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Curry FE, Michel CC. The patterns in urine excretion and transvascular fluid exchange in human subjects during intravenous fluid infusion: A quantitative analysis. Clin Physiol Funct Imaging 2024; 44:396-406. [PMID: 38752734 DOI: 10.1111/cpf.12887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/24/2024] [Accepted: 04/30/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Investigations of responses of animals and humans to changes of plasma volume are usually reported as average responses of groups of individuals. This ignores considerable quantitative variation between individuals. We examined the hypothesis that individual responses follow a common temporal pattern with variations reflecting different parameters describing that pattern. METHODS We illustrate this approach using data of Hahn, Lindahl and Drobin (Acta Anaesthesiol Scand.2011, 55:987-94) who measured urine volume and haemoglobin dilution of 10 female subjects during intravenous Ringer infusions for 30 min and subsequent 3.5 h. The published time courses were digitised and analysed to determine if a family of mathematical functions accounted for the variation in individual responses. RESULTS Urine excretion was characterised by a time delay (Td) before urine flow increased and a time course of cumulative urine excretion described by a logarithmic function. This logarithmic relation forms the theoretical basis of a family of linear relations describing urine excretion as a function of Td. Measurement of Td enables estimation of subsequent values of urine excretion and thereby the fraction of infused fluid retained in the body. CONCLUSION The approach might be useful for physiologists and clinical investigators to compare the response to infusion protocols when both test and control responses can be described by linear relations between cumulative urine volume at specific times and Td. The approach may also be useful for clinicians by complementing strategies to guide fluid therapy by enabling the later responses of an individual to be predicted from their earlier response.
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Affiliation(s)
- FitzRoy E Curry
- Department of Physiology and Membrane Biology and Biomedical Engineering, University of California Davis, Davis, California, USA
| | - C Charles Michel
- Department of Bioengineering, Imperial College London, London, UK
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Obara S, Hirata N, Hagihira S, Yoshida K, Kotake Y, Takagi S, Masui K. What are standard monitoring devices for anesthesia in future? J Anesth 2024; 38:537-541. [PMID: 38748064 DOI: 10.1007/s00540-024-03347-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 07/30/2024]
Abstract
Monitoring the patient's physiological functions is critical in clinical anesthesia. The latest version of the Japanese Society of Anesthesiologists' Guidelines for Safe Anesthesia Monitoring, revised in 2019, covers various factors, including electroencephalogram monitoring, oxygenation, ventilation, circulation, and muscle relaxation. However, with recent advances in monitoring technologies, the information provided has become more detailed, requiring practitioners to update their knowledge. At a symposium organized by the Journal of Anesthesia in 2023, experts across five fields discussed their respective topics: anesthesiologists need to interpret not only the values displayed on processed electroencephalogram monitors but also raw electroencephalogram data in the foreseeable future. In addition to the traditional concern of preventing hypoxemia, monitoring for potential hyperoxemia and the effects of mechanical ventilation itself will become increasingly important. The importance of using AI analytics to predict hypotension, assess nociception, and evaluate microcirculation may increase. With the recent increase in the availability of neuromuscular monitoring devices in Japan, it is important for anesthesiologists to become thoroughly familiar with the features of each device to ensure its effective use. There is a growing desire to develop and introduce a well-organized, integrated "single screen" monitor.
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Affiliation(s)
- Shinju Obara
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
- Center for Pain Management, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
- Surgical Operation Department, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Naoyuki Hirata
- Department of Anesthesiology, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Satoshi Hagihira
- Department of Anesthesiology, Kansai Medical University, 3-1 Shinmachi 2 Chome, Hirakata, Osaka, 573-1191, Japan
| | - Keisuke Yoshida
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, 6-11-1 Omorinishi, Ota-Ku, Tokyo, 143-8540, Japan
| | - Shunichi Takagi
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Kenichi Masui
- Department of Anesthesiology, Yokohama City University, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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Højlund J, Cihoric M, Foss NB. Vasoconstriction with phenylephrine increases cardiac output in preload dependent patients. J Clin Monit Comput 2024:10.1007/s10877-024-01186-7. [PMID: 38907106 DOI: 10.1007/s10877-024-01186-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/02/2024] [Indexed: 06/23/2024]
Abstract
General Anaesthesia (GA) is accompanied by a marked decrease in sympathetic outflow and thus loss of vasomotor control of cardiac preload. The use of vasoconstriction during GA has mainly focused on maintaining blood pressure. Phenylephrine (PE) is a pure α1-agonist without inotropic effects widely used to correct intraoperative hypotension. The potential of PE for augmenting cardiac stroke volume (SV) and -output (CO) by venous recruitment is controversial and no human studies have explored the effects of PE in preload dependent circulation using indicator dilution technique. We hypothesized that PE-infusion in patients with cardiac stroke volume limited by reduced preload would restore preload and thus augment SV and CO. 20 patients undergoing GA for gastrointestinal surgery were monitored with arterial catheter and LiDCO unity monitor. Upon stable haemodynamics after induction patients were placed in head-up tilt (HUT). All patients became preload responsive as verified by a stroke volume variation (SVV) of > 12%. PE-infusion was then started at 15-20mikrg/min and adjusted until preload was restored (SVV < 12%). Li-dilution cardiac output (CO) was initially measured after induction (baseline), again with HUT in the preload responsive phase, and finally when preload was restored with infusion of PE.At baseline SVV was 10 ± 3% (mean ± st.dev.), CI was 2,6 ± 0,4 L/min*m2, and SVI 43 ± 7mL/m2. With HUT SVV was 19 ± 4%, CI was 2,2 ± 0,4 L/min*m2, SVI 35 ± 7mL/m2. During PE-infusion SVV was reduced to 6 ± 3%, CI increased to 2,6 ± 0,5 L/min*m2, and SVI increased to 49 ± 11mL/m2. All differences p < 0,001. In conclusion: Infusion of phenylephrine during preload dependency increased venous return abolishing preload dependency as evaluated by SVV and increased cardiac stroke volume and -output as measured by indicator-dilution technique. (ClinicalTrials.gov NCT05193097).
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Affiliation(s)
- Jakob Højlund
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark.
| | - Mirjana Cihoric
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
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White SM. A retrospective, observational, single-centre, cohort database analysis of the haemodynamic effects of low-dose spinal anaesthesia for hip fracture surgery. BJA OPEN 2024; 9:100261. [PMID: 38390395 PMCID: PMC10882127 DOI: 10.1016/j.bjao.2024.100261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/24/2024] [Indexed: 02/24/2024]
Abstract
Background Careful administration of either spinal (intrathecal) or general anaesthesia probably has a greater impact on outcomes after hip fracture surgery than which method is used per se. Intraoperative hypotension is associated with poorer outcomes, but appears less prevalent using lower doses of spinal anaesthesia. Methods In this observational single-centre study, intraoperative noninvasive blood pressure data were analysed from 280 patients undergoing unilateral hip fracture surgery after the administration of hyperbaric spinal bupivacaine 0.5%, 1.3 ml (0.65 mg). Results Mean cohort mean arterial pressure (MAP) remained within 10% of baseline (spinal injection) MAP for 97/98 (99.0%) subsequent aggregated 1-min recording intervals. The prevalences of lowest MAP <70 mm Hg and <55 mm Hg were significantly lower than historical equivalents (Anaesthesia Sprint Audit of Practice 1 and 2) (52.9% and 10.4% vs 71.9% and 23.8%, respectively, both <0.0001). The proportions of 10 551 MAP readings <70 mm Hg and <55 mm Hg were 6.7% and 0.4%, respectively. Forty-five (16.1%) patients had relatively persistent hypotension (MAP ≤70 mm Hg for five or more intraoperative readings), and were statistically more likely to be frail (Nottingham Hip Fracture Score ≥7/10, 37.8% vs 19.6%, P=0.0109) and be taking alpha-/beta-blockers (44.4% vs 24.3%, P=0.0099) than the remaining 'normotensive' cohort. Surgical anaesthesia remained effective for up to 190 min, with only one patient requiring supplemental local anaesthesia during skin closure. Conclusions Low doses of hyperbaric spinal 0.5% bupivacaine (1.3 ml, 6.5 mg) are associated with minimal reductions in blood pressure during surgery and provide adequate duration of surgical anaesthesia. Randomised comparisons of lower vs higher/standard doses of spinal anaesthesia are now required to confirm outcome benefits in this vulnerable patient group. Clinical trial registration NCT05799300.
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Affiliation(s)
- Stuart M White
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Oh C, Lee S, Song BS, Kwon S, Kim YH, Yoon SH, Shin YS, Ko Y, Lim C, Hong B. Comparative effects of desflurane and sevoflurane on intraoperative peripheral perfusion index: a retrospective, propensity score matched, cohort study. Sci Rep 2023; 13:2991. [PMID: 36878940 PMCID: PMC9988875 DOI: 10.1038/s41598-022-27253-0] [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: 08/13/2022] [Accepted: 12/28/2022] [Indexed: 03/08/2023] Open
Abstract
Desflurane is known to have a larger vasodilatory effect than that of sevoflurane. However, its generalizability and effect size in actual clinical practice are yet to be proven. Patients aged ≥ 18 years who underwent noncardiac surgery under general anesthesia using inhalation anesthetics (desflurane or sevoflurane) were matched 1:1 by propensity score. The mean intraoperative perfusion index (PI) of each patient were compared between the two groups. Propensity score matching of 1680 patients in the study cohort identified 230 pairs of patients. PI was significantly higher in the desflurane group (median of paired difference, 0.45; 95% CI 0.16 to 0.74, p = 0.002). PI durations below 1.0 and 1.5 were significantly longer in the sevoflurane group. Mean arterial pressure (MAP) and durations of low MAP did not differ significantly between the two groups. Generalized linear mixed models revealed that the use of sevoflurane, mean MAP, mean heart rate, age, and duration of anesthesia had significant negative effects (lower PI), whereas mean age-adjusted minimum alveolar concentration of inhalation agent had a positive effect on PI (higher value). Intraoperative PI was significantly higher in patients administered desflurane than sevoflurane. However, the impact of the choice between desflurane and sevoflurane on intraoperative PI in this clinical setting was minimal.
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Affiliation(s)
- Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Seounghun Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
- Department of Anesthesiology and Pain Medicine, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Byong-Sop Song
- Core Laboratory of Translational Research, Biomedical Convergence Research Center, Chungnam National University Hospital, Daejeon, South Korea
| | - Sanghun Kwon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Seok-Hwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Yong Sup Shin
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Chaeseong Lim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea.
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea.
- Big Data Center, Biomedical Research Institute, Chungnam National University Hospital, Daejeon, South Korea.
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Cihoric M, Kehlet H, Højlund J, Lauritsen ML, Kanstrup K, Foss NB. Perioperative changes in fluid distribution and haemodynamics in acute high-risk abdominal surgery. Crit Care 2023; 27:20. [PMID: 36647120 PMCID: PMC9841944 DOI: 10.1186/s13054-023-04309-9] [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] [Received: 11/02/2022] [Accepted: 01/07/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Understanding the pathophysiology of fluid distribution in acute high-risk abdominal (AHA) surgery is essential in optimizing fluid management. There is currently no data on the time course and haemodynamic implications of fluid distribution in the perioperative period and the differences between the surgical pathologies. METHODS Seventy-three patients undergoing surgery for intestinal obstruction, perforated viscus, and anastomotic leakage within a well-defined perioperative regime, including intraoperative goal-directed therapy, were included in this prospective, observational study. From 0 to 120 h, we measured body fluid volumes and hydration status by bioimpedance spectroscopy (BIA), fluid balance (input vs. output), preload dependency defined as a > 10% increase in stroke volume after preoperative fluid challenge, and post-operatively evaluated by passive leg raise. RESULTS We observed a progressive increase in fluid balance and extracellular volume throughout the study, irrespective of surgical diagnosis. BIA measured variables indicated post-operative overhydration in 36% of the patients, increasing to 50% on the 5th post-operative day, coinciding with a progressive increase of preload dependency, from 12% immediately post-operatively to 58% on the 5th post-operative day and irrespective of surgical diagnosis. Patients with overhydration were less haemodynamically stable than those with normo- or dehydration. CONCLUSION Despite increased fluid balance and extracellular volumes, preload dependency increased progressively during the post-operative period. Our observations indicate a post-operative physiological incoherence between changes in the extracellular volume compartment and inadequate physiological preload control in patients undergoing AHA surgery. Considering the increasing overhydration during the observational period, our findings show that an indiscriminate correction of preload dependency with intravenous fluid bolus could lead to overhydration. Trial registration clinicaltrials.gov. (NCT03997721), Registered 23 May 2019, first participant enrolled 01 June 2019.
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Affiliation(s)
- Mirjana Cihoric
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Henrik Kehlet
- grid.475435.4Section for Surgical Pathophysiology, JMC, Rigshospitalet, Copenhagen, Capital Region of Denmark Denmark
| | - Jakob Højlund
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Morten Laksáfoss Lauritsen
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Katrine Kanstrup
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Nicolai Bang Foss
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
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7
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Sigvardt E, Rasmussen SM, Eiberg JP, Sørensen HBD, Meyhoff CS, Aasvang EK. Transcutaneous blood gas monitoring and tissue perfusion during common femoral thromboendarterectomy. Scandinavian Journal of Clinical and Laboratory Investigation 2022; 82:334-340. [PMID: 35767233 DOI: 10.1080/00365513.2022.2092900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Improving tissue perfusion can improve clinical outcomes in surgical patients, where monitoring may aid clinicians in detecting adverse conditions and guide interventions. Transcutaneous monitoring (TCM) of oxygen (tcpO2) and carbon dioxide (tcpCO2) is a well-proven technology and could potentially serve as a measure of local circulation, perfusion and metabolism, but the clinical use is not thoroughly explored. The purpose of this proof-of-concept study was to investigate whether TCM of blood gasses could detect changes in perfusion during major vascular surgery. METHODS Ten patients with peripheral arterial disease scheduled for lower limb major arterial revascularization under general anaesthesia were consecutively included. TcpO2 and tcpCO2 were continuously recorded from anaesthesia induction until skin closure with a TCM monitor placed on both legs and the thorax. Peripheral oxygen saturation was kept ≥94% and mean arterial blood pressure ≥65 mmHg. The primary outcomes were changes in tcpO2 and tcpCO2 related to arterial clamping and declamping during the procedure and analyzed by paired statistics. RESULTS Femoral artery clamping resulted in a significant decrease in tcpO2 (-2.1 kPa, IQR-4.2; -0.8), p=.017)), followed by a significant increase in response to arterial declamping (5.5 kPa, IQR 0-7.3), p=.017)). Arterial clamping resulted in a statistically significant increase in tcpCO2 (0.9 kPa, IQR 0.3-5.4), p=.008)) and a significant decrease following declamping (-0.7 kPa, IQR -2.6; -0.2), p=.011)). CONCLUSION Transcutaneous monitoring of oxygen and carbon dioxide is a feasible method for detection of extreme changes in tissue perfusion during arterial clamping and declamping, and its use for improving patient outcomes should be explored. Clinical Trials identifier: NCT04040478. Registered on July 31, 2019.
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Affiliation(s)
- Emilie Sigvardt
- Department of Anaesthesiology, Center of Organ and Cancer Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Møller Rasmussen
- Department of Health Technology, Technical University of Denmark, Section for Digital Health, Lyngby, Denmark
| | - Jonas Peter Eiberg
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Vascular Surgery, Heart Center, Copenhagen University Hospital, Copenhagen, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Copenhagen, Denmark
| | | | - Christian Sylvest Meyhoff
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Eske Kvanner Aasvang
- Department of Anaesthesiology, Center of Organ and Cancer Diseases, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial. Acta Anaesthesiol Scand 2022; 66:640-650. [PMID: 35124808 DOI: 10.1111/aas.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/10/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction. AIM To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV. METHODS AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol. DISCUSSION The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Rigshospitalet Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
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Agerskov M, Sørensen H, Højlund J, Secher NH, Foss NB. Fluid-responsiveness, blood volume and perfusion in preoperative haemodynamic optimisation of hip fracture patients; a prospective observational study. Acta Anaesthesiol Scand 2022; 66:660-673. [PMID: 35396854 DOI: 10.1111/aas.14070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preoperative resuscitation strategies in patients with hip fracture (HF) are lacking. We aimed to investigate fluid-responsiveness, peripheral perfusion index (PPI) and blood volume (BV)-status in patients with HF undergoing resuscitation in the preoperative phase. METHODS In a prospective observational study, we evaluated preoperative fluid-responsiveness, indices of perfusion and BV before and after lumbar epidural analgesia in 50 patients with HF shortly after admittance. RESULTS Initially, 18 (36%) patients were fluid-responsive (≥10% increased SV in response to 250 ml fluid bolus) and 13 (26%) presented hypovolaemia (deviation of measured BV from estimated BV ≤ 0.9). According to fluid-responsiveness, no difference in absolute values of cardiac index (CI) (2.7 L [2.1-3.3] vs. 2.8 L [2.3-3.4], p = .5) was seen, but cardiac output (CO) rose significantly in the hypovolaemic patients: 9% [5-18] vs. 1% [-3-7], p = .004. After epidural analgesia, 26 (52%) patients were again fluid-responsive and 15 (30%) were hypovolaemic. CI was now significantly lower in fluid-responsive patients (2.2 L [1.7-2.7] vs. 2.9 L [2.3-3.5], p = .001). Prior to epidural analgesia, no significant trend towards hypovolaemic patients having lower indices of perfusion was seen. After epidural analgesia, more patients with hypovolaemia presented with PPI≤1.5 (8 (53%) vs. 3 (9%), p = .001) and absolute values of PPI were also significantly lower if IBV was low (1.4 [0.9-3.2] vs. 3.2 [2.4-4.8], p = .01). PPI correlated with hypovolaemia after epidural analgesia (rho 0.4 [0.1-0.7], p = .007). CONCLUSIONS Preoperative fluid-responsivity in HF patients might be attributable to elements of hypovolaemia and sympathetic compensatory ability conjointly, confounding the use of SV-guided resuscitation. PPI could be associated with BV, which may support clinicians during perioperative haemodynamic optimisation.
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Affiliation(s)
- Marianne Agerskov
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Henrik Sørensen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Niels H. Secher
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
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10
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Agerskov M, Sørensen H, Højlund J, Kjær S, Secher NH, Foss NB. The effect of vasoconstriction on intestinal perfusion is determined by preload dependency: A prospective observational study. Acta Anaesthesiol Scand 2022; 66:713-721. [PMID: 35338646 DOI: 10.1111/aas.14059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/21/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effects of vasoconstriction on cardiac stroke volume (SV) and indices of peripheral and intestinal perfusion are insufficiently described. METHODS In a non-randomized clinical study, 30 patients undergoing elective rectal surgery were exposed to modulation of preload. The primary endpoint was intestinal perfusion (flux), measured by single-point laser Doppler flowmetry. Secondary endpoints were central cardiovascular variables obtained by the LiDCO rapid monitor, the peripheral perfusion index (PPI) derived from the pulse oximetry signal and muscle (StO2 ) and cerebral oxygenation (ScO2 ) determined by near-infrared spectroscopy. RESULTS For the whole cohort (n = 30), administration of Phenylephrine during HUT induced a median [IQR] increase in SV by 22% [14-41], p = .003 and in mean arterial pressure (MAP) by 54% [31-62], p < .001, with no change in PPI, StO2 and ScO2 or flux. In patients who were preload dependent during HUT (stroke volume variation; SSV >10%; n = 23), administration of phenylephrine increased SV by 29% [12-43], p = .01 and MAP by 54% [33-63], p < .001, followed by an increase in intestinal perfusion flux by 60% [15-289], p = .05, while PPI, StO2 and ScO2 remained unchanged. For non-preload dependent patients (SSV <10%; n = 7), no changes in hemodynamic indices were seen besides an increase in MAP by 54% [33-58], p = .002. CONCLUSION The reflection of vasoconstrictive modulation of preload in systemic cardiovascular variables and indices of perfusion was dependent on preload responsiveness. Administration of phenylephrine to increase preload did not appear to compromise organ perfusion.
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Affiliation(s)
- Marianne Agerskov
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Henrik Sørensen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Søren Kjær
- Gastroenterology Surgical Section Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Niels H. Secher
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Nicolai B. Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
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11
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Rollins KE, Lobo DN, Joshi GP. Enhanced recovery after surgery: Current status and future progress. Best Pract Res Clin Anaesthesiol 2021; 35:479-489. [PMID: 34801211 DOI: 10.1016/j.bpa.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) pathways were first introduced almost a quarter of a century ago and represent a paradigm shift in perioperative care that reduced postoperative complications and hospital length of stay, improved postoperative quality of life, and reduced overall healthcare costs. Gradual recognition of the generalizability of the interventions and transferable improvements in postoperative outcomes, led them to become standard of care for several surgical procedures. In this article, we critically review the current status of ERAS pathways, address related controversies, and propose measures for future progress.
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Affiliation(s)
- Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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12
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Frandsen MN, Mehlsen J, Bang Foss N, Kehlet H. Pre-operative autonomic nervous system function - a missing link for post-induction hypotension? Anaesthesia 2021; 77:139-142. [PMID: 34291821 DOI: 10.1111/anae.15546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 01/07/2023]
Affiliation(s)
- M N Frandsen
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - J Mehlsen
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - N Bang Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidore, Denmark
| | - H Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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13
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Agerskov M, Thusholdt ANW, Holm-Sørensen H, Wiberg S, Meyhoff CS, Højlund J, Secher NH, Foss NB. Association of the intraoperative peripheral perfusion index with postoperative morbidity and mortality in acute surgical patients: a retrospective observational multicentre cohort study. Br J Anaesth 2021; 127:396-404. [PMID: 34226038 PMCID: PMC8451236 DOI: 10.1016/j.bja.2021.06.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background We hypothesised that in acute high-risk surgical patients, a lower intraoperative peripheral perfusion index (PPI) would indicate a higher risk of postoperative complications and mortality. Methods This retrospective observational study included 1338 acute high-risk surgical patients from November 2017 until October 2018 at two University Hospitals in Denmark. Intraoperative PPI was the primary exposure variable and the primary outcome was severe postoperative complications defined as a Clavien–Dindo Class ≥III or death, within 30 days. Results intraoperative PPI was associated with severe postoperative complications or death: odds ratio (OR) 1.12 (95% confidence interval [CI] 1.05–1.19; P<0.001), with an association of intraoperative mean PPI ≤0.5 and PPI ≤1.5 with the primary outcome: OR 1.79 (95% CI 1.09–2.91; P=0.02) and OR 1.65 (95% CI 1.20–2.27; P=0.002), respectively. Each 15-min increase in intraoperative time spend with low PPI was associated with the primary outcome (per 15 min with PPI ≤0.5: OR 1.11 (95% CI 1.05–1.17; P<0.001) and with PPI ≤1.5: OR 1.06 (95% CI 1.02–1.09; P=0.002)). Thirty-day mortality in patients with PPI ≤0.5 was 19% vs 10% for PPI >0.5, P=0.003. If PPI was ≤1.5, 30-day mortality was 16% vs 8% in patients with a PPI >1.5 (P<0.001). In contrast, intraoperative mean MAP ≤65 mm Hg was not significantly associated with severe postoperative complications or death (OR 1.21 [95% CI 0.92–1.58; P=0.2]). Conclusions Low intraoperative PPI was associated with severe postoperative complications or death in acute high-risk surgical patients. To guide intraoperative haemodynamic management, the PPI should be further investigated.
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Affiliation(s)
- Marianne Agerskov
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Anna N W Thusholdt
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Holm-Sørensen
- Department of Integrative Physiology, NEXS, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Højlund
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Secher
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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14
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. Inflammatory response, fluid balance and outcome in emergency high-risk abdominal surgery. Acta Anaesthesiol Scand 2021; 65:730-739. [PMID: 33548067 DOI: 10.1111/aas.13792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The main disease etiologies requiring emergency high-risk abdominal surgery are intestinal obstruction and perforated viscus and the differences in immune response to these pathologies are largely unexplored. In search of improvement of patient assessment in the perioperative phase, we examined the inflammatory response in this setting, focusing on potential difference in pathophysiology. METHODS The electronic medical records of 487 patients who underwent emergency abdominal surgery from year 2013-2015 for intestinal obstruction and perforated viscus were reviewed. We evaluated the relationship between pre- and postoperative C-reactive protein (CRP) trajectory, fluid balance, and perioperative morbidity and mortality according to type of surgery, intervention, and surgical pathology. RESULTS A total of 418 patients were included. Pre- and postoperative absolute CRP values were significantly higher in patients with perforated viscus (n = 203) than in intestinal obstruction (n = 215) (P < .0001). Relative changes at hour 6 and POD 1 were non-significant (P = .716 and P = .816 respectively). There was significant association between both pre- (quartile 1 vs 4, OR 5.11; P < .01) and postoperative (quartile 1 vs 4, OR 4.10; P < .001) CRP and adverse outcome, along with fluid balance and adverse outcome in patients with obstruction but not in those with perforation. Fluid balance and CRP had statistically significant positive correlation in patients with obstruction. CONCLUSIONS In this explorative study, a high pre- and postoperative CRP and a high positive fluid balance were associated with worse outcome in patients with intestinal obstruction, but not in patients with perforated viscus. Future studies should address the different inflammatory and fluid trajectories in these specific pathologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Morten L. Lauritsen
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Katrine Kanstrup
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Nicolai B. Foss
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
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15
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Ren X, Liu S, Lian C, Li H, Li K, Li L, Zhao G. Dysfunction of the Glymphatic System as a Potential Mechanism of Perioperative Neurocognitive Disorders. Front Aging Neurosci 2021; 13:659457. [PMID: 34163349 PMCID: PMC8215113 DOI: 10.3389/fnagi.2021.659457] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
Perioperative neurocognitive disorder (PND) frequently occurs in the elderly as a severe postoperative complication and is characterized by a decline in cognitive function that impairs memory, attention, and other cognitive domains. Currently, the exact pathogenic mechanism of PND is multifaceted and remains unclear. The glymphatic system is a newly discovered glial-dependent perivascular network that subserves a pseudo-lymphatic function in the brain. Recent studies have highlighted the significant role of the glymphatic system in the removal of harmful metabolites in the brain. Dysfunction of the glymphatic system can reduce metabolic waste removal, leading to neuroinflammation and neurological disorders. We speculate that there is a causal relationship between the glymphatic system and symptomatic progression in PND. This paper reviews the current literature on the glymphatic system and some perioperative factors to discuss the role of the glymphatic system in PND.
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Affiliation(s)
- Xuli Ren
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shan Liu
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Chuang Lian
- Department of Anaesthesiology, Jilin City People's Hospital, Jilin, China
| | - Haixia Li
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Kai Li
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Longyun Li
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Guoqing Zhao
- Department of Anaesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China.,Jilin University, Changchun, China
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16
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Rasmussen PS, Aasvang EK, Olsen RM, Haahr‐Raunkjaer C, Elvekjaer M, Sørensen HBD, Meyhoff CS. Continuous peripheral perfusion index in patients admitted to hospital wards - An observational study. Acta Anaesthesiol Scand 2021; 65:257-265. [PMID: 32959371 DOI: 10.1111/aas.13711] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 08/25/2020] [Accepted: 09/09/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Risk patients admitted to hospital wards may quickly develop haemodynamic deterioration and early recognition has high priority to allow preventive intervention. The peripheral perfusion index (PPI) may be an indicator of circulatory distress by assessing peripheral perfusion non-invasively from photoplethysmography. We aimed to describe the characteristics of PPI in hospitalized patients since this is not well-studied. MATERIALS AND METHODS Patients admitted due to either acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or after major abdominal cancer surgery were included in this study. Patients were monitored continuously up to 96 hours with a pulse oximeter. Comparisons between median PPI each day, time of day and admission type were described with mean difference (MD) and were analysed using Wilcoxon rank sum test and related to morbidity and mortality. RESULTS PPI data from 291 patients were recorded for a total of 9279 hours. Median PPI fell from 1.4 (inter quartile range, IQR 0.9-2.3) on day 1 to 1.0 (IQR 0.6-1.6) on day 4. Significant differences occurred between PPI day vs evening (MD = 0.18, 95% CI 0.16-0.20, P = .028), day vs night (MD = 0.56, 95% CI 0.49-0.62, P < .0001) and evening vs night (MD = 0.38, 95% CI 0.33-0.42, P = .002). No significant difference in median PPI between AECOPD and surgical patients was found (MD = 0.15, 95% CI -0.08-0.38, P = .62). CONCLUSION Lower PPI during daytime vs evening and night-time were seen for both populations. The highest frequency of serious adverse events and mortality was seen among patients with low median PPI. The clinical impact of PPI monitoring needs further confirmation.
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Affiliation(s)
- Patrick S. Rasmussen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital, Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Eske K. Aasvang
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases Rigshospitalet, University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Rasmus M. Olsen
- Biomedical Engineering, Department of Health Technology Technical University of Denmark Kgs. Lyngby Denmark
| | - Camilla Haahr‐Raunkjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital, Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Mikkel Elvekjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital, Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Helge B. D. Sørensen
- Biomedical Engineering, Department of Health Technology Technical University of Denmark Kgs. Lyngby Denmark
| | - Christian S. Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital, Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Le Manach Y, Meyhoff CS, Collins GS, Aasvang EK, London MJ. Of Railroads and Roller Coasters: Considerations for Perioperative Blood Pressure Management? Anesthesiology 2020; 133:489-492. [PMID: 32739992 DOI: 10.1097/aln.0000000000003446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Ripollés-Melchor J, Zaballos-García M, Monge García MI. The phenylephrine challenge. Minerva Anestesiol 2020; 86:1015-1018. [PMID: 32613813 DOI: 10.23736/s0375-9393.20.14716-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Javier Ripollés-Melchor
- Department of Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain - .,Spanish Perioperative Audit and Research Network (REDGERM), Zaragoza, Spain -
| | - Matilde Zaballos-García
- Department of Anesthesia and Critical Care, Gregorio Maranon University Hospital, Madrid, Spain
| | - Manuel I Monge García
- Department of Critical Care, University Hospital of Jerez, Jerez de la Frontera, Spain
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19
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Foss NB, Kehlet H. Challenges in optimising recovery after emergency laparotomy. Anaesthesia 2020; 75 Suppl 1:e83-e89. [PMID: 31903571 DOI: 10.1111/anae.14902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2019] [Indexed: 12/19/2022]
Abstract
Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Kehlet H. Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia 2020; 75 Suppl 1:e54-e61. [DOI: 10.1111/anae.14860] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 12/15/2022]
Affiliation(s)
- H. Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University Copenhagen Denmark
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21
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Højlund J, Agerskov M, Clemmesen CG, Hvolris LE, Foss NB. The Peripheral Perfusion Index tracks systemic haemodynamics during general anaesthesia. J Clin Monit Comput 2019; 34:1177-1184. [DOI: 10.1007/s10877-019-00420-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 11/04/2019] [Indexed: 01/09/2023]
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22
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Saugel B, Kouz K, Scheeren TWL. The '5 Ts' of perioperative goal-directed haemodynamic therapy. Br J Anaesth 2019; 123:103-107. [PMID: 31126619 DOI: 10.1016/j.bja.2019.04.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 12/15/2022] Open
Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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