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YAYLA A, ESKİCİ V, AY E, ÖZER N, KURT G. Ameliyat Öncesi ve Sonrası Dönemde Yapılan Uygulamaların ERAS Protokolüne Uygunluğunun Değerlendirilmesi. İSTANBUL GELIŞIM ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2022. [DOI: 10.38079/igusabder.980901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Amaç: Bu çalışma, ameliyat öncesi ve sonrası dönemde yapılan uygulamaların ERAS (Enhanced Recovery After Surgery) protokolüne uygunluğunun değerlendirilmesi amacıyla yapılmıştır.Yöntem: Tanımlayıcı-kesitsel nitelikte tasarlanan araştırma, Ocak – Temmuz 2019 tarihleri arasında bir üniversitenin Sağlık Araştırma ve Uygulama Merkezinin cerrahi kliniklerinde yürütülmüştür. Ameliyatı planlanan, çalışmaya katılmayı kabul eden 863 hasta araştırma örneklemini oluşturmuştur. Veriler, araştırmacılar tarafından literatür doğrultusunda hazırlanan anket formu, Vizüel Analog Skala ve Bulantı Sayısal Ölçeği ile yüz yüze görüşme yöntemiyle toplanmıştır. Veriler, SPSS 20.0 paket programında tanımlayıcı istatistikler kullanılarak değerlendirilmiştir.Bulgular: Çalışmadaki hastaların tamamının ameliyat öncesi dönemde oral karbonhidrat almadığı, ameliyat öncesi aç kalma sürelerinin 10,55±6,91 saat olduğu ve hastalara premedikasyon uygulanmadığı belirlenmiştir. Hastaların ameliyat sonrası; ilk sıvı alma zamanı ortalamasının 10,45±15,44 saat, ilk katı gıda alma zamanı ortalamasının 18,70±29,23 saat olduğu, ilk mobilizasyon süresinin 19,02±21,39 saat, nazogastrik sonda kalış süresi ortalamasının 29,33±28,80 saat, drenin kalış süresi ortalamasının 54,30±28,06 saat, üriner kateter kalış süresi ortalamasının 49,51±27,40 saat olduğu saptanmıştır.Sonuç: Çalışma sonucunda ERAS protokollerine uyumun istenilen düzeyde olmadığı ve sağlık çalışanlarına ERAS’la uyumlu olmayan uygulamalarla ilgili eğitim verilmesi önerilebilir.
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Pharmacodynamic analysis of a fluid challenge with 4 ml kg -1 over 10 or 20 min: a multicenter cross-over randomized clinical trial. J Clin Monit Comput 2021; 36:1193-1203. [PMID: 34494204 PMCID: PMC8423602 DOI: 10.1007/s10877-021-00756-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/01/2021] [Indexed: 12/25/2022]
Abstract
Purpose A number of studies performed in the operating room evaluated the hemodynamic effects of the fluid challenge (FC), solely considering the effect before and after the infusion. Few studies have investigated the pharmacodynamic effect of the FC on hemodynamic flow and pressure variables. We designed this trial aiming at describing the pharmacodynamic profile of two different FC infusion times, of a fixed dose of 4 ml kg−1. Methods
Forty-nine elective neurosurgical patients received two consecutive FCs of 4 ml kg−1 of crystalloids in 10 (FC10) or 20 (FC20) minutes, in a random order. Fluid responsiveness was defined as stroke volume index increase ≥ 10%. We assessed the net area under the curve (AUC), the maximal percentage difference from baseline (dmax), time when the dmax was observed (tmax), change from baseline at 1-min (d1) and 5-min (d5) after FC end. Results After FC10 and FC20, 25 (51%) and 14 (29%) of 49 patients were classified as fluid responders (p = 0.001). With the exception of the AUCs of SAP and MAP, the AUCs of all the considered hemodynamic variables were comparable. The dmax and the tmax were overall comparable. In both groups, the hemodynamic effects on flow variables were dissipated within 5 min after FC end. Conclusions The infusion time of FC administration affects fluid responsiveness, being higher for FC10 as compared to FC20. The effect on flow variables of either FCs fades 5 min after the end of infusion. Supplementary Information The online version contains supplementary material available at 10.1007/s10877-021-00756-3.
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2020; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.,Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Tapia B, Garrido E, Cebrian JL, Castillo JLD, Alsina E, Gilsanz F. New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients. Minerva Anestesiol 2020; 86:861-871. [PMID: 32486605 DOI: 10.23736/s0375-9393.20.13997-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.
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Affiliation(s)
- Blanca Tapia
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain -
| | - Elena Garrido
- Department of Anesthesia an Intensive Care, Wexner Medical Center, Columbus, OH, USA
| | - Jose L Cebrian
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Jose L Del Castillo
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Estibaliz Alsina
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
| | - Fernando Gilsanz
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
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Associations Between Perioperative Crystalloid Volume and Adverse Outcomes in Five Surgical Populations. J Surg Res 2020; 251:26-32. [PMID: 32109743 DOI: 10.1016/j.jss.2019.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/26/2019] [Accepted: 12/06/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Optimal administration of fluids is an important part of enhanced recovery after surgery (ERAS) protocols. We sought to examine the relationship between perioperative crystalloid volume and adverse outcomes in five common types of surgical procedures with ERAS fluid guidelines in place where large randomized controlled trials have not been conducted: breast reconstruction, bariatric, major urologic, gynoncologic, and head and neck oncologic procedures. METHODS This retrospective cohort study included patients who had undergone any one of the aforementioned procedures within any facility in a large multihospital alliance (Premier, Inc, Charlotte, NC) between 2008 and 2014. We used multivariable generalized additive models to examine relationships between the total crystalloid volume (TCV) on the day of surgery and a composite adverse outcome of prolonged (>75th percentile) hospital or intensive care unit stay or in-hospital mortality. Models were constructed separately within each surgical category and adjusted for demographic, clinical, and hospital characteristics. Informed consent requirements were waived because deidentified data were used. RESULTS We identified 83,685 patients within 312 US hospitals undergoing breast reconstruction (n = 8738), bariatric surgery (n = 8067), major urologic surgery (n = 28,654), gynoncologic surgery (n = 34,559), and head/neck oncology surgery (n = 3667). There was significant patient-independent variation in TCV. Probabilities of adverse outcomes increased at a TCV below 3 L and above 6 L for all types of surgeries except bariatric surgery, where larger volumes were associated with progressively better outcomes. CONCLUSIONS AND RELEVANCE Relationships between TCV and adverse outcomes were generally J shaped with higher volumes (>6 L) associated with increased risk. As per current ERAS guidelines, it is important to avoid excessive crystalloid volume in most surgical procedures except for bariatric surgery.
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Resalt-Pereira M, Muñoz JL, Miranda E, Cuquerella V, Pérez A. Goal-directed fluid therapy on laparoscopic colorectal surgery within enhanced recovery after surgery program. ACTA ACUST UNITED AC 2019; 66:259-266. [PMID: 30862401 DOI: 10.1016/j.redar.2019.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Enhanced recovery after surgery protocols (ERAS) are used in peri-operative care to reduce the stress response to surgical aggression. As fluid overload has been associated with increased morbidity and delayed hospital discharge, a major aspect of this is fluid management. Intra-operative goal-directed fluid protocols have been shown to reduce post-operative complications, particularly in high risk patients.?. OBJECTIVE To compare 2fluid therapy models (zero-balance versus goal-directed fluid therapy) in patients who were scheduled for laparoscopic colorectal surgery within an ERAS program, recording the rate of complications such as surgical site infection, ileus, post-operative náusea and vomiting, and variability of the estimated glomerular filtration rate (eGFR). MATERIALS AND METHODS An observational, retrospective study was conducted including adults who were scheduled for elective laparoscopic colorectal surgery within an ERAS program, and to investigate the postoperative complication rate. RESULTS A total of 128 patients were included in this study; 43 (33.6%) in the zero-balance group and 85 (66.4%) in the goal-directed fluid therapy group. The total fluids administered was lower in the goal-directed fluid therapy group, as well as the incidence of post-operative complications (surgical site infection, anastomotic leak, ileus, and postoperative náusea and vomiting). No significant differences were found for length of stay, intra-operative urine output, and variability of the eGFR.?. CONCLUSION The results of this study show that by using a goal-directed fluid therapy algorithm, the total amount of fluids administered can be reduced, as well as obtaining a lower incidence of post-operative complications.
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Affiliation(s)
- M Resalt-Pereira
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España.
| | - J L Muñoz
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
| | - E Miranda
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
| | - V Cuquerella
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
| | - A Pérez
- Departamento de Anestesiología, Reanimación y Terapéutica de Dolor, Hospital General Universitario de Elche, Camí de l'Almazara 11, CP 03203 Elche, Alicante, España
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Analysis of Goal-directed Fluid Therapy and Patient Monitoring in Enhanced Recovery After Surgery. Int Anesthesiol Clin 2019; 55:21-37. [PMID: 28901979 DOI: 10.1097/aia.0000000000000159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Oh TK, Park IS, Ji E, Na HS. Value of preoperative spirometry test in predicting postoperative pulmonary complications in high-risk patients after laparoscopic abdominal surgery. PLoS One 2018; 13:e0209347. [PMID: 30566448 PMCID: PMC6300335 DOI: 10.1371/journal.pone.0209347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 12/04/2018] [Indexed: 11/18/2022] Open
Abstract
Whether preoperative spirometry in non-thoracic surgery can predict postoperative pulmonary complications (PPCs) is controversial. We investigated whether preoperative spirometry results can predict the occurrence of PPCs in patients who had undergone laparoscopic abdominal surgery. This retrospective observational study analyzed the records of patients who underwent inpatient laparoscopic gastric or colorectal cancer surgery at Seoul National University Bundang Hospital between January 2010 and June 2017. Preoperative spirometry was performed for patients at a high risk of PPCs, such as elderly patients (age >60 years), patients aged <60 years with chronic pulmonary disease, and current smokers. The main outcome was the association between the results of spirometry tests performed within 1 month prior to surgery and the occurrence of PPCs, as determined by multivariable logistic regression analysis. Of the 898 included patients who underwent laparoscopic gastric (372 patients) or colorectal cancer surgery (526 patients), PPC occurred in 117 patients (gastric cancer: 74, colorectal cancer: 43). A 1% greater preoperative forced vital capacity (FVC) was associated with a 2% lower incidence of PPCs after laparoscopic gastric or colorectal cancer surgery (odds ratio: 0.98, 95% confidence interval: 0.97–0.99, P = 0.018). However, the preoperative forced expiratory volume in 1 second (FEV1) (%) and FEV1/FVC (%) were not significantly associated with PPCs (P = 0.059 and P = 0.147, respectively). In conclusion, lower preoperative spirometry FVC, but not FEV1 or FEV1/FVC, may predict PPCs in high-risk patients undergoing laparoscopic abdominal surgery.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In Sun Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Eunjeong Ji
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- * E-mail:
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Messina A, Pelaia C, Bruni A, Garofalo E, Bonicolini E, Longhini F, Dellara E, Saderi L, Romagnoli S, Sotgiu G, Cecconi M, Navalesi P. Fluid Challenge During Anesthesia. Anesth Analg 2018; 127:1353-1364. [DOI: 10.1213/ane.0000000000003834] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Brown JK, Singh K, Dumitru R, Chan E, Kim MP. The Benefits of Enhanced Recovery After Surgery Programs and Their Application in Cardiothoracic Surgery. Methodist Debakey Cardiovasc J 2018; 14:77-88. [PMID: 29977464 DOI: 10.14797/mdcj-14-2-77] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The perioperative care of the surgical patient is undergoing a paradigm shift. Enhanced Recovery After Surgery (ERAS) programs are becoming the standard of care and best practice in many surgical specialties throughout the world. ERAS is a multimodal, multidisciplinary, evidence-based approach to care of the surgical patient that aims to optimize perioperative management and outcomes. Implementation, however, has been slow because it challenges traditional surgical doctrine. The key elements of ERAS Pathways strive to reduce the response to surgical stress, decrease insulin resistance, and maintain anabolic homeostasis to help the patient return to baseline function more quickly. Data suggest that these pathways have produced not only improvements in clinical outcome and quality of care but also significant cost savings. Large trials reveal an increase in 5-year survival and a decrease in immediate complication rates when strict compliance is maintained with all pathway components. Years of success using ERAS in colorectal surgery have helped to establish a body of evidence through a number of randomized controlled trials that encourage application of these pathways in other surgical specialties.
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Affiliation(s)
| | | | | | | | - Min P Kim
- HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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Abstract
Enhanced recovery after surgery is a concept initially developed for patients undergoing colorectal surgery but has been adopted by other surgical specialties with similar positive outcomes. The adoption of enhanced recovery after surgery in the obstetric patient population is rapidly gaining popularity. This review highlights perioperative interventions that should be considered in an enhanced recovery after surgery protocol for women undergoing cesarean delivery.
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Affiliation(s)
- Unyime Ituk
- Department of Anesthesia, University of Iowa, Iowa City, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
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Umbrain V, Verborgh C, Chierchia GB, de Asmundis C, Brugada P, Meir ML. One-stage Approach for Hybrid Atrial Fibrillation Treatment. Arrhythm Electrophysiol Rev 2017; 6:210-216. [PMID: 29326837 PMCID: PMC5739889 DOI: 10.15420/2017.36.2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/16/2017] [Indexed: 01/13/2023] Open
Abstract
The one-stage approach for hybrid atrial fibrillation involves the simultaneous and close cooperation of different medical specialties. This review attempts to describe its challenging issues, exposing a plan to balance thrombotic risk and bleeding risk. It describes the combined surgical-electrophysiological procedure. Specific topics, involving hemodynamic, fluid and respiratory management during surgery are considered, and problems related to postoperative pain are surveyed.
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Affiliation(s)
- Vincent Umbrain
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Brussels,Free University of Brussels, Belgium
| | - Christian Verborgh
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Brussels,Free University of Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, University Hospital Brussels,Free University of Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, University Hospital Brussels,Free University of Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Centre, University Hospital Brussels,Free University of Brussels, Belgium
| | - Mark La Meir
- Department of Cardiac Surgery, University Hospital Brussels,Free University of Brussels, Belgium
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Gonzalez-Castro A, Ortiz-Lasa M, Peñasco Y, González C, Blanco C, Rodriguez-Borregan JC. Elección de fluidos en el periodo perioperatorio del trasplante renal. Nefrologia 2017; 37:572-578. [DOI: 10.1016/j.nefro.2017.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 12/13/2016] [Accepted: 03/16/2017] [Indexed: 12/25/2022] Open
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Saline is as effective as nitrogen scavengers for treatment of hyperammonemia. Sci Rep 2017; 7:13112. [PMID: 29030642 PMCID: PMC5640627 DOI: 10.1038/s41598-017-12686-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/14/2017] [Indexed: 12/22/2022] Open
Abstract
Urea cycle enzyme deficiency (UCED) patients with hyperammonemia are treated with sodium benzoate (SB) and sodium phenylacetate (SPA) to induce alternative pathways of nitrogen excretion. The suggested guidelines supporting their use in the management of hyperammonemia are primarily based on non-analytic studies such as case reports and case series. Canine congenital portosystemic shunting (CPSS) is a naturally occurring model for hyperammonemia. Here, we performed cross-over, randomized, placebo-controlled studies in healthy dogs to assess safety and pharmacokinetics of SB and SPA (phase I). As follow-up safety and efficacy of SB was evaluated in CPSS-dogs with hyperammonemia (phase II). Pharmacokinetics of SB and SPA were comparable to those reported in humans. Treatment with SB and SPA was safe and both nitrogen scavengers were converted into their respective metabolites hippuric acid and phenylacetylglutamine or phenylacetylglycine, with a preference for phenylacetylglycine. In CPSS-dogs, treatment with SB resulted in the same effect on plasma ammonia as the control treatment (i.e. saline infusion) suggesting that the decrease is a result of volume expansion and/or forced diuresis rather than increased production of nitrogenous waste. Consequentially, treatment of hyperammonemia justifies additional/placebo-controlled trials in human medicine.
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Pillinger NL, Kam P. Endothelial glycocalyx: basic science and clinical implications. Anaesth Intensive Care 2017; 45:295-307. [PMID: 28486888 DOI: 10.1177/0310057x1704500305] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The classic Starling principle proposed that microvascular fluid exchange was determined by a balance of hydrostatic and oncotic pressures relative to the vascular wall and this movement of water was regulated by gaps in the intercellular spaces. However, current literature on the endothelial glycocalyx (a jelly-like protective layer covering the luminal surface of the endothelium) has revised Starling's traditional concepts. This article aims to summarise the literature on the glycocalyx related to its basic science, clinical settings inciting injury, protective strategies and clinical perspectives. Perioperative damage to the glycocalyx structure can increase vascular permeability leading to interstitial fluid shifts, oedema, and increased surgical morbidity. Pathological shedding of the glycocalyx occurs in response to mechanical cellular stress, endotoxins, inflammatory mediators, atrial natriuretic peptide, ischaemia-reperfusion injury, free oxygen radicals and hyperglycaemia. Increased understanding of the endothelial glycocalyx may change perioperative fluid management, and therapeutic strategies aimed at its preservation may improve patient outcomes.
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Affiliation(s)
- N L Pillinger
- Staff Specialist Anaesthetist, Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - Pca Kam
- Nuffield Professor of Anaesthetics, University of Sydney, Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales
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Michelet D, Brasher C, Kaddour HB, Diallo T, Abdat R, Malbezin S, Bonnard A, Dahmani S. Postoperative complications following neonatal and infant surgery: Common events and predictive factors. Anaesth Crit Care Pain Med 2017; 36:163-169. [DOI: 10.1016/j.accpm.2016.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 01/10/2023]
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A mini volume loading test (mVLT) using 2.5-mLkg -1 boluses of crystalloid for indication of perioperative changes in hydration status. MEDICINA-LITHUANIA 2016; 52:354-365. [PMID: 27932196 DOI: 10.1016/j.medici.2016.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 09/20/2016] [Accepted: 11/14/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE A mini volume loading test (mVLT) evaluating hemodilution during step-wise crystalloid infusion has established that the arterio-capillary plasma dilution difference is inversely correlated to the body hydration level of subjects. This observational study aimed to test whether this can be replicated in a perioperative setting using a 2.5-mLkg-1 boluses. MATERIALS AND METHODS The mVLT was performed before induction of regional anesthesia and 24h later. Step-wise infusion implied six mini fluid challenges. These consisted of 2.5-mLkg-1 boluses of Ringer's acetate infused during 2-3min and followed by 5-min periods with no fluids. Invasive (arterial) and noninvasive (capillary) measurements of hemoglobin were performed before and after each mini fluid challenge, as well as after a 20-min period without fluid following the last bolus. Hemoglobins were used to calculate the arterio-capillary plasma dilution difference which is used as an indication of changes in body hydration level. The 24-h fluid balance was calculated. RESULTS Subjects were 69.5 (6.0) years old, their height was 1.62m (1.56-1.65), weight was 87.0kg (75.5-97.5) and body mass index (BMI) was 33.5kg/m2 (31.0-35.1). Preoperative arterio-capillary plasma dilution difference was significantly higher than postoperative (0.085 [0.012-0.141] vs. 0.006 [-0.059 to 0.101], P=0.000). The perioperative 24-h fluid balance was 1976mL (870-2545). CONCLUSIONS The mVLT using 2.5-mLkg-1 boluses of crystalloid was able to detect the higher postoperative body hydration level in total knee arthroplasty patients.
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Song IK, Ro S, Lee JH, Kim EH, Kim HS, Bahk JH, Kim JT. Reference Levels for Central Venous Pressure and Pulmonary Artery Occlusion Pressure Monitoring in the Lateral Position. J Cardiothorac Vasc Anesth 2016; 31:939-943. [PMID: 27919724 DOI: 10.1053/j.jvca.2016.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate reference levels for central venous pressure or pulmonary artery occlusion pressure monitoring in a lateral position. DESIGN Retrospective observational study. SETTING A tertiary university hospital. PARTICIPANTS A total of 204 adults who underwent chest computed tomography scan in the 90° lateral position from November 2006 to February 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Distances from the mid-sternum to the uppermost and lowermost blood levels of both atria were measured. Ratios of the distance from the bottom of the thorax to the uppermost and the lowermost blood levels of both atria to the largest diameter of the thorax were calculated. There were significant differences between the distances from the mid-sternum to the uppermost and the lowermost blood levels of the right atrium and those of the left atrium in the right and left lateral positions, respectively. There were significant differences in the uppermost (3.3±0.1 cm; 95% confidence interval [CI] 3.1-3.5) and the lowermost (4.4±0.1 cm; 95% CI 4.2-4.7) blood levels of the right atrium between the right and left lateral positions. Although the uppermost (1.5±0.1 cm; 95% CI 1.3-1.8) and the lowermost (0.4±0.1 cm; 95% CI 0.2-0.6) blood levels of the left atrium between the right and left lateral positions showed differences, their extent was smaller than the right atrium. The uppermost and the lowermost blood levels of the right atrium lay lower than those of the left atrium in the 90° right lateral position. In contrast, in the 90° left lateral position, the uppermost and the lowermost blood levels of the right atrium lay higher than those of the left atrium. CONCLUSIONS When monitoring the central venous pressure and pulmonary artery occlusion pressure with patients in the lateral position, changes in the blood level of both atria should be considered when releveling the reference transducer.
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Affiliation(s)
- In-Kyung Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soohan Ro
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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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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Haapio E, Kinnunen I, Airaksinen JKE, Irjala H, Kiviniemi T. Excessive intravenous fluid therapy in head and neck cancer surgery. Head Neck 2016; 39:37-41. [PMID: 27299857 DOI: 10.1002/hed.24525] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The purpose of this retrospective study was to present our assessment of modifiable perioperative factors for major cardiac and cerebrovascular events (MACCE). METHODS This study included an unselected cohort of patients with head and neck cancer (n = 456) treated in Turku University Hospital between 1999 and 2008. RESULTS Perioperative and postoperative univariate predictors of MACCE at 30-day follow-up were: total amount of fluids (during 24 hours) over 4000 mL, any red blood cell (RBC) infusion, treatment in the intensive care unit (ICU), tracheostomy, and microvascular reconstruction surgery. Median time from operation to MACCE was 3 days. Patients receiving >4000 mL of fluids had MACCE more often compared with those receiving <4000 mL (10.8% vs 2.4%; p < .001, respectively). Moreover, every RBC unit transfused or every liter of fluid administered over 4000 mL/24h increased the risk of MACCE 18% per unit/liter, respectively. CONCLUSION Patients with head and neck cancer receiving excessive intravenous fluid administration perioperatively and postoperatively are at high risk for cardiac complications, especially heart failure. © 2016 Wiley Periodicals, Inc. Head Neck 39: 37-41, 2017.
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Affiliation(s)
- Eeva Haapio
- Department of Otorhinolaryngology, Turku University Hospital and University of Turku, Turku, Finland
| | - Ilpo Kinnunen
- Department of Otorhinolaryngology, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Heikki Irjala
- Department of Otorhinolaryngology, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
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Dobson GP. Addressing the Global Burden of Trauma in Major Surgery. Front Surg 2015; 2:43. [PMID: 26389122 PMCID: PMC4558465 DOI: 10.3389/fsurg.2015.00043] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/17/2015] [Indexed: 12/18/2022] Open
Abstract
Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University , Townsville, QLD , Australia
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Norberg Å, Rooyackers O, Segersvärd R, Wernerman J. Albumin Kinetics in Patients Undergoing Major Abdominal Surgery. PLoS One 2015; 10:e0136371. [PMID: 26313170 PMCID: PMC4552033 DOI: 10.1371/journal.pone.0136371] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/31/2015] [Indexed: 12/23/2022] Open
Abstract
Background The drop in plasma albumin concentration following surgical trauma is well known, but the temporal pattern of the detailed mechanisms behind are less well described. The aim of this explorative study was to assess changes in albumin synthesis and transcapillary escape rate (TER) following major surgical trauma, at the time of peak elevations in two well-recognized markers of inflammation. Methods This was a clinical trial of radiolabeled human serum albumin for the study of TER and plasma volume. Ten patients were studied immediately preoperatively and on the 2nd postoperative day after major pancreatic surgery. Albumin synthesis rate was measured by the flooding dose technique employing incorporation of isotopically labelled phenylalanine. Results Fractional synthesis rate of albumin increased from 11.7 (95% CI: 8.9, 14.5) to 15.0 (11.7, 18.4) %/day (p = 0.027), whereas the corresponding absolute synthesis rate was unchanged, 175 (138, 212) versus 150 (107, 192) mg/kg/day (p = 0.21). TER was unchanged, 4.9 (3.1, 6.8) %/hour versus 5.5 (3.9, 7.2) (p = 0.63). Plasma volume was unchanged but plasma albumin decreased from 33.5 (30.9, 36.2) to 22.1 (19.8, 24.3) g/L. (p<0.001). Conclusion Two days after major abdominal surgery, at the time-point when two biomarkers of generalised inflammation were at their peak and the plasma albumin concentration had decreased by 33%, we were unable to show any difference in the absolute synthesis rate of albumin, TER and plasma volume as compared with values obtained immediately pre-operatively. This suggests that capillary leakage, if elevated postoperatively, had ceased at that time-point. The temporal relations between albumin kinetics, capillary leakage and generalised inflammation need to be further explored. Trial Registration clinicaltrialsregister.eu: EudraCT 2010-08529-21 ClinicalTrials.gov NCT01194492
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Affiliation(s)
- Åke Norberg
- Department of Anaesthesia and Intensive Care, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Olav Rooyackers
- Department of Anaesthesia and Intensive Care, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ralf Segersvärd
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jan Wernerman
- Department of Anaesthesia and Intensive Care, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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