buléon C, Hanouz JL. Perioperative non-invasive haemodynamic optimisation using photoplethysmography: A randomised controlled trial and meta-analysis. Anaesth Crit Care Pain Med 2020; 39:421-428. [DOI: 10.1016/j.accpm.2020.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/08/2020] [Accepted: 03/08/2020] [Indexed: 12/27/2022]
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Ramdas Y, Benn CA, Grubnik A, Mayat Y, Holmes DR. Targeted Intraoperative Radiotherapy Is a Safe Approach for Patients with Pacemakers: A Case Study and Literature Review. Case Rep Oncol 2020; 13:916-922. [PMID: 32884540 PMCID: PMC7443642 DOI: 10.1159/000508946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 02/03/2023] Open
Abstract
Case reports detailing the effects of targeted intraoperative radiation therapy (IORT) on patients with cardiac pacemakers (PMs) are rare. This growing population sub-group requiring IORT and lack of standardized guidelines necessitate more practical published research. An 81-year-old patient with clinical stage II, T1 N0 grade III, triple-negative invasive ductal carcinoma and an implanted single-lead chamber PM (VVIR mode, model: Biotronik, type Effecta SR) received targeted intraoperative radiotherapy at the time of wide local excision and sentinel lymph node biopsy. It presents the shortest distance between the outer diameter of the PM and IORT applicator in literature. Target IORT was performed utilizing an Intrabeam device (50 kV, Carl Zeiss Surgical, Oberkochen, Germany). This case elucidates the successful use of targeted IORT for breast-conserving surgery in a patient with a single ipsilateral chamber VVIR mode PM. No device failure or malfunction was reported for the PM before, during, or after the procedure. These findings support the use of targeted IORT for patients diagnosed with early-stage breast carcinomas who have a PM implanted. However, further research is needed to understand the safety of other methods and devices for IORT patients with cardiac implantable electronic devices.
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Affiliation(s)
- Yastira Ramdas
- The Breast Care Unit, NetCare Milpark, Johannesburg, South Africa
| | - Carol-Ann Benn
- The Breast Care Unit, NetCare Milpark, Johannesburg, South Africa
| | | | - Yasmin Mayat
- The Breast Care Unit, NetCare Milpark, Johannesburg, South Africa
| | - Dennis R. Holmes
- Department of Surgery, Glendale Adventist Medical Center, Glendale, California, USA
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Zaouter C, Joosten A, Rinehart J, Struys MMRF, Hemmerling TM. Autonomous Systems in Anesthesia. Anesth Analg 2020; 130:1120-1132. [DOI: 10.1213/ane.0000000000004646] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
A moderately liberal IV fluid regimen, using a balanced crystalloid, and consideration of the use of an advanced hemodynamic monitor in a setting of an enhanced recovery pathway are recommended for major surgery.
Supplemental Digital Content is available in the text.
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Hikasa Y, Suzuki S, Mihara Y, Tanabe S, Shirakawa Y, Fujiwara T, Morimatsu H. Intraoperative fluid therapy and postoperative complications during minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study. J Anesth 2020; 34:404-412. [PMID: 32232660 DOI: 10.1007/s00540-020-02766-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/21/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Compared with open thoracotomy, minimally invasive esophagectomy (MIE) methods, such as transhiatal or thoracoscopic esophagectomy, likely have lower morbidity. However, the relationship between intraoperative fluid management and postoperative complications after MIE remains unclear. Thus, we investigated the association of cumulative intraoperative fluid balance and postoperative complications in patients undergoing MIE. METHODS This single-center retrospective cohort study examined patients undergoing thoracoscopic esophagectomy for esophageal cancer in the prone position. Postoperative complications included pneumonia, arrhythmia, thrombotic events and acute kidney injury (AKI). We compared patients with higher and lower intraoperative fluid balance (higher and lower than the median). Multivariable logistic regression analyses were performed to estimate the odds ratio of intraoperative fluid balance status on the incidence of postoperative complications. RESULTS In total, 135 patients were included in the study. Postoperative complications occurred in 43 (32%), including cardiac arrhythmia (n = 12, 9%), thrombosis (n = 20, 15%), pneumonia (n = 13, 10%), and AKI required hemodialysis (n = 1, 1%). Patients with a higher fluid balance had higher incidence of complications than those with a lower fluid balance (46% vs. 18%, p < 0.001). After adjusting for age, ASA-PS ≥ III, blood loss, and the use of radical surgery, the higher intraoperative fluid balance group was significantly and independently associated with postoperative complications (adjusted OR 5.31, 95% CI 2.26-13.6, p < 0.0001). CONCLUSIONS In patients undergoing thoracoscopic esophagectomy in the prone position, a greater intraoperative positive fluid balance was independently associated with a higher incidence of complications.
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Affiliation(s)
- Yukiko Hikasa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Satoshi Suzuki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yuko Mihara
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shunsuke Tanabe
- Department of Gastroenterological Surgery Transplant and Surgical Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhiro Shirakawa
- Department of Gastroenterological Surgery Transplant and Surgical Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery Transplant and Surgical Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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Perioperative Interstitial Fluid Expansion Predicts Major Morbidity Following Pancreatic Surgery: Appraisal by Bioimpedance Vector Analysis. Ann Surg 2020; 270:923-929. [PMID: 31592889 DOI: 10.1097/sla.0000000000003536] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate whether perioperative bioimpedance vector analysis (BIVA) predicts the occurrence of surgery-related morbidity. SUMMARY BACKGROUND DATA BIVA is a reliable tool to assess hydration status and compartimentalized fluid distribution. METHODS The BIVA of patients undergoing resection for pancreatic malignancies was prospectively measured on the day prior to surgery and on postoperative day (POD)1. Postoperative morbidity was scored per the Clavien-Dindo classification (CDC), and the Comprehensive Complication Index (CCI). RESULTS Out of 249 patients, the overall and major complication rates were 61% and 16.5% respectively. The median CCI was 24 (IQR 0.0-24.2), and 24 patients (9.6%) had a complication burden with CCI≥40. At baseline the impedance vectors of severe complicated patients were shorter compared to the vectors of uncomplicated patients only for the female subgroup (P=0.016). The preoperative extracellular water (ECW) was significantly higher in patients who experienced severe morbidity according to the CDC or not [19.4L (17.5-22.0) vs. 18.2L (15.6-20.6), P=0.009, respectively] and CCI≥40, or not [20.3L (18.5-22.7) vs. 18.3L (15.6-20.6), P=0.002, respectively]. The hydration index on POD1 was significantly higher in patients who experienced major complications than in uncomplicated patients (P=0.020 and P=0.025 for CDC and CCI, respectively).At a linear regression model, age (β=0.14, P=0.035), sex female (β=0.40, P<0.001), BMI (β=0.30, P<0.001), and malnutrition (β=0.14, P=0.037) were independent predictors of postoperative ECW. CONCLUSION The amount of extracellular fluid accumulation predicts major morbidity after pancreatic surgery. Female, obese and malnourished patients were at high risk of extracellular fluid accumulation.
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
An appropriate perioperative infusion management is pivotal for the perioperative outcome of the patient. Optimization of the perioperative fluid treatment often results in enhanced postoperative outcome, reduced perioperative complications and shortened hospitalization. Hypovolemia as well as hypervolemia can lead to an increased rate of perioperative complications. The main goal is to maintain perioperative euvolemia by goal-directed therapy (GDT), a combination of fluid management and inotropic medication, to optimize perfusion conditions in the perioperative period; however, perioperative fluid management should also include the preoperative and postoperative periods. This encompasses the preoperative administration of carbohydrate-rich drinks up to 2 h before surgery. In the postoperative period, patients should be encouraged to start per os hydration early and excessive i.v. fluid administration should be avoided. Implementation of a comprehensive multimodal, goal-directed fluid management within an enhanced recovery after surgery (ERAS) protocol is efficient but the exact status of indovodual items remains unclear at present.
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Sadeghian M, Sadeghi O, Rahmani S, Esmaillzadeh A. Reply to F Haghighatdoost. Adv Nutr 2020; 11:466-467. [PMID: 32173752 PMCID: PMC7073308 DOI: 10.1093/advances/nmz102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mehdi Sadeghian
- From the Department of Nutrition, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
| | - Omid Sadeghi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran,Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepideh Rahmani
- Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Esmaillzadeh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran,Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran,Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran,Address correspondence to AE (e-mail: )
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Perioperative Fluid Administration in Pancreatic Surgery: a Comparison of Three Regimens. J Gastrointest Surg 2020; 24:569-577. [PMID: 30945088 DOI: 10.1007/s11605-019-04166-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Optimization of perioperative fluid management is a controversial issue. Weight-adjusted, fixed fluid strategies do not take into account patient hemodynamic status, so that individualized strategies guided by relevant variables may be preferable. We studied this issue in patients undergoing pancreatic surgery within our institution. METHODS All patients who underwent a laparotomy for pancreatic cancer during a 5-month period at our hospital (AOUI of Verona, Italy) were eligible to be included in this prospective, observational study. According to the responsible anesthesiologist's free choice, patients received, during surgery, either liberal (12 ml/kg/h) or restricted (4 ml/kg/h) fixed-volume weight-guided replacement fluids or goal-directed (GD) fluid replacement using stroke volume variation (SVV) determined by the FloTrac Vigileo device. RESULTS Eighty-six patients were included: 29 in the liberal group, 23 in the restricted group, and 34 in the GD group. The mean duration of surgery was 6 [4-7] h. Patients in the liberal group received more perioperative fluid than those in the GD and restricted groups. Nearly one third of all patients had a major complication, including delayed enteral feeding, and presented a longer duration of hospital stay. Despite the biases related to our limited cohort, there were significantly fewer postoperative complications (such as postoperative fistula, abdominal collection, and hemorrhage) in the restricted and GD groups of patients than in the liberal one. CONCLUSION In patients undergoing pancreatic surgery, a restricted or individually guided GD strategy for management of perioperative fluids can result in fewer complications than a liberal fluid strategy. Larger and randomized investigations are warranted to confirm these data on this domain.
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Rollins KE, Mathias NC, Lobo DN. Authors' reply: Meta-analysis of goal-directed fluid therapy using transoesophageal Doppler in patients undergoing elective colorectal surgery. BJS Open 2020; 4:165. [PMID: 32011824 PMCID: PMC6996629 DOI: 10.1002/bjs5.50228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/23/2022] Open
Affiliation(s)
- K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - N C Mathias
- University of Exeter Medical School, Exeter, UK
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.,MRC Arthritis Research UK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Grass F, Pache B, Butti F, Solà J, Hahnloser D, Demartines N, Hübner M. Fluid management for critical patients undergoing urgent colectomy. J Eval Clin Pract 2020; 26:109-114. [PMID: 31206242 DOI: 10.1111/jep.13207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 12/20/2022]
Abstract
RATIONALE The present study aimed to define thresholds for perioperative fluids and weight gain after urgent colectomies. METHOD Consecutive urgent colonic resections within an enhanced recovery pathway (2011-2017) were included. Primary outcomes were postoperative complications, stratified as overall (I-V) and major (IIIb-V) according to Clavien scale. Fluid-management-related thresholds were identified through receiver operating characteristics (ROC) analysis. Outcomes were compared for patients above vs below threshold, and multivariable logistic regression was performed to identify risk factors for overall complications. RESULTS Overall, complications were observed in 133 out of 224 patients (59%), severe complications in 43 patients (19%). For overall complications, area under ROC (AUROC) was 0.71, identifying a critical cut-off of 3 L of total IV fluid administration at the day of surgery (negative predictive value [NPV]: 90%). Further, a critical cut-off for postoperative weight gain of 2.3 kg at postoperative day (POD) 2 was identified (AUROC 0.7, NPV 92%). Multivariable analysis identified fluid administration of >3 L (OR 5.33; 95% CI, 2.36-12.02) and weight gain of >2.3 kg at POD 2 (OR 2.5; 95% CI, 1.13-5.53) as independent predictors for overall complications. Median length of stay was 7 (5-10) days in patients receiving <3 L at POD 0 and 13 (9-19) days in patients receiving >3 L (P < .001). CONCLUSIONS Fluid administration of 3 L at the day of surgery and weight gain of 2.3 kg at POD 2 may represent critical thresholds for adverse outcomes after urgent colectomy. The suggested thresholds need to be confirmed through independent validation.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Fabio Butti
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Josep Solà
- Centre Suisse d'Electronique et de Microtechnique (CSEM), Neuchâtel, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
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MySurgeryRisk: Development and Validation of a Machine-learning Risk Algorithm for Major Complications and Death After Surgery. Ann Surg 2020; 269:652-662. [PMID: 29489489 DOI: 10.1097/sla.0000000000002706] [Citation(s) in RCA: 169] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To accurately calculate the risk for postoperative complications and death after surgery in the preoperative period using machine-learning modeling of clinical data. BACKGROUND Postoperative complications cause a 2-fold increase in the 30-day mortality and cost, and are associated with long-term consequences. The ability to precisely forecast the risk for major complications before surgery is limited. METHODS In a single-center cohort of 51,457 surgical patients undergoing major inpatient surgery, we have developed and validated an automated analytics framework for a preoperative risk algorithm (MySurgeryRisk) that uses existing clinical data in electronic health records to forecast patient-level probabilistic risk scores for 8 major postoperative complications (acute kidney injury, sepsis, venous thromboembolism, intensive care unit admission >48 hours, mechanical ventilation >48 hours, wound, neurologic, and cardiovascular complications) and death up to 24 months after surgery. We used the area under the receiver characteristic curve (AUC) and predictiveness curves to evaluate model performance. RESULTS MySurgeryRisk calculates probabilistic risk scores for 8 postoperative complications with AUC values ranging between 0.82 and 0.94 [99% confidence intervals (CIs) 0.81-0.94]. The model predicts the risk for death at 1, 3, 6, 12, and 24 months with AUC values ranging between 0.77 and 0.83 (99% CI 0.76-0.85). CONCLUSIONS We constructed an automated predictive analytics framework for machine-learning algorithm with high discriminatory ability for assessing the risk of surgical complications and death using readily available preoperative electronic health records data. The feasibility of this novel algorithm implemented in real time clinical workflow requires further testing.
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Czajka S, Marczenko K, Włodarczyk M, Szczepańska AJ, Olakowski M, Mrowiec S, Krzych ŁJ. Fluid Therapy in Patients Undergoing Abdominal Surgery: A Bumpy Road Towards Individualized Management. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1324:63-72. [PMID: 33230636 DOI: 10.1007/5584_2020_597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Prudent intraoperative fluid replacement therapy, inotropes, and vasoactive drugs should be guided by adequate hemodynamic monitoring. The study aimed to evaluate the single-centre practice on intraoperative fluid therapy in abdominal surgery (AS). The evaluation, based on a review of medical files, included 235 patients (103 men), aged 60 ± 15 years who underwent AS between September and November 2017. Fluid therapy was analyzed in terms of quality and quantity. There were 124 high-risk patients according to the American Society of Anaesthesiologists Classification (ASA Class 3+) and 89 high-risk procedures performed. The median duration of procedures was 175 (IQR 106-284) min. Eleven patients died post-operatively. The median fluids volume was 10.4 mL/kg/h of anaesthesia, including 9.1 mL/kg/h of crystalloids and 2.7 mL/kg/h of synthetic colloids. Patients undergoing longer than the median procedures received significantly fewer fluids than those who underwent shorter procedures. The volume of fluids in the longer procedures depended on the procedural risk classification and was significantly greater in high-risk patients undergoing high-risk surgery. Patients who died received significantly more fluids than survivors. In all patients, a non-invasive blood pressure monitoring was used and only six patients had therapy guided by metabolic equilibrium. The fluid therapy used was liberal but complied with the recommendations regarding the type of fluid and risk-adjusted dosing. Hemodynamic monitoring was suboptimal and requires modifications. In conclusion, the optimization of intraoperative fluid therapy requires a balanced and standardized approach consistent with treatment procedures.
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Affiliation(s)
- Szymon Czajka
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Konstanty Marczenko
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Martyna Włodarczyk
- Students' Scientific Society, Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anna J Szczepańska
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Marek Olakowski
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, Zarbock A, Stoppe C, Meineri M, Grocott HP, Ghadimi K, Gutsche JT, Patel PA, Denault A, Shaw A, Fletcher N, Levy JH. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step-But There Is Much Work to Be Done. J Cardiothorac Vasc Anesth 2020; 34:39-47. [PMID: 31570245 DOI: 10.1053/j.jvca.2019.09.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/02/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Anesthesiology, Perioperative and Pain Medicine, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Albert T Cheung
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Herzzentrum Leipzig, Leipzig, Germany
| | - Michael Sander
- Department of Anaesthesiology and Intensive Care Medicine, UKGM University Hospital Gießen, Justus-Liebig-University Giessen, Gießen, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Aachen, Germany
| | | | - Hilary P Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine and Department of Surgery, University of Manitoba, Winnipeg, Canada
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
| | - Jacob T Gutsche
- Division of Cardiac Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Andre Denault
- Département d'Anesthésiologie et de Médecine de la Douleur, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Division des Soins Intensifs, Département de Chirurgie Cardiaque, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Département de Pharmacologie et de Physiologie, Institut de Cardiologie de Montréal, Montréal, Quebec Canada
| | - Andrew Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nick Fletcher
- Department of Cardiothoracic Anesthesia and Critical Care, St. Georges University Hospital, London, United Kingdom; Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
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Wrzosek A, Jakowicka‐Wordliczek J, Zajaczkowska R, Serednicki WT, Jankowski M, Bala MM, Swierz MJ, Polak M, Wordliczek J. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery. Cochrane Database Syst Rev 2019; 12:CD012767. [PMID: 31829446 PMCID: PMC6953415 DOI: 10.1002/14651858.cd012767.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization. OBJECTIVES To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery. SEARCH METHODS We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person. MAIN RESULTS From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment. AUTHORS' CONCLUSIONS Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.
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Affiliation(s)
- Anna Wrzosek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
- University HospitalDepartment of Anaethesiology and Intensive CareKrakowPoland
| | | | - Renata Zajaczkowska
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Wojciech T Serednicki
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Milosz Jankowski
- University HospitalDepartment of Anaesthesiology and Intensive CareKrakowPoland
- Jagiellonian University Medical CollegeDepartment of Internal Medicine; Systematic Reviews UnitKrakowPoland
| | - Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics; Systematic Reviews UnitKopernika 7KrakowPoland31‐034
| | - Mateusz J Swierz
- Jagiellonian University Medical CollegeDepartment of Hygiene and Dietetics; Systematic Reviews UnitKrakowPoland
| | - Maciej Polak
- Jagiellonian University Medical CollegeDepartment of Epidemiology and Population Studies in the Institute of Public HealthKrakowPoland
| | - Jerzy Wordliczek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
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Wu H, Wang W, Zhao G, Xue Q. Effect of intraoperative fluid administration on perioperative outcomes in patients undergoing McKeown esophagogastrectomy. Chin J Cancer Res 2019; 31:742-748. [PMID: 31814678 PMCID: PMC6856707 DOI: 10.21147/j.issn.1000-9604.2019.05.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective Fluid therapy is one of the key components of perioperative management. However, evidence of intraoperative fluid (IOF) administration affecting clinical outcomes following McKeown esophagogastrectomy remains limited. This study investigated the impact of IOF on clinical outcomes after McKeown esophagogastrectomy. Methods Patients who underwent McKeown esophagogastrectomy between July 2013 and July 2016 were identified. Preoperative, intraoperative and postoperative variables for each eligible patient were retrospectively collected from our electronic medical records and anesthetic records. IOF rates were determined and their relationships to postoperative clinical outcomes were compared. Results A total of 546 patients were enrolled in the analysis. The median IOF rate was 8.87 mL/kg/h. We divided the patients into two groups: a low fluid volume group (LFVG <8.87 mL/kg/h, n=273) and a high fluid volume group (HFVG ≥8.87 mL/kg/h, n=273). No statistically significant differences in postoperative clinical outcomes were found between LFVG and HFVG either before or after propensity score matching. Conclusions No effect of IOF administration on clinical outcomes in patients undergoing McKeown esophagogastrectomy was identified. Further high-quality studies examining the influence of IOF administration on clinical outcomes following McKeown esophagogastrectomy are still needed.
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Affiliation(s)
- Hongliang Wu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wen Wang
- Department of Pain Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Gefei Zhao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Qi Xue
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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An Enhanced Recovery Protocol that Facilitates Same-day Discharge for Simple Laparoscopic Appendectomies. Pediatr Qual Saf 2019; 4:e243. [PMID: 32010869 PMCID: PMC6946221 DOI: 10.1097/pq9.0000000000000243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022] Open
Abstract
Acute appendicitis is the most common gastrointestinal condition requiring urgent operation in the pediatric population with laparoscopic appendectomy (LA) being the current surgical technique. We describe the implementation of a standardized protocol to reduce postoperative nausea and vomiting (PONV) and facilitate same-day discharge after LA.
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72
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Dean HF, Carter F, Francis NK. Modern perioperative medicine - past, present, and future. Innov Surg Sci 2019; 4:123-131. [PMID: 33977121 PMCID: PMC8059350 DOI: 10.1515/iss-2019-0014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022] Open
Abstract
Modern perioperative medicine has dramatically altered the care for patients undergoing major surgery. Anaesthetic and surgical practice has been directed at mitigating the surgical stress response and reducing physiological insult. The development of standardised enhanced recovery programmes combined with minimally invasive surgical techniques has lead to reduction in length of stay, morbidity, costs, and improved outcomes. The enhanced recovery after surgery (ERAS) society and its national chapters provide a means for sharing best practice in this field and developing evidence based guidelines. Research has highlighted persisting challenges with compliance as well as ensuring the effectiveness and sustainability of ERAS. There is also a growing need for increasingly personalised care programmes as well as complex geriatric assessment of frailer patients. Continuous collection of outcome and process data combined with machine learning, offers a potentially powerful solution to delivering bespoke care pathways and optimising individual management. Long-term data from ERAS programmes remain scarce and further evaluation of functional recovery and quality of life is required.
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Affiliation(s)
- Harry F. Dean
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - Fiona Carter
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil, UK
| | - Nader K. Francis
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil BA21 4AT, UK
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil BA20 2RH, UK
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK, Tel.: (01935) 384244
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Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis. Eur J Anaesthesiol 2019; 35:469-483. [PMID: 29369117 DOI: 10.1097/eja.0000000000000778] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Much uncertainty exists as to whether peri-operative goal-directed therapy is of benefit. OBJECTIVES To discover if peri-operative goal-directed therapy decreases mortality and morbidity in adult surgical patients. DESIGN An updated systematic review and random effects meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase and the Cochrane Library were searched up to 31 December 2016. ELIGIBILITY CRITERIA Randomised controlled trials enrolling adult surgical patients allocated to receive goal-directed therapy or standard care were eligible for inclusion. Trauma patients and parturients were excluded. Goal-directed therapy was defined as fluid and/or vasopressor therapy titrated to haemodynamic goals [e.g. cardiac output (CO)]. Outcomes included mortality, morbidity and hospital length of stay. Risk of bias was assessed using Cochrane methodology. RESULTS Ninety-five randomised trials (11 659 patients) were included. Only four studies were at low risk of bias. Modern goal-directed therapy reduced mortality compared with standard care [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.50 to 0.87; number needed to treat = 59; N = 52; I = 0.0%]. In subgroup analysis, there was no mortality benefit for fluid-only goal-directed therapy, cardiac surgery patients or nonelective surgery. Contemporary goal-directed therapy also reduced pneumonia (OR 0.69; 95% CI, 0.51 to 0. 92; number needed to treat = 38), acute kidney injury (OR 0. 73; 95% CI, 0.58 to 0.92; number needed to treat = 29), wound infection (OR 0.48; 95% CI, 0.37 to 0.63; number needed to treat = 19) and hospital length of stay (days) (-0.90; 95% CI, -1.32 to -0.48; I = 81. 2%). No important differences in outcomes were found for the pulmonary artery catheter studies, after accounting for advances in the standard of care. CONCLUSION Peri-operative modern goal-directed therapy reduces morbidity and mortality. Importantly, the quality of evidence was low to very low (e.g. Grading of Recommendations, Assessment, Development and Evaluation scoring), and there was much clinical heterogeneity among the goal-directed therapy devices and protocols. Additional well designed and adequately powered trials on peri-operative goal-directed therapy are necessary.
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Rollins KE, Mathias NC, Lobo DN. Meta-analysis of goal-directed fluid therapy using transoesophageal Doppler monitoring in patients undergoing elective colorectal surgery. BJS Open 2019; 3:606-616. [PMID: 31592512 PMCID: PMC6773648 DOI: 10.1002/bjs5.50188] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/09/2019] [Indexed: 12/15/2022] Open
Abstract
Background Intraoperative goal-directed fluid therapy (GDFT) is recommended in most perioperative guidelines for intraoperative fluid management in patients undergoing elective colorectal surgery. However, the evidence in elective colorectal surgery alone is not well established. The aim of this meta-analysis was to compare the effects of GDFT with those of conventional fluid therapy on outcomes after elective colorectal surgery. Methods A meta-analysis of RCTs examining the role of transoesophageal Doppler-guided GDFT with conventional fluid therapy in adult patients undergoing elective colorectal surgery was performed in accordance with PRISMA methodology. The primary outcome measure was overall morbidity, and secondary outcome measures were length of hospital stay, time to return of gastrointestinal function, 30-day mortality, acute kidney injury, and surgical-site infection and anastomotic leak rates. Results A total of 11 studies were included with a total of 1113 patients (556 GDFT, 557 conventional fluid therapy). There was no significant difference in any clinical outcome measure studied between GDFT and conventional fluid therapy, including overall morbidity (risk ratio (RR) 0·90, 95 per cent c.i. 0·75 to 1·08, P = 0·27; I 2 = 47 per cent; 991 patients), 30-day mortality (RR 0·67, 0·23 to 1·92, P = 0·45; I 2 = 0 per cent; 1039 patients) and length of hospital stay (mean difference 0·01 (95 per cent c.i. -0·92 to 0·94) days, P = 0·98; I 2 = 34 per cent; 1049 patients). Conclusion This meta-analysis does not support the perceived benefits of GDFT guided by transoesophageal Doppler monitoring in the setting of elective colorectal surgery.
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Affiliation(s)
- K. E. Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals and University of Nottingham, Queen's Medical CentreNottinghamUK
| | - N. C. Mathias
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals and University of Nottingham, Queen's Medical CentreNottinghamUK
- University of Exeter Medical SchoolExeterUK
| | - D. N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals and University of Nottingham, Queen's Medical CentreNottinghamUK
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Ageing Research, School of Life SciencesUniversity of Nottingham, Queen's Medical CentreNottinghamUK
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Cros J, Dalmay F, Yonnet S, Charpentier M, Tran-Van-Ho J, Renaudeau F, Drouet A, Guilbaut P, Marin B, Nathan N. Continuous hemoglobin and plethysmography variability index monitoring can modify blood transfusion practice and is associated with lower mortality. J Clin Monit Comput 2019; 34:683-691. [PMID: 31376030 DOI: 10.1007/s10877-019-00367-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/17/2019] [Indexed: 01/28/2023]
Abstract
To determine the effect of implementing an algorithm of fluid and blood administration based on continuous monitoring of hemoglobin (SpHb) and PVI (plethysmography variability index) on mortality and transfusion on a whole hospital scale. This single-center quality program compared transfusion at 48 h and mortality at 30 days and 90 days after surgery between two 11-month periods in 2013 and 2014 during which all the operating and recovery rooms and intensive care units were equipped with SpHb/PVI monitors. The entire team was trained to use monitors and the algorithm. Team members were free to decide whether or not to use devices. Each device was connected to an electronic wireless acquired database to anonymously acquire parameters on-line and identify patients who received the monitoring. All data were available from electronic files. Patients were divided in three groups; 2013 (G1, n = 9285), 2014 without (G2, n = 5856) and with (G3, n = 3575) goal-directed therapy. The influence of age, ASA class, severity and urgency of surgery and use of algorithm on mortality and blood use were analyzed with cox-proportional hazard models. Because in 2015, SpHb/PVI monitors were no longer available, we assessed post-study mortality observed in 2015 to measure the impact of team training to adjust vascular filling on a patient to patient basis. During non-cardiac surgery, blood was more often transfused during surgery in G3 patients as compared to G2 (66.6% vs. 50.7%, p < 0.001) but with fewer blood units per patient. After adjustment, survival analysis showed a lower risk of transfusion at 48 h in G3 [OR 0.79 (0.68-0.93), p = 0.004] but not in G2 [OR 0.90 (0.78-1.04) p = 0.17] as compared to G1. When adjusting to the severity of surgery as covariable, there was 0.5 and 0.7% differences of mortality at day 30 and 90 whether patients had goal directed therapy (GDT). After high risk surgery, the mortality at day 30 is reduced by 4% when using GDT, and 1% after intermediate risk surgery. There was no difference for low risk surgery. G3 Patients had a lower risk of death at 30 days post-surgery [OR 0.67 (0.49-0.92) p = 0.01] but not G2 patients [OR 1.01, (0.78-1.29), p = 0.96]. In 2015, mortality at 30 days and 90 days increased again to similar levels as those of 2013, respectively 2.18 and 3.09%. Monitoring SpHb and PVI integrated in a vascular filling algorithm is associated with earlier transfusion and reduced 30 and 90-day mortality on a whole hospital scale.
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Affiliation(s)
- Jérôme Cros
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France. .,Anesthésie Réanimation, Hôpital Mère-Enfant, Ave Docteur Larrey, 87042, Limoges, France. .,Département d'Anesthésie-Réanimation, Hôpital de la Mère et de l'enfant, 8, Avenue Dominique Larrey, 87000, Limoges, France.
| | - François Dalmay
- INSERM, U1094, Neuroépidémiologie Tropicale, 87000, Limoges, France.,Univ. Limoges, UMR_S 1094, Neuroépidémiologie Tropicale, Institut d'Epidémiologie Neurologique et de Neurologie Tropicale, CNRS FR, 3503 GEIST, 87000, Limoges, France.,CEBIMER, CHU Limoges, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Sandra Yonnet
- SIME, CHU Limoges, and Faculté de Médecine, Limoges, France
| | - Matthieu Charpentier
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Jessica Tran-Van-Ho
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - François Renaudeau
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Anais Drouet
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Pierre Guilbaut
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Benoit Marin
- INSERM, U1094, Neuroépidémiologie Tropicale, 87000, Limoges, France.,Univ. Limoges, UMR_S 1094, Neuroépidémiologie Tropicale, Institut d'Epidémiologie Neurologique et de Neurologie Tropicale, CNRS FR, 3503 GEIST, 87000, Limoges, France.,CEBIMER, CHU Limoges, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Nathalie Nathan
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France. .,Anesthésie Réanimation, Hôpital Mère-Enfant, Ave Docteur Larrey, 87042, Limoges, France.
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76
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Brienza N, Biancofiore G, Cavaliere F, Corcione A, De Gasperi A, De Rosa RC, Fumagalli R, Giglio MT, Locatelli A, Lorini FL, Romagnoli S, Scolletta S, Tritapepe L. Clinical guidelines for perioperative hemodynamic management of non cardiac surgical adult patients. Minerva Anestesiol 2019; 85:1315-1333. [PMID: 31213042 DOI: 10.23736/s0375-9393.19.13584-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.
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Affiliation(s)
- Nicola Brienza
- Unit of Anesthesia and Resuscitation, Department of Emergencies and Organ Transplantations, Aldo Moro University, Bari, Italy -
| | | | - Franco Cavaliere
- Unit of Cardiac Anesthesia and Cardiosurgical Intensive Therapy, A. Gemelli University Polyclinic, Sacred Heart Catholic University, Rome, Italy
| | - Antonio Corcione
- Operative Unit of Anesthesia and Intensive Postoperative Therapy, Department of Critical Area, Colli-Monaldi Hospital, Naples, Italy
| | - Andrea De Gasperi
- Operative Unit of Anesthesia and Resuscitation II, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Rosanna C De Rosa
- Operative Unit of Anesthesia and Intensive Postoperative Therapy, Department of Critical Area, Colli-Monaldi Hospital, Naples, Italy
| | - Roberto Fumagalli
- Operative Unit of Anesthesia and Resuscitation I, Milano Bicocca University, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Maria T Giglio
- Unit of Anesthesia and Resuscitation, Department of Emergencies and Organ Transplantations, Aldo Moro University, Bari, Italy
| | - Alessandro Locatelli
- Service of Anesthesia and Cardiovascular Intensive Therapy, Department of Emergency and Critical Area, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Ferdinando L Lorini
- Department of Emergency, Urgency and Critical Area, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Resuscitation, University of Florence, Careggi University Hospital, Florence, Italy
| | - Sabino Scolletta
- Unit of Resuscitation and Critical Medicine, Department of Medicine, Surgery and Neurosciences, University Hospital of Siena, Siena, Italy
| | - Luigi Tritapepe
- Operative Unit of Anesthesia and Intensive Therapy in Cardiosurgery, Department of Emergency and Admission, Anesthesia and Critical Areas, Umberto I Policlinic, Sapienza University, Rome, Italy
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77
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Elgendy MA, Esmat IM, Kassim DY. Outcome of intraoperative goal-directed therapy using Vigileo/FloTrac in high-risk patients scheduled for major abdominal surgeries: A prospective randomized trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2017.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Mohammed A. Elgendy
- Anesthesia and Intensive Care Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Ibrahim M. Esmat
- Anesthesia and Intensive Care Medicine, Ain Shams University Hospitals, 29-Ahmed Fuad St., Saint Fatima Square, Heliopolis, Cairo, 11361, Egypt
| | - Dina Y. Kassim
- Anesthesia and Intensive Care Medicine, BeniSweif University Hospitals, El Rehab City, Group 71, Building 15, New Cairo, 11841, Egypt
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78
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Fawcett WJ. Enhanced recovery after surgery pathways in gynecologic surgery: great strides already, but more still to come. Int J Gynecol Cancer 2019; 29:649-650. [PMID: 31064861 DOI: 10.1136/ijgc-2019-000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/03/2022] Open
Affiliation(s)
- William J Fawcett
- Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford GU2 7XX, UK
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79
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Closed-loop hemodynamic management. Best Pract Res Clin Anaesthesiol 2019; 33:199-209. [PMID: 31582099 DOI: 10.1016/j.bpa.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
As the operating room and intensive care settings become increasingly complex, the required vigilance practitioners must dedicate to a wide array of clinical systems has increased concordantly. The resulting shortage of available attention to these various clinical tasks creates a vacuum for the introduction of systems that can administer well-established goal-directed therapies without significant provider feedback. Recently, there has been an explosion of academic exploration into creating such automated systems, with a strong specific focus on hemodynamic control. Within this field, the largest focus has been on goal-directed fluid therapy as systems automating vasopressor administration have only recently become viable options. Our goal in this review article is to summarize the validity of the relevant goal-directed hemodynamic systems and explore the expanding role of automation within these systems.
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80
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Hasanin A, Mourad KH, Farouk I, Refaat S, Nabih A, Raouf SA, Ezzat H. The Impact of Goal-Directed Fluid Therapy in Prolonged Major Abdominal Surgery on Extravascular Lung Water and Oxygenation: A Randomized Controlled Trial. Open Access Maced J Med Sci 2019; 7:1276-1281. [PMID: 31110569 PMCID: PMC6514339 DOI: 10.3889/oamjms.2019.173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND: A growing interest had been paid to goal-directed fluid therapy (GDT) in abdominal surgery; however, its impact on the respiratory profile was not well investigated. AIM: We evaluated the impact of GDT on postoperative extravascular lung water and oxygenation after prolonged major abdominal surgery. METHODS: A randomised, controlled study was conducted in Kasr Alainy hospital from April 2016 till December 2017 including 120 adult patients scheduled for prolonged major abdominal surgery. Patients were randomised into either GDT group (n = 60) who received baseline restricted fluid therapy (2 mL/Kg/hour) which is guided by stroke volume variation, or control group (n = 60) who received standard care. Both study groups were compared according to hemodynamic data, fluid requirements, lung ultrasound score, and PaO2/fraction of inspired oxygen ratio (P/F ratio), RESULTS: Intraoperatively, GDT group received less volume of fluids and showed higher intraoperative mean arterial pressure compared to the control group. Postoperatively, lung ultrasound score was lower, and P/F ratio was higher in the GDT group compared to the control group. The number of patients who showed a significant postoperative increase in LUS was higher in the control group 44 (73%) patients versus 14 (23%) patients, P < 0.001). CONCLUSIONS: Using stroke volume variation for guiding fluid therapy in prolonged, major abdominal operations were associated with better hemodynamic profile, less intraoperative fluid administration, lower extravascular lung water and better oxygenation compared to standard care.
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Affiliation(s)
- Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Karim Hussein Mourad
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Inas Farouk
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Sherin Refaat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Nabih
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Sabah Abdel Raouf
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Hala Ezzat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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81
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Hübner M, Pache B, Solà J, Blanc C, Hahnloser D, Demartines N, Grass F. Thresholds for optimal fluid administration and weight gain after laparoscopic colorectal surgery. BJS Open 2019; 3:532-538. [PMID: 31388646 PMCID: PMC6677103 DOI: 10.1002/bjs5.50166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 02/26/2019] [Indexed: 12/20/2022] Open
Abstract
Background Perioperative fluid overload is an important modifiable risk factor for adverse outcomes after colorectal surgery. This study aimed to define critical thresholds for perioperative fluid management and postoperative weight gain for patients undergoing elective laparoscopic colorectal surgery. Methods This was an analysis of consecutive elective laparoscopic colorectal resections at Lausanne University Hospital from May 2011 to May 2017. Main outcomes were overall, major (Clavien–Dindo grade IIIb or above) and respiratory complications, and postoperative ileus. Thresholds regarding perioperative fluid management and postoperative weight gain were identified through receiver operating characteristic (ROC) analysis and clinical judgement. Independent risk factors for all four outcomes were assessed by multinominal logistic regression. Results Overall and major complications occurred in 210 (36·2 per cent) and 46 (7·9 per cent) of 580 patients respectively. Twenty‐three patients (4·0 per cent) had respiratory complications and 98 (16·9 per cent) had postoperative ileus. Median length of hospital stay was 5 (i.q.r. 3–9) days. Based on respiratory complications, thresholds for perioperative intravenous fluid administration (postoperative day (POD) 0) were set pragmatically at 3000 ml for colonic (calculated threshold 3120 ml (area under ROC curve (AUROC) 0·63)) and 4000 ml for rectal (AUROC 0·79) procedures. Postoperative weight gain of 2·5 kg at POD 2 was predictive of respiratory complications. Multivariable analysis retained perioperative intravenous fluid administration over the above thresholds as an independent risk factor for overall (odds ratio (OR) 2·25, 95 per cent c.i. 1·23 to 4·11), major (OR 2·49, 1·17 to 5·31) and respiratory (OR 4·71, 1·42 to 15·58) complications. Weight gain above 2·5 kg at POD 2 was identified as a risk factor for respiratory complications (OR 3·58, 1·10 to 11·70) and ileus (OR 1·82, 1·02 to 3·52). Conclusion Perioperative intravenous fluid and weight thresholds were associated with postoperative adverse outcomes. These thresholds need independent validation.
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Affiliation(s)
- M Hübner
- Department of Visceral Surgery Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - B Pache
- Department of Visceral Surgery Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - J Solà
- Centre Suisse d'Electronique et de Microtechnique Neuchâtel Switzerland
| | - C Blanc
- Department of Anaesthesiology Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - D Hahnloser
- Department of Visceral Surgery Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - N Demartines
- Department of Visceral Surgery Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - F Grass
- Department of Visceral Surgery Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
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82
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Fawcett WJ, Thomas M. Pre-operative chewing gum, and carbohydrates - a reply. Anaesthesia 2019; 74:541-542. [DOI: 10.1111/anae.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- W. J. Fawcett
- Royal Surrey County Hospital NHS Foundation Trust; Guildford UK
| | - M. Thomas
- Great Ormond Street Hospital for Children; NHS Foundation Trust; London UK
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83
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Perioperative Fluid Strategies to Prevent Lung Injury. Int Anesthesiol Clin 2019; 56:107-117. [PMID: 29189438 DOI: 10.1097/aia.0000000000000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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84
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Boisson M, Poignard ME, Pontier B, Mimoz O, Debaene B, Frasca D. Cardiac output monitoring with thermodilution pulse‐contour analysis vs. non‐invasive pulse‐contour analysis. Anaesthesia 2019; 74:735-740. [DOI: 10.1111/anae.14638] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2019] [Indexed: 11/28/2022]
Affiliation(s)
- M. Boisson
- Service d'anesthésie‐réanimation CHU de Poitiers France
| | | | - B. Pontier
- Service d'anesthésie‐réanimation CHU de Poitiers France
| | - O. Mimoz
- Service des Urgences CHU de Poitiers France
| | - B. Debaene
- Service d'anesthésie‐réanimation CHU de Poitiers France
| | - D. Frasca
- Service d'anesthésie‐réanimation CHU de Poitiers France
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85
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Hendrix RJ, Lambert LA. ASO Author Reflections: Intraoperative Fluid Restriction During CRS-HIPEC-Less is More. Ann Surg Oncol 2019; 26:575-576. [PMID: 30838480 DOI: 10.1245/s10434-019-07283-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Laura A Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA. .,Peritoneal Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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86
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:454-465. [DOI: 10.1213/ane.0000000000003663] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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87
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 1056] [Impact Index Per Article: 211.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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88
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick E, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:441-453. [DOI: 10.1213/ane.0000000000003564] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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89
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Ban KA, Berian JR, Ko CY. Does Implementation of Enhanced Recovery after Surgery (ERAS) Protocols in Colorectal Surgery Improve Patient Outcomes? Clin Colon Rectal Surg 2019; 32:109-113. [PMID: 30833859 DOI: 10.1055/s-0038-1676475] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Enhanced Recovery after Surgery (ERAS) protocols are multimodal perioperative care pathways designed to accelerate recovery by minimizing the physiologic stress of a surgical procedure. Benefits of ERAS implementation in colorectal surgery include reduced length of stay and decreased complications without an increase in readmissions. Though there is evidence associating individual ERAS protocol elements (e.g., preoperative carbohydrate loading, judicious perioperative fluid administration, and early initiation of postoperative nutrition) with improved outcomes, ensuring high compliance with all elements of an ERAS protocol will maximize benefits to the patient. After ERAS implementation, data collection on protocol process measures can help providers target education and interventions to improve protocol compliance and patient outcomes.
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Affiliation(s)
- Kristen A Ban
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Julia R Berian
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, University of Chicago, Chicago, Illinois
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, University of California Los Angeles, Los Angeles, California
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90
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Zhu ACC, Agarwala A, Bao X. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clin Colon Rectal Surg 2019; 32:114-120. [PMID: 30833860 DOI: 10.1055/s-0038-1676476] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Fluid management is an essential component of the Enhanced Recovery after Surgery (ERAS) pathway. Optimal management begins in the preoperative period and continues through the intraoperative and postoperative phases. In this review, we outline current evidence-based practices for fluid management through each phase of the perioperative period. Preoperatively, patients should be encouraged to hydrate until 2 hours prior to the induction of anesthesia with a carbohydrate-containing clear liquid. When mechanical bowel preparation is necessary, with modern isoosmotic solutions, fluid repletion is not necessary. Intraoperatively, fluid therapy should aim to maintain euvolemia with an individualized approach. While some patients may benefit from goal-directed fluid therapy, a restrictive, zero-balance approach to intraoperative fluid management may be reasonable. Postoperatively, early initiation of oral intake and cessation of intravenous therapy are recommended.
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Affiliation(s)
- Alyssa Cheng-Cheng Zhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aalok Agarwala
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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91
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Lohsiriwat V, Jitmungngan R. Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices. World J Gastrointest Surg 2019; 11:41-52. [PMID: 30842811 PMCID: PMC6397799 DOI: 10.4240/wjgs.v11.i2.41] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 02/06/2023] Open
Abstract
Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.
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Affiliation(s)
- Varut Lohsiriwat
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Romyen Jitmungngan
- Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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92
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Analysis of Goal-directed Fluid Therapy and Patient Monitoring in Enhanced Recovery After Surgery. Int Anesthesiol Clin 2019; 55:21-37. [PMID: 28901979 DOI: 10.1097/aia.0000000000000159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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93
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Mungroop TH, Geerts BF, Veelo DP, Pawlik TM, Bonnet A, Lesurtel M, Reyntjens KM, Noji T, Liu C, Jonas E, Wu CL, de Santibañes E, Abu Hilal M, Hollmann MW, Besselink MG, van Gulik TM. Fluid and pain management in liver surgery (MILESTONE): A worldwide study among surgeons and anesthesiologists. Surgery 2019; 165:337-344. [DOI: 10.1016/j.surg.2018.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/17/2018] [Accepted: 08/12/2018] [Indexed: 02/07/2023]
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94
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Elias KM, Stone AB, McGinigle K, Tankou JI, Scott MJ, Fawcett WJ, Demartines N, Lobo DN, Ljungqvist O, Urman RD. The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS ® and ERAS ® USA Societies. World J Surg 2019; 43:1-8. [PMID: 30116862 PMCID: PMC6313353 DOI: 10.1007/s00268-018-4753-0] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. METHODS To improve the quality of ERAS reporting, ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus. RESULTS The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines. CONCLUSIONS The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals.
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Affiliation(s)
- Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Alexander B Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katharine McGinigle
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jo'An I Tankou
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, VA, USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital and University of Surrey, Guilford, UK
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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95
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Vistisen ST, Keus E, Scheeren TWL. Methodology in systematic reviews of goal-directed therapy: improving but not perfect. Br J Anaesth 2018; 119:18-21. [PMID: 28974083 DOI: 10.1093/bja/aex206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- S T Vistisen
- Research Centre for Emergency Medicine, Institute of Clinical Medicine, Aarhus University, Denmark.,Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark.,University of Groningen, University Medical Center Groningen, Department of Anaesthesiology, Groningen, The Netherlands
| | - E Keus
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
| | - T W L Scheeren
- University of Groningen, University Medical Center Groningen, Department of Anaesthesiology, Groningen, The Netherlands
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96
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Hendrix RJ, Damle A, Williams C, Harris A, Spanakis S, Lambert DH, Lambert LA. Restrictive Intraoperative Fluid Therapy is Associated with Decreased Morbidity and Length of Stay Following Hyperthermic Intraperitoneal Chemoperfusion. Ann Surg Oncol 2018; 26:490-496. [PMID: 30515670 DOI: 10.1245/s10434-018-07092-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent data have demonstrated multiple benefits of intra- and postoperative fluid restriction in major abdominal surgery; however, data regarding the outcomes of fluid restriction in cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) are limited. This study evaluates the safety and short-term clinical outcomes of restricted intraoperative fluid therapy in CRS/HIPEC. METHODS This was a single-institution, retrospective review of all CRS/HIPEC procedures performed at the University of Massachusetts Medical School between January 2009 and July 2017. Recorded variables included demographics, intraoperative factors, 60-day postoperative complications, and length of stay (LOS). Outcomes based on the use of intraoperative permissive fluid therapy (PFT) versus restrictive fluid therapy (RFT) were compared. RESULTS Overall, 169 CRS/HIPEC cases were performed during the study period; 84 were managed with PFT and 85 were managed with RFT. No significant differences were identified in patient demographics. There was a decrease in intraoperative administration of crystalloid (8.0 vs. 4.4 L, p < 0.01), colloid (900 vs. 300 mL, p < 0.01), and blood transfusion (0.26 vs. 0.04 units, p < 0.01) in the RFT cohort. LOS was reduced from 11.5 to 9.7 days (p < 0.01) and the incidence of any 60-day complication decreased from 45 to 28% (p = 0.02) in the RFT group. The overall 90-day mortality rate was 0.6% (n = 1). Adjusted logistic regression demonstrated the odds of having a Clavien-Dindo grade III or higher complication was 0.31 (95% confidence interval 0.10-0.95) with RFT. CONCLUSION Intraoperative RFT with standard anesthesia monitoring devices can be safely used in CRS/HIPEC and is associated with a decreased LOS and decreased rate of postoperative complications.
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Affiliation(s)
- Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Aneel Damle
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Chloe Williams
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ariana Harris
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Spiro Spanakis
- Division of Perioperative Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Donald H Lambert
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA
| | - Laura A Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA. .,Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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97
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98
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99
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Buhrman WC, Lyman WB, Kirks RC, Passeri M, Vrochides D. Current State of Enhanced Recovery After Surgery in Hepatopancreatobiliary Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:1471-1475. [DOI: 10.1089/lap.2018.0314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- William C. Buhrman
- Department of Anesthesiology, Carolinas Medical Center, Charlotte, North Carolina
| | - William B. Lyman
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Russell C. Kirks
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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100
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Sulzer JK, Sastry AV, Meyer LM, Cochran A, Buhrman WC, Baker EH, Martinie JB, Iannitti DA, Vrochides D. The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy. Ann Med Surg (Lond) 2018; 36:23-28. [PMID: 30370053 PMCID: PMC6199772 DOI: 10.1016/j.amsu.2018.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Optimal fluid balance is critical to minimize anastomotic edema in patients undergoing pancreaticoduodenectomy. We examined the effects of decreased fluid administration on rates of postoperative pancreatic leak and delayed gastric emptying. METHODS Retrospective study of 105 patients undergoing pancreaticoduodenectomy at a single institution from January 2015 through July 2016. Stroke volume variation (SVV) was tracked and titrated during the procedure. A comparative analysis of postoperative complications was performed between patients with a median SVV < 12 during the extirpative and reconstructive phases of the procedure compared with patients with an SVV ≥ 12. RESULTS Of 64 patients who met selection criteria, 42 (65.6%) had a SVV < 12 and 22 (34.4%) had a SVV ≥ 12. Patients with an SVV ≥ 12 during the extirpative phase of the procedure had lower rates of postoperative pancreatic leaks compared to patients with an SVV < 12 (5.9% vs 21.3%)). Patients with an SVV ≥ 12 during the extirpative phase had lower rates of postoperative delayed gastric emptying compared to patients with an SVV < 12 (41.2% vs 46.8%). CONCLUSION Goal-directed fluid restriction before the reconstructive phase of pancreaticoduodenectomy may contribute to lower postoperative rates of pancreatic leak and delayed gastric emptying.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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