Exploration of Fluid Dynamics in Perioperative Patients Using Bioimpedance Analysis

An Elemental Diet Reduces Chylous Ascites of Patients Undergoing Pancreatoduodenectomy in the Setting of Early Enteral Feeding

OBJECTIVES

The elemental diet (ED) is a formula to support nutritional status without increasing chylous burden. This study evaluates the efficacy of early ED feeding after pancreatoduodenectomy (PD).

MATERIALS AND METHODS

A prospective phase II study of consecutive patients who underwent PD with early ED feeding was conducted. Patient backgrounds, surgical outcomes, and ED feeding tolerability were compared with a historical cohort of 74 PD patients with early enteral feeding of a low residue diet (LRD).

RESULTS

The ED group comprised 104 patients. No patient in the ED group discontinued enteral feeding because of chylous ascites (CAs), whereas 17.6% of the LRD group experienced refractory CAs that disrupted further enteral feeding. The CAs rate was significantly decreased in the ED group compared with the LRD group (3.9% and 48.7%, respectively; P < 0.001). There was no significant difference in the incidence of major complications (ED: 17.3%, LRD: 18.9%; P = 0.844). Postoperative prognostic nutritional index was similar between the 2 groups ( P = 0.764). In multivariate analysis, enteral feeding formula, and sex were independent risk factors for CAs (LRD: P < 0.001, odds ratio, 22.87; female: P = 0.019, odds ratio, 2.78).

CONCLUSIONS

An ED reduces postoperative CAs of patients undergoing PD in the setting of early enteral feeding.

Pharmacodynamics Research on Danggui-Shaoyao-San through Body Fluid Indexes of Spleen Deficiency-water Dampness Rats using Bio-impedance Technology

BACKGROUND

Spleen deficiency-water dampness symptom is closely related to body fluid-mediated organism metabolism and circulation. However, previous clinical evaluation of spleen deficiency-water dampness model was based only on body weight, D-xylose excretion rate, serum gastrin content, etc. Therefore, we established a large sample of normal rats and model rats experiment to verify the scientific nature of bio-impedance measuring body fluid indexes for evaluation of the modeling state. Pharmacodynamics research on Danggui-Shaoyao- San (DSS) was conducted through body fluid index changes of rats using bio-impedance technology.

METHODS

A spleen deficiency-water dampness symptom rat model was established through an inappropriate diet combined with excess fatigue. Experimental rats were divided into a normal control group, a model control group, a positive drug control group (hydrochlorothiazide), a blood-activating group, a water-disinhibiting group, and a DSS group. Total Body Water/Body Weight (TBW%), extracellular fluid/total body water content (ECF%), intracellular fluid/total body water content (ICF%), extracellular fluid/intracellular fluid (ECF/ICF), fat mass/body weight (FM%), fat-free mass/body weight (FFM%), and fat mass/fat-free mass (FM/FFM) of 150 rats were detected by a Bio-Imp Vet Body analyzer.

RESULTS

The TBW% of the model control group increased significantly, and the FM/FFM was significantly reduced compared with the normal group (P < 0.05) (P < 0.01), showing symptoms of spleen deficiency and diarrhea; the TBW% of the blood-activating group, and the waterdisinhibiting group decreased significantly, and the FM/FFM increased significantly (P < 0.05) (P < 0.01). The TBW% and FM/FFM in the water-disinhibiting group had returned to nearnormal values compared with the model control group. The blood-activating and waterdisinhibiting split prescriptions in DSS are both effective in treating spleen deficiency-water dampness rats. Comparatively, the fluid-regulating effect of split prescriptions in DSS was even stronger than that of DSS as shown in the present study.

CONCLUSIONS

These findings suggest that using bio-impedance technology to measure body fluid indexes can pave a road for further exploring the molecular mechanism of the reason why the blood-activating and disinhibit-water split prescriptions in DSS are both effective in treating spleen deficiency-water dampness rats.

Handgrip strength is correlated with activities of daily living, balance, and body composition in patients with thoracolumbar compression fracture

This study assessed the relationship between handgrip strength (HGS) and activities of daily living, balance, walking speed, calf circumference, body muscle, and body composition in elderly patients with thoracolumbar vertebral compression fracture (VCF). A cross-sectional study in a single hospital was performed with elderly patients diagnosed with VCF. After admission, we evaluated HGS, 10-meter walk test (speed), Barthel Index, Berg Balance Scale (BBS), numerical rating scale of body pain, and calf circumference. We examined skeletal muscle mass, skeletal muscle mass index, total body water (TBW), intracellular water, extracellular water (ECW), and phase angle (PhA) in patients with VCF using multi-frequency direct segmental bioelectrical impedance analysis after admission. A total of 112 patients admitted for VCF were enrolled (26 males, 86 females; mean age 83.3 years). The prevalence of sarcopenia according to the 2019 Asian Working Group for Sarcopenia guideline was 61.6%. HGS was significantly correlated with walking speed (P < .001, R = 0.485), Barthel Index (P < .001, R = 0.430), BBS (P < .001, R = 0.511), calf circumference (P < .001, R = 0.491), skeletal muscle mass index (P < .001, R = 0.629), ECW/TBW (P < .001, r = -0.498), and PhA (P < .001, R = 0.550). HGS was more strongly correlated with walking speed, Barthel Index, BBS, ECW/TBW ratio, and PhA in men than women. In patients with thoracolumbar VCF, HGS is associated with walking speed, muscle mass, activities of daily living measured using the Barthel Index, and balance measured using BBS. The findings suggest that HGS is an important indicator of activities of daily living, balance, and whole-body muscle strength. Furthermore, HGS is related to PhA and ECW/TBW.

Bio-impedance spectroscopy for total body water assessment in pediatric surgical patients: A single center pilot cohort study

BACKGROUND

Excess peri‑operative fluid administration is associated with higher morbidity and mortality. We aimed to examine the feasibility of bio-impedance spectroscopy (BIS) to record serial peri‑operative fluid volumes in the pediatric surgical population.

METHODS

Children who underwent major elective general surgery from March 2019 to March 2020 were included. Total body water (TBW) assessment by BIS was recorded prior to surgery and on subsequent post-operative days (POD). We recorded the duration, tolerance and completion of each BIS assessment. We used Spearman coefficient and Bland Altman analysis to examine correlation and agreement between fluid balance (FB) in ml/kg calculated from intake/output (IO) recording and measured by BIS.

RESULTS

20 (87%) of 23 consented patients, median age 2.5 (1-17) years and 13 (65%) male, completed pre-operative and post-operative measurements, and were included in the analysis. Median time required for BIS assessments was 10 (5-15) minutes, and there were no recorded side effects or intolerance. The correlation coefficient for fluid balance measurements on POD 1 between BIS and IO methods was 0.59 (p = 0.01); mean bias (limits) of agreement was 26 (111 to 163) mL/kg. The trend in TBW measured by BIS declined from POD 1-3, while the recorded FB increased.

CONCLUSION

Bedside BIS is feasible and well-tolerated. Despite moderate correlation between fluid balance assessment by BIS and IO on POD 1, the wide limits of agreement between values from these methods preclude their use interchangeably. The role of BIS in assessment of fluid status in the pediatric surgical population should be further examined.

LEVEL OF EVIDENCE

Level III.

Perioperative fluid dynamics evaluated by bioelectrical impedance analysis predict infectious surgical complications after esophagectomy

BACKGROUND

Transthoracic esophagectomy, among the most invasive surgeries, is highly associated with postoperative infectious complications which adversely affect postoperative management including fluid dynamics. The aim of the study is to evaluate the utility of perioperative bioelectrical impedance analysis (BIA) measurements for the patients after transthoracic esophagectomy.

METHOD

Multi-frequency BIA measurements were conducted in 24 patients undergoing transthoracic esophagectomy preoperatively, at 1 h after surgery, and twice daily for the following 7 days. The amounts of extracellular water (ECW), internal cellular water (ICW), total body water (TBW), and fat-free mass (FFM) were calculated. Changing trends in variables were analyzed, and the patients were subdivided according to the presence of infectious surgical adverse events to identify differences in fluid dynamics.

RESULTS

ECW was the major body fluid compartment showing an increase after surgery, and peaked on postoperative day (POD) 2. Twelve patients experienced infectious complications. The peaks of changes in ECW and ECW/TBW appeared earlier and their values at the highest peak were significantly lower in the group without infectious complications on POD 2. The ICW/FFM value showed a mild decrease as compared to POD1 and then gradually recovered. It was significantly lower even before surgery and showed the most significant stratification on POD2. ECW/TBW of 48% and ICW/FFM of 37% on POD2 were predictive cut-off values for infectious adverse events with high area-under receiver operating characteristic (ROC) curves: 0.80 or higher.

CONCLUSION

BIA measurements are useful for monitoring fluid retention and may predict infectious complications in the early phase after transthoracic esophagectomy.

TRIAL REGISTRATION

Registry name: UMIN-CTR, ID: UMIN000030734, Registered on January 9, 2018, retrospectively registered.

Body fluid status assessment by bio-impedance analysis in patients presenting to the emergency department with dyspnea

BACKGROUND/AIMS

Fluid retention occurs in patients with heart failure, accounting for dyspnea. We investigated the diagnostic implication of body fluid status, assessed by bio-impedance analysis (BIA), in acute heart failure (AHF) among patients who presented with dyspnea.

METHODS

A total of 100 patients who presented with dyspnea and suspected with AHF were analyzed in this study. We enrolled 50 AHF and 50 non-AHF patients discriminated through echocardiographic analysis and Framingham criteria and were matched by age and sex. Body composition was analyzed using a multifrequency BIA.

RESULTS

AHF patients demonstrated higher extracellular water (ECW)/total body water (TBW) compared with non-AHF patients (0.412 ± 0.017 vs. 0.388 ± 0.023, p < 0.001). A significant difference of ECW/TBW between AHF patients and nonAHF patients was noted when the upper extremities, trunk, and lower extremities were analyzed (all p < 0.001, respectively). ECW/TBW was not different between patients with reduced ejection fraction (EF) and preserved EF along body compartments. The best cut-off value to predict AHF was > 0.412 at lower extremities with sensitivity and specificity of 0.780 and 0.960. The ECW/TBW of the lower extremities (ECW/TBWL) was correlated with log B-type natriuretic peptide (BNP) levels (r = 0.603, p < 0.001) and also improved the net reclassification improvement and integrated discriminated improvement when added to log BNP level. Multivariate analysis revealed that ECW/TBWL > 0.412 had an independent association with AHF patients (p = 0.011).

CONCLUSION

The ECW/TBWL was higher in patients with dyspnea caused by AHF than their counterparts and demonstrated an independent diagnostic implication. It may be a promising marker to diagnose AHF at bedside.

Bioelectrical impedance analysis; a new method to evaluate lymphoedema, fluid status, and tissue damage after gynaecological surgery - A systematic review

The aim of this descriptive review is to summarise the current knowledge of non-invasive bioelectrical impedance analysis (BIA) used with gynaecological surgical patients in regard to postoperative development of lymphoedema and determination of perioperative fluid balance, and as a prognostic factor in cancer mortality and a predictor of postoperative complications. The databases PubMed, MEDLINE, Scopus Web of Science, the Cochrane Library, and reference lists of selected articles were searched for relevant articles published during the period January 2008-April 2018. Only papers published in English were retrieved. Thirty-seven articles were evaluated. Where gynaecological studies were lacking, studies with a study population from neighbouring clinical fields were used instead. Studies on the clinical use of BIA with gynaecological surgical patients were divided into three categories: the postoperative development of lower limb lymphoedema (n = 7), perioperative hydration measuring (n = 3), and the BIA parameter phase angle as a prognostic factor in cancer survival and as predictive for postoperative complications (n = 6). Of these 16 studies only three used a pure gynaecological study population. Three different methods of BIA were used in these articles: single frequency-BIA, multifrequency-BIA and bioimpedance spectroscopy. BIA was found to detect lymphoedema with a sensitivity of 73% and a specificity of 84%. Studies indicated that BIA was able to detect lower limb lymphoedema at an early stage even before it became clinically detectable. During postoperative hydration measurements, an increase in extracellular fluid volume and extracellular fluid volume in relation to total body fluid volume, as well as a decrease in phase angle, were associated with higher frequencies of postoperative complications. Moreover, low values for the phase angle have been associated with increased mortality in cancer patients. However, the number of studies in this field was limited. From our review, BIA seems to be a useful tool for use in the clinical setting of the gynaecological surgical patient. The theoretical approach of using bioelectrical impedance values to measure the fluid distribution in the body compartments offers wide opportunities in the clinical setting. However, so far, all studies have set up cut-off limits within the study population, and reference values for a general population need to be defined. There are also rather few studies on a gynaecological study population. Hence, there is a need for further studies within gynaecological surgery focusing on early detection of lower limb lymphoedema, perioperative fluid balance, and postoperative complications in order to establish the value of BIA in clinical praxis.