Coloides versus cristaloides em fluidoterapia guiada por objetivos, revisão sistemática e metanálise. Demasiadamente cedo ou demasiadamente tarde para obter conclusões

Fluid administration in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: neither too much nor too little

INTRODUCTION

Intraoperative fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy plays an important role in postoperative morbidity. Studies have found an association between overload fluid therapy and increased postoperative complications, advising restrictive intraoperative fluid therapy. Our objective in this study was to compare the morbidity associated with restrictive versus non-restrictive intraoperative fluid therapy.

METHODS

Retrospective analysis of a database collected prospectively in the Anesthesiology Service of Virgen del Rocío Hospital, from December 2016 to April 2019. One hundred and six patients who underwent complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were divided into two cohorts according to Fluid Therapy received 1. Restrictive ≤ 9 mL.kg^-1.h^-1 (34 patients), 2. Non-restrictive   ≥ 9 mL.kg^-1.h^-1 (72 patients). Percentage of major complications (Clavien-Dindo grade III-IV) and length hospital stay were the main outcomes variables.

RESULTS

Of the 106 enrolled patients, 68.9% were women; 46.2% had ovarian cancer, 35.84% colorectal cancer, and 7.5% peritoneal cancer. The average fluid administration rate was 11 ± 3.58 mL.kg^-1.h^-1. The restrictive group suffered a significantly higher percentage of Clavien-Dindo grade III-IV complications (35.29%) compared with the non-restrictive group (15.27%) (p = 0.02). The relative risk associated with restrictive therapy was 1.968 (95% confidence interval: 1.158-3.346). We also found a significant difference for hospital length of stay, 20.91 days in the restrictive group vs 16.19 days in the non-restrictive group (p = 0.038).

CONCLUSIONS

Intraoperative fluid therapy restriction below 9 mL.kg^-1.h^-1 in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was associated with a higher percentage of major postoperative complications.

Goal-directed fluid therapy on laparoscopic colorectal surgery within enhanced recovery after surgery program

INTRODUCTION

Enhanced recovery after surgery protocols (ERAS) are used in peri-operative care to reduce the stress response to surgical aggression. As fluid overload has been associated with increased morbidity and delayed hospital discharge, a major aspect of this is fluid management. Intra-operative goal-directed fluid protocols have been shown to reduce post-operative complications, particularly in high risk patients.?.

OBJECTIVE

To compare 2fluid therapy models (zero-balance versus goal-directed fluid therapy) in patients who were scheduled for laparoscopic colorectal surgery within an ERAS program, recording the rate of complications such as surgical site infection, ileus, post-operative náusea and vomiting, and variability of the estimated glomerular filtration rate (eGFR).

MATERIALS AND METHODS

An observational, retrospective study was conducted including adults who were scheduled for elective laparoscopic colorectal surgery within an ERAS program, and to investigate the postoperative complication rate.

RESULTS

A total of 128 patients were included in this study; 43 (33.6%) in the zero-balance group and 85 (66.4%) in the goal-directed fluid therapy group. The total fluids administered was lower in the goal-directed fluid therapy group, as well as the incidence of post-operative complications (surgical site infection, anastomotic leak, ileus, and postoperative náusea and vomiting). No significant differences were found for length of stay, intra-operative urine output, and variability of the eGFR.?.

CONCLUSION

The results of this study show that by using a goal-directed fluid therapy algorithm, the total amount of fluids administered can be reduced, as well as obtaining a lower incidence of post-operative complications.

Hydroxyethyl starch and kidney function: A retrospective study in patients undergoing therapeutic plasma exchange

PURPOSE

Hydroxyethyl starch (HES) and albumin are used as replacement fluids during therapeutic plasma exchange (TPE). HES solutions are no longer recommended in critically ill patients due to its effect on kidneys and coagulation. In this retrospective study, we tried to look at the association between cumulative HES administration and kidney function in patients undergoing TPE.

METHODS

Transfusion medicine department register was scrutinized to identify adult patients who had completed at least 5 cycles of TPE during the period June 2014-May 2015. Patient demographics, indication for TPE, amount of plasma removed, amount of colloid administered, adverse events and vascular access details were collected. Electronic hospital database was scrutinized to retrieve lab parameters, including blood urea and serum creatinine (before and after 5 cycles of TPE) and platelet count. Baseline renal parameters were compared with post TPE values using Wilcoxon signed rank test. A p value <0.05 was kept as significant.

RESULTS

Of the 593 patients who received TPE during the study period, 104 patients fulfilled the inclusion criteria. Forty-five patients out of 104 received TPE in the intensive care unit. All patients received 2500 ml of HES during the study period. Blood urea and serum creatinine values, when compared to baseline, significantly decreased after 5 cycles of TPE (p = 0.004, p = 0.001, respectively).

CONCLUSION

Blood urea and serum creatinine, used as markers of renal function, improved in patients requiring multiple doses of HES solutions during TPE. Further studies using novel renal biomarkers are required to examine whether HES induces any structural damage to kidneys.

A Systematic Review of the Quality of IV Fluid Therapy in Veterinary Medicine

Objective

To evaluate the quality of the veterinary literature investigating IV fluid therapy in dogs, cats, horses, and cattle.

Design

Systematic review.

Procedures

The preferred reporting of items for systematic review and meta-analysis protocols (PRISMA-P) was employed for systematic review of all relevant IV fluid therapy manuscripts published from January 1969 through December 2016 in the Commonwealth Agricultural Bureaux International (CABI) database. Independent grading systems used to evaluate manuscripts included the updated CONsolidated Standards of Reporting Trials 2012 checklist, risk of bias for animal intervention studies, criteria for levels of evidence, and methodological quality (Jadad scale). The quality of articles published before and after 2010 was compared.

Results

One hundred and thirty-nine articles (63 dogs, 7 cats, 39 horses, 30 cattle) from 7,258 met the inclusion criteria. More than 50% of the manuscripts did not comply with minimal requirements for reporting randomized controlled trials. The most non-compliant items included identification of specific predefined objectives or a hypothesis, identification of trial design, how sample size was determined, randomization, and blinding procedures. Most studies were underpowered and at risk for selection, performance, and detection bias. The overall quality of the articles improved for articles published after 2010.

Conclusion and clinical relevance

Most of the veterinary literature investigating the administration of IV fluid therapy in dogs, cats, horses, and cattle is descriptive, does not comply with standards for evidence, or provide adequate translation to clinical practice. Authors should employ and journal editors should enforce international consensus recommendations and guidelines for publication of data from animal experiments investigating IV fluid therapy.