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Alves MRD, Saturnino SF, Zen AB, de Albuquerque DGS, Diegoli H. Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis. CRITICAL CARE SCIENCE 2024; 36:e20240196en. [PMID: 38775544 PMCID: PMC11098079 DOI: 10.62675/2965-2774.20240196-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/08/2023] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE. RESULTS We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%). CONCLUSION Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.
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Affiliation(s)
| | - Saulo Fernandes Saturnino
- Universidade Federal de Minas GeraisBelo HorizonteMGBrazilUniversidade Federal de Minas Gerais - Belo Horizonte (MG), Brazil.
| | - Ana Beatriz Zen
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
| | | | - Henrique Diegoli
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
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Sun Y, Liang X, Chai F, Shi D, Wang Y. Goal-directed fluid therapy using stroke volume variation on length of stay and postoperative gastrointestinal function after major abdominal surgery-a randomized controlled trial. BMC Anesthesiol 2023; 23:397. [PMID: 38049713 PMCID: PMC10694978 DOI: 10.1186/s12871-023-02360-1] [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: 06/07/2023] [Accepted: 11/27/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The effectiveness of goal-directed fluid therapy (GDFT) in promoting postoperative recovery remains unclear, the aim of this study was to evaluate the effect of GDFT on length of hospital stay and postoperative recovery of GI function in patients undergoing major abdominal oncologic surgery. METHODS In this randomized, double- blinded, controlled trial, adult patients scheduled for elective major abdominal surgery with general anesthesia, were randomly divided into the GDFT protocol (group G) or conventional fluid therapy group (group C). Patients in group C underwent conventional fluid therapy based on mean arterial pressure (MAP) and central venous pressure (CVP) whereas those in group G received GDFT protocol associated with the SVV less than 12% and the cardiac index (CI) was controlled at a minimum of 2.5 L/min/m2. The primary outcomes were the length of hospital stay and postoperative GI function. RESULTS One hundred patients completed the study protocol. The length of hospital stay was significantly shorter in group G compared with group C [9.0 ± 5.8 days versus 12.0 ± 4.6 days, P = 0.001]. Postoperative gastrointestinal dysfunction (POGD) occurred in two of 50 patients (4%) in group G and 16 of 50 patients (32%) in the control group (P < 0.001). GDFT significantly also shorten time to first flatus by 11 h (P = 0.009) and time to first tolerate oral diet by 2 days (P < 0.001). CONCLUSIONS Guided by SVV and CI, the application of GDFT has the potential to expedite postoperative recovery of GI function and reduce hospitalization duration after major abdominal surgery. TRIAL REGISTRATION This study was registered on www. CLINICALTRIALS gov on 07/05/2019 with registration number: NCT03940144.
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Affiliation(s)
- Yanxia Sun
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.
| | - Xuan Liang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Fang Chai
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Dongjing Shi
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Yue Wang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
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Peltoniemi P, Lehto I, Pere P, Mustonen H, Lehtimäki T, Seppänen H. Goal-directed fluid management associates with fewer postoperative fluid collections in pancreatoduodenectomy patients. Pancreatology 2023; 23:456-464. [PMID: 37258370 DOI: 10.1016/j.pan.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND The association between perioperative fluid management and complications in pancreatoduodenectomy patients remains controversial. We explored the association between fluid management and radiological signs of complications. METHODS We examined pancreatoduodenectomy patients operated between July 2014 and December 2015 (n = 125) and between January 2017 and June 2018 (n = 124). The first cohort received intraoperative fluid management according to a goal-directed strategy and the second cohort was treated conventionally. We analyzed fluid administration, edema visible in computed tomography (CT) scans seven days postoperatively, and radiological signs of complications occurring up to 30 days. We performed multivariable logistic regression analyses to identify risk factors for fluid collections. RESULTS No statistically significant difference in postoperative edema via CT scans emerged between the fluid management groups. However, the intraperitoneal space expanded in patients with severe Clavien-Dindo complications compared with patients experiencing mild or no complications (19.1% (IQR 10.4-40.5) vs 2.5% (IQR -7.9-16.6), p = 0.004). Fluid collections were less frequent in the goal-directed group than in the conventional fluid management group (16.8% vs 34.7%, p = 0.001). Risk factors for fluid collections included main pancreatic duct size ≤3 mm, less intraoperative fluid volume accompanying conventional fluid management, a lower postoperative urine output, and postoperative congestive heart failure. The goal-directed group received more intraoperative fluids than the conventional fluid management group and postoperative urine output was higher in the goal-directed group on postoperative days 1-3. CONCLUSIONS Optimization of intraoperative fluid management through target-controlled strategies and early diuresis were associated with a lower frequency of fluid collections in postoperative CT.
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Affiliation(s)
- Piia Peltoniemi
- Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inkeri Lehto
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Pertti Pere
- Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Mustonen
- Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
| | | | - Hanna Seppänen
- Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
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Yang TX, Tan AY, Leung WH, Chong D, Chow YF. Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review. Cureus 2023; 15:e38238. [PMID: 37261162 PMCID: PMC10226838 DOI: 10.7759/cureus.38238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.
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Affiliation(s)
- Timothy Xianyi Yang
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Adrian Y Tan
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Wesley H Leung
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - David Chong
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Yu Fat Chow
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
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Effect of inferior vena cava respiratory variability-guided fluid therapy after laparoscopic hepatectomy: a randomized controlled clinical trial. Chin Med J (Engl) 2023:00029330-990000000-00327. [PMID: 36752804 DOI: 10.1097/cm9.0000000000002484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND After major liver resection, the volume status of patients is still undetermined. However, few concerns have been raised about postoperative fluid management. We aimed to compare gut function recovery and short-term prognosis of the patients after laparoscopic liver resection (LLR) with or without inferior vena cava (IVC) respiratory variability-directed fluid therapy in the anesthesia intensive care unit (AICU). METHODS This randomized controlled clinical trial enrolled 70 patients undergoing LLR. The IVC respiratory variability was used to optimize fluid management of the intervention group in AICU, while the standard practice of fluid management was used for the control group. The primary outcome was the time to flatus after surgery. The secondary outcomes included other indicators of gut function recovery after surgery, postoperative length of hospital stay (LOS), liver and kidney function, the severity of oxidative stress, and the incidence of severe complications associated with hepatectomy. RESULTS Compared with patients receiving standard fluid management, patients in the intervention group had a shorter time to anal exhaust after surgery (1.5 ± 0.6 days vs. 2.0 ± 0.8 days) and lower C-reactive protein activity (21.4 [95% confidence interval (CI): 11.9-36.7] mg/L vs. 44.8 [95%CI: 26.9-63.1] mg/L) 24 h after surgery. There were no significant differences in the time to defecation, serum concentrations of D-lactic acid, malondialdehyde, renal function, and frequency of severe postoperative complications as well as the LOS between the groups. CONCLUSION Postoperative IVC respiratory variability-directed fluid therapy in AICU was facilitated in bowel movement but elicited a negligible beneficial effect on the short-term prognosis of patients undergoing LLR. TRIAL REGISTRATION ChiCTR-INR-17013093.
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Peltoniemi P, Pere P, Mustonen H, Seppänen H. Optimal Perioperative Fluid Therapy Associates with Fewer Complications After Pancreaticoduodenectomy. J Gastrointest Surg 2023; 27:67-77. [PMID: 36131201 PMCID: PMC9876870 DOI: 10.1007/s11605-022-05453-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal fluid management in pancreaticoduodenectomy patients remains contested. We aimed to examine the association between perioperative fluid administration and postoperative complications. METHODS We studied 168 pancreaticoduodenectomy patients operated in 2015 (n = 93) or 2017 (n = 75) at Helsinki University Hospital. In 2015, patients received intraoperative fluids following a goal-directed approach and, in 2017, according to anesthesiologist's clinical practice (conventional fluid management). We analyzed the differences in perioperative fluid administration between the groups, specifically examining the occurrence of severe complications (Clavien-Dindo ≥ III), pancreatic fistulas, cardiovascular complications, and the length of hospital stay. RESULTS The goal-directed group received more intraoperative fluids than the conventional fluid management group (12.0 ml/kg/h vs. 8.3 ml/kg/h, p < 0.001). Urine output (770 ml vs. 575 ml, p = 0.004) and intraoperative fluid balance (9.4 ml/kg/h vs. 6.3 ml/kg/h, p < 0.001) were higher in the goal-directed group than in the conventional fluid management group. Severe surgical complications (19.4% vs. 38.7%, p = 0.009) as well as clinically relevant pancreatic fistulas (1.1% vs. 10.7%, p = 0.011) occurred more frequently in patients receiving conventional fluid management. Moreover, the conventional fluid management group experienced longer hospital stays (9.0 vs. 11.5 days, p = 0.02). Lower intraoperative fluid volume accompanying conventional fluid management was associated with a higher risk of severe postoperative complications compared with higher volume in the goal-directed group (odds ratio 2.58 (95% confidence interval 1.04-6.42), p = 0.041). CONCLUSIONS The goal-directed group experienced severe complications less frequently. Our findings indicate that optimizing the intraoperative fluid administration benefits patients, while adopting a too-restrictive approach represents an inferior choice.
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Affiliation(s)
- Piia Peltoniemi
- grid.7737.40000 0004 0410 2071Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pertti Pere
- grid.7737.40000 0004 0410 2071Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Mustonen
- grid.7737.40000 0004 0410 2071Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Seppänen
- grid.7737.40000 0004 0410 2071Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Chang YT, Lai CS, Lu CT, Wu CY, Shen CH. Effect of Total Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Microvascular Reconstruction for Head and Neck Cancer: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2022; 148:2795921. [PMID: 36107412 PMCID: PMC9478882 DOI: 10.1001/jamaoto.2022.2552] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 07/08/2022] [Indexed: 09/17/2023]
Abstract
Importance Free flap surgery is a lengthy procedure with massive tissue destruction and reconstruction, which makes postoperative pulmonary complications (PPCs) a noticeable issue among patients with head and neck cancer. Propofol-based total intravenous anesthesia (TIVA) has better survival outcomes than inhalational anesthesia (INH) in several types of cancer surgery. A previous retrospective study found that patients in the TIVA group had a lower PPC rate, which may be correlated with a lower intraoperative fluid requirement. We hypothesize that the protective effect remains among patients undergoing free flap surgery for head and neck cancer in a prospective and goal-directed fluid therapy setting. Objective To assess the effect of TIVA vs INH on PPCs in patients undergoing microvascular reconstruction for head and neck cancer. Design, Setting, and Participants This prospective, 2-arm, randomized clinical trial was conducted at a tertiary hospital in Taiwan; a total of 78 patients 18 years and older with American Society of Anesthesiologists physical status classification 1 to 3 who were scheduled for elective free flap surgery under general anesthesia were included. The trial started in October 2017, completed in October 2019, and finished analysis in January 2022. Interventions Patients were enrolled and randomized to the TIVA or INH group. All patients received goal-directed fluid therapy and hemodynamic management if they had a mean arterial pressure (MAP) below 75 mm Hg or a reduction of 10% from baseline MAP. Main Outcomes and Measures The primary outcome was a composite of PPCs. The secondary outcomes were the differences in intraoperative hemodynamic values (mean arterial pressure, MAP; cardiac index, CI; systemic vascular resistance index, SVRI; and stroke volume variation, SVV). Results A total of 70 patients (65 men [93%]; 5 women [7%]) completed the trial; median (IQR) age was 52.0 (48-59) years in the TIVA group and 57.0 (46-64) years in the INH group. The demographic characteristics were similar between the 2 groups, except that patients in the TIVA group had a slightly lower body mass index. Patients in the TIVA group had a lower risk of developing PPCs (unadjusted odds ratio, 0.25; 95% CI, 0.08-0.80). The TIVA group had significantly higher MAP, lower CI, and higher SVRI than the INH group after the third hour of monitoring. The TIVA group showed a relatively stable hourly MAP, CI, SVRI, and SVV across time points, while the INH group showed a more varying pattern. The generalized estimating equation showed no clinical differences in the trend of hemodynamic parameters across time between groups. Conclusions and Relevance In this randomized clinical trial, using propofol-based TIVA reduced the incidence of PPCs in free flap surgery. This finding may be related to more stable hemodynamic manifestations and a lower total balance of fluid throughout the surgery. Trial Registration ClinicalTrials.gov Identifier: NCT03263078.
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Affiliation(s)
- Yi-Ting Chang
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chun-Te Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Yeu Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Holst JM, Klitholm MP, Henriksen J, Vallentin MF, Jessen MK, Bolther M, Holmberg MJ, Høybye M, Lind PC, Granfeldt A, Andersen LW. Intraoperative Respiratory and Hemodynamic Strategies for Reducing Nausea, Vomiting, and Pain after Surgery: Systematic Review and Meta-Analysis. Acta Anaesthesiol Scand 2022; 66:1051-1060. [PMID: 35924389 PMCID: PMC9545575 DOI: 10.1111/aas.14127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/08/2022] [Accepted: 07/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite improved medical treatment strategies, post-operative pain, nausea, and vomiting remain major challenges. This systematic review investigated the relationship between perioperative respiratory and hemodynamic interventions and postoperative pain, nausea, and vomiting. METHODS PubMed and Embase were searched on March 8, 2021 for randomized clinical trials investigating the effect of perioperative respiratory or hemodynamic interventions in adults undergoing non-cardiac surgery. Investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed when feasible. GRADE was used to assess the certainty in the evidence. RESULTS This review included 65 original trials; of these 48% had pain, nausea and/or vomiting as the primary focus. No reduction of postoperative pain was found in meta-analyses when comparing recruitment maneuvers with no recruitment, high (80%) to low (30%) fraction of oxygen, low (5-7 ml/kg) to high (9-12 ml/kg) tidal volume, or goal-directed hemodynamic therapy to standard care. In the meta-analysis comparing recruitment maneuvers with no recruitment maneuvers, patients undergoing laparoscopic gynecological surgery had less shoulder pain 24 hours postoperatively (mean difference in the numeric rating scale from 0 to 10: -1.1, 95% CI: -1.7, -0.5). In meta-analyses, comparing high to low fraction of inspired oxygen and goal-directed hemodynamic therapy to standard care in patients undergoing abdominal surgery, the risk of postoperative nausea and vomiting was reduced (odds ratio: 0.45, 95% CI: 0.24, 0.87 and 0.48, 95% CI: 0.27, 0.85). The certainty in the evidence was mostly very low to low. The results should be considered exploratory given the lack of pre-specified hypotheses and corresponding risk of Type 1 errors. CONCLUSION There is limited evidence regarding the impact of intraoperative respiratory and hemodynamic interventions on postoperative pain or nausea and vomiting. More definitive trials are needed to guide clinical care within this area. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Johanne M Holst
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Maibritt P Klitholm
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Henriksen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Bolther
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Anesthesiology and Intensive Care, Randers Regional Hospital, Randers, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Carøe Lind
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
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9
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Jessen MK, Vallentin MF, Holmberg MJ, Bolther M, Hansen FB, Holst JM, Magnussen A, Hansen NS, Johannsen CM, Enevoldsen J, Jensen TH, Roessler LL, Lind PC, Klitholm MP, Eggertsen MA, Caap P, Boye C, Dabrowski KM, Vormfenne L, Høybye M, Henriksen J, Karlsson CM, Balleby IR, Rasmussen MS, Pælestik K, Granfeldt A, Andersen LW. Goal-directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis. Br J Anaesth 2022; 128:416-433. [PMID: 34916049 PMCID: PMC8900265 DOI: 10.1016/j.bja.2021.10.046] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/28/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND During general anaesthesia for noncardiac surgery, there remain knowledge gaps regarding the effect of goal-directed haemodynamic therapy on patient-centred outcomes. METHODS Included clinical trials investigated goal-directed haemodynamic therapy during general anaesthesia in adults undergoing noncardiac surgery and reported at least one patient-centred postoperative outcome. PubMed and Embase were searched for relevant articles on March 8, 2021. Two investigators performed abstract screening, full-text review, data extraction, and bias assessment. The primary outcomes were mortality and hospital length of stay, whereas 15 postoperative complications were included based on availability. From a main pool of comparable trials, meta-analyses were performed on trials with homogenous outcome definitions. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). RESULTS The main pool consisted of 76 trials with intermediate risk of bias for most outcomes. Overall, goal-directed haemodynamic therapy might reduce mortality (odds ratio=0.84; 95% confidence interval [CI], 0.64 to 1.09) and shorten length of stay (mean difference=-0.72 days; 95% CI, -1.10 to -0.35) but with low certainty in the evidence. For both outcomes, larger effects favouring goal-directed haemodynamic therapy were seen in abdominal surgery, very high-risk surgery, and using targets based on preload variation by the respiratory cycle. However, formal tests for subgroup differences were not statistically significant. Goal-directed haemodynamic therapy decreased risk of several postoperative outcomes, but only infectious outcomes and anastomotic leakage reached moderate certainty of evidence. CONCLUSIONS Goal-directed haemodynamic therapy during general anaesthesia might decrease mortality, hospital length of stay, and several postoperative complications. Only infectious postoperative complications and anastomotic leakage reached moderate certainty in the evidence.
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Affiliation(s)
- Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Maria Bolther
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Johanne M Holst
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niklas S Hansen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Thomas H Jensen
- Department of Internal Medicine, University Hospital of North Norway, Narvik, Norway
| | - Lara L Roessler
- Department of Emergency Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peter C Lind
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Maibritt P Klitholm
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mark A Eggertsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Philip Caap
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Caroline Boye
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karol M Dabrowski
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lasse Vormfenne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeppe Henriksen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Carl M Karlsson
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Ida R Balleby
- National Hospital of the Faroe Islands, Torshavn, Faroe Islands, Denmark
| | - Marie S Rasmussen
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Kim Pælestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lars W Andersen
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.
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10
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Akyol D, Cukurova Z, Tulubas E, Yıldız G, Sabaz M. Goal-directed fluid therapy in gastrointestinal cancer surgery: A prospective randomized study. JOURNAL OF ACUTE DISEASE 2022. [DOI: 10.4103/2221-6189.342661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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AIM in Anesthesiology. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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Ramsingh D, Staab J, Flynn B. Application of perioperative hemodynamics today and potentials for tomorrow. Best Pract Res Clin Anaesthesiol 2021; 35:551-564. [PMID: 34801217 DOI: 10.1016/j.bpa.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
Hemodynamic (HD) monitoring remains integral to the assessment and management of perioperative and critical care patients. This review article seeks to provide an update on the different types of flow-guided HD monitoring technologies available, highlight their limitations, and review the therapies associated with the application of these technologies. Additionally, we will also comment on the expanding roles of HD monitoring in the future.
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Affiliation(s)
- Davinder Ramsingh
- Department of Anesthesiology Loma Linda University Medical Center, Loma Linda, CA, USA; VP for Clinical and Medical Affairs, Edwards Lifesciences Critical Care Division, USA.
| | - Jared Staab
- Director of Perioperative Ultrasound, Program Director Critical Care Anesthesiology Fellowship, Department of Anesthesiology, University of Kansas Medical Center, USA.
| | - Brigid Flynn
- Chief, Division of Critical Care, Co-Director Cardiothoracic ICUChair Anesthesia Research Committee, Department of Anesthesiology, University of Kansas Medical, USA.
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13
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Prasad C, Radhakrishna N, Pandia MP, Khandelwal A, Singh GP, Bithal PK. The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position. J Neurosci Rural Pract 2021; 12:745-750. [PMID: 34737510 PMCID: PMC8559088 DOI: 10.1055/s-0041-1735321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective
Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay.
Materials and Methods
Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18–60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients (
n
= 15) served as control group and received SFT intraoperatively, while patients in group G (
n
= 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLV
AI
) and before extubation (CLV
BE
).
Statistical Analysis and Results
CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL;
p
-value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G (
p
-value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower (
p
-value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable.
Conclusion
GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.
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Affiliation(s)
- Chandrakant Prasad
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Nayani Radhakrishna
- Department of Anaesthesia, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | - Mihir Prakash Pandia
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Khandelwal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Gyaninder Pal Singh
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Parmod Kumar Bithal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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14
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A 2-Year Experience With Enhanced Recovery After Surgery: Evaluation of Compliance and Outcomes in Pancreatic Surgery. J Nurs Care Qual 2021; 36:E24-E28. [PMID: 32282506 DOI: 10.1097/ncq.0000000000000487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programs reduce recovery time, length of stay (LOS), and complications after major surgical procedures. PURPOSE We evaluated our 2-year experience with a newly implemented comprehensive ERAS program at a high-volume center after pancreatic surgery. METHODS Outcomes, cost, and compliance metrics were assessed in 215 patients who underwent elective pancreatic surgery (pre-ERAS; n = 99; post-ERAS: n = 116). Mann-Whitney U and χ2 tests were used to evaluate continuous and categorical variables. RESULTS There were significant decreases in LOS and cost in the post-ERAS cohorts. There were significant increases in compliance with ERAS implementation. Postoperative complication, readmission, and survival rates did not increase. CONCLUSIONS Implementation of ERAS at a large-volume hospital may improve compliance and reduce costs and LOS without increasing adverse outcomes.
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15
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Perioperative outcomes of goal-directed versus conventional fluid therapy in radical cystectomy with enhanced recovery protocol. Int Urol Nephrol 2021; 53:1827-1833. [PMID: 34089170 DOI: 10.1007/s11255-021-02903-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of this study is to evaluate the intra/perioperative fluid management and early postoperative outcomes of patients who underwent radical cystectomy with Enhanced Recovery After Surgery protocol, using goal-directed fluid therapy compared to conventional fluid therapy. METHODS This cohort study included patients who underwent open RC for urothelial bladder carcinoma with intent to cure and Enhanced Recovery After Surgery protocol between May 2012 and August 2019. Patients who had palliative or salvage cystectomy and/or adjunct procedures, as well as those with missing detailed perioperative data were excluded. Data were compared between patients who received goal-directed fluid therapy using stroke volume variation by FloTrac™/Vigileo system (n = 119) and conventional fluid therapy based on the anesthesiologist discretion (n = 192). Primary outcome variable was 90-day complications and secondary outcome measures included in-hospital GFR trend, length of stay, and 90-day readmission. RESULTS The goal-directed fluid therapy group received less total and net intra/perioperative fluid, yet early postoperative glomerular filtration rate trends were similar between both groups (p = 0.7). Estimated blood loss, blood transfusion, index hospital stay, 90-day complication and readmission rates were also comparable between the two groups. Multivariable logistic regression showed no significant association between perioperative fluid management method and 90-day complication rate (OR 1.4, 95% CI 0.8-2.4, p = 0.2). CONCLUSION Stroke volume variation guided goal-directed fluid therapy is safe in radical cystectomy without compromising the renal function. It is associated with less intra- and perioperative fluid infusion; however, no association with hospital stay, 90-day complication or readmission rates were noted.
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16
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Komorowski M, Joosten A. AIM in Anesthesiology. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Goal-directed versus Standard Fluid Therapy to Decrease Ileus after Open Radical Cystectomy: A Prospective Randomized Controlled Trial. Anesthesiology 2020; 133:293-303. [PMID: 32472804 DOI: 10.1097/aln.0000000000003367] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Postoperative ileus is a common complication of intraabdominal surgeries, including radical cystectomy with reported rates as high as 32%. Perioperative fluid administration has been associated with improvement in postoperative ileus rates, but it is difficult to generalize because earlier studies lacked standardized definitions of postoperative ileus and other relevant outcomes. The hypothesis was that targeted individualized perioperative fluid management would improve postoperative ileus in patients receiving radical cystectomy. METHODS This is a parallel-arm, double-blinded, single-center randomized trial of goal-directed fluid therapy versus standard fluid therapy for patients undergoing open radical cystectomy. The primary outcome was postoperative ileus, and the secondary outcome was complications within 30 days post-surgery. Participants were at least 21 yr old, had a maximum body mass index of 45 kg/m and no active atrial fibrillation. The intervention in the goal-directed therapy arm combined preoperative and postoperative stroke volume optimization and intraoperative stroke volume variation minimization to guide fluid administration, using advanced hemodynamic monitoring. RESULTS Between August 2014 and April 2018, 283 radical cystectomy patients (142 goal-directed fluid therapy and 141 standard fluid therapy) were included in the analysis. Postoperative ileus occurred in 25% (36 of 142) of patients in the goal-directed fluid therapy arm and 21% (30 of 141) of patients in the standard arm (difference in proportions, 4.1%; 95% CI, -5.8 to 13.9; P = 0.418). There was no difference in incidence of high-grade complications between the two arms (20 of 142 [14%] vs. 23 of 141 [16%]; difference in proportions, -2.2%; 95% CI, -10.6 to 6.1; P = 0.602), with the exception of acute kidney injury, which was more frequent in the goal-directed fluid therapy arm (56% [80 of 142] vs. 40% [56 of 141] in the standard arm; difference in proportions, 16.6%; 95% CI, 5.1 to 28.1; P = 0.005; P = 0.170 after adjustment for multiple testing). CONCLUSIONS Goal-directed fluid therapy may not be an effective strategy for lowering the risk of postoperative ileus in patients undergoing open radical cystectomy.
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18
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Toyoda D, Maki Y, Sakamoto Y, Kinoshita J, Abe R, Kotake Y. Comparison of volume and hemodynamic effects of crystalloid, hydroxyethyl starch, and albumin in patients undergoing major abdominal surgery: a prospective observational study. BMC Anesthesiol 2020; 20:141. [PMID: 32493281 PMCID: PMC7271551 DOI: 10.1186/s12871-020-01051-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The volume effect of iso-oncotic colloid is supposedly larger than crystalloid, but such differences are dependent on clinical context. The purpose of this single center observational study was to compare the volume and hemodynamic effects of crystalloid solution and colloid solution during surgical manipulation in patients undergoing major abdominal surgery. METHODS Subjects undergoing abdominal surgery for malignancies with intraoperative goal-directed fluid management were enrolled in this observational study. Fluid challenges consisted with 250 ml of either bicarbonate Ringer solution, 6% hydroxyethyl starch or 5% albumin were provided to maintain optimal stroke volume index. Hematocrit derived-plasma volume and colloid osmotic pressure was determined immediately before and 30 min after the fluid challenge. Data were expressed as median (IQR) and statistically compared with Kruskal-Wallis test. RESULTS One hundred thirty-nine fluid challenges in 65 patients were analyzed. Bicarbonate Ringer solution, 6% hydroxyethyl starch and 5% albumin were administered in 42, 49 and 48 instances, respectively. Plasma volume increased 7.3 (3.6-10.0) % and 6.3 (1.4-8.8) % 30 min after the fluid challenge with 6% hydroxyethyl starch and 5% albumin and these values are significantly larger than the value with bicarbonate Ringer solution (1.0 (- 2.7-2.3) %) Colloid osmotic pressure increased 0.6 (0.2-1.2) mmHg after the fluid challenge with 6% hydroxyethyl starch and 0.7(0.2-1.3) mmHg with 5% albumin but decreased 0.6 (0.2-1.2) mmHg after the fluid challenge with bicarbonate Ringer solution. The area under the curve of stroke volume index after fluid challenge was significantly larger after 6% hydroxyethyl starch or 5% albumin compared to bicarbonate Ringer solution. CONCLUSIONS Fluid challenge with 6% hydroxyethyl starch and 5% albumin showed significantly larger volume and hemodynamic effects compared to bicarbonate Ringer solution during gastrointestinal surgery. TRIAL REGISTRATION UMIN Clinical Trial Registry UMIN000017964. Registered July 01, 2015.
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Affiliation(s)
- Daisuke Toyoda
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro, Tokyo, 153-8515, Japan.
| | - Yuichi Maki
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Yasumasa Sakamoto
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Junki Kinoshita
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Risa Abe
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro, Tokyo, 153-8515, Japan
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19
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Zaouter C, Joosten A, Rinehart J, Struys MMRF, Hemmerling TM. Autonomous Systems in Anesthesia. Anesth Analg 2020; 130:1120-1132. [DOI: 10.1213/ane.0000000000004646] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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20
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Goal-Directed vs Traditional Approach to Intraoperative Fluid Therapy during Open Major Bowel Surgery: Is There a Difference? Anesthesiol Res Pract 2019; 2019:3408940. [PMID: 31871449 PMCID: PMC6907038 DOI: 10.1155/2019/3408940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Optimum perioperative fluid therapy is important to improve the outcome of the surgical patient. This study prospectively compared goal-directed intraoperative fluid therapy with traditional fluid therapy in general surgical patients undergoing open major bowel surgery. Methodology Patients between 20 and 70 years of age, either gender, ASA I and II, and scheduled for elective open major bowel surgery were included in the study. Patients who underwent laparoscopic and other surgeries were excluded. After routine induction of general anaesthesia, the patients were randomised to either the control group (traditional fluid therapy), the FloTrac group (based on stroke volume variation), or the PVI group (based on pleth variability index). Fluid input and output, recovery characteristics, and complications were noted. Results 306 patients, with 102 in each group, were enrolled. Five patients (control (1), FloTrac (2), and PVI (2)) were inoperable and were excluded. Demographic data, ASA PS, anaesthetic technique, duration of surgery, and surgical procedures were comparable. The control group received significantly more crystalloids (3200 ml) than the FloTrac (2000 ml) and PVI groups (1875 ml), whereas infusion of colloids was higher in the FloTrac (400–700 ml) and PVI (200–500 ml) groups than in the control group (0–500 ml). The control group had significantly positive net fluid balance intraoperatively (2500 ml, 9 ml/kg/h) compared to the FloTrac (1515 ml, 5.4 ml/kg/h) and PVI (1420 ml, 6 ml/kg/h) groups. Days to ICU stay, HDU stay, return of bowel movement, oral intake, morbidity, duration of hospital stay, and survival rate were comparable. The total number of complications was not different between the three groups. Anastomotic leaks occurred more often in the Control group than in the others, but the numbers were small. Conclusions Use of goal-directed fluid management, either with FloTrac or pleth variability index results in a lower volume infusion and lower net fluid balance. However, the complication rate is similar to that of traditional fluid therapy. This trial is registered with CTRI/2018/04/013016.
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Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis. Eur J Anaesthesiol 2019; 35:469-483. [PMID: 29369117 DOI: 10.1097/eja.0000000000000778] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Much uncertainty exists as to whether peri-operative goal-directed therapy is of benefit. OBJECTIVES To discover if peri-operative goal-directed therapy decreases mortality and morbidity in adult surgical patients. DESIGN An updated systematic review and random effects meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase and the Cochrane Library were searched up to 31 December 2016. ELIGIBILITY CRITERIA Randomised controlled trials enrolling adult surgical patients allocated to receive goal-directed therapy or standard care were eligible for inclusion. Trauma patients and parturients were excluded. Goal-directed therapy was defined as fluid and/or vasopressor therapy titrated to haemodynamic goals [e.g. cardiac output (CO)]. Outcomes included mortality, morbidity and hospital length of stay. Risk of bias was assessed using Cochrane methodology. RESULTS Ninety-five randomised trials (11 659 patients) were included. Only four studies were at low risk of bias. Modern goal-directed therapy reduced mortality compared with standard care [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.50 to 0.87; number needed to treat = 59; N = 52; I = 0.0%]. In subgroup analysis, there was no mortality benefit for fluid-only goal-directed therapy, cardiac surgery patients or nonelective surgery. Contemporary goal-directed therapy also reduced pneumonia (OR 0.69; 95% CI, 0.51 to 0. 92; number needed to treat = 38), acute kidney injury (OR 0. 73; 95% CI, 0.58 to 0.92; number needed to treat = 29), wound infection (OR 0.48; 95% CI, 0.37 to 0.63; number needed to treat = 19) and hospital length of stay (days) (-0.90; 95% CI, -1.32 to -0.48; I = 81. 2%). No important differences in outcomes were found for the pulmonary artery catheter studies, after accounting for advances in the standard of care. CONCLUSION Peri-operative modern goal-directed therapy reduces morbidity and mortality. Importantly, the quality of evidence was low to very low (e.g. Grading of Recommendations, Assessment, Development and Evaluation scoring), and there was much clinical heterogeneity among the goal-directed therapy devices and protocols. Additional well designed and adequately powered trials on peri-operative goal-directed therapy are necessary.
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Weinberg L, Ianno D, Churilov L, Mcguigan S, Mackley L, Banting J, Shen SH, Riedel B, Nikfarjam M, Christophi C. Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial. Ann Med Surg (Lond) 2019; 45:45-53. [PMID: 31360460 PMCID: PMC6642079 DOI: 10.1016/j.amsu.2019.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/30/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. Methods We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications. Results Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45–1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed. Conclusion In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified. Major liver resection is a complex procedure with up to 40% patients experiencing complications. Optimisation of perfusion and oxygen delivery to all organs remain the cornerstone of best hemodynamic care. Traditionally, a low central venous pressure strategy during major liver resection has been used to reduce venous bleeding. The impact of a restrictive cardiac output fluid optimisation algorithm during major liver surgery is unknown. After major hepatobiliary surgery, a fluid restrictive algorithm did not reduce length of hospital stay or complications.
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Affiliation(s)
- Laurence Weinberg
- Director of Anesthesia, Austin Hospital; and A/Professor, Department of Surgery, Austin Health, The University of Melbourne, Victoria, Australia
| | - Damian Ianno
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Victoria, Australia.,Department of Medicine (Austin Health), Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Steven Mcguigan
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Lois Mackley
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jonathan Banting
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Shi Hong Shen
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Bernhard Riedel
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
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Improved Outcomes of Enhanced Recovery After Surgery (ERAS) Protocol for Radical Cystectomy with Addition of a Multidisciplinary Care Process in a US Comprehensive Cancer Care Center. World J Surg 2019; 42:2701-2707. [PMID: 29750321 DOI: 10.1007/s00268-018-4665-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Although enhanced recovery after surgery (ERAS) components include both anesthesia and surgical care processes, it is unclear whether a multidisciplinary approach to implementing ERAS care processes improves clinical outcomes. The addition of multidisciplinary care with anesthesiology-related components to an existing ERAS protocol for radical cystectomy at a US comprehensive cancer center provided an opportunity to compare short- and long-term outcomes. METHODS We retrospectively compared the outcomes of 116 consecutive patients who underwent cystectomy after implementation of a multidisciplinary ERAS protocol with those of a historical control group of 143 consecutive patients who had been treated with a surgical ERAS protocol. Length of stay, return of bowel function, rate of blood transfusion, nausea, pain, and readmission rates were examined. RESULTS Implementation of a multidisciplinary ERAS protocol was associated with better postsurgical symptom control, as indicated by lower rates of patient-reported nausea (P < .05). Multivariate Poisson regression analysis showed a decrease in estimated intraoperative transfusions (P ≤ .001) after adjusting for the effects of potential confounding variables. There were no statistically significant differences noted in length of stay, return of bowel function, 30- and 90-day complications, or readmissions. CONCLUSION This is the first study to investigate the effects of adding anesthesia ERAS components to an existing surgical ERAS protocol for radical cystectomy. We found that with the addition of anesthesia-related interventions, there was a decrease in transfusions and nausea.
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Closed-loop hemodynamic management. Best Pract Res Clin Anaesthesiol 2019; 33:199-209. [PMID: 31582099 DOI: 10.1016/j.bpa.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
As the operating room and intensive care settings become increasingly complex, the required vigilance practitioners must dedicate to a wide array of clinical systems has increased concordantly. The resulting shortage of available attention to these various clinical tasks creates a vacuum for the introduction of systems that can administer well-established goal-directed therapies without significant provider feedback. Recently, there has been an explosion of academic exploration into creating such automated systems, with a strong specific focus on hemodynamic control. Within this field, the largest focus has been on goal-directed fluid therapy as systems automating vasopressor administration have only recently become viable options. Our goal in this review article is to summarize the validity of the relevant goal-directed hemodynamic systems and explore the expanding role of automation within these systems.
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Hasanin A, Mourad KH, Farouk I, Refaat S, Nabih A, Raouf SA, Ezzat H. The Impact of Goal-Directed Fluid Therapy in Prolonged Major Abdominal Surgery on Extravascular Lung Water and Oxygenation: A Randomized Controlled Trial. Open Access Maced J Med Sci 2019; 7:1276-1281. [PMID: 31110569 PMCID: PMC6514339 DOI: 10.3889/oamjms.2019.173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND: A growing interest had been paid to goal-directed fluid therapy (GDT) in abdominal surgery; however, its impact on the respiratory profile was not well investigated. AIM: We evaluated the impact of GDT on postoperative extravascular lung water and oxygenation after prolonged major abdominal surgery. METHODS: A randomised, controlled study was conducted in Kasr Alainy hospital from April 2016 till December 2017 including 120 adult patients scheduled for prolonged major abdominal surgery. Patients were randomised into either GDT group (n = 60) who received baseline restricted fluid therapy (2 mL/Kg/hour) which is guided by stroke volume variation, or control group (n = 60) who received standard care. Both study groups were compared according to hemodynamic data, fluid requirements, lung ultrasound score, and PaO2/fraction of inspired oxygen ratio (P/F ratio), RESULTS: Intraoperatively, GDT group received less volume of fluids and showed higher intraoperative mean arterial pressure compared to the control group. Postoperatively, lung ultrasound score was lower, and P/F ratio was higher in the GDT group compared to the control group. The number of patients who showed a significant postoperative increase in LUS was higher in the control group 44 (73%) patients versus 14 (23%) patients, P < 0.001). CONCLUSIONS: Using stroke volume variation for guiding fluid therapy in prolonged, major abdominal operations were associated with better hemodynamic profile, less intraoperative fluid administration, lower extravascular lung water and better oxygenation compared to standard care.
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Affiliation(s)
- Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Karim Hussein Mourad
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Inas Farouk
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Sherin Refaat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Nabih
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Sabah Abdel Raouf
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Hala Ezzat
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Goal-directed therapy during transthoracic oesophageal resection does not improve outcome. Eur J Anaesthesiol 2019; 36:153-161. [DOI: 10.1097/eja.0000000000000908] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Joosten A, Jacobs A, Desebbe O, Vincent JL, Sarah S, Rinehart J, Van Obbergh L, Hapfelmeier A, Saugel B. Monitoring of pulse pressure variation using a new smartphone application (Capstesia) versus stroke volume variation using an uncalibrated pulse wave analysis monitor: a clinical decision making study during major abdominal surgery. J Clin Monit Comput 2019; 33:787-793. [PMID: 30607806 DOI: 10.1007/s10877-018-00241-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
Abstract
Pulse pressure variation (PPV) and stroke volume variation (SVV) can be used to assess fluid status in the operating room but usually require dedicated advanced hemodynamic monitors. Recently, a smartphone application (Capstesia™), which automatically calculates PPV from a picture of the invasive arterial pressure waveform from any monitor screen (PPVCAP), has been developed. The purpose of this study was to compare PPVCAP with SVV from an uncalibrated pulse wave analysis monitor (SVVPC). In 40 patients undergoing major abdominal surgery, we compared PPVCAP with SVVPC at post-induction, pre-incision, post-incision, end of surgery, and during every hypotensive episode (mean arterial pressure < 65 mmHg). We classified PPVCAP and SVVPC into three categories reflecting the thresholds used for the decision to administer fluids: no fluid administration (PPV and SVV < 9%), gray zone (PPV and SVV 9-13%), and fluid administration (PPV and SVV > 13%). The agreement between SVVPC and PPVCAP for these three categories was measured by the number of concordant paired measurements divided by the total number of paired measurements and Cohen's kappa coefficient. In the 549 pairs of PPV-SVV data obtained, the overall agreement of PPVCAP with SVVPC was 79%, and the kappa coefficient was moderate (0.55). The highest agreement and kappa coefficient value were observed after the induction of anesthesia before surgical incision. PPVCAP and SVVPC would have resulted in completely opposite clinical decisions regarding fluid administration in 1% of the cases. In this clinical decision making study in patients undergoing major abdominal surgery, we observed a moderate agreement between PPVCAP and SVVPC with regard to categories used to guide fluid administration. Trial Registration: Clinical Trials.gov (NCT03137901).
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium. .,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.
| | - Alexandra Jacobs
- Department of Anesthesiology, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Olivier Desebbe
- Department of Anesthesiology and Intensive Care, Clinique de la Sauvegarde, 80 Avenue Ben Gourion, 69009, Lyon, France
| | - Jean-Louis Vincent
- Department of Intensive Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Saxena Sarah
- Department of Anesthesiology, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 101 the City Drive South, Orange, USA
| | - Luc Van Obbergh
- Department of Anesthesiology, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Technische Universität München, Munich, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Messina A, Pelaia C, Bruni A, Garofalo E, Bonicolini E, Longhini F, Dellara E, Saderi L, Romagnoli S, Sotgiu G, Cecconi M, Navalesi P. Fluid Challenge During Anesthesia. Anesth Analg 2018; 127:1353-1364. [DOI: 10.1213/ane.0000000000003834] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Deng QW, Tan WC, Zhao BC, Wen SH, Shen JT, Xu M. Is goal-directed fluid therapy based on dynamic variables alone sufficient to improve clinical outcomes among patients undergoing surgery? A meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:298. [PMID: 30428928 PMCID: PMC6237035 DOI: 10.1186/s13054-018-2251-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/29/2018] [Indexed: 12/31/2022]
Abstract
Background Whether goal-directed fluid therapy based on dynamic predictors of fluid responsiveness (GDFTdyn) alone improves clinical outcomes in comparison with standard fluid therapy among patients undergoing surgery remains unclear. Methods PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov were searched for relevant studies. Studies comparing the effects of GDFTdyn with that of standard fluid therapy on clinical outcomes among adult patients undergoing surgery were considered eligible. Two analyses were performed separately: GDFTdyn alone versus standard fluid therapy and GDFTdyn with other optimization goals versus standard fluid therapy. The primary outcomes were short-term mortality and overall morbidity, while the secondary outcomes were serum lactate concentration, organ-specific morbidity, and length of stay in the intensive care unit (ICU) and in hospital. Results We included 37 studies with 2910 patients. Although GDFTdyn alone lowered serum lactate concentration (mean difference (MD) − 0.21 mmol/L, 95% confidence interval (CI) (− 0.39, − 0.03), P = 0.02), no significant difference was found between groups in short-term mortality (odds ratio (OR) 0.85, 95% CI (0.32, 2.24), P = 0.74), overall morbidity (OR 1.03, 95% CI (0.31, 3.37), P = 0.97), organ-specific morbidity, or length of stay in the ICU and in hospital. Analysis of trials involving the combination of GDFTdyn and other optimization goals (mainly cardiac output (CO) or cardiac index (CIx)) showed a significant reduction in short-term mortality (OR 0.45, 95% CI (0.24, 0.85), P = 0.01), overall morbidity (OR 0.41, 95% CI (0.28, 0.58), P < 0.00001), serum lactate concentration (MD − 0.60 mmol/L, 95% CI (− 1.04, − 0.15), P = 0.009), cardiopulmonary complications (cardiac arrhythmia (OR 0.58, 95% CI (0.37, 0.92), P = 0.02), myocardial infarction (OR 0.35, 95% CI (0.16, 0.76), P = 0.008), heart failure/cardiovascular dysfunction (OR 0.31, 95% CI (0.14, 0.67), P = 0.003), acute lung injury/acute respiratory distress syndrome (OR 0.13, 95% CI (0.02, 0.74), P = 0.02), pneumonia (OR 0.4, 95% CI (0.24, 0.65), P = 0.0002)), length of stay in the ICU (MD − 0.77 days, 95% CI (− 1.07, − 0.46), P < 0.00001) and in hospital (MD − 1.18 days, 95% CI (− 1.90, − 0.46), P = 0.001). Conclusions It was not the optimization of fluid responsiveness by GDFTdyn alone but rather the optimization of tissue and organ perfusion by GDFTdyn and other optimization goals that benefited patients undergoing surgery. Patients managed with the combination of GDFTdyn and CO/CI goals might derive most benefit. Electronic supplementary material The online version of this article (10.1186/s13054-018-2251-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qi-Wen Deng
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Wen-Cheng Tan
- Department of Endoscopy, Sun Yat-sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, China
| | - Bing-Cheng Zhao
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, No. 1838, Guangzhou Avenue North, Guangzhou, 510515, China
| | - Shi-Hong Wen
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Jian-Tong Shen
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Miao Xu
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China.
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A Review of Enhanced Recovery After Surgery Principles Used for Scheduled Caesarean Delivery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:1775-1788. [PMID: 30442516 DOI: 10.1016/j.jogc.2018.05.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/23/2018] [Indexed: 12/14/2022]
Abstract
There is an increasing body of evidence to support the success of Enhanced Recovery After Surgery (ERAS) for a wide range of surgical procedures. There has been little formalized application, however, of ERAS principles in obstetrical surgery. The aim of this review was to examine the evidence base of perioperative care for patients undergoing Caesarean delivery (CD) and to determine the feasibility of developing an ERAS Society guideline for this obstetrical care plan. The literature on enhanced recovery programs was reviewed, including fast-track surgery and perioperative care components in the preoperative, intraoperative, and postoperative phases of CD. These studies included randomized controlled trials (RCTs), prospective cohort studies, non-RCT studies, meta-analyses, systematic reviews, reviews, and case studies. This is not a systematic review because each ERAS topic area would require a new question. Certain ERAS elements have the potential to benefit patients undergoing CD. These elements include patient education, preoperative optimization, prophylaxis against thromboembolism, antimicrobial prophylaxis, postoperative nausea and vomiting prevention, hypothermia prevention, perioperative fluid management, postoperative analgesia, ileus prevention, breastfeeding promotion, and early mobilization. ERAS has the potential to be successfully implemented in CD on the basis of the evidence obtained from this review. Knowledge transfer and implementation will require multidisciplinary coordination in the preoperative, intraoperative, and postoperative phases and the development of a formalized ERAS guideline.
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Kaufmann T, Clement RP, Scheeren TWL, Saugel B, Keus F, Horst ICC. Perioperative goal-directed therapy: A systematic review without meta-analysis. Acta Anaesthesiol Scand 2018; 62:1340-1355. [PMID: 29978454 DOI: 10.1111/aas.13212] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/03/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Perioperative goal-directed therapy aims to optimise haemodynamics by titrating fluids, vasopressors and/or inotropes to predefined haemodynamic targets. Perioperative goal-directed therapy is a complex intervention composed of several independent component interventions. Trials on perioperative goal-directed therapy show conflicting results. We aimed to conduct a systematic review and meta-analysis to investigate the benefits and harms of perioperative goal-directed therapy. METHODS PubMED, EMBASE, Web of Science and Cochrane Library were searched. Trials were included if they had a perioperative goal-directed therapy protocol. The primary outcome was all-cause mortality. The first secondary outcome was serious adverse events excluding mortality. Risk of bias was assessed, and GRADE was used to evaluate quality of evidence. RESULTS One hundred and twelve randomised trials were included of which one trial (1%) had low risk of bias. Included trials varied in patients: types of surgery which was expected due to inclusion criteria; in intervention and comparison: timing of intervention, monitoring devices, haemodynamic variables, target values, use of fluids, vasopressors and/or inotropes as well as combinations of these within protocols; and in outcome: mortality was reported in 87 trials (78%). Due to substantial clinical heterogeneity also within the various types of surgery a meta-analysis of data, including subgroup analyses, as defined in our protocol was considered inappropriate. CONCLUSION Clinical heterogeneity in patients, interventions and outcomes in perioperative goal-directed therapy trials is too large to perform meta-analysis on all trials. Future trials and meta-analyses highly depend on universally agreed definitions on aspects beyond type of surgery of the complex intervention and its evaluation.
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Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Ramon P. Clement
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Thomas W. L. Scheeren
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Bernd Saugel
- Department of Anesthesiology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Frederik Keus
- Department of Critical Care University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Iwan C. C. Horst
- Department of Critical Care University Medical Center Groningen University of Groningen Groningen The Netherlands
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Zhang L, Dai F, Brackett A, Ai Y, Meng L. Association of conflicts of interest with the results and conclusions of goal-directed hemodynamic therapy research: a systematic review with meta-analysis. Intensive Care Med 2018; 44:1638-1656. [PMID: 30105599 DOI: 10.1007/s00134-018-5345-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE The association between conflicts of interest (COI) and study results or article conclusions in goal-directed hemodynamic therapy (GDHT) research is unknown. METHODS Randomized controlled trials comparing GDHT with usual care were identified. COI were classified as industry sponsorship, author conflict, device loaner, none, or not reported. The association between COI and study results (complications and mortality) was assessed using both stratified meta-analysis and mixed effects meta-regression. The association between COI and an article's conclusion (graded as GDHT-favorable, neutral, or unfavorable) was investigated using logistic regression. RESULTS Of the 82 eligible articles, 43 (53%) had self-reported COI, and 50 (61%) favored GDHT. GDHT significantly reduced complications on the basis of the meta-analysis of studies with any type of COI, studies declaring no COI, industry-sponsored studies, and studies with author conflict but not on studies with a device loaner. However, no significant relationship between COI and the relative risk (GDHT vs. usual care) of developing complications was found on the basis of meta-regression (p = 0.25). No significant effect of GDHT was found on mortality. COI had a significant overall effect (p = 0.016) on the odds of having a GDHT-favorable vs. neutral conclusion based on 81 studies. Eighty-four percent of the industry-sponsored studies had a GDHT-favorable conclusion, while only 27% of the studies with a device loaner had the same conclusion grade. CONCLUSIONS The available evidence does not suggest a close relationship between COI and study results in GDHT research. However, a potential association may exist between COI and an article's conclusion in GDHT research.
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Affiliation(s)
- Lina Zhang
- Department of Critical Care Medicine, Central South University, Xiangya Hospital, Changsha, Hunan Province, China
| | - Feng Dai
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | | | - Yuhang Ai
- Department of Critical Care Medicine, Central South University, Xiangya Hospital, Changsha, Hunan Province, China
| | - Lingzhong Meng
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, New Haven, CT, 208051, USA.
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Kim HJ, Kim EJ, Lee HJ, Min JY, Kim TW, Choi EC, Kim WS, Koo BN. Effect of goal-directed haemodynamic therapy in free flap reconstruction for head and neck cancer. Acta Anaesthesiol Scand 2018; 62:903-914. [PMID: 29574681 DOI: 10.1111/aas.13100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In free flap reconstruction for head and neck cancer, achieving a haemodynamic target using excessive fluid infusion is associated with decreased flap survival rates and extended hospital stays. We hypothesized that goal-directed haemodynamic therapy would improve flap survival rates and shorten hospitalization periods. METHODS Patients scheduled for free flap reconstruction were randomly assigned to a goal-directed haemodynamic therapy group (n = 31) or a conventional haemodynamic therapy control group (n = 31). The control group received extra bolus fluid and ephedrine or norepinephrine to maintain a mean arterial pressure ≥ 65 mmHg. The goal-directed haemodynamic therapy group received a colloid solution as the extra bolus fluid to maintain a stroke volume variation < 12%; dobutamine, ephedrine, or norepinephrine was administered to maintain a cardiac index ≥ 2.5 l/min/m2 and mean arterial pressure ≥ 65 mmHg. Enhanced recovery after surgery protocols were not used except for fluid therapy. An otolaryngologist blinded to group assignments assessed flap outcomes and classified them as 'survival,' 'at risk' or 'failure.' RESULTS The hospitalization period was not significantly different between the groups. The goal-directed haemodynamic therapy group had significantly shorter intensive care unit stays and a higher flap survival rate. The crystalloid volume was significantly lower in goal-directed haemodynamic therapy group. Reoperation rates, post-operative complications, and laboratory data including inflammatory markers were similar between the groups. CONCLUSION Compared to conventional haemodynamic therapy, goal-directed haemodynamic therapy does not reduce hospitalization periods; it may, however, reduce the length of intensive care unit stays and increase flap survival rates. Further studies including multi-centre trials with larger sample sizes are warranted.
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Affiliation(s)
- H. J. Kim
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - E. J. Kim
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - H. J. Lee
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - J. Y. Min
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - T. W. Kim
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - E. C. Choi
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Hospital; Seoul National University College of Medicine, Seoul Korea
| | - W. S. Kim
- Department of Otorhinolaryngology-Head and Neck Surgery; Seoul National University Hospital; Seoul National University College of Medicine, Seoul Korea
| | - B.-N. Koo
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
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Szturz P, Folwarczny P, Kula R, Neiser J, Ševčík P, Benes J. Multi-parametric functional hemodynamic optimization improves postsurgical outcome after intermediate risk open gastrointestinal surgery: a randomized controlled trial. Minerva Anestesiol 2018; 85:244-254. [PMID: 29756693 DOI: 10.23736/s0375-9393.18.12467-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Perioperative goal directed therapy (pGDT) using flow monitoring has been associated with improved outcomes. However, its protocols are often based on stroke volume only: as a target for fluid loading, inotropic support and vasopressors (via mathematical coupling of systemic vascular resistance). In this trial, we have tested the multi-parametric pGDT protocol based on esophageal Doppler variables (corrected flow time, peak velocity) in intermediate-to-high risk patients undergoing gastrointestinal surgery. METHODS Intermediate-to-high risk patients undergoing gastrointestinal surgery were randomized to standard care (control) or multi-parametric pGDT (intervention). Postoperative complications and death rate as well as hospital length of stay were assessed as primary and secondary outcomes. RESULTS Overall, 140 patients (intervention, N.=71, and control, N.=69) were included and randomized out of 197 eligible. Higher vasoactive/inotropic drug use and lower fluid balance were observed in the intervention group leading to favorable hemodynamic profile. The pGDT intervention was associated with improved primary outcome (28 days mortality and morbidity defined as occurrence of any defined complication) - 20 patients (28.2%) versus 32 (46.4%) in the control group (P=0.036); RR 0.61 (95% CI: 0.39-0.95), P=0.03. No differences in mortality and hospital length of stay were observed between groups. CONCLUSIONS In this monocentric trial the multi-parametric pGDT protocol based on domain specific functional hemodynamic parameters was associated with lower rate of postoperative complications in intermediate-to-high risk patients undergoing scheduled gastrointestinal procedures.
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Affiliation(s)
- Pavel Szturz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic.,Department of Intensive Care Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Pavel Folwarczny
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Roman Kula
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic
| | - Jan Neiser
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic.,Department of Intensive Care Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Pavel Ševčík
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Ostrava, Ostrava, Czech Republic.,Department of Intensive Care Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic -
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Manning MW, Dunkman WJ, Miller TE. Perioperative fluid and hemodynamic management within an enhanced recovery pathway. J Surg Oncol 2017; 116:592-600. [DOI: 10.1002/jso.24828] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/11/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Michael W. Manning
- Division of Cardiothroacic Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
- Division of General, Vascular, and Transplant Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
| | - William Jonathan Dunkman
- Division of General, Vascular, and Transplant Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
| | - Timothy E. Miller
- Division of General, Vascular, and Transplant Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
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Weinberg L, Ianno D, Churilov L, Chao I, Scurrah N, Rachbuch C, Banting J, Muralidharan V, Story D, Bellomo R, Christophi C, Nikfarjam M. Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial. PLoS One 2017; 12:e0183313. [PMID: 28880931 PMCID: PMC5589093 DOI: 10.1371/journal.pone.0183313] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 07/31/2017] [Indexed: 12/16/2022] Open
Abstract
We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. “precision” fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.
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Affiliation(s)
- Laurence Weinberg
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
- Anaesthesia and Perioperative and Pain Medicine Unit, The University of Melbourne, Parkville, Victoria, Australia
- * E-mail:
| | - Damian Ianno
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia
| | - Ian Chao
- Department of Anaesthesia, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Nick Scurrah
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Clive Rachbuch
- Department of Anaesthesia, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Jonathan Banting
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Vijaragavan Muralidharan
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
| | - David Story
- Anaesthesia and Perioperative and Pain Medicine Unit, The University of Melbourne, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
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Michard F, Giglio M, Brienza N. Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome. Br J Anaesth 2017; 119:22-30. [DOI: 10.1093/bja/aex138] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Pre-anesthetic stroke volume variation can predict cardiac output decrease and hypotension during induction of general anesthesia. J Clin Monit Comput 2017. [DOI: 10.1007/s10877-017-0038-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Sun Y, Chai F, Pan C, Romeiser JL, Gan TJ. Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:141. [PMID: 28602158 PMCID: PMC5467058 DOI: 10.1186/s13054-017-1728-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/22/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Goal-directed hemodynamic therapy (GDHT) has been used in the clinical setting for years. However, the evidence for the beneficial effect of GDHT on postoperative recovery remains inconsistent. The aim of this systematic review and meta-analysis was to evaluate the effect of perioperative GDHT in comparison with conventional fluid therapy on postoperative recovery in adults undergoing major abdominal surgery. METHODS Randomized controlled trials (RCTs) in which researchers evaluated the effect of perioperative use of GDHT on postoperative recovery in comparison with conventional fluid therapy following abdominal surgery in adults (i.e., >16 years) were considered. The effect sizes with 95% CIs were calculated. RESULTS Forty-five eligible RCTs were included. Perioperative GDHT was associated with a significant reduction in short-term mortality (risk ratio [RR] 0.75, 95% CI 0.61-0.91, p = 0.004, I 2 = 0), long-term mortality (RR 0.80, 95% CI 0.64-0.99, p = 0.04, I 2 = 4%), and overall complication rates (RR 0.76, 95% CI 0.68-0.85, p < 0.0001, I 2 = 38%). GDHT also facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 0.4 days (95% CI -0.72 to -0.08, p = 0.01, I 2 = 74%) and the time to toleration of oral diet by 0.74 days (95% CI -1.44 to -0.03, p < 0.0001, I 2 = 92%). CONCLUSIONS This systematic review of available evidence suggests that the use of perioperative GDHT may facilitate recovery in patients undergoing major abdominal surgery.
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Affiliation(s)
- Yanxia Sun
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China.
| | - Fang Chai
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China
| | - Chuxiong Pan
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China
| | - Jamie Lee Romeiser
- Department of Surgery, Stony Brook University, Stony Brook, NY, USA.,Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
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Stens J, Hering JP, van der Hoeven CWP, Boom A, Traast HS, Garmers LE, Loer SA, Boer C. The added value of cardiac index and pulse pressure variation monitoring to mean arterial pressure-guided volume therapy in moderate-risk abdominal surgery (COGUIDE): a pragmatic multicentre randomised controlled trial. Anaesthesia 2017; 72:1078-1087. [PMID: 28543041 DOI: 10.1111/anae.13834] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 02/06/2023]
Abstract
There is disagreement regarding the benefits of goal-directed therapy in moderate-risk abdominal surgery. Therefore, we tested the hypothesis that the addition of non-invasive cardiac index and pulse pressure variation monitoring to mean arterial pressure-based goal-directed therapy would reduce the incidence of postoperative complications in patients having moderate-risk abdominal surgery. In this pragmatic multicentre randomised controlled trial, we randomly allocated 244 patients by envelope drawing in a 1:1 fashion, stratified per centre. All patients had mean arterial pressure, cardiac index and pulse pressure variation measured continuously. In one group, healthcare professionals were blinded to cardiac index and pulse pressure variation values and were asked to guide haemodynamic therapy only based on mean arterial pressure (control group). In the second group, cardiac index and pulse pressure variation values were displayed and kept within target ranges following a pre-defined algorithm (CI-PPV group). The primary endpoint was the incidence of postoperative complications within 30 days. One hundred and seventy-five patients were eligible for final analysis. Overall complication rates were similar (42/94 (44.7%) vs. 38/81 (46.9%) in the control and CI-PPV groups, respectively; p = 0.95). The CI-PPV group had lower mean (SD) pulse pressure variation values (9.5 (2.0)% vs. 11.9 (4.6)%; p = 0.003) and higher mean (SD) cardiac indices (2.76 (0.62) l min-1 .m-2 vs. 2.53 (0.66) l min-1 .m-2 ; p = 0.004) than the control group. In moderate-risk abdominal surgery, we observed no additional value of cardiac index and pulse pressure variation-guided haemodynamic therapy to mean arterial pressure-guided volume therapy with regard to postoperative complications.
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Affiliation(s)
- J Stens
- Department of Anaesthesiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - J-P Hering
- Department of Anaesthesiology, Westfriesgasthuis, Hoorn, the Netherlands
| | | | - A Boom
- Department of Anaesthesiology, Spaarneziekenhuis, Hoofddorp, the Netherlands
| | - H S Traast
- Department of Anaesthesiology, Medical Center Alkmaar, Alkmaar, the Netherlands
| | - L E Garmers
- Department of Anaesthesiology, Medical Center Alkmaar, Alkmaar, the Netherlands
| | - S A Loer
- Department of Anaesthesiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - C Boer
- Department of Anaesthesiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
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Lighthall GK, Singh S. Perioperative Maintenance of Tissue Perfusion and Cardiac Output in Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth 2017; 18:117-36. [PMID: 24876228 DOI: 10.1177/1089253214534781] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Sumit Singh
- University of California Los Angeles, CA, USA
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Kratz T, Steinfeldt T, Exner M, Dell´Orto MC, Timmesfeld N, Kratz C, Skrodzki M, Wulf H, Zoremba M. Impact of Focused Intraoperative Transthoracic Echocardiography by Anesthesiologists on Management in Hemodynamically Unstable High-Risk Noncardiac Surgery Patients. J Cardiothorac Vasc Anesth 2017; 31:602-609. [DOI: 10.1053/j.jvca.2016.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Indexed: 11/11/2022]
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Watson X, Cecconi M. Haemodynamic monitoring in the peri-operative period: the past, the present and the future. Anaesthesia 2017; 72 Suppl 1:7-15. [DOI: 10.1111/anae.13737] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 12/17/2022]
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Ito K, Ito M, Ando A, Sakuma Y, Suzuki T. Simplified Intraoperative Goal-Directed Therapy Using the FloTrac/Vigileo System: An Analysis of Its Usefulness and Safety. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ojanes.2017.71001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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46
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Kratz T, Simon C, Fendrich V, Schneider R, Wulf H, Kratz C, Efe T, Schüttler KF, Zoremba M. Implementation and effects of pulse-contour- automated SVV/CI guided goal directed fluid therapy algorithm for the routine management of pancreatic surgery patients. Technol Health Care 2016; 24:899-907. [DOI: 10.3233/thc-161237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Thomas Kratz
- Department of Anesthesia and Intensive Care Medicine, Philipps-University of Marburg, Marburg, Germany
- Department of Anesthesia and Intensive Care Medicine, Clinique Bénigne Joly, Talant, France
| | - Christina Simon
- Department of Anesthesia and Intensive Care Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Volker Fendrich
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University of Marburg, Marburg, Germany
| | - Ralph Schneider
- Center for Hereditary Tumors at the Surgical Center, HELIOS Klinikum Wuppertal, University Witten/Herdecke, Wuppertal, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Caroline Kratz
- Department of Anesthesia and Intensive Care Medicine, Philipps-University of Marburg, Marburg, Germany
- Department of Anesthesia and Intensive Care Medicine, Clinique Bénigne Joly, Talant, France
| | - Turgay Efe
- Department of Orthopedics and Rheumatology, University Hospital Marburg, Marburg, Germany
| | - Karl F. Schüttler
- Department of Orthopedics and Rheumatology, University Hospital Marburg, Marburg, Germany
| | - Martin Zoremba
- Department of Anesthesia and Intensive Care Medicine, Philipps-University of Marburg, Marburg, Germany
- Department of Anesthesia, Intensive Care Medicine and Pain Therapy, Kreisklinikum, Siegen, Germany
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Joosten A, Tircoveanu R, Arend S, Wauthy P, Gottignies P, Van der Linden P. Impact of balanced tetrastarch raw material on perioperative blood loss: a randomized double blind controlled trial. Br J Anaesth 2016; 117:442-449. [PMID: 28077530 DOI: 10.1093/bja/aew249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND As 6% hydroxyethyl starch (HES) 130/0.40 or 130/0.42 can originate from different vegetable sources, they might have different clinical effects. The purpose of this prospective, randomized, double-blind controlled trial was to compare two balanced tetrastarch solutions, one maize-derived and one potato-derived, on perioperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS We randomly assigned 118 patients undergoing elective cardiac surgery into two groups, to receive either a maize- or a potato-derived HES solution. Study fluids were administered perioperatively (including priming of CPB) until the second postoperative day (POD#2) using a goal directed algorithm. The primary outcome was calculated postoperative blood loss up to POD#2. Secondary outcomes included short-term incidence of acute kidney injury (AKI), and long-term effect (up to one yr) on renal function. RESULTS Preoperative and intraoperative characteristics of the subjects were similar between groups. Similar volumes of HES were administered (1950 ml [1250-2325] for maize-HES and 2000 ml [1500-2700] for potato-HES; P=0.204). Calculated blood loss (504 ml [413-672] for maize-HES vs 530 ml [468-705] for potato-HES; P=0.107) and the need for blood components were not different between groups. The incidence of AKI was similar in both groups (P=0.111). Plasma creatinine concentration and glomerular filtration rates did vary over time, although changes were minimal. CONCLUSIONS Under our study conditions, HES 130/0.4 or 130/0.42 raw material did not have a significant influence on perioperative blood loss. Moreover, we did not find any effect of tetrastarch raw material composition on short and long-term renal function. CLINICAL TRIAL REGISTRATION EudraCT number: 2011-005920-16.
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Affiliation(s)
- A Joosten
- Department of Anesthesiology and Perioperative Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - R Tircoveanu
- Department of Anesthesiology and Perioperative Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - S Arend
- Department of Anesthesiology and Perioperative Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P Wauthy
- Department of Cardiac Surgery, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P Gottignies
- Department of Intensive Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - P Van der Linden
- Department of Anesthesiology and Perioperative Care, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Som A, Maitra S, Bhattacharjee S, Baidya DK. Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials. J Anesth 2016; 31:66-81. [PMID: 27738801 DOI: 10.1007/s00540-016-2261-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/30/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Optimum perioperative fluid administration may improve postoperative outcome after major surgery. This meta-analysis and systematic review has been aimed to determine the effect of dynamic goal directed fluid therapy (GDFT) on postoperative morbidity and mortality in non-cardiac surgical patients. MATERIAL AND METHODS Meta-analysis of published prospective randomized controlled trials where GDFT based on non-invasive flow based hemodynamic measurement has been compared with a standard care. Data from 41 prospective randomized trials have been included in this study. RESULTS Use of GDFT in major surgical patients does not decrease postoperative hospital/30-day mortality (OR 0.70, 95 % CI 0.46-1.08, p = 0.11) length of post-operative hospital stay (SMD -0.14; 95 % CI -0.28, 0.00; p = 0.05) and length of ICU stay (SMD -0.12; 95 % CI -0.28, 0.04; p = 0.14). However, number of patients having at least one postoperative complication is significantly lower with use of GDFT (OR 0.57; 95 % CI 0.43, 0.75; p < 0.0001). Abdominal complications (p = 0.008), wound infection (p = 0.002) and postoperative hypotension (p = 0.04) are also decreased with used of GDFT as opposed to a standard care. Though patients who received GDFT were infused more colloid (p < 0.0001), there is no increased risk of heart failure or pulmonary edema and renal failure. CONCLUSION GDFT in major non- cardiac surgical patients has questionable benefit over a standard care in terms of postoperative mortality, length of hospital stay and length of ICU stay. However, incidence of all complications including wound infection, abdominal complications and postoperative hypotension is reduced.
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Affiliation(s)
- Anirban Som
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Sulagna Bhattacharjee
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
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Thiele RH, Raghunathan K, Brudney CS, Lobo DN, Martin D, Senagore A, Cannesson M, Gan TJ, Mythen MMG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med (Lond) 2016; 5:24. [PMID: 27660701 PMCID: PMC5027098 DOI: 10.1186/s13741-016-0049-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/24/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery "bundles" because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain. METHODS In the "Perioperative Quality Initiative (POQI) Fluids" workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP. DISCUSSION We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.
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Affiliation(s)
- Robert H Thiele
- Departments of Anesthesiology and Biomedical Engineering, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, UVA Enhanced Recovery after Surgery (ERAS) Program, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| | - C S Brudney
- Duke University and Durham VA Medical Center, Durham, NC USA
| | - Dileep N Lobo
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH UK
| | - Daniel Martin
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, NW3 2QG UK ; Anaesthetic Department, Royal Free Perioperative Research Group, Royal Free Hospital, London, NW3 2QG UK
| | - Anthony Senagore
- Department of Surgery, University of Texas-Medical Branch at Galveston, Galveston, TX 77555 USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Tong Joo Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Michael Monty G Mythen
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, American Society for Enhanced Recovery, Duke University Medical Center, Durham, NC 27710 USA
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Nakasuji M, Okutani A, Miyata T, Imanaka N, Tanaka M, Nakasuji K, Nagai M. Disagreement between fourth generation FloTrac and LiDCOrapid measurements of cardiac output and stroke volume variation during laparoscopic colectomy. J Clin Anesth 2016; 35:150-156. [PMID: 27871513 DOI: 10.1016/j.jclinane.2016.07.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/11/2016] [Accepted: 07/14/2016] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE To determine the agreement between cardiac output (CO) and stroke volume variation (SVV) measured simultaneously by the fourth generation FloTrac/Vigileo system and LiDCOrapid system during pneumoperitoneum in patients undergoing laparoscopic colectomy. DESIGN Retrospective observational study. SETTINGS Operating room in a general hospital. PATIENTS Ten patients (American Society of Anesthesiologist 1 or 2) without preoperative anemia. INTERVENTIONS A 22-gauge catheter was inserted in the radial artery after induction of anesthesia. The arterial line was split to monitor CO and SVV simultaneously with the LiDCOrapid and fourth generation FloTrac/Vigileo systems. All data were downloaded from each system after surgery and simultaneous paired COFloTrac, COLiDCO and SVVFloTrac, SVVLiDCO values estimated every 1 minute during the pneumoperitoneum were analyzed. MEASUREMENTS To assess the agreement after carbon dioxide insufflation, a scatter 4-quadrant plot was generated using paired ΔCO values (changes in COFloTrac and COLiDCO just before pneumoperitoneum and 3 minutes after the induction of pneumoperitoneum). For data in which SVVFloTrac was >9% but <16% and cardiac index measured by FloTrac/Vigileo was <2.5 L/min per m2 during stable pneumoperitoneum (the period from 5 minutes after Trendelenburg position until discontinuation of pneumoperitoneum), simultaneously measured paired SVVFloTrac and SVVLiDCO were plotted every 1 minute using the Bland-Altman method. MAIN RESULTS A concordance ratio for changes in CO after the induction of pneumoperitoneum was 83% in 4-quadrant plot. During stable pneumoperitoneum, 702 paired SVVFloTrac and SVVLiDCO matched the criteria. These data sets were plotted by the Bland-Altman method and the bias and 95% limit of agreement of SVV were 2.01 and -2.63% to 6.65%, respectively, with 38% percentage error. The regression equation was SVVLiDCO = 0.98 × SVVFloTrac- 1.73 with Pearson correlation coefficient of 0.55. CONCLUSIONS Our study showed disagreement between the 2 methods and the hemodynamic parameters measured by one of the two devices should be interpreted with caution before therapeutic interventions.
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Affiliation(s)
- Masato Nakasuji
- Department of Anesthesiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan; Division of Anesthesiology and Critical Care Medicine, Kansai Electric Power Medical Research Institute, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
| | - Aki Okutani
- Department of Anesthesiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
| | - Taeko Miyata
- Department of Anesthesiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
| | - Norie Imanaka
- Department of Anesthesiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
| | - Masuji Tanaka
- Department of Anesthesiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
| | - Kae Nakasuji
- Department of Anesthesiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
| | - Miwako Nagai
- Department of Anesthesiology, Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
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