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Fluid Therapy: Double-Edged Sword during Critical Care? BIOMED RESEARCH INTERNATIONAL 2015; 2015:729075. [PMID: 26798642 PMCID: PMC4700172 DOI: 10.1155/2015/729075] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/25/2015] [Indexed: 12/11/2022]
Abstract
Fluid therapy is still the mainstay of acute care in patients with shock or cardiovascular compromise. However, our understanding of the critically ill pathophysiology has evolved significantly in recent years. The revelation of the glycocalyx layer and subsequent research has redefined the basics of fluids behavior in the circulation. Using less invasive hemodynamic monitoring tools enables us to assess the cardiovascular function in a dynamic perspective. This allows pinpointing even distinct changes induced by treatment, by postural changes, or by interorgan interactions in real time and enables individualized patient management. Regarding fluids as drugs of any other kind led to the need for precise indication, way of administration, and also assessment of side effects. We possess now the evidence that patient centered outcomes may be altered when incorrect time, dose, or type of fluids are administered. In this review, three major features of fluid therapy are discussed: the prediction of fluid responsiveness, potential harms induced by overzealous fluid administration, and finally the problem of protocol-led treatments and their timing.
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102
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Hodgson LE, Venn R, Forni LG, Samuels TL, Wakeling HG. Measuring the cardiac output in acute emergency admissions: use of the non-invasive ultrasonic cardiac output monitor (USCOM) with determination of the learning curve and inter-rater reliability. J Intensive Care Soc 2015; 17:122-128. [PMID: 28979476 DOI: 10.1177/1751143715619186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Traditionally, assessment of the cardiac output has been limited to theatre or the intensive care unit. However, non-invasive cardiac output estimation is now readily available, and its application may have wider benefit in the emergency setting. The non-invasive ultrasonic cardiac output monitor (USCOM) was investigated to determine its learning curve and inter-rater reliability. Four trainee operators each performed stroke volume measurements on 25 volunteers, compared to an experienced operator pre- and post-passive leg raise. Inter-rater reliability was then assessed on 24 acute emergency in-patients. Mean percentage difference in stroke volume decreased from 19% (95% confidence intervals 14-23) across volunteers 1-5, to 6% (4-8) for the last 5 volunteers scanned. Consequently, on acute emergency in-patients, excellent inter-rater reliability (Lin's concordance correlation coefficient (ρc) 0.96 (0.92-0.98)) and agreement of a change ≥10% in stroke volume following passive leg raise on 23/24 cases were found. Following a training period of less than 5 h, USCOM stroke volume measurements demonstrated excellent inter-rater reliability.
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Affiliation(s)
- Luke E Hodgson
- Anaesthetics & Intensive Care Department, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, Worthing, UK.,Primary Care and Population Sciences, University of Southampton, Southampton General Hospital, Southampton, Hampshire, UK
| | - Richard Venn
- Anaesthetics & Intensive Care Department, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, Worthing, UK
| | - Lui G Forni
- Intensive Care Department, The Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Theophilus L Samuels
- Intensive Care Department, The Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Howard G Wakeling
- Anaesthetics & Intensive Care Department, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, Worthing, UK
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103
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Abstract
Emergency abdominal surgery has a high mortality, with an incidence of around 15% for all patients. Mortality in elderly patients is up to 25%, and 1-year mortality for emergent colorectal resection for patients over 80 years is around 50%. Patients presenting to hospital are often given low priority. Definitive surgery is not always possible and it may be more important to control the septic focus and to revisit surgery later. The literature is poor for such a common procedure, but there is evidence that a standardized pathway focusing on rapid diagnosis; resuscitation; sepsis treatment; and, if appropriate, urgent surgery followed by admission to intensive care improves outcomes.
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Affiliation(s)
- Carol Peden
- Royal United Hospital, Combe Park, Bath BA1 3NG, UK.
| | - Michael J Scott
- Department of Anesthesia and Perioperative Medicine, Royal Surrey County Hospital NHS Foundation Trust, Surrey, Guildford GU1 7XX, UK; Surrey Perioperative Anesthesia Critical Care Research Group (SPACeR), University of Surrey, Surrey, Guildford GU2 7XH, UK
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104
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Abstract
Anesthesiologists play a pivotal role in facilitating recovery of patients undergoing colorectal surgery, as many Enhanced Recovery After Surgery (ERAS) elements are under their direct control. Successful implementation of ERAS programs requires that anesthesiologists become more involved in perioperative care and more aware of the impact of anesthetic techniques on surgical outcomes and recovery. Key to achieving success is strict adherence to the principle of aggregation of marginal gains. This article reviews anesthetic and analgesic care of patients undergoing elective colorectal surgery in the context of an ERAS program, and also discusses anesthesia considerations for emergency colorectal surgery.
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Affiliation(s)
- Gabriele Baldini
- Department of Anesthesia, Montreal General Hospital, McGill University Health Centre, 1650 Avenue Cedar, Montreal, Quebec H3G 1A4, Canada.
| | - William J Fawcett
- Royal Surrey County Hospital, Postgraduate School, University of Surrey, Guildford GU2 7XX, UK
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105
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Benes J, Haidingerova L, Pouska J, Stepanik J, Stenglova A, Zatloukal J, Pradl R, Chytra I, Kasal E. Fluid management guided by a continuous non-invasive arterial pressure device is associated with decreased postoperative morbidity after total knee and hip replacement. BMC Anesthesiol 2015; 15:148. [PMID: 26471495 PMCID: PMC4608292 DOI: 10.1186/s12871-015-0131-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 10/07/2015] [Indexed: 12/14/2022] Open
Abstract
Background The use of goal directed fluid protocols in intermediate risk patients undergoing hip or knee replacement was studied in few trials using invasive monitoring. For this reason we have implemented two different fluid management protocols, both based on a novel totally non-invasive arterial pressure monitoring device and compared them to the standard (no-protocol) treatment applied before the transition in our academic institution. Methods Three treatment groups were compared in this prospective study: the observational (CONTROL, N = 40) group before adoption of fluid protocols and two randomized groups after the transition to protocol fluid management with the use of the continuous non-invasive blood pressure monitoring (CNAP®) device. In the PRESSURE group (N = 40) standard variables were used for restrictive fluid therapy. Goal directed fluid therapy using pulse pressure variation was used in the GDFT arm (N = 40). The influence on the rate of postoperative complications, on the hospital length of stay and other parameters was assessed. Results Both protocols were associated with decreased fluid administration and maintained hemodynamic stability. Reduced rate of postoperative infection and organ complications (22 (55 %) vs. 33 (83 %) patients; p = 0.016; relative risk 0.67 (0.49–0.91)) was observed in the GDFT group compared to CONTROL. Lower number of patients receiving transfusion (4 (10 %) in GDFT vs. 17 (43 %) in CONTROL; p = 0.005) might contribute to this observation. No significant differences were observed in other end-points. Conclusion In our study, the use of the fluid protocol based on pulse pressure variation assessed using continuous non-invasive arterial pressure measurement seems to be associated with a reduction in postoperative complications and transfusion needs as compared to standard no-protocol treatment. Trial registration ACTRN12612001014842 Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0131-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jan Benes
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic.
| | - Lenka Haidingerova
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
| | - Jiri Pouska
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
| | - Jan Stepanik
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
| | - Alena Stenglova
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
| | - Jan Zatloukal
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
| | - Richard Pradl
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
| | - Ivan Chytra
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
| | - Eduard Kasal
- Department of Anesthesia and Intensive Care Medicine, Teaching Hospital and Faculty of Medicine in Plzen, Charles University Prague, alej Svobody 80, 306 40, Plzen, Czech Republic
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Non-ventilatory approaches to prevent postoperative pulmonary complications. Best Pract Res Clin Anaesthesiol 2015; 29:397-410. [PMID: 26643103 DOI: 10.1016/j.bpa.2015.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/27/2015] [Accepted: 08/28/2015] [Indexed: 02/07/2023]
Abstract
This educational narrative review provides a summary of non-ventilatory strategies to prevent postoperative pulmonary complications (PPCs). It highlights patient- and procedure-related risk factors for PPCs that are non-modifiable, potentially modifiable, or well modifiable. Non-ventilatory strategies, mainly based on the modification of risk factors, play a key role in reducing PPCs. Non-modifiable risk factors, most importantly age, American Society of Anesthesiologists (ASA) class, and risk of the procedure, should be recognized and patients intensively screened for the potential to optimize other, potentially or well-modifiable, risk factors. Potentially modifiable risk factors, mainly comorbidities and the surgical approach, increase the risk of PPCs. Patient-related factors can be improved while procedure-related factors may be adapted in high-risk patients. Well-modifiable risk factors, mainly certain anesthesia techniques, for example, general anesthesia, intravenous opioids or liberal fluid management, and smoking or alcohol abuse, should be avoided as far as possible in order to prevent PPCs.
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108
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Watt DG, McSorley ST, Horgan PG, McMillan DC. Enhanced Recovery After Surgery: Which Components, If Any, Impact on The Systemic Inflammatory Response Following Colorectal Surgery?: A Systematic Review. Medicine (Baltimore) 2015; 94:e1286. [PMID: 26356689 PMCID: PMC4616657 DOI: 10.1097/md.0000000000001286] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Enhanced Recovery or Fast Track Recovery after Surgery protocols (ERAS) have significantly changed perioperative care following colorectal surgery and are promoted as reducing the stress response to surgery.The present systematic review aimed to examine the impact on the magnitude of the systemic inflammatory response (SIR) for each ERAS component following colorectal surgery using objective markers such as C-reactive protein (CRP) and interleukin-6 (IL-6).A literature search was performed of the US National Library of Medicine (MEDLINE), EMBASE, PubMed, and the Cochrane Database of Systematic Reviews using appropriate keywords and subject headings to February 2015.Included studies had to assess the impact of the selected ERAS component on the SIR using either CRP or IL-6.Nineteen studies, including 1898 patients, were included. Fourteen studies (1246 patients) examined the impact of laparoscopic surgery on the postoperative markers of SIR. Ten of these studies (1040 patients) reported that laparoscopic surgery reduced postoperative CRP. One study (53 patients) reported reduced postoperative CRP using opioid-minimising analgesia. One study (142 patients) reported no change in postoperative CRP following preoperative carbohydrate loading. Two studies (108 patients) reported conflicting results with respect to the impact of goal-directed fluid therapy on postoperative IL-6. No studies examined the effect of other ERAS components, including mechanical bowel preparation, antibiotic prophylaxis, thromboprophylaxis, and avoidance of nasogastric tubes and peritoneal drains on markers of the postoperative SIR following colorectal surgery.The present systematic review shows that, with the exception of laparoscopic surgery, objective evidence of the effect of individual components of ERAS protocols in reducing the stress response following colorectal surgery is limited.
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Affiliation(s)
- David G Watt
- From the Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland
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109
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Gillies MA, Shah ASV, Mullenheim J, Tricklebank S, Owen T, Antonelli J, Strachan F, Mills NL, Pearse RM. Perioperative myocardial injury in patients receiving cardiac output-guided haemodynamic therapy: a substudy of the OPTIMISE Trial. Br J Anaesth 2015; 115:227-33. [PMID: 26001837 DOI: 10.1093/bja/aev137] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2015] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Evidence suggests that cardiac output-guided haemodynamic therapy algorithms improve outcomes after high-risk surgery, but there is some concern that this could promote acute myocardial injury. We evaluated the incidence of myocardial injury in a perioperative goal-directed therapy trial. METHODS Patients undergoing major gastrointestinal surgery (n=723) were randomly assigned to cardiac output-guided haemodynamic therapy (intervention group) or usual care as part of the OPTIMISE trial. At four participating sites, 288 patients were enrolled in a biomarker substudy. Serum high-sensitivity cardiac troponin I (TnI) concentration and N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration were measured before and at 24 and 72 h after surgery. RESULTS Median preoperative TnI and NT-ProBNP concentrations were 4.3 ng litre(-1) and 144 pg ml(-1), respectively. After surgery, 67 (46%) patients in the intervention group and 68 (48%) patients receiving usual care had TnI concentrations above the 99th centile upper reference limit (P=0.82). Peak serum TnI concentration was similar in the intervention and usual care groups (median [interquartile range]: 10.0 [5.3-21.5] vs 7.8 [5.0-21.8] ng litre(-1); P=0.85), and no differences were observed in serum TnI concentrations over 72 h (repeated-measures anova, P=0.51). Likewise, there were no differences in peak NT-proBNP concentration between intervention and usual care groups (645 [362-1169] vs 659 [381-1028] pg ml(-1); P=0.86) or in serial NT-proBNP concentrations over 72 h (P=0.20). CONCLUSIONS Myocardial injury is common among patients undergoing major gastrointestinal surgery. In this study, the frequency was not affected by cardiac output-guided fluid and low-dose inotropic therapy.
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Affiliation(s)
- M A Gillies
- Department of Critical Care, University of Edinburgh, Edinburgh, UK
| | - A S V Shah
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - J Mullenheim
- The James Cook University Hospital, Middlesbrough, UK
| | - S Tricklebank
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - T Owen
- Lancashire Teaching Hospitals NHS Trust, Preston, UK
| | - J Antonelli
- Department of Critical Care, University of Edinburgh, Edinburgh, UK
| | - F Strachan
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - N L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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110
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Jammer I, Tuovila M, Ulvik A. Stroke volume variation to guide fluid therapy: is it suitable for high-risk surgical patients? A terminated randomized controlled trial. Perioper Med (Lond) 2015. [PMID: 26203353 PMCID: PMC4511544 DOI: 10.1186/s13741-015-0016-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Perioperative goal-directed fluid therapy (GDFT) may improve outcome after high-risk surgery. Minimal invasive measurement of stroke volume variation (SVV) has been recommended to guide fluid therapy. We intended to study how perioperative GDFT with arterial-based continuous SVV monitoring influences postoperative complications in a high-risk surgical population. Methods From February 1st 2012, all ASA 3 and 4 patients undergoing abdominal surgery in two university hospitals were assessed for randomization into a control group or GDFT group. An arterial-line cardiac output monitor was used to measure SVV, and fluid was given after an algorithm in the intervention group. Restrictions of the method excluded patients undergoing laparoscopic surgery, patients with atrial fibrillation and patients with severe mitral/aortal stenosis. To detect a decrease in number of complication from 40 % in the control group to 20 % in the GDFT group, n = 164 patients were needed (power 80 %, alpha 0.05, two-sided test). To include the needed amount of patients, the study was estimated to last for 2 years. Results After 1 year, 30 patients were included and the study was halted due to slow inclusion rate. Of 732 high-risk patients scheduled for abdominal surgery, 391 were screened for randomization. Of those, n = 249 (64 %) were excluded because a laparoscopic technique was preferred and n = 95 (24 %) due to atrial fibrillation. Conclusions Our study was stopped due to a slow inclusion rate. Methodological restrictions of the arterial-line cardiac output monitor excluded the majority of patients. This leaves the question if this method is appropriate to guide fluid therapy in high-risk surgical patients. Trial registration ClinicalTrials.gov: NCT01473446. Electronic supplementary material The online version of this article (doi:10.1186/s13741-015-0016-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ib Jammer
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway ; Department of Anaesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway
| | - Mari Tuovila
- Department of Anesthesiology and Intensive Care, Oulu University Hospital, PL 21, 90029 Oulu, Finland
| | - Atle Ulvik
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway
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111
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De Santis V, Singer M. Tissue oxygen tension monitoring of organ perfusion: rationale, methodologies, and literature review. Br J Anaesth 2015. [PMID: 26198717 DOI: 10.1093/bja/aev162] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Tissue oxygen tension is the partial pressure of oxygen within the interstitial space of an organ bed. As it represents the balance between local oxygen delivery and consumption at any given time, it offers a ready monitoring capability to assess the adequacy of tissue perfusion relative to local demands. This review covers the various methodologies used to measure tissue oxygen tension, describes the underlying physiological and pathophysiological principles, and summarizes human and laboratory data published to date.
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Affiliation(s)
- V De Santis
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
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112
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Cannesson M, Ramsingh D, Rinehart J, Demirjian A, Vu T, Vakharia S, Imagawa D, Yu Z, Greenfield S, Kain Z. Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study. Crit Care 2015; 19:261. [PMID: 26088649 PMCID: PMC4512146 DOI: 10.1186/s13054-015-0945-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/07/2015] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention. METHODS This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database). RESULTS In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1-13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7-9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6-16) days to 7 (5-11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18% (95% confidence interval 9-27%). The incidence of NSQIP complications decreased from 39% to 25% (p = 0.04). CONCLUSION These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries. TRIAL REGISTRATION Clinicaltrials.gov NCT02057653. Registered 17 December 2013.
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Affiliation(s)
- Maxime Cannesson
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
- Health Policy Research Institute, University of California, Irvine, CA, USA.
| | - Davinder Ramsingh
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Aram Demirjian
- Department of Surgery, University of California, Irvine, CA, USA.
| | - Trung Vu
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Shermeen Vakharia
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - David Imagawa
- Department of Surgery, University of California, Irvine, CA, USA.
| | - Zhaoxia Yu
- Department of Statistics, University of California, Irvine, CA, USA.
| | - Sheldon Greenfield
- Health Policy Research Institute, University of California, Irvine, CA, USA.
| | - Zeev Kain
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
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113
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Haas SA, Saugel B, Trepte CJ, Reuter DA. [Goal-directed hemodynamic therapy: Concepts, indications and risks]. Anaesthesist 2015; 64:494-505. [PMID: 26081011 DOI: 10.1007/s00101-015-0035-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Goal-directed hemodynamic therapy is becoming increasingly more interesting for anesthesiologists and intensive care physicians. Meta-analyses of studies evaluating perioperative therapy algorithms demonstrated a reduction of postoperative morbidity compared to the previous clinical practices. In this review article the basic concepts of goal-directed hemodynamic therapy and the principles of previously employed therapy algorithms are described and discussed. Furthermore, the questions of how these therapy strategies can be transferred into daily clinical practice and whether these therapeutic approaches might even bear risks for patients are elucidated.
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Affiliation(s)
- S A Haas
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland,
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114
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Parke RL, McGuinness SP, Gilder E, McCarthy LW, Cowdrey KAL. A randomised feasibility study to assess a novel strategy to rationalise fluid in patients after cardiac surgery. Br J Anaesth 2015; 115:45-52. [PMID: 25991758 DOI: 10.1093/bja/aev118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND After cardiac surgery, patients receive large amounts of fluid in the Intensive Care Unit (ICU). We plan to conduct a multi-centre randomised controlled trial, of a conservative fluid regime, in patients after cardiac surgery, and have reported results of a feasibility study that evaluated efficacy and safety of the proposed regime. METHODS After ethical approval, a single-centre, prospectively randomised interventional study was undertaken. Participants were randomised to either usual care, or to a protocolised algorithm, utilising stroke volume variation, to guide fluid administration to patients who were deemed to have inadequate cardiac output and were likely to be volume responsive. The study protocol lasted from ICU admission to de-sedation or 24 h, whichever occurred first. RESULTS We randomised 144 subjects over 9 months. Less bolus fluid and less total overall fluid volume was administered in the intervention group (median (IQR) 1620 ml (500-3410) and 2525 ml (1440-5250; P<0.001), compared with the usual care group (2050 ml (910-4280) and 2980 ml (2070-6580; P=0.001), from ICU admission to extubation. There was no significant difference in incidence of acute kidney injury or the average amount of fluid administered to the usual care group at the beginning compared with the end of the study. CONCLUSION It is both possible and safe to achieve a significant reduction in the amount of fluid administered to patients, allocated to a conservative fluid protocol. These results suggest that a planned multi-centre study is both justified and feasible. CLINICAL TRIAL REGISTRATION Australia New Zealand Clinical Trials Registry www.anzctr.org.au (ACTRN12612000754842).
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Affiliation(s)
- R L Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia Medical Research Institute of New Zealand, Wellington, New Zealand
| | - S P McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia Medical Research Institute of New Zealand, Wellington, New Zealand
| | - E Gilder
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - L W McCarthy
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - K-A L Cowdrey
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
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Stens J, de Wolf SP, van der Zwan RJ, Koning NJ, Dekker NA, Hering JP, Boer C. Microcirculatory Perfusion During Different Perioperative Hemodynamic Strategies. Microcirculation 2015; 22:267-75. [DOI: 10.1111/micc.12194] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/11/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Jurre Stens
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Steven P. de Wolf
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - René J. van der Zwan
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Nick J. Koning
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Nicole A.M. Dekker
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | | | - Christa Boer
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
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116
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Pavlovic G, Diaper J, Ellenberger C, Frei A, Bendjelid K, Bonhomme F, Licker M. Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial. J Clin Monit Comput 2015; 30:87-99. [PMID: 25851818 DOI: 10.1007/s10877-015-9691-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/31/2015] [Indexed: 02/06/2023]
Abstract
Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P < 0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2 ± 2.5 versus 6.6 ± 2.2 in the control group, P = 0.001), POD2 (8.4 ± 2.6 vs 5.0 ± 2.4 in the control group, P = 0.002) and POD 3 (5.2 ± 3.6 and 2.2 ± 1.3 in the control group, P = 0.01). There was no significant difference in hospital mortality (13 % in the control group and 25 % in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.
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Affiliation(s)
- Gordana Pavlovic
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - John Diaper
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Angela Frei
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Karim Bendjelid
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.,Faculty of medecine, University of Geneva, Geneva, Switzerland
| | - Fanny Bonhomme
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland. .,Faculty of medecine, University of Geneva, Geneva, Switzerland.
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117
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Saugel B, Cecconi M, Wagner J, Reuter D. Noninvasive continuous cardiac output monitoring in perioperative and intensive care medicine. Br J Anaesth 2015; 114:562-75. [DOI: 10.1093/bja/aeu447] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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118
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Moppett IK, Rowlands M, Mannings A, Moran CG, Wiles MD. LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review. Br J Anaesth 2015; 114:444-59. [PMID: 25500940 DOI: 10.1093/bja/aeu386] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hip fracture is a condition with high mortality and morbidity in elderly frail patients. Intraoperative fluid optimization may be associated with benefit in this population. We investigated whether intraoperative fluid management using pulse-contour analysis cardiac monitoring, compared with standard care in patients undergoing spinal anaesthesia, would provide benefits in terms of reduced time until medically fit for discharge and postoperative complications. METHODS Patients undergoing surgical repair of fractured neck of femur, aged >60 yr, receiving spinal anaesthesia were enrolled in this single-centre, blinded, randomized, parallel group trial. Patients were allocated to either anaesthetist-directed fluid therapy or a pulse-contour-guided fluid optimization strategy using colloid (Gelofusine) boluses to optimize stroke volume. The primary outcome was time until medically fit for discharge. Secondary outcomes included postoperative complications, mobility, and mortality. We updated a systematic review to include relevant trials to 2014. RESULTS We recruited 130 patients. Time until medically fit for discharge was similar in both groups, mean [95% confidence interval (CI)] 12.2 (11.1-13.5) vs 13.1 (11.9-14.5) days (P=0.31), as was total length of stay 14.2 (12.9-15.8) vs 15.3 (13.8-17.2) days (P=0.32). There were no significant differences in complications, function, or mortality. An updated meta-analysis (four studies, 355 patients) found non-significant reduction in early mortality [relative risk 0.66 (0.24-1.79)] and in-hospital complications [relative risk 0.80 (0.61-1.05)]. CONCLUSIONS Goal-directed fluid therapy during hip fracture repair under spinal anaesthesia does not result in a significant reduction in length of stay or postoperative complications. There is insufficient evidence to either support or discount its routine use. CLINICAL TRIAL REGISTRATION ISRCTN88284896.
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Affiliation(s)
- I K Moppett
- Anaesthesia and Critical Care, Division of Clinical Neuroscience , Queen's Medical Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham NG7 2UH, UK
| | - M Rowlands
- Anaesthesia and Critical Care, Division of Clinical Neuroscience , Queen's Medical Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham NG7 2UH, UK
| | - A Mannings
- Anaesthesia and Critical Care, Division of Clinical Neuroscience , Queen's Medical Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham NG7 2UH, UK
| | - C G Moran
- Department of Trauma and Orthopaedics, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham NG7 2UH, UK
| | - M D Wiles
- Department of Anaesthetics, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield S10 2JF, UK
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119
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Joosten A, Huynh T, Suehiro K, Canales C, Cannesson M, Rinehart J. Goal-Directed fluid therapy with closed-loop assistance during moderate risk surgery using noninvasive cardiac output monitoring: A pilot study. Br J Anaesth 2015; 114:886-92. [PMID: 25690834 DOI: 10.1093/bja/aev002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Goal directed fluid therapy (GDFT) has been shown to improve outcomes in moderate to high-risk surgery. However, most of the present GDFT protocols based on cardiac output optimization use invasive devices and the protocols may require significant practitioner attention and intervention to apply them accurately. The aim of this prospective pilot study was to evaluate the clinical feasibility of GDFT using a closed-loop fluid administration system with a non-invasive cardiac output monitoring device (Nexfin™, BMEYE, Amsterdam, Netherlands). METHODS Patients scheduled for elective moderate risk surgery under general anaesthesia were enrolled. The primary anaesthesia team managing the case selected GDFT targets using the controller interface and all patients received a baseline 3 ml kg(-1) h(-1) crystalloid infusion. Colloid solutions were delivered by the closed-loop system for intravascular volume expansion using data from the Nexfin™ monitor. Compliance with GDFT management was defined as acceptable when a patient spent more than 85% of the surgery time in a preload independent state (defined as pulse pressure variation <13%) or when average cardiac index during surgery was >2.5 litre min(-1) m(-2). RESULTS A total of 13 patients were included in the study group. All patients met the established criteria for delivery of GDFT for greater than 85% of case time. The median length of stay in the hospital was 5 [3-6] days. CONCLUSION In this pilot study, GDFT management using the closed-loop fluid administration system with a non-invasive CO monitoring device was feasible and maintained a high rate of protocol compliance. CLINICAL TRIAL REGISTRATION NCT02020863.
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Affiliation(s)
- A Joosten
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA Department of Anesthesiology and Critical Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium
| | - T Huynh
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - K Suehiro
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - C Canales
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - M Cannesson
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - J Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
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O'Neal JB, Shaw AD. Goal-directed therapy: what we know and what we need to know. Perioper Med (Lond) 2015; 4:1. [PMID: 25685329 PMCID: PMC4328058 DOI: 10.1186/s13741-015-0012-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/14/2015] [Indexed: 01/20/2023] Open
Abstract
Goal-directed therapy (GDT) utilizes monitoring techniques to help guide clinicians with administering fluids, vasopressors, inotropes, or other treatments to patients in various clinical settings. Multiple studies have investigated the potential benefits of GDT, but no consensus on the use of GDT exists. Future trials which address fluid and inotrope choice as well as expanding the results to evaluate patient-centered outcomes in addition to survival are warranted.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
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121
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Poth JM, Beck DR, Bartels K. Ultrasonography for haemodynamic monitoring. Best Pract Res Clin Anaesthesiol 2014; 28:337-51. [DOI: 10.1016/j.bpa.2014.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 08/05/2014] [Accepted: 08/27/2014] [Indexed: 01/10/2023]
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122
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Huddart S, Peden CJ, Swart M, McCormick B, Dickinson M, Mohammed MA, Quiney N. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg 2014; 102:57-66. [PMID: 25384994 PMCID: PMC4312892 DOI: 10.1002/bjs.9658] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/05/2014] [Accepted: 08/21/2014] [Indexed: 02/06/2023]
Abstract
Background Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. Methods The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. Results Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6·47 in the baseline interval (299 patients included) to 12·44 after implementation (427 patients included) (P < 0·001). The overall case mix-adjusted risk of death decreased from 15·6 to 9·6 per cent (risk ratio 0·614, 95 per cent c.i. 0·451 to 0·836; P = 0·002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0·197 and 0·223 before and after implementation respectively; P = 0·395). Conclusion Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.
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Affiliation(s)
- S Huddart
- Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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Wolff CB, Green DW. Clarification of the circulatory patho-physiology of anaesthesia - implications for high-risk surgical patients. Int J Surg 2014; 12:1348-56. [PMID: 25448657 DOI: 10.1016/j.ijsu.2014.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 08/21/2014] [Accepted: 10/25/2014] [Indexed: 10/24/2022]
Abstract
The paper examines the effects of anaesthesia on circulatory physiology and their implications regarding improvement in perioperative anaesthetic management. Changes to current anaesthetic practice, recommended recently, such as the use of flow monitoring in high risk patients, are already beginning to have an impact in reducing complications but not mortality [1]. Better understanding of the patho-physiology should help improve management even further. Analysis of selected individual clinical trials has been used to illustrate particular areas of patho-physiology and how changes in practice have improved outcome. There is physiological support for the importance of achieving an appropriate rate of oxygen delivery (DO2), particularly following induction of anaesthesia. It is suggested that ensuring adequate DO2 during anaesthesia will avoid development of oxygen debt and hence obviate the need to induce a high, compensatory, DO2 in the post-operative period. In contrast to the usual assumptions underlying strategies requiring a global increase in blood flow [1] by a stroke volume near maximization strategy, blood flow control actually resides entirely at the tissues not at the heart. This is important as the starting point for understanding failed circulatory control as indicated by 'volume dependency'. Local adjustments in blood flow at each individual organ - auto-regulation - normally ensure the appropriate local rate of oxygen supply, i.e. local DO2. Inadequate blood volume leads to impairment of the regulation of blood flow, particularly in the individual tissues with least capable auto-regulatory capability. As demonstrated by many studies, inadequate blood flow first occurs in the gut, brain and kidney. The inadequate blood volume which occurs with induction of anaesthesia is not due to blood volume loss, but probably results from redistribution due to veno-dilation. The increase in venous capacity renders the existing blood volume inadequate to maintain venous return and pre-load. Blood volume shifted to the veins will, necessarily, also reduce the arterial volume. As a result stroke volume and cardiac output fall below normal with little or no change in peripheral resistance. The resulting pre-load dependency is often successfully treated with colloid infusion and, in some studies, 'inotropic' agents, particularly in the immediate post-operative phase. Treatment during the earliest stage of anaesthesia can avoid the build up of oxygen debt and may be supplemented by drugs which maintain or restore venous tone, such as phenylephrine; an alternative to volume expansion. Interpretation of circulatory patho-physiology during anaesthesia confirms the need to sustain appropriate oxygen delivery. It also supports reduction or even elimination of supplementary crystalloid maintenance infusion, supposedly to replace the "mythical" third space loss. As a rational evidence base for future research it should allow for further improvements in anaesthetic management.
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Affiliation(s)
- Christopher B Wolff
- Clinical Research Centre, William Harvey Research Institute, Barts and The London Hospital Medical and Dental School, Queen Mary College, Charterhouse Square, London EC1M 6BQ, UK.
| | - David W Green
- Anaesthetics Department, King's College Hospital NHS Foundation Trust and King's College School of Medicine and Dentistry, London SE5 9RS, UK
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Benes J, Giglio M, Brienza N, Michard F. The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:584. [PMID: 25348900 PMCID: PMC4234857 DOI: 10.1186/s13054-014-0584-z] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 10/09/2014] [Indexed: 12/21/2022]
Abstract
Introduction Dynamic predictors of fluid responsiveness, namely systolic pressure variation, pulse pressure variation, stroke volume variation and pleth variability index have been shown to be useful to identify in advance patients who will respond to a fluid load by a significant increase in stroke volume and cardiac output. As a result, they are increasingly used to guide fluid therapy. Several randomized controlled trials have tested the ability of goal-directed fluid therapy (GDFT) based on dynamic parameters (GDFTdyn) to improve post-surgical outcome. These studies have yielded conflicting results. Therefore, we performed this meta-analysis to investigate whether the use of GDFTdyn is associated with a decrease in post-surgical morbidity. Methods A systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through September 2013 was conducted. Data synthesis was obtained by using odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) by random-effects model. Results In total, 14 studies met the inclusion criteria (961 participants). Post-operative morbidity was reduced by GDFTdyn (OR 0.51; CI 0.34 to 0.75; P <0.001). This effect was related to a significant reduction in infectious (OR 0.45; CI 0.27 to 0.74; P = 0.002), cardiovascular (OR 0.55; CI 0.36 to 0.82; P = 0.004) and abdominal (OR 0.56; CI 0.37 to 0.86; P = 0.008) complications. It was associated with a significant decrease in ICU length of stay (WMD −0.75 days; CI −1.37 to −0.12; P = 0.02). Conclusions In surgical patients, we found that GDFTdyn decreased post-surgical morbidity and ICU length of stay. Because of the heterogeneity of studies analyzed, large prospective clinical trials would be useful to confirm our findings. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0584-z) contains supplementary material, which is available to authorized users.
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125
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Yates DRA, Davies SJ, Warnakulasuriya SR, Wilson RJT. Volume Management and Resuscitation in Colorectal Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0078-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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126
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Perioperative hemodynamic optimization: a revised approach. J Clin Anesth 2014; 26:500-5. [DOI: 10.1016/j.jclinane.2014.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 01/22/2023]
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127
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Miller TE, Raghunathan K, Gan TJ. State-of-the-art fluid management in the operating room. Best Pract Res Clin Anaesthesiol 2014; 28:261-73. [PMID: 25208961 DOI: 10.1016/j.bpa.2014.07.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 06/27/2014] [Accepted: 07/02/2014] [Indexed: 12/20/2022]
Abstract
The underlying principles guiding fluid management in any setting are very simple: maintain central euvolemia, and avoid salt and water excess. However, these principles are frequently easier to state than to achieve. Evidence from recent literature suggests that avoidance of fluid excess is important, with excessive crystalloid use leading to perioperative weight gain and an increase in complications. A zero-balance approach aimed at avoiding fluid excess is recommended for all patients. For major surgery, there is a sizeable body of evidence that an individualized goal-directed fluid therapy (GDFT) improves outcomes. However, within an Enhanced Recovery program only a few studies have been published, yet so far GDFT has not achieved the same benefit. Balanced crystalloids are recommended for most patients. The use of colloids remains controversial; however, current evidence suggests they can be beneficial in intraoperative patients with objective evidence of hypovolemia.
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Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; Durham VAMC, Durham, NC 27710, USA.
| | - Tong J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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128
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Moonesinghe SR, Harris S, Mythen MG, Rowan KM, Haddad FS, Emberton M, Grocott MPW. Survival after postoperative morbidity: a longitudinal observational cohort study. Br J Anaesth 2014; 113:977-84. [PMID: 25012586 PMCID: PMC4235571 DOI: 10.1093/bja/aeu224] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Previous studies have suggested that there may be long-term harm associated with postoperative complications. Uncertainty exists however, because of the need for risk adjustment and inconsistent definitions of postoperative morbidity. Methods We did a longitudinal observational cohort study of patients undergoing major surgery. Case-mix adjustment was applied and morbidity was recorded using a validated outcome measure. Cox proportional hazards modelling using time-dependent covariates was used to measure the independent relationship between prolonged postoperative morbidity and longer term survival. Results Data were analysed for 1362 patients. The median length of stay was 9 days and the median follow-up time was 6.5 yr. Independent of perioperative risk, postoperative neurological morbidity (prevalence 2.9%) was associated with a relative hazard for long-term mortality of 2.00 [P=0.001; 95% confidence interval (CI) 1.32–3.04]. Prolonged postoperative morbidity (prevalence 15.6%) conferred a relative hazard for death in the first 12 months after surgery of 3.51 (P<0.001; 95% CI 2.28–5.42) and for the next 2 yr of 2.44 (P<0.001; 95% CI 1.62–3.65), returning to baseline thereafter. Conclusions Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complications.
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Affiliation(s)
- S R Moonesinghe
- UCL/UCLH Surgical Outcomes Research Centre, Department of Anaesthetics, University College Hospital, London NW1 2BU, UK UCL Centre for Anaesthesia, University College Hospital, London NW1 2BU, UK National Institute for Academic Anaesthesia's Health Services Research Centre, Royal College of Anaesthetists, 35 Red Lion Square, London WC1R 4SG, UK
| | - S Harris
- UCL Centre for Anaesthesia, University College Hospital, London NW1 2BU, UK London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - M G Mythen
- UCL/UCLH Surgical Outcomes Research Centre, Department of Anaesthetics, University College Hospital, London NW1 2BU, UK UCL Centre for Anaesthesia, University College Hospital, London NW1 2BU, UK
| | - K M Rowan
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London WC1 V 6AZ, UK
| | - F S Haddad
- UCL/UCLH Surgical Outcomes Research Centre, Department of Anaesthetics, University College Hospital, London NW1 2BU, UK Institute of Sports, Exercise and Health, University College London, Gower Street, London WC1E 6BT, UK
| | - M Emberton
- UCL/UCLH Surgical Outcomes Research Centre, Department of Anaesthetics, University College Hospital, London NW1 2BU, UK Division of Surgery and Interventional Science, University College London, Gower Street, London WC1E 6BT, UK
| | - M P W Grocott
- UCL/UCLH Surgical Outcomes Research Centre, Department of Anaesthetics, University College Hospital, London NW1 2BU, UK National Institute for Academic Anaesthesia's Health Services Research Centre, Royal College of Anaesthetists, 35 Red Lion Square, London WC1R 4SG, UK Integrative Physiology and Critical Illness Group, University of Southampton, Southampton, UK Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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129
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Kelleher MC, Buggy DJ. Pendulum swings again: crystalloid or colloid fluid therapy? Br J Anaesth 2014; 113:335-7. [PMID: 24633662 DOI: 10.1093/bja/aeu015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- M C Kelleher
- Department of Anaesthesia, Mater Misericordiae University Hospital & School of Medicine & Medical Science, University College Dublin, Ireland
| | - D J Buggy
- Department of Anaesthesia, Mater Misericordiae University Hospital & School of Medicine & Medical Science, University College Dublin, Ireland Outcomes Research Consortium, Cleveland Clinic, OH, USA
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Powell M. Use of the oesophageal Doppler in major gynaecological surgery. Anaesthesia 2014; 69:282. [PMID: 24548359 DOI: 10.1111/anae.12613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M Powell
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK.
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131
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Rinehart J, Le Manach Y, Douiri H, Lee C, Lilot M, Le K, Canales C, Cannesson M. First closed-loop goal directed fluid therapy during surgery: a pilot study. ACTA ACUST UNITED AC 2013; 33:e35-41. [PMID: 24378044 DOI: 10.1016/j.annfar.2013.11.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 11/20/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Intraoperative haemodynamic optimization based on fluid management and stroke volume optimization (Goal Directed Fluid Therapy [GDFT]) can improve patients' postoperative outcome. We have described a closed-loop fluid management system based on stroke volume variation and stroke volume monitoring. The goal of this system is to apply GDFT protocols automatically. After conducting simulation, engineering, and animal studies the present report describes the first use of this system in the clinical setting. STUDY DESIGN Prospective pilot study. PATIENTS Patients undergoing major surgery. METHODS Twelve patients at two institutions had intraoperative GDFT delivered by closed-loop controller under the direction of an anaesthesiologist. Compliance with GDFT management was defined as acceptable when a patient spent more than 85% of the surgery time in a preload independent state (defined as stroke volume variation<13%), or when average cardiac index during the case was superior or equal to 2.5l/min/m(2). RESULTS Closed-loop GDFT was completed in 12 patients. Median surgery time was 447 [309-483] min and blood loss was 200 [100-1000] ml. Average cardiac index was 3.2±0.8l/min/m(2) and on average patients spent 91% (76 to 100%) of the surgery time in a preload independent state. Twelve of 12 patients met the criteria for compliance with intraoperative GDFT management. CONCLUSION Intraoperative GDFT delivered by closed-loop system under anaesthesiologist guidance allowed to obtain targeted objectives in 91% of surgery time. This approach may provide a way to ensure consistent high-quality delivery of fluid administration and compliance with perioperative goal directed therapy.
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Affiliation(s)
- J Rinehart
- Department of anesthesiology and perioperative care, university of California Irvine, 101 S City Drive, Orange, CA 92868 Irvine, CA, USA
| | - Y Le Manach
- Department of anesthesiology and critical Care medicine, CHU Pitié-Salpêtrière, Paris, France; Departments of anesthesia and clinical epidemiology and biostatistics, faculty of health sciences, McMaster university and population health research institute, perioperative medicine and surgical research Unit, Hamilton, ON, Canada
| | - H Douiri
- Department of anesthesiology and critical Care medicine, CHU Pitié-Salpêtrière, Paris, France
| | - C Lee
- Department of anesthesiology and perioperative care, university of California Irvine, 101 S City Drive, Orange, CA 92868 Irvine, CA, USA
| | - M Lilot
- Department of anesthesiology and perioperative care, university of California Irvine, 101 S City Drive, Orange, CA 92868 Irvine, CA, USA
| | - K Le
- Department of anesthesiology and perioperative care, university of California Irvine, 101 S City Drive, Orange, CA 92868 Irvine, CA, USA
| | - C Canales
- Department of anesthesiology and perioperative care, university of California Irvine, 101 S City Drive, Orange, CA 92868 Irvine, CA, USA
| | - M Cannesson
- Department of anesthesiology and perioperative care, university of California Irvine, 101 S City Drive, Orange, CA 92868 Irvine, CA, USA.
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Stoneham M, Murray D, Foss N. Emergency surgery: the big three - abdominal aortic aneurysm, laparotomy and hip fracture. Anaesthesia 2013; 69 Suppl 1:70-80. [DOI: 10.1111/anae.12492] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 01/23/2023]
Affiliation(s)
- M. Stoneham
- Nuffield Division of Anaesthetics; Oxford University Hospitals NHS Trust; Oxford UK
| | - D. Murray
- James Cook University Hospital; Middlesbrough UK
| | - N. Foss
- Department of Anaesthesia; Hvidovre University Hospital; Copenhagen Denmark
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133
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Our study 20 years on: a randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. Intensive Care Med 2013; 39:2107-14. [DOI: 10.1007/s00134-013-3098-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/02/2013] [Indexed: 10/26/2022]
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Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R191. [PMID: 24010849 PMCID: PMC4057030 DOI: 10.1186/cc12885] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 08/02/2013] [Indexed: 12/30/2022]
Abstract
Introduction Several single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients. We hypothesized that using a treatment algorithm based on pulse pressure variation, cardiac index trending by radial artery pulse contour analysis, and mean arterial pressure in a study group (SG), would result in reduced complications, reduced length of hospital stay and quicker return of bowel movement postoperatively in abdominal surgical patients, when compared to a control group (CG). Methods 160 patients undergoing elective major abdominal surgery were randomized to the SG (79 patients) or to the CG (81 patients). In the SG hemodynamic therapy was guided by pulse pressure variation, cardiac index trending and mean arterial pressure. In the CG hemodynamic therapy was performed at the discretion of the treating anesthesiologist. Outcome data were recorded up to 28 days postoperatively. Results The total number of complications was significantly lower in the SG (72 vs. 52 complications, p = 0.038). In particular, infection complications were significantly reduced (SG: 13 vs. CG: 26 complications, p = 0.023). There were no significant differences between the two groups for return of bowel movement (SG: 3 vs. CG: 2 days postoperatively, p = 0.316), duration of post anesthesia care unit stay (SG: 180 vs. CG: 180 minutes, p = 0.516) or length of hospital stay (SG: 11 vs. CG: 10 days, p = 0.929). Conclusions This multi-center study demonstrates that hemodynamic goal-directed therapy using pulse pressure variation, cardiac index trending and mean arterial pressure as the key parameters leads to a decrease in postoperative complications in patients undergoing major abdominal surgery. Trial registration ClinicalTrial.gov, NCT01401283.
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135
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Grocott MPW, Dushianthan A, Hamilton MA, Mythen MG, Harrison D, Rowan K. Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane Database Syst Rev 2012; 11:CD004082. [PMID: 23152223 PMCID: PMC6477700 DOI: 10.1002/14651858.cd004082.pub5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Studies have suggested that increasing whole body blood flow and oxygen delivery around the time of surgery reduces mortality, morbidity and the expense of major operations. OBJECTIVES To describe the effects of increasing perioperative blood flow using fluids with or without inotropes or vasoactive drugs. Outcomes were mortality, morbidity, resource utilization and health status. SEARCH METHODS We searched CENTRAL (The Cochrane Library 2012, Issue 1), MEDLINE (1966 to March 2012) and EMBASE (1982 to March 2012). We manually searched the proceedings of major conferences and personal reference databases up to December 2011. We contacted experts in the field and pharmaceutical companies for published and unpublished data. SELECTION CRITERIA We included randomized controlled trials with or without blinding. We included studies involving adult patients (aged 16 years or older) undergoing surgery (patients having a procedure in an operating room). The intervention met the following criteria. 'Perioperative' was defined as starting up to 24 hours before surgery and stopping up to six hours after surgery. 'Targeted to increase global blood flow' was defined by explicit measured goals that were greater than in controls, specifically one or more of cardiac index, oxygen delivery, oxygen consumption, stroke volume (and the respective derived indices), mixed venous oxygen saturation (SVO(2)), oxygen extraction ratio (0(2)ER) or lactate. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data. We contacted study authors for additional data. We used Review Manager software. MAIN RESULTS We included 31 studies of 5292 participants. There was no difference in mortality: 282/2615 (10.8%) died in the control group and 238/2677 (8.9%) in the treatment group, RR of 0.89 (95% CI 0.76 to 1.05, P = 0.18). However, the results were sensitive to analytical methods and the intervention was better than control when inverse variance or Mantel-Haenszel random-effects models were used, RR of 0.72 (95% CI 0.55 to 0.95, P = 0.02). The results were also sensitive to withdrawal of studies with methodological limitations. The rates of three morbidities were reduced by increasing global blood flow: renal failure, RR of 0.71 (95% CI 0.57 to 0.90); respiratory failure, RR of 0.51 (95% CI 0.28 to 0.93); and wound infections, RR of 0.65 (95% CI 0.51 to 0.84). There were no differences in the rates of nine other morbidities: arrhythmia, pneumonia, sepsis, abdominal infection, urinary tract infection, myocardial infarction, congestive cardiac failure or pulmonary oedema, or venous thrombosis. The number of patients with complications was reduced by the intervention, RR of 0.68 (95% CI 0.58 to 0.80). Hospital length of stay was reduced in the treatment group by a mean of 1.16 days (95% CI 0.43 to 1.89, P = 0.002). There was no difference in critical care length of stay. There were insufficient data to comment on quality of life and cost effectiveness. AUTHORS' CONCLUSIONS It remains uncertain whether increasing blood flow using fluids, with or without inotropes or vasoactive drugs, reduces mortality in adults undergoing surgery. The primary analysis in this review (mortality at longest follow-up) showed no difference between the intervention and control, but this result was sensitive to the method of analysis, the withdrawal of studies with methodological limitations, and is dominated by a single large RCT. Overall, for every 100 patients in whom blood flow is increased perioperatively to defined goals, one can expect 13 in 100 patients (from 40/100 to 27/100) to avoid a complication, 2/100 to avoid renal impairment (from 8/100 to 6/100), 5/100 to avoid respiratory failure (from 10/100 to 5/100), and 4/100 to avoid postoperative wound infection (from 10/100 to 6/100). On average, patients receiving the intervention stay in hospital one day less. It is unlikely that the intervention causes harm. The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced.
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Affiliation(s)
- Michael PW Grocott
- UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise HealthUniversity College London Centre for Altitude Space and Extreme Environment (CASE) MedicineLondonUK
| | | | - Mark A Hamilton
- St. George's HospitalGeneral Intensive Care Unit1st Floor St. James wingBlackshaw RoadLondonUKSW17 0QT
| | - Michael G Mythen
- University College LondonDepartment Anaesthesia and Critical Care1st Floor Maple House149 Tottenham Court RoadLondonUKWC1E 6DB
| | - David Harrison
- Intensive Care National Audit & Research CentreNapier House24 High HolbornLondonUKWC1V 6AZ
| | - Kathy Rowan
- Intensive Care National Audit & Research CentreNapier House24 High HolbornLondonUKWC1V 6AZ
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