Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery

Pulmonary carbon dioxide elimination for cardiac output monitoring in peri-operative and critical care patients: history and current status

Minimally invasive measurement of cardiac output as a central component of advanced haemodynamic monitoring has been increasingly recognised as a potential means of improving perioperative outcomes in patients undergoing major surgery. Methods based upon pulmonary carbon dioxide elimination are among the oldest techniques in this field, with comparable accuracy and precision to other techniques. Modern adaptations of these techniques suitable for use in the perioperative and critical are environment are based on the differential Fick approach, and include the partial carbon dioxide rebreathing method. The accuracy and precision of this approach to cardiac output measurement has been shown to be similar to other minimally invasive techniques. This paper reviews the underlying principles and evolution of the method, and future directions including recent adaptations designed to deliver continuous breath-by-breath monitoring of cardiac output.

Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes

BACKGROUND

The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority.

METHODS

Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus.

RESULTS

The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management.

CONCLUSION

The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.

Intraoperative esophageal Doppler hemodynamic monitoring in free perforator flap surgery

Goal-directed fluid therapy optimizes cardiac output and flap perfusion during anesthesia. Intraoperative esophageal Doppler (ED) monitoring has been reported as more accurate and reliable, demonstrating improved surgical outcomes compared with central venous pressure and arterial catheter monitoring. A prospective study of patients undergoing free perforator (deep inferior epigastric artery perforator/anterolateral thigh) flap surgery with intraoperative ED monitoring (51 patients) or central venous pressure monitoring (53 patients) was undertaken. Fluid input included crystalloids, colloids, or blood products. Fluid output included urine, blood, or suctioned fluid. Postoperative fluid balance was calculated as fluid input - output. Fluid input between groups was not different. Fluid output was greater in the ED group (P = 0.008). The ED group showed less fluid balance (P = 0.023), less anesthetic time (P = 0.001), less hospital stay (mean 1.9 days; P = 0.147), less monitoring and flap complications (P = 0.062). ED monitoring demonstrated no monitoring complications, provides a favorable postoperative fluid balance, and may reduce flap complications and hospital stay.

The maintenance and monitoring of perioperative blood volume

The assessment and maintenance of perioperative blood volume is important because fluid therapy is a routine part of intraoperative care. In the past, patients undergoing major surgery were given large amounts of fluids because health-care providers were concerned about preoperative dehydration and intraoperative losses to a third space. In the last decade it has become clear that fluid therapy has to be more individualized. Because the exact determination of blood volume is not clinically possible at every timepoint, there have been different approaches to assess fluid requirements, such as goal-directed protocols guided by invasive and less invasive devices.

This article focuses on laboratory volume determination, capillary dynamics, aspects of different fluids and how to clinically assess and monitor perioperative blood volume.

Clinical review: What are the best hemodynamic targets for noncardiac surgical patients?

Perioperative hemodynamic optimization, or goal-directed therapy (GDT), has been show to significantly decrease complications and risk of death in high-risk patients undergoing noncardiac surgery. An important aim of GDT is to prevent an imbalance between oxygen delivery and oxygen consumption in order to avoid the development of multiple organ dysfunction. The utilization of cardiac output monitoring in the perioperative period has been shown to improve outcomes if integrated into a GDT strategy. GDT guided by dynamic predictors of fluid responsiveness or functional hemodynamics with minimally invasive cardiac output monitoring is suitable for the majority of patients undergoing major surgery with expected significant volume shifts due to bleeding or other significant intravascular volume losses. For patients at higher risk of complications and death, such as those with advanced age and limited cardiorespiratory reserve, the addition of dobutamine or dopexamine to the treatment algorithm, to maximize oxygen delivery, is associated with better outcomes.

Goal-directed fluid therapy- a survey of anaesthetists in the UK, USA, Australia and New Zealand

Background

Goal-directed fluid therapy (GDFT) has been shown to reduce complications and hospital length of stay following major surgery. However, there has been no assessment regarding its use in clinical practice.

Methods

An electronic survey was administered to randomly selected anaesthetists from the United Kingdom (UK, n = 2000) and the United States of America (USA, n = 2000), and 500 anaesthetists from Australia/New Zealand (AUS/NZ). Preferences, clinical use and attitudes towards GDFT were investigated. Results were collated to examine regional differences.

Results

The response rates from the UK (n = 708) and AUS/NZ (n = 180) were 35%, and 36% respectively. The response rate from the USA was very low (n = 178; 9%). GDFT use was significantly more common in the UK than in AUS/NZ (p < 0.01). The Oesophageal Doppler Monitor was the most preferred instrument in the UK (n = 362; h76%) with no clear preferences in other regions. GDFT was most commonly utilised in major abdominal surgery and for patients with significant comorbidities. The commonest reasons stated for not using GDFT were either lack of availability of monitoring tools (AUS/NZ: 57 (70%); UK: 94 (64%)) or a lack of experience with instruments (AUS/NZ: 43 (53%); UK: 51 (35%)). A subset of respondents (AUS/NZ: 22(27%); UK: 45 (30%)) felt GDFT provided no perceived benefit. Enthusiasm towards the use of GDFT in the absence of existing barriers was high.

Conclusion

Several hypotheses were generated regarding important differences in the use of GDFT between anaesthetists from the UK and AUS/NZ. There is significant interest in utilising GDFT in clinical practice and existing barriers should be addressed.

Perioperative fluid administration: historical highlights and implications for practice

Perioperative fluid administration is an important aspect of surgical care but is often poorly understood. Surgeons have historically made a considerable contribution to the evidence base governing current practice. This review provides an overview of the history of perioperative fluid therapy and its relevance to modern practice.Intravenous fluids (IVF) first gained therapeutic importance in the treatment of cholera in the 1830s. From the 1880s, IVF began to be administered perioperatively to compensate for the "injurious" effects of anaesthesia. Clinical improvements were consequently noted, though the adverse effects of saline were observed. The work of Ringer, Hartmann, and others emphasized the importance of the composition of IVF and laid the foundations for the balanced solutions in use today.The intravenous "drip" was introduced by Rudolph Matas in 1924. As the metabolic response to injury was increasingly investigated in the 1940s and 1950s, the cause of post-operative oliguria was debated widely with the most prominent surgeons being Moore and Shires. These differences in opinion, coupled with reports of injured soldiers from the Korean War receiving large IVF infusions and surviving, dictated the surgical practice of liberal IVF administration until very recently.Newer work in fluid therapy has explored the concept of fluid restriction. Shoemaker and colleagues also pioneered the concept of fluid administration to achieve supranormal indices of cardiorespiratory function, which has led to the advent of goal-directed fluid therapy. Alongside the development of balanced solutions, the renewed focus on perioperative fluid therapy has led to IVF administration being guided by physiological principles with a new consideration of the lessons gleaned from history.

[Risk factors of nasogastric tube placement after elective colorectal surgery included in a rehabilitation programme: a multivariate analysis]

OBJECTIVE

Nasogastric tube placement (NTP) is no more systematically recommended in patients scheduled for elective colorectal surgery but could be necessary in case of postoperative vomiting. The aim of this study was to determine independent risk factors for NTP after colorectal surgery.

PATIENTS AND METHODS

We performed an observational study including 290 patients scheduled for elective colorectal surgery included in an enhanced recovery programme: immunonutrition, thoracic epidural analgesia, antiemetic prophylaxis, respiratory physiotherapy, absence of NT and drainage, forced mobilization and oral nutrition. The main outcome was the occurrence of vomiting requiring NTP. Univariate analysis included: age, sex, BMI, American Society of Anesthesiologist Physical Status Classification System (ASA), duration of surgery, epidural analgesia, and mobilization, intraoperative fluid, temperature, laparotomy, use of droperidol, parenteral nutrition, stoma, diabetes, hypertension or coronary disease, COPD, type of surgery. A logistic regression was performed to determine independent risk factors of NTP.

RESULTS

Among the 290 patients included, 277 were analyzed. The incidence of NTP was 10.5% (95%CI [7.4-14.6%]). Univariate analysis documented BMI, low temperature in PACU (<35°C), ASA scores, duration of surgery and epidural analgesia, rectal and sigmoid resections, diabetes, transfusion, no use of droperidol, duration of mobilization, conversion to laparotomy. Three independent risk factors were associated with NTP: temperature in SSPI<35.5°C (OR: 14.49; IC95% [4.52-45.45], P<0.0001), BMI<21kg/m(2) (8.40; [1.99-35.71], P=0.0038) and lack of postoperative droperidol administration (3.37 [1.02-11.39], P=0.04).

CONCLUSIONS

After colorectal surgery tolerance to rapid oral feeding is impaired by denutrition and postoperative hypothermia. The combined used of postoperative droperidol should also be considered to avoid postoperative NTP.

The Role of Intraoperative Fluid Optimization Using the Esophageal Doppler in Advanced Gynecological Cancer: Early Postoperative Recovery and Fitness for Discharge

Objective

To determine the effect of fluid optimization using esophageal Doppler monitoring (EDM) when compared to standard fluid management in women who undergo major gynecological cancer surgery and whether its use is associated with reduced postoperative morbidity.

Methods

From January 2009 to December 2010, women undergoing laparotomy for pelvic masses or uterine cancer had either fluid optimization using intraoperative EDM or standard fluid replacement without using EDM. Cases were selected from 2 surgeons to control for variability in surgical practice. Demographic and surgical details were collected prospectively. Univariate and multivariate analyses were performed to quantify the association between the use of EDM with “early postoperative recovery” and “early fitness for discharge.”

Results

A total of 198 women were operated by the 2 prespecified surgeons; 79 women had fluid optimization with EDM, whereas 119 women had standard anesthetic care. The use of ODM was associated with earlier postoperative recovery (adjusted odds ratio, 2.83; 95% confidence interval, 1.20–6.68; P = 0.02) and earlier fitness for discharge (adjusted odds ratio, 2.81; 95% confidence interval, 1.01–7.78; P = 0.05). Women with advanced-stage disease in the “EDM” group resumed oral diet earlier than women in the “no EDM” group (median, 1 day vs 2 days; P = 0.02). These benefits with EDM did not extend to women with early-stage disease/benign/borderline tumors. No significant difference in postoperative complications was noted.

Conclusions

Intraoperative fluid optimization with EDM in women with advanced gynecological cancer may be associated with improved postoperative recovery and early fitness for discharge. Studies with adequate power are needed to investigate its role in reducing postoperative complications.

Stroke volume optimization in elective bowel surgery: a comparison between pulse power wave analysis (LiDCOrapid) and oesophageal Doppler (CardioQ)

BACKGROUND

Goal-directed fluid therapy improves outcome in major surgery. We evaluated a new device (LiDCOrapid) against our standard oesophageal Doppler method (ODM) for stroke volume (SV) optimization during colorectal surgery.

METHODS

This was an observational study in 20 patients undergoing major colorectal surgery within a fast-track protocol. We compared SV values measured simultaneously by LiDCOrapid and ODM before and after 86 fluid challenges. We also evaluated the LiDCOrapid dynamic indices SV variation (SVV) and pulse pressure variation (PPV) as predictors for volume responsiveness, defined as an increase in SV ≥ 10% after 200 ml of colloid.

RESULTS

SV increased ≥ 10% after 27 out of 86 fluid challenges. For 172 paired SV values, the overall correlation was r=0.39, and bias (limits of agreement) -28 (-91-35) ml, percentage error 70%. The ability of LiDCOrapid to track changes in SV was weak with a concordance rate of 80%, and a sensitivity and specificity of 48% and 81%, respectively, to detect a positive fluid challenge. The area under the curve values (with 95% confidence intervals) for SVV and PPV were 0.72 (0.60-0.83) and 0.66 (0.52-0.79), respectively, indicating low predictive capacity in these setting.

CONCLUSIONS

LiDCOrapid and ODM devices are not interchangeable. We cannot recommend that the LiDCOrapid replace the standard Doppler method until further device-specific outcome studies on volume optimization are available. The dynamic indices SVV and PPV add little value to a fluid optimization protocol, and should not replace SV measurements with a validated technique.

Contemporary perioperative care strategies

Background

Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes.

Methods

A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German.

Results

Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.

Conclusion

Multidisciplinary management of perioperative patient care has improved outcomes.

Less-invasive approaches to perioperative haemodynamic optimization

PURPOSE OF REVIEW

A number of less-invasive haemodynamic monitoring devices have been introduced in recent years, largely replacing the pulmonary artery catheter (PAC) as a standard monitoring tool. Apart from tracking cardiac output (CO), these monitors provide additional haemodynamic parameters. The aim of this article is to review the most widely used less-invasive monitoring modalities, their technical characteristics and limitations regarding their clinical performance.

RECENT FINDINGS

The utilization of CO monitoring in the perioperative setting has been shown to be associated with improved outcomes if integrated into a haemodynamic optimization strategy. These findings provide the basis of recent recommendations for perioperative monitoring.

SUMMARY

An array of monitoring modalities have been introduced that can reliably track CO in the perioperative setting and make the PAC dispensable in most clinical situations. In order to be used safely and efficiently, knowledge regarding the inherent monitoring techniques and their limitations, their clinical validity and the utility of the parameters provided is crucial.

Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy

BACKGROUND

Goal-directed fluid therapy (GDFT) has been compared with liberal fluid administration in non-optimized perioperative settings. It is not known whether GDFT is of value within an enhanced recovery protocol incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy.

METHODS

Patients undergoing elective laparoscopic or open colectomy within an established enhanced recovery protocol (including fluid restriction) were randomized to GDFT or no GDFT. Bowel preparation was permitted for left colonic operations at the surgeon's discretion. Exclusion criteria included rectal tumours and stoma formation. The primary outcome was a patient-reported surgical recovery score (SRS). Secondary endpoints included clinical outcomes and physiological measures of recovery.

RESULTS

Eighty-five patients were randomized, and there were 37 patients in each group for analysis. Nine patients in the GDFT and four in the fluid restriction group received oral bowel preparation for either anterior resection (12) or subtotal colectomy (1). Patients in the GDFT group received more colloid during surgery (mean 591 versus 297 ml; P = 0·012) and had superior cardiac indices (mean corrected flow time 374 versus 355 ms; P = 0·018). However, no differences were observed between the GDFT and fluid restriction groups with regard to surgical recovery (mean SRS after 7 days 47 versus 46 respectively; P = 0·853), other secondary outcomes (mean aldosterone/renin ratio 9 versus 8; P = 0·898), total postoperative fluid (median 3750 versus 2400 ml; P = 0·604), length of hospital stay (median 6 versus 5 days; P = 0·570) or number of patients with complications (26 versus 27; P = 1·000).

CONCLUSION

GDFT did not provide clinical benefit in patients undergoing elective colectomy within a protocol incorporating fluid restriction.

REGISTRATION NUMBER

NCT00911391 (http://www.clinicaltrials.gov).

The development of fast-track principles in gynecological surgery

Fast-track is a multimodal strategy aimed at reducing the physiological burden of surgery to achieve an enhanced postoperative recovery. The strategy combines unimodal evidence-based interventions in the areas of preoperative preparation, anesthesia, surgical factors and postoperative care. The advantages of fast-track most likely extend to gynecology, although so far have scarcely been reported. This review summarizes current evidence concerning use of fast-track in general and in gynecological surgery. The main findings of this review are that there are benefits within elective gynecological surgery, but studies of quality of life, patient satisfaction and health economics in elective surgery are needed. Studies of fast-track within the field of non-elective gynecological surgery are lacking. Widespread education is needed to improve the rate of implementation of fast-track. Close involvement of the entire surgical team is imperative to ensure a structured perioperative care aiming for enhanced postoperative recovery.

Enhanced recovery after surgery (ERAS) workshop: effect on attitudes of the perioperative care team

BACKGROUND

Enhanced recovery after surgery (ERAS) or 'fast track' surgery is heavily based on a multidisciplinary focused perioperative care model with all players being equally important for successful implementation. Several institutions run an ERAS course but few data are available on their effect on attitudes and perceptions to perioperative care principles.

METHODS

A ten item survey was designed for perioperative care clinicians attending an annual ERAS workshop. The survey was administered one week before and three weeks after the workshop.

RESULTS

Seventy seven eligible participants were identified. Forty four (57%) responded to the questionnaire prior to the course. On repeat administration of the survey three weeks after the course there were 28 (36%) responses. The results of the survey indicate that the majority of perioperative care staff were already aware of the evidence behind some of the principles applied in colectomy, with a high pre-course level of understanding shown. However the course significantly changed opinion regarding some other aspects of care to align opinion with evidence amongst the responders.

CONCLUSION

There appears to be a high rate of evidence agreement with some interventions but not others amongst perioperative staff. Attending a multidisciplinary ERAS workshop seems to align opinion with evidence.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

Residents and ICU nurses get reliable static and dynamic haemodynamic assessments with aortic oesophageal Doppler

BACKGROUND

Aortic oesophageal Doppler (ODM) allows continuous non-invasive haemodynamic monitoring. We tested to confirm if residents and nurses were able to reposition oesophageal probe (OP), obtain aortic blood flow of good quality and so perform reliable static and dynamic haemodynamic assessments.

METHODS

Prospective observational study assessing ODM measurements were obtained by six residents and three nurses after they have participated in training. Measured (aortic diameter) and calculated haemodynamic data [indexed stroke volume (SVI), cardiac index] were directly obtained from ODM, after residents and nurses repositioned the OP. In a second group of patients, we tested the ability of residents and nurses to detect rapid haemodynamic changes after a passive leg raising. SVI comparison was the primary end point. Statistical analysis was performed using the method of Bland and Altman.

RESULTS

Sixty-six haemodynamic measurements were performed on 42 patients. Mean bias for SVI between the skilled physician and residents, and between the skilled physician and nurses were -0.9 ± 5.2 ml/m(2) (P = 0.15), with a percentage error of 31%, and 0.9 ± 5.1 ml/m(2) (P = 0.14), with a percentage error of 33%, respectively. There was an excellent correlation for SVI between the physician and residents (r = 0.9; P < 0.0001) and between the physician and nurses (r = 0.9; P < 0.0001). Induced changes in SVI measured by residents and nurses strongly followed those of our skilled physician.

CONCLUSION

Residents and nurses get reliable static and dynamic haemodynamic assessments with ODM compared to our skilled physician.

Perioperative fluid management strategies in major surgery: a stratified meta-analysis

BACKGROUND

Both "liberal" and "goal-directed" (GD) therapy use a large amount of perioperative fluid, but they appear to have very different effects on perioperative outcomes. We sought to determine whether one fluid management strategy was superior to the others.

METHODS

We selected randomized controlled trials (RCTs) on the use of GD or restrictive versus liberal fluid therapy (LVR) in major adult surgery from MEDLINE, EMBASE, PubMed (1951 to April 2011), and Cochrane controlled trials register without language restrictions. Indirect comparison between the GD and LVR strata was performed.

RESULTS

A total of 3861 patients from 23 GD RCTs (median sample size = 90, interquartile range [IQR] 57 to 109) and 1160 patients from 12 LVR RCTs (median sample size = 80, IQR36 to 151) were considered. Both liberal and GD therapy used more fluid compared to their respective comparative arm, but their effects on outcomes were very different. Patients in the liberal group of the LVR stratum had a higher risk of pneumonia (risk ratio [RR] 2.2, 95% confidence interval [CI] 1.0 to 4.5), pulmonary edema (RR 3.8, 95% CI 1.1 to 13), and a longer hospital stay than those in the restrictive group (mean difference [MD] 2 days, 95% CI 0.5 to 3.4). Using GD therapy also resulted in a lower risk of pneumonia (RR 0.7, 95% CI 0.6 to 0.9) and renal complications (0.7, 95% CI 0.5 to 0.9), and a shorter length of hospital stay (MD 2 days, 95% CI 1 to 3) compared to not using GD therapy. Liberal fluid therapy was associated with an increased length of hospital stay (4 days, 95% CI 3.4 to 4.4), time to first bowel movement (2 days, 95% CI 1.3 to 2.3), and risk of pneumonia (RR ratio 3, 95% CI 1.8 to 4.8) compared to GD therapy.

CONCLUSION

Perioperative outcomes favored a GD therapy rather than liberal fluid therapy without hemodynamic goals. Whether GD therapy is superior to a restrictive fluid strategy remains uncertain.

Risk factors for postoperative complications after fast-track abdominal hysterectomy

BACKGROUND

Fast-track regimen has been shown to reduce postoperative complications in gastrointestinal surgery.

AIMS

We investigated the incidence and type of postoperative complications and associated risk factors after benign abdominal hysterectomy undertaken in a fast-track program.

METHODS

A prospective longitudinal cohort study. In five Swedish hospitals, a cohort of 162 women, ASA 1-2, undergoing abdominal hysterectomy in a fast-track program was prospectively studied. Surgery was performed under spinal or general anaesthesia. The fast-track concept was standardised with discharge criteria and a restricted intravenous fluid regimen. Complications were systematically registered during the five-week follow-up period. Risk factors for complications were analysed using multiple logistic regression models.

RESULTS

Forty-one (25.3%) developed postoperative complications, mainly infection and wound healing complications. The majority of the complications developed after discharge and were treated in the outpatient clinics. Four women (2.5%) were readmitted to hospital. Substantial risk factors for postoperative complications were obesity (OR 8.83), prior laparotomy (OR 2.92) and relative increase in body weight on the first postoperative day (OR 1.52).

CONCLUSIONS

Minor infection and wound healing complications seem to be common in healthy women undergoing abdominal hysterectomy in a fast-track program. Obesity is an important risk factor also in fast-track abdominal hysterectomy. A modest increase in postoperative relative weight gain during the first postoperative day seemed to increase the risk of postoperative complications. This factor merits further study. Randomised studies are necessary to determine the impact of fast-track program and perioperative fluid regimens on postoperative complications.

Perioperative care: a survey of New Zealand and Australian colorectal surgeons

AIM

Recent surveys in Europe and North America have demonstrated significant challenges in the implementation of evidence-based surgical practice.

METHOD

A survey of New Zealand and Australian colorectal surgeons was conducted to help understand current practice and perceived barriers to interventions in this region. Questions were based around elective colorectal resection care.

RESULTS

There were 152 eligible participants identified. Over a 60-day period, 82 (54%) surgeons responded but only 76 (50%) of the questionnaires were complete; they were used for data analysis. The majority of surgeons indicated a preference for laparoscopic techniques. Barriers to laparoscopy include lack of operating time, lack of adequate training and institutional pressures. Only 28 (37%) indicated that they cared for patients in a formalized enhanced recovery programme (ERAS). Barriers to implementing ERAS included lack of support from institutions and other specialities. Routine oral 'mechanical' bowel preparation for colon and rectal resection was preferred by 28% and 63%, respectively. Drainage after routine colon and rectal resection was not used by 62 (83%) and 39 (53%). Prophylactic nasogastric intubation afterwards was not used by 66 (87%) responders. The preferred mode of analgesia was patient-controlled opioid analgesia (PCA) for 52%. A 'restrictive' intravenous fluid therapy was preferred by 34 (49%) while 33 (48%) preferred no fluid restriction. A prolonged 'nil by mouth' status was preferred by 28%.

CONCLUSION

There appears to be a high rate of evidence in agreement with some interventions but not others. The systemic barriers to implementing evidence-based perioperative care need attention.

Pleth variability index to predict fluid responsiveness in colorectal surgery

BACKGROUND

Goal-directed fluid therapy during major abdominal surgery may reduce postoperative morbidity. The Pleth Variability Index (PVI), derived from the pulse oximeter waveform, has been shown to be able to predict fluid responsiveness in a number of surgical circumstances. In the present study, we sought to determine whether PVI could predict fluid responsiveness in low-risk colorectal surgery patients who had fluid therapy guided by esophageal Doppler stroke volume measurements.

METHODS

Twenty-five low-risk patients undergoing colorectal resection under general anesthesia were studied. Baseline values for esophageal Doppler stroke volume and PVI taken from finger and ear probes were compared with final values after (a) a 500-mL fluid bolus immediately after induction (steady state) and tracheal intubation before the start of the surgery, and (b) 250-mL boluses given in response to a decrease in stroke volume of 10% during surgery as measured by esophageal Doppler (dynamic). Patients were classified into responders and nonresponders based on a stroke volume increase of >10%.

RESULTS

Baseline PVI at the finger was significantly higher in responders in both steady-state and intraoperative conditions. In steady state, PVI at both finger and earlobe had significant predictive ability of an increase in stroke volume: area under the curve for finger 0.96 (95% confidence interval [CI], 0.88-1.00; P=0.011) and for earlobe 0.98 (95% CI, 0.93-1.00; P=0.008). In dynamic intraoperative conditions, PVI at the finger predicted increases in stroke volume, area under the curve 0.71 (95% CI, 0.57-0.85; P=0.006), but PVI at the earlobe had no predictive value.

CONCLUSIONS

PVI measured at the finger may be able to predict fluid responsiveness during surgery in ventilated patients.

Fluids and gastrointestinal function

PURPOSE OF REVIEW

To highlight recent developments relating perioperative fluid therapy to gastrointestinal function by reviewing clinically pertinent English language articles mainly from January 2010 to March 2011.

RECENT FINDINGS

The control of fluid and electrolyte balance involves multiple processes in which the gastrointestinal tract plays an integral role. Diseases affecting the gastrointestinal tract commonly cause fluid and electrolyte disturbance. Similarly, intravenous fluid therapy in the perioperative period can affect gastrointestinal function and have a bearing on postoperative outcome. Striking a balance, in terms of both fluid composition and volume, is likely to reduce the morbidity associated with interstitial edema, a frequently observed occurrence with contemporary perioperative fluid regimens. This balance may be best achieved using individualized and goal-directed approaches to fluid therapy, in order to provide fluid when it is needed and in the correct quantities.

SUMMARY

In planning strategies of fluid therapy, the possibility of adverse effects on the gastrointestinal tract should be considered, as this is likely to have an impact on fluid and electrolyte balance and postoperative outcome.

Advanced hemodynamic monitoring in critically ill children

Circulatory shock is an important cause of pediatric morbidity and mortality and requires early recognition and prompt institution of adequate treatment protocols. Unfortunately, the hemodynamic status of the critically ill child is poorly reflected by physical examination, heart rate, blood pressure, or laboratory blood tests. Advanced hemodynamic monitoring consists, among others, of measuring cardiac output, predicting fluid responsiveness, calculating systemic oxygen delivery in relation to oxygen demand, and quantifying (pulmonary) edema. We discuss here the potential value of these hemodynamic monitoring technologies in relation to pediatric physiology.

Clinical review: Update on hemodynamic monitoring--a consensus of 16

Hemodynamic monitoring plays a fundamental role in the management of acutely ill patients. With increased concerns about the use of invasive techniques, notably the pulmonary artery catheter, to measure cardiac output, recent years have seen an influx of new, less-invasive means of measuring hemodynamic variables, leaving the clinician somewhat bewildered as to which technique, if any, is best and which he/she should use. In this consensus paper, we try to provide some clarification, offering an objective review of the available monitoring systems, including their specific advantages and limitations, and highlighting some key principles underlying hemodynamic monitoring in critically ill patients.