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Hahn RG, Dull RO. A Slow-Exchange Interstitial Fluid Compartment in Volunteers and Anesthetized Patients: Kinetic Analysis and Physiology. Anesth Analg 2024:00000539-990000000-00687. [PMID: 38153873 DOI: 10.1213/ane.0000000000006767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
BACKGROUND Physiological studies suggest that the interstitial space contains 2 fluid compartments, but no analysis has been performed to quantify their sizes and turnover rates. METHODS Retrospective data were retrieved from 270 experiments where Ringer's solution of between 238 and 2750 mL (mean, 1487 mL) had been administered by intravenous infusion to awake and anesthetized humans (mean age 39 years, 47% females). Urinary excretion and hemoglobin-derived plasma dilution served as input variables in a volume kinetic analysis using mixed-models software. RESULTS The kinetic analysis successfully separated 2 interstitial fluid compartments. One equilibrated rapidly with the plasma and the other equilibrated slowly. General anesthesia doubled the rate constants for fluid entering these 2 compartments (from 0.072 to 0.155 and from 0.026 to 0.080 min -1 , respectively). The return flows to the plasma were impeded by intensive fluid therapy; the rate constant for the fast-exchange compartment decreased from 0.251 to 0.050 when the infusion time increased from 15 to 60 minutes, and the rate constant for the slow-exchange compartment decreased from 0.019 to 0.005 when the infused volume increased from 500 to 1500 mL. The slow-exchange compartment became disproportionately expanded when larger fluid volumes were infused and even attained an unphysiologically large size when general anesthesia was added, suggesting that the flow of fluid was restrained and not solely determined by hydrostatic and oncotic forces. The dependence of the slow-exchange compartment on general anesthesia, crystalloid infusion rate, and infusion volume all suggest a causal physiological process. CONCLUSIONS Kinetic analysis supported that Ringer's solution distributes in 2 interstitial compartments with different turnover times. The slow compartment became dominant when large amounts of fluid were infused and during general anesthesia. These findings may explain why fluid accumulates in peripheral tissues during surgery and why infused fluid can remain in the body for several days after general anesthesia.
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Affiliation(s)
- Robert G Hahn
- From the Department of Clinical Sciences, Karolinska Institute at Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Randal O Dull
- Department of Anesthesiology, University of Arizona College of Medicine, Tucson, Arizona
- Department of Pathology, University of Arizona College of Medicine, Tucson, Arizona
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
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2
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West SJ, Trewren TJ, Stretton B, Kovoor JG, Maddern GJ. What is the optimal approach to perioperative fluid management? J Perioper Pract 2024; 34:4-5. [PMID: 36945830 DOI: 10.1177/17504589231159195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Affiliation(s)
| | | | - Brandon Stretton
- Royal Adelaide Hospital, Adelaide, SA, Australia
- The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
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3
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Clemente-Suárez VJ, Martín-Rodríguez A, Redondo-Flórez L, Villanueva-Tobaldo CV, Yáñez-Sepúlveda R, Tornero-Aguilera JF. Epithelial Transport in Disease: An Overview of Pathophysiology and Treatment. Cells 2023; 12:2455. [PMID: 37887299 PMCID: PMC10605148 DOI: 10.3390/cells12202455] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
Epithelial transport is a multifaceted process crucial for maintaining normal physiological functions in the human body. This comprehensive review delves into the pathophysiological mechanisms underlying epithelial transport and its significance in disease pathogenesis. Beginning with an introduction to epithelial transport, it covers various forms, including ion, water, and nutrient transfer, followed by an exploration of the processes governing ion transport and hormonal regulation. The review then addresses genetic disorders, like cystic fibrosis and Bartter syndrome, that affect epithelial transport. Furthermore, it investigates the involvement of epithelial transport in the pathophysiology of conditions such as diarrhea, hypertension, and edema. Finally, the review analyzes the impact of renal disease on epithelial transport and highlights the potential for future research to uncover novel therapeutic interventions for conditions like cystic fibrosis, hypertension, and renal failure.
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Affiliation(s)
- Vicente Javier Clemente-Suárez
- Faculty of Sports Sciences, Universidad Europea de Madrid, Tajo Street, s/n, 28670 Madrid, Spain;
- Group de Investigación en Cultura, Educación y Sociedad, Universidad de la Costa, Barranquilla 080002, Colombia
| | | | - Laura Redondo-Flórez
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, C/Tajo s/n, Villaviciosa de Odón, 28670 Madrid, Spain; (L.R.-F.); (C.V.V.-T.)
| | - Carlota Valeria Villanueva-Tobaldo
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, C/Tajo s/n, Villaviciosa de Odón, 28670 Madrid, Spain; (L.R.-F.); (C.V.V.-T.)
| | - Rodrigo Yáñez-Sepúlveda
- Faculty of Education and Social Sciences, Universidad Andres Bello, Viña del Mar 2520000, Chile;
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4
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Kaufman DA, Lopes M, Maviya N, Magder SA. The Ins and Outs of IV Fluids in Hemodynamic Resuscitation. Crit Care Med 2023; 51:1397-1406. [PMID: 37707377 DOI: 10.1097/ccm.0000000000006001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVES Concise definitive review of the physiology of IV fluid (IVF) use in critically ill patients. DATA SOURCES Available literature on PubMed and MEDLINE databases. STUDY SELECTION Basic physiology studies, observational studies, clinical trials, and reviews addressing the physiology of IVF and their use in the critically ill were included. DATA EXTRACTION None. DATA SYNTHESIS We combine clinical and physiologic studies to form a framework for understanding rational and science-based use of fluids and electrolytes. CONCLUSIONS IVF administration is among the most common interventions for critically ill patients. IVF can be classified as crystalloids or colloids, and most crystalloids are sodium salts. They are frequently used to improve hemodynamics during shock states. Many recent clinical trials have sought to understand which kind of IVF might lead to better patient outcomes, especially in sepsis. Rational use of IVF rests on understanding the physiology of the shock state and what to expect IVF will act in those settings. Many questions remain unanswered, and future research should include a physiologic understanding of IVF in study design.
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Affiliation(s)
- David A Kaufman
- Division of Pulmonary and Critical Care Medicine, NYU Grossman School of Medicine, New York, NY
| | - Marcela Lopes
- Intensive Care Unit, Hospital da Cidade, Salvador, Bahia, Brazil
| | | | - Sheldon A Magder
- Department of Critical Care, McGill University Health Centre, Montréal, Québec, Canada
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5
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Lorente JV, Hahn RG, Jover JL, Del Cojo E, Hervías M, Jiménez I, Uña R, Clau-Terré F, Monge MI, Llau JV, Colomina MJ, Ripollés-Melchor J. Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols. J Clin Med 2023; 12:5930. [PMID: 37762871 PMCID: PMC10531658 DOI: 10.3390/jcm12185930] [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: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body's internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient's physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles.
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Affiliation(s)
- Juan V. Lorente
- Department of Anesthesiology and Critical Care, Juan Ramón Jiménez University Hospital, 21005 Huelva, Spain
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Robert G. Hahn
- Karolinska Institute, Danderyds Hospital (KIDS), 171 77 Stockholm, Sweden
| | - José L. Jover
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Verge del Lliris Hospital, 03802 Alcoy, Spain
| | - Enrique Del Cojo
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Don Benito-Villanueva de la Serena Health District, 06400 Don Benito, Spain
| | - Mónica Hervías
- Department of Anesthesiology and Critical Care, Gregorio Marañón General University Hospital, 28007 Madrid, Spain
- Paediatric Anaesthesiology Section, Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Ignacio Jiménez
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Virgen del Rocío University Hospital, 41013 Seville, Spain
| | - Rafael Uña
- Department of Anesthesiology and Critical Care, La Paz University General Hospital, 28046 Madrid, Spain
| | - Fernando Clau-Terré
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Vall d’Hebron Institut Recerca, Vall d’Hebrón University Hospital, 08035 Barcelona, Spain
| | - Manuel I. Monge
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Juan V. Llau
- Department of Anesthesiology and Critical Care, Doctor Peset Hospital, 46017 Valencia, Spain
| | - Maria J. Colomina
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Bellvitge University Hospital, University of Barcelona, 08907 Barcelona, Spain
| | - Javier Ripollés-Melchor
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Infanta Leonor Hospital, 28031 Madrid, Spain
- Department of Toxicology, Universidad Complutense de Madrid, 28040 Madrid, Spain
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6
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Mladinov D, Isaza E, Gosling AF, Clark AL, Kukreja J, Brzezinski M. Perioperative Fluid Management. Anesthesiol Clin 2023; 41:613-629. [PMID: 37516498 DOI: 10.1016/j.anclin.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the elderly are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the elderly. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, CWN-L1, Boston, MA 02115, USA
| | - Erin Isaza
- University of California, San Francisco, School of Medicine, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Andre F Gosling
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845D, Birmingham, AL 35249, USA
| | - Adrienne L Clark
- Department of Anesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Marek Brzezinski
- Department of Anesthesia and Perioperative Care, University of California, VA Medical Center-San Francisco, 4150 Clement Street, San Francisco CA 94121, USA.
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7
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Duan Q, Zhang Y, Yang D. Perioperative fluid management for lung transplantation is challenging. Heliyon 2023; 9:e14704. [PMID: 37035359 PMCID: PMC10073756 DOI: 10.1016/j.heliyon.2023.e14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/24/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Lung transplantation is the definitive end-stage treatment for many lung diseases, and postoperative pulmonary oedema severely affects survival after lung transplantation. Optimizing perioperative fluid management can reduce the incidence of postoperative pulmonary oedema and improve the prognosis of lung transplant patients by removing the influence of patient, donor's lung and ECMO factors. Therefore, this article reviews seven aspects of lung transplant patients' pathophysiological characteristics, physiological characteristics of fluids, the influence of the donor lung on pulmonary oedema as well as current fluid rehydration concepts, advantages or disadvantages of intraoperative monitoring tools or types of fluids on postoperative pulmonary oedema, while showing the existing challenges in section 7. The aim is to show the specificity of perioperative fluid management in lung transplant patients and to provide new ideas for individualised fluid management in lung transplantation.
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Affiliation(s)
- Qirui Duan
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, China
| | - Yajun Zhang
- China-Japan Friendship Hospital, Beijing, 100020, China
- Corresponding author.
| | - Dong Yang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, China
- Corresponding author.,
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8
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Alonso A, Liauw W, Kennedy H, Alzahrani NA, Morris DL. Sodium thiosulfate during cisplatin-based hyperthermic intraperitoneal chemotherapy is associated with transient hypernatraemia without clinical sequelae. Pleura Peritoneum 2022; 7:87-93. [PMID: 35812006 PMCID: PMC9166178 DOI: 10.1515/pp-2022-0107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/23/2022] [Indexed: 12/25/2022] Open
Abstract
Objectives Cisplatin is commonly used during intraperitoneal chemotherapy however has well-established nephrotoxic side-effects. Sodium thiosulfate is often added to cisplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) protocols to mitigate this, however evidence regarding risk of hypernatraemia is scarce as of yet. Methods We retrospectively identified patients undergoing cytoreductive surgery (CRS) for peritoneal surface malignancies of any origin at a single high-volume unit between April 2018 and December 2020. Patients were included if they received cisplatin-based HIPEC with intravenous sodium thiosulfate. Blood tests were collected pre-surgery and then daily during admission. Hypernatraemia was defined as serum sodium >145 mmol/L. Renal impairment was defined using the RIFLE criteria. Results Eleven CRSs met inclusion criteria, the majority of which were indicated for ovarian cancer (72.7%). One (9.1%) patient with mesothelioma received mitomycin C as an additional chemotherapy agent. The incidence of hypernatraemia was 100% but all cases were transient, with no clinical sequelae observed. The rate of AKI was 36.4%, with three (27.3%) patients classified as risk and one (9.1%) instance of failure. No long-term renal impairment was observed. Conclusions Despite biochemical evidence of mild hypernatraemia but with the absence of clinical sequelae, sodium thiosulfate appears to be safe when used in adjunct to cisplatin-based HIPEC during CRS. These findings should be evaluated with further comparative studies. When describing renal impairment, it is important that standardisation in reporting occurs, with the RIFLE and Acute Kidney Injury Network criteria now the preferred consensus definitions.
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Affiliation(s)
- Anais Alonso
- Liver and Peritonectomy Unit, St George Hospital , Kogarah , Australia
- St George and Sutherland Clinical School, University of New South Wales , Kogarah , Australia
| | - Winston Liauw
- Liver and Peritonectomy Unit, St George Hospital , Kogarah , Australia
- St George and Sutherland Clinical School, University of New South Wales , Kogarah , Australia
| | - Helen Kennedy
- Liver and Peritonectomy Unit, St George Hospital , Kogarah , Australia
| | - Nayef A. Alzahrani
- Liver and Peritonectomy Unit, St George Hospital , Kogarah , Australia
- College of Medicine, Al Imam Mohammad Ibn Saud Islamic University , Riyadh , Saudi Arabia
| | - David L. Morris
- Liver and Peritonectomy Unit, St George Hospital , Kogarah , Australia
- St George and Sutherland Clinical School, University of New South Wales , Kogarah , Australia
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9
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Jiang J, Gao G, Pan Q, Liu J, Tian Y, Zhang X. Circular RNA circHIPK3 is downregulated in diabetic cardiomyopathy and overexpression of circHIPK3 suppresses PTEN to protect cardiomyocytes from high glucose-induced cell apoptosis. Bioengineered 2022; 13:6272-6279. [PMID: 35200097 PMCID: PMC8974065 DOI: 10.1080/21655979.2022.2031395] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
It has been reported that circHIPK3 can be downregulated by high glucose, suggesting its potential involvement in diabetes and diabetic complications. This study aimed to explore the role of circHIPK3 in diabetic cardiomyopathy (DC). PTEN is a kind of tumor suppressor gene, which is very commonly lost in human cancer. We detected the expression of circHIPK3 and PTEN in plasma samples from DC patients, diabetic patients without complications diabetes mellitus (DM) and health controls by RT-qPCR and ELISA. In vitro cell experiment, AC16 cells (cardiomyocytes) were treated with high glucose, followed by expression analysis of circHIPK3 and PTEN mRNA by RT-qPCR. CircHIPK3 or PTEN expression vector were used to overexpress circHIPK3 and PTEN in AC16 cells to explore the relationship between them. The role of circHIPK3 and PTEN in regulating the apoptosis of AC16 cells was analyzed by cell apoptosis assay. The result showed that CircHIPK3 was downregulated in diabetes and further downregulated in DC. In AC16 cells, high glucose treatment decreased the expression levels of circHIPK3. Across DC samples, the expression of circHIPK3 was inversely correlated with PTEN. In AC16 cells, overexpression of circHIPK3 decreased the expression levels of PTEN. CircHIPK3 may suppress AC16 cell apoptosis induced by high glucose and inhibited the role of PTEN in cell apoptosis. Therefore, circHIPK3 may downregulate PTEN to protect cardiomyocytes from high glucose-induced cell apoptosis.
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Affiliation(s)
- Jun Jiang
- Department of Cardiology, Baoquanling Central Hospital, Hegang City, Heilongjiang Province, PR. China
| | - Guannan Gao
- Department of Cardiology, Baoquanling Central Hospital, Hegang City, Heilongjiang Province, PR. China
| | - Qiang Pan
- Department of Cardiology, Baoquanling Central Hospital, Hegang City, Heilongjiang Province, PR. China
| | - Jing Liu
- Department of Cardiology, Baoquanling Central Hospital, Hegang City, Heilongjiang Province, PR. China
| | - Yu Tian
- Department of Cardiology, Baoquanling Central Hospital, Hegang City, Heilongjiang Province, PR. China
| | - Xiaoji Zhang
- Department of Cardiology, Baoquanling Central Hospital, Hegang City, Heilongjiang Province, PR. China
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10
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Weinberg L, Lee DK, Bergin H, Koshy AN, Tully PA, Meyerov J, Louis M, Yang BO, Grover-Johnson O, Scurrah N, Cosic L, Story D, Bellomo R. MEasuring the impact of Anesthetist-administered medications volumeS on intraoperative flUid balance duRing prolonged abdominal surgEry (MEASURE Study). Minerva Anestesiol 2022; 88:334-342. [PMID: 35164486 DOI: 10.23736/s0375-9393.22.15918-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The contribution of intraoperative anesthetist-administered medications (IAAMs) to the total volume of intraoperative intravenous (IV) fluid therapy and their association with postoperative outcomes has never been formally investigated. METHODS We performed a retrospective study of adult patients undergoing pancreaticoduodenectomy. The volume of IAAMs, crystalloids and colloids, blood and blood products, blood loss, urine output and intraoperative fluid balance were collected. The contribution of IAAMs to the total intraoperative IV fluid volume and postoperative complications was evaluated. RESULTS A total of 152 consecutive patients were included. The median volume of IAAMs was 363.8 mL (interquartile range [IQR], (241.0-492.5) delivered at a median rate of 0.61 mL kg hr-1 (0.40-0.87) over a median duration of surgery of 489 minutes (416.3-605.3). This increased the total administered fluid volume by 5.2% (95% confidence intervals [CI]: 4.6, 5.9%) (Cohen's d=1.33, P<0.001). The volume of IAAMs was comparable to the intraoperative colloid volume administered (median colloid volume, 400 mL). Overall, fluid volumes correlated significantly with the severity of complications (P=0.011), and the correlation strength increased when the IAAMs volume was included (P=0.005). On addition of IAAMs, the area under the receiver operator characteristic curve for prediction of postoperative complications increased from 0.580 (95%CI: 0.458, 0.701) to 0.603 (95%CI: 0.483, 0.723), P=0.041). CONCLUSIONS IAAMs significantly increased the total administered fluid volume during pancreaticoduodenectomy. Their inclusion increases the accuracy of postoperative complications predictions. These findings support their inclusion in fluid volumes and balances in future interventional studies.
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Affiliation(s)
- Laurence Weinberg
- Department of Anesthesia, Austin Health, Victoria, Australia - .,Department of Critical Care, University of Melbourne, Victoria, Australia - .,Department of Surgery, University of Melbourne, Austin Health, Victoria, Australia -
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Hannah Bergin
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Victoria, Australia
| | - Patrick A Tully
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Joshua Meyerov
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Maleck Louis
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Bobby Ou Yang
- Department of Anesthesia, Austin Health, Victoria, Australia
| | | | | | - Luka Cosic
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - David Story
- Department of Anesthesia, Austin Health, Victoria, Australia.,Department of Critical Care, University of Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Victoria, Australia
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11
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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12
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Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3830. [PMID: 34549012 PMCID: PMC8447987 DOI: 10.1097/gox.0000000000003830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/28/2021] [Indexed: 11/27/2022]
Abstract
Background: The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions. Methods: This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay. Results: Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome. Conclusions: The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.
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13
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Hahn RG. Fluid escapes to the "third space" during anesthesia, a commentary. Acta Anaesthesiol Scand 2021; 65:451-456. [PMID: 33174218 PMCID: PMC7983898 DOI: 10.1111/aas.13740] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/15/2020] [Accepted: 10/22/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The "third fluid space" is a concept that has caused much confusion for more than half a century, dividing anesthesiologists into believers and non-believers. AIM To challenge the existence of the "third fluid space" based on analysis of crystalloid fluid kinetics. METHODS Data on hemodilution patterns from 157 infusion experiments performed in volunteers and from 85 patients undergoing surgery under general anesthesia were studied by population volume kinetic analysis. Elimination of infused crystalloid fluid from the kinetic model could occur either as urine or "third space" accumulation. The latter fluid volume remained in the body, but without equilibrating with the plasma within the 3-4 h of the experiment. RESULTS The rate constant for "third space" loss of fluid accounted for 20% of the elimination in conscious volunteers and for 75% during general anesthesia and surgery. The two elimination constants showed a reciprocal relationship, resulting in that "third-space" losses increase when urinary excretion is restricted. The effect on the plasma volume was smaller than indicated by these figures because fluid distributed to the extravascular space continuously redistributed to the plasma. Worked-out examples show that one-third of an infused crystalloid volume has been confined to the "third space" after 3 h of surgery. When equilibration with the plasma eventually occurs, which is necessary for excretion of the fluid, is not known. CONCLUSION During anesthesia and surgery one third of the infused crystalloid fluid is at least temporarily unavailable for excretion, which probably contributes to postoperative weight increase and edema.
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Affiliation(s)
- Robert G. Hahn
- Research UnitSödertälje HospitalSödertäljeSweden
- Karolinska Institutet at Danderyds Hospital (KIDS)StockholmSweden
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Renner J, Moikow L, Lorenzen U. [Enhanced recovery after surgery (ERAS): less is more : What must be considered from an anesthesiological perspective?]. Chirurg 2021; 92:421-427. [PMID: 33570691 DOI: 10.1007/s00104-021-01360-6] [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] [Accepted: 01/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a multidisciplinary treatment model with the aim of guaranteeing a reduction of postoperative complications by the maintenance or early restoration of the patient-specific homoeostasis. From the anesthesiologist's perspective in all three areas of the perioperative phases there are important aspects that need to be addressed in the sense of a holistic treatment concept in order to achieve the highest possible benefit for the patient. OBJECTIVE In the perioperative period there is a bundle of anesthesiological measures, which make the ERAS concept into what it is now. At this point the focus is on the preoperative preparation and optimization of the patient and on the intraoperative and postoperative fluid management. MATERIAL AND METHODS A selective literature search was carried out in the Medline and Cochrane Library databases including consideration of national and international guidelines. RESULTS From an anesthesiological perspective there are relevant aspects in all three pillars of the perioperative phase, the adherence of which will improve the outcome of the patient: a comprehensive risk evaluation in the preoperative period and the avoidance of any sedative drugs; intraoperative individualized fluid management in the sense of a target-oriented optimization; early postoperative enteral nutrition and the avoidance of intravenous fluid administration, whenever justifiable. CONCLUSION Implementing the ERAS concept in the daily clinical routine in combination with maintaining a high compliance with the protocols is a demanding interdisciplinary challenge that urgently needs to be continued.
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Affiliation(s)
- Jochen Renner
- Klinik für Anästhesiologie und Operative Intensivmedizin, Städtisches Krankenhaus Kiel, Chemnitzstr. 33, 24116, Kiel, Deutschland.
| | - Lutz Moikow
- Klinik für Anästhesiologie, Helios Kliniken Schwerin, Schwerin, Deutschland
| | - Ulf Lorenzen
- Klinik für Anästhesiologie und Operative Intensivmedizin, UKSH, Campus Kiel, Kiel, Deutschland
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Chow RS. Terms, Definitions, Nomenclature, and Routes of Fluid Administration. Front Vet Sci 2021; 7:591218. [PMID: 33521077 PMCID: PMC7844884 DOI: 10.3389/fvets.2020.591218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/02/2020] [Indexed: 12/14/2022] Open
Abstract
Fluid therapy is administered to veterinary patients in order to improve hemodynamics, replace deficits, and maintain hydration. The gradual expansion of medical knowledge and research in this field has led to a proliferation of terms related to fluid products, fluid delivery and body fluid distribution. Consistency in the use of terminology enables precise and effective communication in clinical and research settings. This article provides an alphabetical glossary of important terms and common definitions in the human and veterinary literature. It also summarizes the common routes of fluid administration in small and large animal species.
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Affiliation(s)
- Rosalind S Chow
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MI, United States
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Abstract
A moderately liberal IV fluid regimen, using a balanced crystalloid, and consideration of the use of an advanced hemodynamic monitor in a setting of an enhanced recovery pathway are recommended for major surgery.
Supplemental Digital Content is available in the text.
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BİRİCİK E, GÜNEŞ Y. Nörocerrahi ve Eras (Enhanced Recovery After Surgery). ARŞIV KAYNAK TARAMA DERGISI 2020. [DOI: 10.17827/aktd.604717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Bongers BC, Dejong CHC, den Dulk M. Enhanced recovery after surgery programmes in older patients undergoing hepatopancreatobiliary surgery: what benefits might prehabilitation have? Eur J Surg Oncol 2020; 47:551-559. [PMID: 32253075 DOI: 10.1016/j.ejso.2020.03.211] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/05/2020] [Accepted: 03/21/2020] [Indexed: 12/14/2022] Open
Abstract
Due to an aging population and the related growing number of less physically fit patients with multiple comorbidities, adequate perioperative care is a new and rapidly developing clinical science that is becoming increasingly important. This narrative review focuses on enhanced recovery after surgery (ERAS®) programmes and the growing interest in prehabilitation programmes to improve patient- and treatment-related outcomes in older patients undergoing hepatopancreatobiliary (HPB) surgery. Future steps required in the further development of optimal perioperative care in HPB surgery are also discussed. Multidisciplinary preoperative risk assessment in multiple domains should be performed to identify, discuss, and reduce risks for optimal outcomes, or to consider alternative treatment options. Prehabilitation should focus on high-risk patients based on evidence-based cut-off values and should aim for (partly) supervised multimodal prehabilitation tailored to the individual patient's risk factors. The program should be executed in the living context of these high-risk patients to improve the participation rate and adherence, as well as to involve the patient's informal support system. Developing tailored (multimodal) prehabilitation programmes for the right patients, in the right context, and using the right outcome measures is important to demonstrate its potential to further improve patient- and treatment-related outcomes following HPB surgery.
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Affiliation(s)
- Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Uniklinikum RWTH-Aachen, Aachen, Germany.
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Uniklinikum RWTH-Aachen, Aachen, Germany.
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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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Wrzosek A, Jakowicka‐Wordliczek J, Zajaczkowska R, Serednicki WT, Jankowski M, Bala MM, Swierz MJ, Polak M, Wordliczek J. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery. Cochrane Database Syst Rev 2019; 12:CD012767. [PMID: 31829446 PMCID: PMC6953415 DOI: 10.1002/14651858.cd012767.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization. OBJECTIVES To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery. SEARCH METHODS We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person. MAIN RESULTS From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment. AUTHORS' CONCLUSIONS Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.
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Affiliation(s)
- Anna Wrzosek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
- University HospitalDepartment of Anaethesiology and Intensive CareKrakowPoland
| | | | - Renata Zajaczkowska
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Wojciech T Serednicki
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
| | - Milosz Jankowski
- University HospitalDepartment of Anaesthesiology and Intensive CareKrakowPoland
- Jagiellonian University Medical CollegeDepartment of Internal Medicine; Systematic Reviews UnitKrakowPoland
| | - Malgorzata M Bala
- Jagiellonian University Medical CollegeChair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics; Systematic Reviews UnitKopernika 7KrakowPoland31‐034
| | - Mateusz J Swierz
- Jagiellonian University Medical CollegeDepartment of Hygiene and Dietetics; Systematic Reviews UnitKrakowPoland
| | - Maciej Polak
- Jagiellonian University Medical CollegeDepartment of Epidemiology and Population Studies in the Institute of Public HealthKrakowPoland
| | - Jerzy Wordliczek
- Jagiellonian University Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
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Oya S, Yamashita H, Iwata R, Kawasaki K, Tanabe A, Yagi K, Aikou S, Seto Y. Perioperative fluid dynamics evaluated by bioelectrical impedance analysis predict infectious surgical complications after esophagectomy. BMC Surg 2019; 19:184. [PMID: 31791292 PMCID: PMC6889694 DOI: 10.1186/s12893-019-0652-z] [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: 11/13/2018] [Accepted: 11/26/2019] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Shuichiro Oya
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hiroharu Yamashita
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ryohei Iwata
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koichiro Kawasaki
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Asami Tanabe
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koichi Yagi
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Susumu Aikou
- Department of Bariatric & Metabolic Care, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Omesiete N, Martinez C, Pandit V, Villalvazo Y, Jecius H, Thompson E, Norcera M, Nfonsam V. Restricting Intraoperative Fluid Volume Allows Earlier Return of Bowel Function After Colon and Rectal Surgery. J Surg Res 2019; 244:130-135. [PMID: 31284142 DOI: 10.1016/j.jss.2019.06.013] [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: 02/20/2019] [Revised: 04/17/2019] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Return of bowel function (ROBF) after abdominal surgery is an important determinant of patient outcomes. The role of intraoperative fluids (IOFs) in colon surgery remains unclear. The aim of this study was to assess the impact of IOF on ROBF in patients undergoing colon surgery. We hypothesized that minimizing IOFs allows earlier ROBF. METHODS A 2-year (2016-2017) retrospective analysis of all patients undergoing elective colon resection was performed at our tertiary hospital using a protocol limiting IOF and postoperative narcotics. Patients were divided into two groups: preprotocol (2016) and postprotocol (PoP) (2017). Patients were matched using propensity score matching for age, gender, comorbidities, Anesthesiology Severity Score, indication for procedure, and procedure type. The outcome measured was ROBF. Secondary outcome measures were complication rates and hospital length of stay. RESULTS A total of 360 patients were analyzed. After propensity matching, 90 patients (preprotocol: 45; PoP: 45) were included. The mean age was 62.2 ± 14.8 y, 43.3% male, and 44.4% of procedures were performed laparoscopically. There was no difference in demographics and comorbidities between groups. PoP patients received lower IOF (P = 0.036, 2016: 1198.8 ± 1096.5 mL, 2017: 2176.7 ± 1458.3 mL) and lower postoperative narcotics (P = 0.042). PoP patients had earlier ROBF 2[2-4], 4[3-5] (odds ratio: 1.18 [1.05-1.52], P = 0.04), shorter length of stay 3[2-5] d versus 5[4-7] (odds ratio: 1.11 [1.09-1.89], P = 0.043), and trended toward lower complication rates (P = 0.09). CONCLUSIONS IOF volume independently impacts ROBF after colon surgery. Restricting IOF allows for earlier bowel function and shorter hospital stay. Further studies defining optimum fluid management impacting ROBF may help optimize patient care.
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Affiliation(s)
| | | | - Viraj Pandit
- Department of Surgery, University of Arizona, Tucson, Arizona
| | | | - Hunter Jecius
- College of Medicine, University of Arizona, Tucson, Arizona
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Affiliation(s)
- Mohammed Ezzat Moemen
- Department of Anaesthesia and Intensive Care
Faculty of Medicine
Zagazig University
Zagazig Egypt
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Perioperative Fluid Strategies to Prevent Lung Injury. Int Anesthesiol Clin 2019; 56:107-117. [PMID: 29189438 DOI: 10.1097/aia.0000000000000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Minasyan H, Flachsbart F. Blood coagulation: a powerful bactericidal mechanism of human innate immunity. Int Rev Immunol 2019; 38:3-17. [DOI: 10.1080/08830185.2018.1533009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hayk Minasyan
- Private laboratory, Immunology Microbiology, Yerevan, Armenia
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Vetrugno L, Barnariol F, Bignami E, Centonze GD, De Flaviis A, Piccioni F, Auci E, Bove T. Transesophageal ultrasonography during orthotopic liver transplantation: Show me more. Echocardiography 2018; 35:1204-1215. [PMID: 29858886 DOI: 10.1111/echo.14037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The first perioperative transesophageal echocardiography (TEE) guidelines published 21 years ago were mainly addressed to cardiac anesthesiologists. TEE has since expanded its role outside this setting and currently represents an invaluable tool to assess chamber sizes, ventricular hypertrophy, and systolic, diastolic, and valvular function in patients undergoing orthotopic liver transplantation (OLT). Right-sided microemboli, right ventricular dysfunction, and patent foramen ovale (PFO) are the most common intra-operative findings described during OLT. However, left ventricular outflow tract obstruction and left ventricular ballooning syndrome are more difficult to recognize and less frequent. Transesophageal ultrasonography (TEU) during OLT is also underused. Its applications are as follows: (1) assistance in the difficult placement of pulmonary arterial catheters; (2) help with catheterization of great vessels for external veno-venous bypass placement; (3) intra-operative evaluation of surgical liver anastomosis patency, if feasible, through the liver window; and (4) intra-operative investigation of "acute hypoxemia" due to pulmonary and cardiac issues using trans-esophageal lung ultrasound (TELU). The aims of this review are as follows: (1) to summarize the uses of TEE and TEU throughout all phases of OLT, and (2) to describe other new feasible applications.
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Affiliation(s)
- Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Barnariol
- Anesthesiology and Intensive Care 1, Department of Anesthesia and Intensive Care Medicine, University-Hospital of Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Grazia D Centonze
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Adelisa De Flaviis
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Piccioni
- Department of Critical Care Medicine and Support Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elisabetta Auci
- Anesthesiology and Intensive Care 2, Department of Anesthesia and Intensive Care Medicine, University-Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
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Abstract
Currently, there is no consensus about the optimum intraoperative fluid therapy strategy. There is growing body of evidence supports the beneficial effects of adopting “Goal-directed therapy” over either the “liberal” or “restrictive” fluid therapy strategies. In this narrative review, we have presented the evidence to support the optimum strategy for intraoperative therapy. In conclusion, whatever the intravenous fluid replacement strategy used, the anesthesiologist must be prepared to adjust the composition and rate of the fluids administered to provide sufficient intravascular fluid volume for adequate perfusion of vital organs without overwhelming the glycocalyx function with fluid overloads.
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Abstract
R Adams Cowley (1917–1991), the Baltimore thoracic and trauma surgeon, was an outstanding politician and promoter of emergency medical services. His skills included the effective use of language, for example, identifying the critical time immediately after injury as a “golden hour,” and describing shock as a “momentary pause in the act of death.” Conversely, Cowley avoided the tendency of some contemporaries to justify massive crystalloid infusion by invoking a “third space.” Cowley is often assumed to have originated the first two phrases, but, in fact, their histories go back at least to the 19th century and illustrate the development of surgical science. The “third space” is often assumed to have originated with Cowley's contemporary, Tom Shires (1925–2007), but, in fact, neither of them used the phrase to describe Shires’ controversial theories about an extracellular fluid deficit after trauma. Reviewing the actual etymology of these terms may help clarify the history of the underlying scientific ideas and enable more effective communication in the future.
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Affiliation(s)
- David E. Clark
- Department of Surgery, Maine Medical Center, Portland, Maine
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Structural Behavior of the Endothelial Glycocalyx Is Associated With Pathophysiologic Status in Septic Mice: An Integrated Approach to Analyzing the Behavior and Function of the Glycocalyx Using Both Electron and Fluorescence Intravital Microscopy. Anesth Analg 2017; 125:874-883. [PMID: 28504989 DOI: 10.1213/ane.0000000000002057] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The endothelial surface layer (ESL) regulates vascular permeability to maintain fluid homeostasis. The glycocalyx (GCX), which has a complex and fragile ultrastructure, is an important component of the ESL. Abnormalities of the GCX have been hypothesized to trigger pathological hyperpermeability. Here, we report an integrated in vivo analysis of the morphological and functional properties of the GCX in a vital organ. METHODS We examined the behavior of the ESL and GCX, using both electron microscopy (EM) and intravital microscopy (IVM). We also compared morphological changes in the ESL of mouse skin in a glycosidase-treated and control group. Combined approaches were also used to examine both morphology and function in a lipopolysaccharide-induced septic model and the pathophysiological features of leukocyte-endothelial interactions and in vivo vascular permeability. RESULTS Using IVM, we identified an illuminated part of the ESL as the GCX and confirmed our observation using morphological and biochemical means. In septic mice, we found that the GCX was thinner than in nonseptic controls in both an EM image analysis (0.98 ± 2.08 nm vs 70.68 ± 36.36 nm, P< .001) and an IVM image analysis (0.36 ± 0.15 μm vs 1.07 ± 0.39 μm, P< .001). Under septic conditions, syndecan-1, a representative core protein of the GCX, was released into the blood serum at a higher rate in septic animals (7.33 ± 3.46 ng/mL) when compared with controls (below the limit of detection, P< .001). Significant increases in leukocyte-endothelial interactions, defined as the numbers of rolling or firm-sticking leukocytes, and molecular hyperpermeability to the interstitium were also observed after GCX shedding in vivo. CONCLUSIONS Using IVM, we visualized an illuminated part of the ESL layer that was subsequently confirmed as the GCX using EM. Severe sepsis induced morphological degradation of the GCX, accompanied by shedding of the syndecan-1 core protein and an increase in leukocyte-endothelial interactions affecting the vascular permeability. Our in vivo model describes a new approach to deciphering the relationship between structural and functional behaviors of the GCX.
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Wrzosek A, Jakowicka-Wordliczek J, Zajaczkowska R, Serednicki WT, Jankowski M, Bala MM, Polak M, Wordliczek J. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery. Hippokratia 2017. [DOI: 10.1002/14651858.cd012767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anna Wrzosek
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | | | - Renata Zajaczkowska
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | - Wojciech T Serednicki
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
| | - Milosz Jankowski
- University Hospital; Department of Anaesthesiology and Intensive Care; Krakow Poland
| | - Malgorzata M Bala
- Jagiellonian University Medical College; Department of Hygiene and Dietetics; Systematic Reviews Unit - Polish Cochrane Branch; Kopernika 7 Krakow Poland 31-034
| | - Maciej Polak
- Jagiellonian University, Medical College Krakow; Department of Epidemiology and Population Studies in the Institute of Public Health; Krakow Poland
| | - Jerzy Wordliczek
- Jagiellonian University, Medical College; Department of Interdisciplinary Intensive Care; Krakow Poland
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Ripollés-Melchor J, Chappell D, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Perioperative fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part I: Physiological background. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:328-338. [PMID: 28364973 DOI: 10.1016/j.redar.2017.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 06/07/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial de Salamanca, Universidad de Salamanca, Salamanca, España
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Rehm M, Hulde N, Kammerer T, Meidert AS, Hofmann-Kiefer K. State of the art in fluid and volume therapy. Anaesthesist 2017; 68:1-14. [DOI: 10.1007/s00101-017-0290-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Rehm M, Hulde N, Kammerer T, Meidert AS, Hofmann-Kiefer K. [State of the art in fluid and volume therapy : A user-friendly staged concept]. Anaesthesist 2017; 66:153-167. [PMID: 28213648 DOI: 10.1007/s00101-017-0272-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adequate fluid therapy is highly important for the perioperative outcome of our patients. Both, hypovolemia and hypervolemia can lead to an increase in perioperative complications and can impair the outcome. Therefore, perioperative infusion therapy should be target-oriented. The main target is to maintain the patient's preoperative normovolemia by using a sophisticated, rational infusion strategy.Perioperative fluid losses should be discriminated from volume losses (surgical blood loss or interstitial volume losses containing protein). Fluid losses as urine or perspiratio insensibilis (0.5-1.0 ml/kg/h) should be replaced by balanced crystalloids in a ratio of 1:1. Volume therapy step 1: Blood loss up to a maximum value of 20% of the patient's blood volume should be replaced by balanced crystalloids in a ratio of 4(-5):1. Volume therapy step 2: Higher blood losses should be treated by using iso-oncotic, preferential balanced colloids in a ratio of 1:1. For this purpose hydroxyethyl starch can also be used perioperatively if there is no respective contraindication, such as sepsis, burn injuries, critically ill patients, renal impairment or renal replacement therapy, and severe coagulopathy. Volume therapy step 3: If there is an indication for red cell concentrates or coagulation factors, a differentiated application of blood and blood products should be performed.
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Affiliation(s)
- M Rehm
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - N Hulde
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - T Kammerer
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - A S Meidert
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - K Hofmann-Kiefer
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
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Bloomstone JA, Dull RO, Navarro LHC. Goal-Directed Fluid Therapy: What the Mind Does Not Know, the Eye Cannot See. Turk J Anaesthesiol Reanim 2017; 45:56-58. [PMID: 28377842 PMCID: PMC5367727 DOI: 10.5152/tjar.2017.24013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 06/07/2023] Open
Affiliation(s)
- Joshua A. Bloomstone
- University of Arizona, Department of Anesthesiology and Perioperative Medicine Banner Thunderbird Medical Center, Valley Anesthesiology Consultants, Inc., Phoenix, AZ, USA
| | - Randal O. Dull
- Department of Anesthesiology, University of Illinois, Chicago, Il, USA
| | - Lais H. C. Navarro
- Department of Anesthesiology of Botucatu Medical School, Botucatu, Sao Paulo, Brazil
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Abstract
Evidence-based medicine has been slow to address the critically important issue of intraoperative fluid maintenance for surgical patients. A "rule" published by Holliday and colleagues in 1957 was the accepted practice for the initial calculation of fluid maintenance for nearly 50 years. Using this formula, the nil per os fluid deficit was based on how long it had been since the preoperative patient had last consumed anything by mouth, even water. New technology and monitoring modalities are being used to guide evidence-supported intraoperative care, leading to better outcomes for surgical patients.
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Affiliation(s)
- Judy Thompson
- Nurse Anesthesia Program, School of Nursing, Quinnipiac University, 275 Mount Carmel Avenue NH-HSC, Hamden, CT 06518, USA.
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Nishimura A, Tabuchi Y, Kikuchi M, Masuda R, Goto K, Iijima T. The Amount of Fluid Given During Surgery That Leaks Into the Interstitium Correlates With Infused Fluid Volume and Varies Widely Between Patients. Anesth Analg 2016; 123:925-32. [DOI: 10.1213/ane.0000000000001505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Della Rocca G, Vetrugno L. What is the Goal of Fluid Management "Optimization"? Turk J Anaesthesiol Reanim 2016; 44:224-226. [PMID: 27909599 DOI: 10.5152/tjar.2016.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Giorgio Della Rocca
- University of Udine, Department of Medical and Biological Sciences, Udine, Italy
| | - Luigi Vetrugno
- University of Udine, Department of Medical and Biological Sciences, Udine, Italy
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Intraoperative Fluid Excess Is a Risk Factor for Pancreatic Fistula after Partial Pancreaticoduodenectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2016; 2016:1601340. [PMID: 27738384 PMCID: PMC5050351 DOI: 10.1155/2016/1601340] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/28/2016] [Indexed: 12/31/2022]
Abstract
Background. After pancreaticoduodenectomy (PD), pancreatic fistulas (PF) are a frequent complication. Infusions may compromise anastomotic integrity. This retrospective analysis evaluated associations between intraoperative fluid excess and PF. Methods. Data on perioperative parameters including age, sex, laboratory findings, histology, infusions, surgery time, and occurrence of grade B/C PF was collected from all PD with pancreaticojejunostomy (PJ) performed in our department from 12/2011 till 02/2015. The glomerular filtration rate (GFR), infusion rate, and the ratio of both and its association with PF were calculated. ROC analysis was employed to identify a threshold. Results. Complete datasets were available for 83 of 86 consecutive cases. Median age was 66 years (34–84; 60% male), GFR was 93 mL/min (IQR 78–113), and surgery time was 259 min (IQR 217–307). Intraoperatively, 13.6 mL/min (7–31) was infused. In total, n = 18 (21%) PF occurred. When the infusion : GFR ratio exceeded 0.15, PF increased from 11% to 34% (p = 0.0157). No significant association was detected for any of the other parameters. Conclusions. This analysis demonstrates for the first time an association between intraoperative fluid excess and PF after PD with PJ even in patients with normal renal function. A carefully patient-adopted fluid management with due regard to renal function may help to prevent postoperative PF.
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Hahn RG, Drobin D, Zdolsek J. Distribution of crystalloid fluid changes with the rate of infusion: a population-based study. Acta Anaesthesiol Scand 2016; 60:569-78. [PMID: 26763732 DOI: 10.1111/aas.12686] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Crystalloid fluid requires 30 min for complete distribution throughout the extracellular fluid space and tends to cause long-standing peripheral edema. A kinetic analysis of the distribution of Ringer's acetate with increasing infusion rates was performed to obtain a better understanding of these characteristics of crystalloids. METHODS Data were retrieved from six studies in which 76 volunteers and preoperative patients had received between 300 ml and 2375 ml of Ringer's acetate solution at a rate of 20-80 ml/min (0.33-0.83 ml/min/kg). Serial measurements of the blood hemoglobin concentration were used as inputs in a kinetic analysis based on a two-volume model with micro-constants, using software for nonlinear mixed effects. RESULTS The micro-constants describing distribution (k12) and elimination (k10) were unchanged when the rate of infusion increased, with half-times of 16 and 26 min, respectively. In contrast, the micro-constant describing how rapidly the already distributed fluid left the peripheral space (k21) decreased by 90% when the fluid was infused more rapidly, corresponding to an increase in the half-time from 3 to 30 min. The central volume of distribution (V(c)) doubled. CONCLUSION The return of Ringer's acetate from the peripheral fluid compartment to the plasma was slower with high than with low infusion rates. Edema is a normal consequence of plasma volume expansion with this fluid, even in healthy volunteers. The results are consistent with the view that the viscoelastic properties of the interstitial matrix are responsible for the distribution and redistribution characteristics of crystalloid fluid.
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Affiliation(s)
- R. G. Hahn
- Research Unit; Södertälje Hospital; Södertälje Sweden
| | - D. Drobin
- Department of Roentgenology; Central Hospital; Karlstad Sweden
| | - J. Zdolsek
- Section for Anesthesiology; Linköping University; Linköping Sweden
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Fluid therapy in the perioperative setting-a clinical review. J Intensive Care 2016; 4:27. [PMID: 27087980 PMCID: PMC4833950 DOI: 10.1186/s40560-016-0154-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/07/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Perioperative hypovolemia and fluid overload have effects on both complications following surgery and on patient survival. Therefore, the administration of intravenous fluids before, during, and after surgery at the right time and in the right amounts is of great importance. This review aims to analyze the literature concerning perioperative fluid therapy in abdominal surgery and to provide evidence-based recommendations for clinical practice. RESULTS Preoperative oral or intravenous administration of carbohydrate containing fluids has been shown to improve postoperative well-being and muscular strength and to reduce insulin resistance. Hence, the intake of fluid (preferably containing carbohydrates) should be encouraged up to 2 h prior to surgery in order to avoid dehydration. Excessive intravenous fluid administration adds to tissue inflammation and edema formation, thereby compromising tissue healing. During major abdominal surgery a "zero-balance" intraoperative fluid strategy aims at avoiding fluid overload (and comparable to the so-called restrictive approach) as well as goal-directed fluid therapy (GDT). Both proved to significantly reduce postoperative complications when compared to "standard fluid therapy". Trials comparing "restrictive" or zero-balance and GDT have shown equal results, as long as fluid overload is avoided in the GDT group as well (categorized as "zero-balance GDT"). It is possible that high-risk surgical patients, such as those undergoing acute surgery, may benefit from the continuous monitoring of circulatory status that the GDT provides. Data on this group of patients is not available at present, but trials are ongoing. CONCLUSION In elective surgery, the zero-balance approach has shown to reduce postoperative complications and is easily applied for most patients. It is less expensive and simpler than the zero-balance GDT approach and therefore recommended in this review. In outpatient surgery, 1-2 L of balanced crystalloids reduces postoperative nausea and vomiting and improves well-being.
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Basora M, Colomina MJ, Moral V, Asuero de Lis MS, Boix E, Jover JL, Llau JV, Rodrigo MP, Ripollés J, Calvo Vecino JM. Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:29-47. [PMID: 26343809 DOI: 10.1016/j.redar.2015.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/24/2015] [Accepted: 06/26/2015] [Indexed: 06/05/2023]
Abstract
The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.
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Affiliation(s)
- M Basora
- Anestesiología y Reanimación, Hospital Clínic, Barcelona, España.
| | - M J Colomina
- Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - V Moral
- Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, España
| | - M S Asuero de Lis
- Anestesiología y Reanimación, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Boix
- Anestesiología y Reanimación, Hospital Universitario del Vinalopó, Elche, Alicante, España
| | - J L Jover
- Anestesiología y Reanimación, Hospital Verge dels Lliris, Alcoi, Alicante, España
| | - J V Llau
- Anestesiología y Reanimación, Hospital Clínico Universitario, Valencia, España
| | - M P Rodrigo
- Anestesiología y Reanimación, Hospital de Basurto, Bilbao, España
| | - J Ripollés
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, España
| | - J M Calvo Vecino
- Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Universidad Complutense, Madrid, España
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Raghunathan K, Singh M, Lobo DN. Fluid management in abdominal surgery: what, when, and when not to administer. Anesthesiol Clin 2015; 33:51-64. [PMID: 25701928 DOI: 10.1016/j.anclin.2014.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The entire team (including anesthesiologists, surgeons, and intensive care physicians) must work together (before, during, and after abdominal surgery) to determine the optimal amount (quantity) and type (quality) of fluid necessary in the perioperative period. The authors present an overview of the basic principles that underlie fluid management, including evidence-based recommendations (where tenable) and a rational approach for when and what to administer.
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Affiliation(s)
- Karthik Raghunathan
- Anesthesiology Service, Durham VA Medical Center, Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
| | - Mandeep Singh
- Division of Anesthesiology and Critical Care Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Dileep N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery. Anaesthesia 2015; 71 Suppl 1:40-5. [DOI: 10.1111/anae.13309] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 01/07/2023]
Affiliation(s)
- R. Gupta
- Department of Anaesthesia; Stony Brook University School of Medicine; Stony Brook New York USA
| | - T. J. Gan
- Department of Anaesthesia; Stony Brook University School of Medicine; Stony Brook New York USA
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Zdolsek JH, Bergek C, Lindahl TL, Hahn RG. Colloid osmotic pressure and extravasation of plasma proteins following infusion of Ringer's acetate and hydroxyethyl starch 130/0.4. Acta Anaesthesiol Scand 2015; 59:1303-10. [PMID: 26079310 DOI: 10.1111/aas.12558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/07/2015] [Accepted: 04/13/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND During fluid infusion therapy, plasma proteins are diluted and leak from the intravascular space, which alters the colloid osmotic pressure (COP) and potentially affects coagulation. We hypothesised that acetated Ringer's and starch solution, alone or in combination, influence these mechanisms differently. MATERIALS AND METHODS On different occasions, 10 male volunteers were infused with 20 ml/kg acetated Ringer's and 10 ml/kg 6% hyroxyethyl starch 130/0.4 (Voluven(®) ) alone or in combination (first with starch solution followed by Ringer's solution). Blood samples were collected every 30-min for measurements of COP, blood haemoglobin, platelets, and plasma concentrations of albumin, immunoglobulins (IgG and IgM), coagulation factor VII (FVII), fibrinogen, cystatin C, activated partial thromboplastin time (APTT) and prothrombin international normalised ratio (PT-INR). Changes were compared with the haemoglobin-derived plasma dilution. RESULTS The COP increased by 8.4% (SD 3) with starch and decreased by 26.2% (7.9) with Ringer's. These infusions diluted the plasma by 23.4% (5.3) and 18.7% (4.9) respectively. The COP changes in the combined experiment followed the same pattern as the individual infusions. Albumin and IgG changes in excess of the plasma dilution were very subtle. The intravascular contents of the IgM and platelets decreased, whereas FVII, fibrinogen and cystatin C increased. PT-INR increased by 1/3 of the plasma dilution, whereas changes in APTT did not correlate with the plasma dilution. CONCLUSIONS The starch increased COP and only minor capillary leak occurred in healthy volunteers. The fluid-induced plasma dilution correlated with mild impairment of the extrinsic coagulation pathway but not of the intrinsic pathway.
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Affiliation(s)
- J. H. Zdolsek
- Department of Anaesthesiology; Vrinnevi Hospital; Norrköping Sweden
- Section for Anaesthesia; Linköping University; Linköping Sweden
| | - C. Bergek
- Section for Anaesthesia; Linköping University; Linköping Sweden
| | - T. L. Lindahl
- Department of Clinical Chemistry; Linköping University; Linköping Sweden
| | - R. G. Hahn
- Section for Anaesthesia; Linköping University; Linköping Sweden
- Research Department; Södertälje Hospital; Södertälje Sweden
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Abstract
How fluid resuscitation has to be performed for acute hemorrhage situations is still controversially discussed. Although the forced administration of crystalloids and colloids has been and still is practiced, nowadays there are good arguments that a cautious infusion of crystalloids may be initially sufficient. Saline should no longer be used for fluid resuscitation. The main argument for cautious fluid resuscitation is that no large prospective randomized clinical trials exist which have provided evidence of improved survival when fluid resuscitation is applied in an aggressive manner. The explanation that no positive effect has so far been observed is that fluid resuscitation is thought to boost bleeding by increasing blood pressure and dilutional coagulopathy. Nevertheless, national and international guidelines recommend that fluid resuscitation should be applied at the latest when hemorrhage causes hemodynamic instability. Consideration should be given to the fact that damage control resuscitation per se will neither improve already reduced tissue perfusion nor hemostasis. In acute and possibly rapidly progressing hypovolemic shock, colloids can be used. The third and fourth generations of hydroxyethyl starch (HES) are safe and effective if used correctly and within prescribed limits. If fluid resuscitation is applied with ongoing re-evaluation of the parameters which determine oxygen supply, it should be possible to keep fluid resuscitation restricted without causing undesirable side effects and also to administer a sufficient quantity so that survival of patients is ensured.
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Affiliation(s)
- M Roessler
- Zentrum Anästhesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland,
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Mandee S, Butmangkun W, Aroonpruksakul N, Tantemsapya N, von Bormann B, Suraseranivongse S. Effects of a restrictive fluid regimen in pediatric patients undergoing major abdominal surgery. Paediatr Anaesth 2015; 25:530-7. [PMID: 25495505 DOI: 10.1111/pan.12589] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the effects of restrictive fluid regimen during major abdominal surgery in pediatric patients. BACKGROUND In adults, a restrictive and goal-directed regimen as opposed to a liberal-fluid regimen results in better outcomes after various major surgical procedures. The different ratio of body fluid distribution in pediatric patients from those of adults may influence different needs of fluid. METHODS This stratified, randomized, controlled trial was conducted in 25 pediatric patients (mean age <3 years) undergoing major abdominal surgery. Patients were allocated to two groups based on their perioperative fluid management. 'control group' received maintenance plus deficit plus interstitial space replacement plus ongoing loss, whereas 'restrictive group' had a similar treatment, but were given no interstitial space replacement. Intraoperative fluid resuscitation was guided by hemodynamics and base excess. Parameters recorded included hemodynamic variables, the volume and type of intravenous fluid, blood chemistry (including lactate, base excess, and electrolyte), chest X-ray, body weight, complications, and return of bowel function. RESULTS Patients in control group needed significantly less additional fluid for resuscitation compared to restrictive group (0.62 ± 3.51 ml · kg(-1) · h(-1) vs 5.04 ± 4.16 ml · kg(-1) · h(-1) ; P = 0.012). In restrictive group, heart rates were higher (P = 0.012) and base excess showed more negative results (P = 0.049). There were no differences between the groups in terms of the total volume requirement, postoperative kidney function, chest X-ray, variation of body weight and the postoperative outcomes. CONCLUSIONS Volume preload corresponding with an estimated interstitial space replacement was suitable for application to pediatric patients undergoing major abdominal surgery.
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Affiliation(s)
- Sahatsa Mandee
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond) 2015; 4:3. [PMID: 25897397 PMCID: PMC4403901 DOI: 10.1186/s13741-015-0014-z] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Perioperative fluid therapy remains a highly debated topic. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo- or hyperperfusion. Relative to perioperative fluid therapy, three inescapable conclusions exist: overhydration is bad, underhydration is bad, and what we assume about the fluid status of our patients may be incorrect. There is wide variability of practice, both between individuals and institutions. The aims of this paper are to clearly define the risks and benefits of fluid choices within the perioperative space, to describe current evidence-based methodologies for their administration, and ultimately to reduce the variability with which perioperative fluids are administered. METHODS Based on the abovementioned acknowledgements, a group of 72 researchers, well known within the field of fluid resuscitation, were invited, via email, to attend a meeting that was held in Chicago in 2011 to discuss perioperative fluid therapy. From the 72 invitees, 14 researchers representing 7 countries attended, and thus, the international Fluid Optimization Group (FOG) came into existence. These researches, working collaboratively, have reviewed the data from 162 different fluid resuscitation papers including both operative and intensive care unit populations. This manuscript is the result of 3 years of evidence-based, discussions, analysis, and synthesis of the currently known risks and benefits of individual fluids and the best methods for administering them. RESULTS The results of this review paper provide an overview of the components of an effective perioperative fluid administration plan and address both the physiologic principles and outcomes of fluid administration. CONCLUSIONS We recommend that both perioperative fluid choice and therapy be individualized. Patients should receive fluid therapy guided by predefined physiologic targets. Specifically, fluids should be administered when patients require augmentation of their perfusion and are also volume responsive. This paper provides a general approach to fluid therapy and practical recommendations.
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New Perioperative Fluid and Pharmacologic Management Protocol Results in Reduced Blood Loss, Faster Return of Bowel Function, and Overall Recovery. Curr Urol Rep 2015; 16:17. [DOI: 10.1007/s11934-015-0490-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth 2014; 62:158-68. [DOI: 10.1007/s12630-014-0266-y] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022] Open
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