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O'Connor GD, Taplin R, Murphy C. Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland. Ir J Med Sci 2024; 193:2461-2468. [PMID: 38850352 PMCID: PMC11450058 DOI: 10.1007/s11845-024-03731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION The ERAS protocol is a set of international guidelines established to expedite patients' discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients' return to home at earlier rates than traditional practice. METHODS A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively. RESULTS In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin. CONCLUSION UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.
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Affiliation(s)
- Gavin David O'Connor
- University Hospital Limerick, Limerick, Ireland.
- University College Cork, Cork, Ireland.
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Dull RO, Hahn RG, Dull GE. Anesthesia-induced Lymphatic Dysfunction. Anesthesiology 2024; 141:175-187. [PMID: 38739769 DOI: 10.1097/aln.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
General anesthetics adversely alters the distribution of infused fluid between the plasma compartment and the extravascular space. This maldistribution occurs largely from the effects of anesthetic agents on lymphatic pumping, which can be demonstrated by macroscopic fluid kinetics studies in awake versus anesthetized patients. The magnitude of this effect can be appreciated as follows: a 30% reduction in lymph flow may result in a fivefold increase of fluid-induced volume expansion of the interstitial space relative to plasma volume. Anesthesia-induced lymphatic dysfunction is a key factor why anesthetized patients require greater than expected fluid administration than can be accounted for by blood loss, urine output, and insensible losses. Anesthesia also blunts the transvascular refill response to bleeding, an important compensatory mechanism during hemorrhagic hypovolemia, in part through lymphatic inhibition. Last, this study addresses how catecholamines and hypertonic and hyperoncotic fluids may mobilize interstitial fluid to mitigate anesthesia-induced lymphatic dysfunction.
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Affiliation(s)
- Randal O Dull
- Departments of Anesthesiology, Pathology, and Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert G Hahn
- Department of Anesthesiology and Intensive Care, Karolinska Institute at Danderyds Hospital, Stockholm, Sweden
| | - Gabriella E Dull
- Department of Nursing, Banner University Medical Center, Tucson, Arizona
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Castro R, Born P, Muñoz F, Guzmán C, Kattan E, Hernandez G, Bakker J. Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery. J Pers Med 2024; 14:429. [PMID: 38673056 PMCID: PMC11051314 DOI: 10.3390/jpm14040429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m2 (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients.
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Affiliation(s)
- Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Pablo Born
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Felipe Muñoz
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Camila Guzmán
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Department of Intensive Care, Erasmus MC University Medical Center, P.O. Box 2040, 3000 Rotterdam, The Netherlands
- Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, NY 10019, USA
- NYU School of Medicine, Langone, New York, NY 10016, USA
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Deslarzes P, Jurt J, Larson DW, Blanc C, Hübner M, Grass F. Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice. J Clin Med 2024; 13:801. [PMID: 38337495 PMCID: PMC10856154 DOI: 10.3390/jcm13030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.
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Affiliation(s)
- Philip Deslarzes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Jonas Jurt
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - David W. Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Catherine Blanc
- Department of Anesthesiology, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland;
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
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Krüger A, Flo Forner A, Ender J, Janai A, Roufail Y, Otto W, Meineri M, Zakhary WZA. Postoperative Weight Gain within Enhanced Recovery after Cardiac Surgery. J Cardiovasc Dev Dis 2023; 10:263. [PMID: 37367428 DOI: 10.3390/jcdd10060263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Optimal fluid therapy during perioperative care as part of enhanced recovery after cardiac surgery (ERACS) should improve the outcome. Our objective was finding out the effects of fluid overload on outcome and mortality within a well-established ERACS program. All consecutive patients undergoing cardiac surgery between January 2020 and December 2021 were enrolled. According to ROC curve analysis, a cut-off of ≥7 kg (group M, n = 1198) and <7 kg (group L, n = 1015) was defined. A moderate correlation was shown between weight gain and fluid balance r = 0.4, and a simple linear regression was significant p < 0.0001, R2 = 0.16. Propensity score matching showed that increased weight gain was associated with a longer hospital length of stay (LOS) (L 8 [3] d vs. M 9 [6] d, p < 0.0001), an increased number of patients who received pRBCs (L 311 (36%) vs. M 429 (50%), p < 0.0001), and a higher incidence of postoperative acute kidney injury (AKI) (L 84 (9.8%) vs. M 165 (19.2%), p < 0.0001). Weight gain can easily represent fluid overload. Fluid overload after cardiac surgery is common and is associated with prolonged hospital LOS and increases the incidence of AKI.
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Affiliation(s)
- Alexandra Krüger
- Heart Center Leipzig, University of Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Anna Flo Forner
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Jörg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Aniruddha Janai
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Youssef Roufail
- Health Sciences, Faculty of Science, Waterloo Campus, Wilfrid Laurier University, Waterloo, ON N2L 3C5, Canada
| | - Wolfgang Otto
- Department of Cardiac Surgery, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Massimiliano Meineri
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Waseem Z A Zakhary
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
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Hahn RG, Olsson J. Diuretic response to Ringer's solution is normal shortly after awakening from general anaesthesia: a retrospective kinetic analysis. BJA OPEN 2022; 2:100013. [PMID: 37588273 PMCID: PMC10430821 DOI: 10.1016/j.bjao.2022.100013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/21/2022] [Indexed: 08/18/2023]
Abstract
Background The elimination of Ringer's solution is severely depressed during general anaesthesia, but the degree to which this continues postoperatively is poorly established. Methods An intravenous infusion of Ringer's acetate solution 20 ml kg-1 was administered over 60 min in 12 patients undergoing laparoscopic cholecystectomy. Population kinetic analysis was performed based on repeated measurements of blood haemoglobin concentration and urinary excretion over 240 min regardless of when the operations were finished. The analysis contrasted the periods before and after awakening from general anaesthesia and compared them with data from 18 volunteers who received the same fluid at the same rate. Results Patients were monitored for approximately 2 h after awakening from general anaesthesia. The rate constant for redistribution of fluid from the extravascular space to the plasma (k21) and the rate constant for urinary excretion (k10) were significantly higher postoperatively than during the surgical period. Computer simulations indicated that urinary excretion after surgery was almost restored to the rate found in the volunteers. In contrast, the redistribution of fluid from the extravascular space to the plasma, which was almost nil during the surgery, showed only limited recovery during the postoperative phase, and was only approximately 10% of the flow rate found in the volunteers. The combination of nearly normalised urinary excretion and lack of adequate return of distributed fluid to the plasma promoted postoperative hypovolaemia. Conclusion The kinetic analysis indicates that plasma volume support should be given during the first 2 h after laparoscopic cholecystectomy.
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Affiliation(s)
- Robert G. Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden
- Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Joel Olsson
- Department of Anaesthesia, Sundsvalls sjukhus, Sundsvall, Sweden
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