Perioperative goal-directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis

Effect of increased systemic oxygen delivery on postoperative outcomes and quality of life in elderly undergoing major abdominal surgery: A randomised controlled trial

Studies comparing the intentional increase in oxygen delivery and normal oxygen delivery during general anaesthesia in elderly patients undergoing major abdominal surgery are limited and have reported contradictory findings. Therefore, the study aimed to evaluate the effect of intraoperative increase in systemic oxygen delivery on postoperative outcomes and quality of life in elderly patients undergoing major abdominal surgery. This randomised, blinded, parallel-arm, pragmatic clinical trial included elderly patients of >60 years of age undergoing major abdominal surgery. The patients in the intervention arm received noradrenaline or increased fractional inspiration of oxygen to augment central venous oxygen saturation ⩾75%. The primary outcome measure was composite of in-hospital mortality and major organ complications. The secondary outcome measure included comparison of quality of life. A total of 160 patients were assessed for eligibility, and 146 were randomised in the study groups. The mean arterial and central venous oxygen saturation increased and were significantly higher in the intervention arm. The composite primary outcome occurred in 49.31% in the intervention arm and 57.53% in the usual care arm (relative risk; 95% confidence interval: 0.85; 0.63-1.16; absolute risk reduction; 8.22%; p = 0.32). Furthermore, quality of life at the end of three months was similar (0.658 ± 0.19 versus 0.647 ± 0.19; p = 0.771). In conclusion, central venous oxygen saturation-guided increase in systemic oxygen delivery during the intraoperative period of major abdominal surgery in elderly patients did not reduce predefined composite outcome of in-hospital mortality or organ-specific complications.

Predicting stroke volume variation using central venous pressure waveform: a deep learning approach

Objective. This study evaluated the predictive performance of a deep learning approach to predict stroke volume variation (SVV) from central venous pressure (CVP) waveforms.Approach. Long short-term memory (LSTM) and the feed-forward neural network were sequenced to predict SVV using CVP waveforms obtained from the VitalDB database, an open-source registry. The input for the LSTM consisted of 10 s CVP waveforms sampled at 2 s intervals throughout the anesthesia duration. Inputs of the feed-forward network were the outputs of LSTM and demographic data such as age, sex, weight, and height. The final output of the feed-forward network was the SVV. The performance of SVV predicted by the deep learning model was compared to SVV estimated derived from arterial pulse waveform analysis using a commercialized model, EV1000.Main results. The model hyperparameters consisted of 12 memory cells in the LSTM layer and 32 nodes in the hidden layer of the feed-forward network. A total of 224 cases comprising 1717 978 CVP waveforms and EV1000/SVV data were used to construct and test the deep learning models. The concordance correlation coefficient between estimated SVV from the deep learning model were 0.993 (95% confidence interval, 0.992-0.993) for SVV measured by EV1000.Significance. Using a deep learning approach, CVP waveforms can accurately approximate SVV values close to those estimated using commercial arterial pulse waveform analysis.

Haemodynamic monitoring during noncardiac surgery: past, present, and future

During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.

Determinants of postoperative complications in high-risk noncardiac surgery patients optimized with hemodynamic treatment strategies: A post-hoc analysis of a randomized multicenter clinical trial

STUDY OBJECTIVE

This post-hoc analysis of a randomized controlled trial was undertaken to establish the determinants of postoperative complications and acute kidney injury in high-risk noncardiac surgery patients supported with hemodynamic treatment strategies.

DESIGN

We conducted a post-hoc analysis of patients enrolled in the OPtimization Hemodynamic Individualized by the respiratory QUotiEnt (OPHIQUE) trial.

SETTING

Operating rooms in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021.

PATIENTS

We enrolled 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia.

INTERVENTIONS

All patients were treated according to hemodynamic treatment strategies which included cardiac output optimization by titration of fluid challenge and targeted systolic blood pressure to remain within ±10% of the reference value.

MEASUREMENTS

We assessed the association between pre-operative and intra-operative exposure of interest with a composite primary outcome of major complications or death within seven days following surgery using a multivariable logistic regression model. We also assessed the association between these exposures of interest and acute kidney injury.

MAIN RESULTS

The data of 341 patients were analyzed. In multivariate analysis, the factors independently associated with the primary outcome were age (OR = 1.04 (1.01-1.06), P = 0.002), preoperative hemoglobin concentration (OR = 0.85 (0.75-0.96), P = 0.012), non-vascular surgery (OR = 0.30 (0.17-0.53), P < 0.0001), and intraoperative surgical complications (OR = 2.08 (1.02-4.24), P = 0.046). The factors independently associated with postoperative acute kidney injury were age (OR = 1.04 (1.01-1.08), P = 0.008), preoperative creatinine concentration (OR = 1.01 (1.00-1.01), P = 0.049), non-vascular surgery (OR = 0.36 (0.20-0.66), P = 0.001), and intraoperative surgical complications (OR = 3.36 (1.50-7.55), P = 0.031).

CONCLUSIONS

Surgical complications, a lower preoperative hemoglobin concentration, age, and vascular surgery were associated with postoperative complications in a high-risk noncardiac surgery population supported with hemodynamic treatment strategies.

Effect of machine learning-guided haemodynamic optimization on postoperative free flap perfusion in reconstructive maxillofacial surgery: A study protocol

AIMS

Intraoperative hypotension and liberal fluid haemodynamic therapy are associated with postoperative medical and surgical complications in maxillofacial free flap surgery. The novel haemodynamic parameter hypotension prediction index (HPI) has shown good performance in predicting hypotension by analysing arterial pressure waveform in various types of surgery. HPI-based haemodynamic protocols were able to reduce the duration and depth of hypotension. We will try to determine whether haemodynamic therapy based on HPI can improve postoperative flap perfusion and tissue oxygenation by improving intraoperative mean arterial pressure and reducing fluid infusion.

METHODS

We present here a study protocol for a single centre, randomized, controlled trial (n = 42) in maxillofacial patients undergoing free flap surgery. Patients will be randomized into an intervention or a control group. In the intervention, group haemodynamic optimization will be guided by machine learning algorithm and functional haemodynamic parameters presented by the HemoSphere platform (Edwards Lifesciences, Irvine, CA, USA), most importantly, HPI. Tissue oxygen saturation of the free flap will be monitored noninvasively by near-infrared spectroscopy during the first 24 h postoperatively. The primary outcome will be the average value of tissue oxygen saturation in the first 24 h postoperatively.

Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study

INTRODUCTION

The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial.

METHODS

Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS).

RESULTS

A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles.

CONCLUSIONS

Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03865810.

Impact of bedside ultrasound to reduce the incidence of acute renal injury in high-risk surgical patients: a randomized clinical trial

PURPOSE

This study aimed to determine whether performing bedside ultrasound impacts the occurrence of acute kidney injury (AKI) in the immediate postoperative period (POP) of high-risk surgery patients.

METHODS

POP patients were randomly assigned to two groups: (i) ultrasound (US) group, in which hemodynamic management was guided with clinical parameters supplemented with the bedside US findings; (ii) control group, hemodynamic management based solely on clinical parameters. Two exams were performed in the first 24 h of admission.

RESULTS

Fifty-one patients were randomized to the US group and 60 to the control group. There was no significant difference for incidence of AKI in both groups assessed 12 h (31.4% vs 35.0%, P = 0.84), 24 h (27.5% vs 23.3%, P = 0.66), or 7 days (17.6 vs 8.3%, P = 0.16) after surgery. No difference was found in the amounts of volume administered over the first 12 h (1000 [500-2000] vs. 1000 [500-1500], P = 0.72) and 24 h (1000 [0-1500] vs. 1000 [0-1500], P = 0.95) between the groups. Patients without AKI in the control group received higher amounts of volume during the ICU stay.

CONCLUSION

The use of bedside US in the immediate postoperative period of high-risk surgery did not show benefits in reducing AKI incidence.

Goal-directed haemodynamic therapy: an imprecise umbrella term to avoid

'Goal-directed haemodynamic therapy' describes various haemodynamic treatment strategies that have in common that interventions are titrated to achieve predefined haemodynamic targets. However, the treatment strategies differ substantially regarding the underlying haemodynamic target variables and target values, and thus presumably have different effects on outcome. It is an over-simplifying approach to lump complex and substantially differing haemodynamic treatment strategies together under the term 'goal-directed haemodynamic therapy', an imprecise umbrella term that we should thus stop using.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Goal-directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis

BACKGROUND

During general anaesthesia for noncardiac surgery, there remain knowledge gaps regarding the effect of goal-directed haemodynamic therapy on patient-centred outcomes.

METHODS

Included clinical trials investigated goal-directed haemodynamic therapy during general anaesthesia in adults undergoing noncardiac surgery and reported at least one patient-centred postoperative outcome. PubMed and Embase were searched for relevant articles on March 8, 2021. Two investigators performed abstract screening, full-text review, data extraction, and bias assessment. The primary outcomes were mortality and hospital length of stay, whereas 15 postoperative complications were included based on availability. From a main pool of comparable trials, meta-analyses were performed on trials with homogenous outcome definitions. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

RESULTS

The main pool consisted of 76 trials with intermediate risk of bias for most outcomes. Overall, goal-directed haemodynamic therapy might reduce mortality (odds ratio=0.84; 95% confidence interval [CI], 0.64 to 1.09) and shorten length of stay (mean difference=-0.72 days; 95% CI, -1.10 to -0.35) but with low certainty in the evidence. For both outcomes, larger effects favouring goal-directed haemodynamic therapy were seen in abdominal surgery, very high-risk surgery, and using targets based on preload variation by the respiratory cycle. However, formal tests for subgroup differences were not statistically significant. Goal-directed haemodynamic therapy decreased risk of several postoperative outcomes, but only infectious outcomes and anastomotic leakage reached moderate certainty of evidence.

CONCLUSIONS

Goal-directed haemodynamic therapy during general anaesthesia might decrease mortality, hospital length of stay, and several postoperative complications. Only infectious postoperative complications and anastomotic leakage reached moderate certainty in the evidence.

Goal-directed fluid therapy vs. low central venous pressure during major open liver resections (GALILEO): a surgeon- and patient-blinded randomized controlled trial

BACKGROUND

Low central venous pressure (low-CVP) is the clinical standard for fluid therapy during major liver surgery. Although goal-directed fluid therapy (GDFT) has been associated with reduced morbidity and mortality in major abdominal surgery, concerns remain on blood loss when applying GDFT in liver surgery. This randomized trial compared outcomes of low-CVP and GDFT during major liver resections.

METHODS

In this surgeon- and patient-blinded RCT, patients undergoing major open liver resections (≥3 segments) were randomized between low-CVP (n = 20) or GDFT (n = 20). Primary outcome was intraoperative blood loss. Secondary outcomes included the quality of the surgical field (VAS scale 0 (worst)-100 (best)) and major morbidity (≥grade 3 Clavien-Dindo).

RESULTS

During surgery, CVP was 3 ± 2 mmHg in the low-CVP group vs. 7 ± 3 mmHg in the GDFT group (P < 0.001). Blood loss (1425 vs. 1275 mL; P = 0.640) and the rate of major morbidity (40% vs. 50%, P = 0.751), did not differ between low-CVP and GDFT, respectively. The quality of the surgical field was comparable between groups (low-CVP 83% vs. GDFT 80%, P = 0.955).

CONCLUSION

In major open liver resections, GDFT was not associated with differences in intraoperative blood loss, major morbidity or quality of the surgical field, compared to low-CVP. Larger RCTs are needed to confirm this finding. Registration number: NTR5821 (www.trialregister.nl).

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Goal-Directed Fluid Therapy and Postoperative Outcomes in an Enhanced Recovery Program for Colorectal Surgery: A Propensity Score-Matched Multicenter Study

INTRODUCTION

Goal-directed fluid therapy (GDFT) has increasingly been utilized in major surgery as a key component to ensure fluid optimization and adequate tissue perfusion, showing improvements in the rate of morbidity and mortality under conventional care. It is unclear if patients derive similar benefit as part of an enhanced recovery program (ERP). Our group sought to assess the association between GDFT and postoperative outcomes within an ERP for colorectal surgery.

METHODS

A propensity score-matched analysis, based upon demographic characteristics, comorbidities, and ERP components, was utilized to assess the association between GDFT and outcomes in a multicenter prospective ERP for colorectal surgery cohort study. Outcomes included pulmonary edema, acute kidney injury (AKI), ileus, surgical site infection (SSI), and anastomotic dehiscence. The calipmatch module was used to match patients who received GDFT to non-GDFT in a 1-to-1 propensity score fashion.

RESULTS

A total of 151 matched pairs were included in the analysis (n = 302, 23%). Both groups had comparable baseline demographics, as well as similar rates of compliance with enhanced recovery after surgery (ERAS) components. Goal-directed fluid therapy patients received significantly more colloid (237 ± 320 mL vs. 140 ± 245 mL, P < .01) than non-GDFT counterparts. Goal-directed fluid therapy was not associated with improved rates of postoperative AKI (odds ratios (OR) 1.00, 95% confidence intervals (CI) .39-2.59, P = 1.00), ileus (OR 1.40, 95% CI .82-2.41, P = .22), SSI (OR 1.06, 95% CI .54-2.08, P = .86), or length of hospital stay (LOS) (10.8 ± 8.9 vs. 11.1±13.2 days, P = .84).

CONCLUSIONS

There was no associated between GDFT and major postoperative outcomes within an ERAS program for colorectal surgery. Additional large-scale or pragmatic randomized trials are necessary to determine whether GDFT has a role in ERP for colorectal surgery.

The effect of adding goal-directed hemodynamic management for elective patients in an established enhanced recovery program for colorectal surgery: results of quasi-experimental pragmatic trial

Background

Recent literature has demonstrated that hemodynamic instability in the intraoperative period places patients at risk of poor outcomes. Furthermore, recent studies have reported that stroke volume optimization and protocolized hemodynamic management may improve perioperative outcomes, especially surgical site infection (SSI), in certain high-risk populations. However, the optimal strategy for intraoperative management of all elective patients within an enhanced recovery program remains to be elucidated.

Methods

We performed a pre-post quasi-experimental study to assess the effect of adding goal-directed hemodynamic therapy to an enhanced recovery program (ERP) for colorectal surgery on SSI and other outcomes. Three groups were compared: “Pre-ERP,” defined as historical control (before enhanced recovery program); “ERP,” defined as enhanced recovery program using zero fluid balance; and “ERP+GDHT,” defined as enhanced recovery program plus goal-directed hemodynamic therapy. Outcomes were obtained through our National Surgical Quality Improvement Program participation.

Results

A total of 623 patients were included in the final analysis (Pre-ERP = 246, ERP = 140, and ERP + GDHT = 237). Demographics and baseline clinical characteristics were balanced between groups. We did not observe statistically significant differences in SSI or composite complication rates in unadjusted or adjusted analysis. There was no evidence of association between study group and 30-day readmission. American Society of Anesthesiologists status ≥ 3 and open surgical approach were significantly associated with increased risk of SSI, composite complication, and 30-day readmission (p < 0.05 for all) in all groups.

Conclusions

There was no evidence that addition of goal-directed hemodynamic therapy for all patients in an enhanced recovery program for colorectal surgery affects the risk of SSI, composite complications, or 30-day readmission. Further research is needed to investigate whether there is benefit of goal-directed hemodynamic therapy for select high-risk populations.

Trial registration

NCT03189550. Registered 16 June 2017–Retrospectively registered, https://www.clinicaltrials.gov/ct2/results?cond=&term=NCT03189550&cntry=&state=&city=&dist=

The association between arterial pulse waveform analysis device and in-hospital mortality in high-risk non-cardiac surgeries

BACKGROUND

Perioperative goal-directed fluid therapy is used for haemodynamic optimization in high-risk surgeries. Cardiac output monitoring can be performed by a specialized pressure transducer for arterial pulse waveform analysis (S-APWA). No study has assessed whether real-world use of S-APWA is associated with post-operative outcomes; therefore, using a Japanese administrative claims database, we retrospectively investigated whether S-APWA use is associated with in-hospital mortality among patients undergoing high-risk surgery under general anaesthesia.

METHODS

Adult patients who underwent high-risk surgery under general anaesthesia and arterial catheterization between 2014 and 2016 were divided into S-APWA and conventional arterial pressure transducer groups, then compared regarding baseline factors and outcomes. Logistic regression analysis was performed to compare in-hospital mortality. Subgroup analyses evaluated S-APWA efficacy and outcomes based on the type of surgery and patients' comorbidity.

RESULTS

S-APWA was used in 6859 of 23 655 (29.0%) patients; the crude in-hospital mortality rate was 3.5%. Adjusted analysis showed no significant association between S-APWA use and in-hospital mortality rate (adjusted odds ratio [aOR] = 0.91; 95% confidence interval [CI]: 0.76-1.07; P = .25). S-APWA use was associated with significantly lower in-hospital mortality in patients undergoing vascular surgery (aOR = 0.67; 95% CI: 0.49-0.94), and significantly higher in-hospital mortality in patients undergoing lower limb amputation (aOR = 2.63; 95% CI: 1.32-5.22). S-APWA use and in-hospital mortality were not significantly associated with other subgroups.

CONCLUSION

S-APWA use was not associated with in-hospital mortality in the entire study population. However, S-APWA was associated with decreased in-hospital mortality among vascular surgery and increased in-hospital mortality among lower limb amputation.

New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients

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.

Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery

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.

Intraoperative Fluid Restriction is Associated with Functional Delayed Graft Function in Living Donor Kidney Transplantation: A Retrospective Cohort Analysis

Background: In 2016 we observed a marked increase in functional delayed graft function (fDGF) in our living donor kidney transplantation (LDKT) recipients from 8.5% in 2014 and 8.8% in 2015 to 23.0% in 2016. This increase coincided with the introduction of a goal-directed fluid therapy (GDFT) protocol in our kidney transplant recipients. Hereupon, we changed our intraoperative fluid regimen to a fixed amount of 50 mL/kg body weight (BW) and questioned whether the intraoperative fluid regimen was related to this increase in fDGF. Methods: a retrospective cohort analysis of all donors and recipients in our LDKT program between January 2014–February 2017 (n = 275 pairs). Results: Univariate analysis detected various risk factors for fDGF. Dialysis dependent recipients were more likely to develop fDGF compared to pre-emptively transplanted patients (p < 0.001). Recipients developing fDGF received less intraoperative fluid (36 (25.9–50.0) mL/kg BW vs. 47 (37.3–55.6) mL/kg BW (p = 0.007)). The GDFT protocol resulted in a reduction of intraoperative fluid administration on average by 850 mL in total volume and 21% in mL/kg BW compared to our old protocol (p < 0.001). In the unadjusted analysis, a higher intraoperative fluid volume in mL/kg BW was associated with a lower risk for the developing fDGF (OR 0.967, CI (0.941–0.993)). After adjustment for the confounders, prior dialysis and the use of intraoperative noradrenaline, the relationship of fDGF with fluid volume was still apparent (OR 0.970, CI (0.943–0.998)). Conclusion: Implementation of a GDFT protocol led to reduced intraoperative fluid administration in the LDKT recipients. This intraoperative fluid restriction was associated with the development of fDGF.

Closed-loop hemodynamic management

As the operating room and intensive care settings become increasingly complex, the required vigilance practitioners must dedicate to a wide array of clinical systems has increased concordantly. The resulting shortage of available attention to these various clinical tasks creates a vacuum for the introduction of systems that can administer well-established goal-directed therapies without significant provider feedback. Recently, there has been an explosion of academic exploration into creating such automated systems, with a strong specific focus on hemodynamic control. Within this field, the largest focus has been on goal-directed fluid therapy as systems automating vasopressor administration have only recently become viable options. Our goal in this review article is to summarize the validity of the relevant goal-directed hemodynamic systems and explore the expanding role of automation within these systems.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

Effects of perioperative goal-directed fluid therapy combined with the application of alpha-1 adrenergic agonists on postoperative outcomes: a systematic review and meta-analysis

Background

Past studies have demonstrated that goal-directed fluid therapy (GDFT) may be more marginal than previously believed. However, beneficial effects of alpha-1 adrenergic agonists combined with appropriate fluid administration is getting more and more attention. This study aimed to systematically review the effects of goal-directed fluid therapy (GDFT) combined with the application of alpha-1 adrenergic agonists on postoperative outcomes following noncardiac surgery.

Methods

This meta-analysis included randomized controlled trials (RCTs) on GDFT combined with the application of alpha-1 adrenergic agonists in patients undergoing noncardiac surgery. The primary outcomes included the postoperative mortality rate and length of hospital stay (LOS). The secondary outcome indexes were the incidence of postoperative complications and recovery of postoperative gastrointestinal (GI) function. The traditional pairwise meta-analysis was conducted to compare the effect of fluid therapy. The quality of included RCTs was evaluated according to the Cochrane Collaboration’s risk-of-bias tool. Also, the publication bias was detected using funnel plots, Egger’s regression test, and Begg’s adjusted rank correlation test. The meta-analysis was conducted using the RevMan 5.3 and Stata 14.0 software.

Results

Thirty-two eligible RCTs were included in this meta-analysis. Perioperative GDFT combined with the application of alpha-1 adrenergic agonists was associated with a significant reduction in LOS (P = 0.002; I² = 69%), and overall complication rates (P = 0.04; I² = 41%). It facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 6.30 h (P < 0.00001; I² = 91%) and the time to toleration of solid food by 1.69 days (P < 0.00001; I² = 0%). Additionally, there was no significant reduction in short-term mortality in the GDFT combined with alpha-1 adrenergic agonists group (P = 0.05; I² = 0%).

Conclusion

This systematic review of available evidence suggested that the use of perioperative GDFT combined with alpha-1 adrenergic agonists might facilitate recovery in patients undergoing noncardiac surgery.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0564-y) contains supplementary material, which is available to authorized users.

Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Goal-directed hemodynamic therapy (GDHT) has been used in the clinical setting for years. However, the evidence for the beneficial effect of GDHT on postoperative recovery remains inconsistent. The aim of this systematic review and meta-analysis was to evaluate the effect of perioperative GDHT in comparison with conventional fluid therapy on postoperative recovery in adults undergoing major abdominal surgery.

METHODS

Randomized controlled trials (RCTs) in which researchers evaluated the effect of perioperative use of GDHT on postoperative recovery in comparison with conventional fluid therapy following abdominal surgery in adults (i.e., >16 years) were considered. The effect sizes with 95% CIs were calculated.

RESULTS

Forty-five eligible RCTs were included. Perioperative GDHT was associated with a significant reduction in short-term mortality (risk ratio [RR] 0.75, 95% CI 0.61-0.91, p = 0.004, I ² = 0), long-term mortality (RR 0.80, 95% CI 0.64-0.99, p = 0.04, I ² = 4%), and overall complication rates (RR 0.76, 95% CI 0.68-0.85, p < 0.0001, I ² = 38%). GDHT also facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 0.4 days (95% CI -0.72 to -0.08, p = 0.01, I ² = 74%) and the time to toleration of oral diet by 0.74 days (95% CI -1.44 to -0.03, p < 0.0001, I ² = 92%).

CONCLUSIONS

This systematic review of available evidence suggests that the use of perioperative GDHT may facilitate recovery in patients undergoing major abdominal surgery.

Significance of perioperative goal-directed hemodynamic approach in preventing postoperative complications in patients after cardiac surgery: a meta-analysis and systematic review

PURPOSE

Goal-directed hemodynamic therapy (GDT) is used to prevent hypoperfusion resulting from surgery. The objective of this study was to analyze the efficacy and importance of perioperative GDT.

METHODS

PUBMED, MEDLINE, CENTRAL, and Google Scholar databases were searched until 17 June 2016 using the search terms: cardiac output, cardiac surgical procedures, hemodynamics, goal-directed therapy, and intraoperative. Randomized-controlled trials with pre-emptive hemodynamic intervention for cardiac surgical population versus standard hemodynamic therapy were included.

RESULTS

Nine studies were included with a total of 1148 patients. The overall analysis revealed no significant difference in the all-cause mortality (pooled peto OR =0.58, 95%CI =0.27-1.525, p = 0.164), duration of mechanical ventilation (pooled difference in mean= -1.48, 95%CI= -3.24 to 0.28, p = 0.099), or length of intensive care unit (ICU) stay (pooled difference in mean= -9.10, 95%CI= -20.14 to 1.93, p = 0.106) between patients in the GDT and control groups. Patients in the GDP group were associated with shorter hospital stay than those in the control group (pooled difference in mean= -1.52, 95%CI= -2.31 to -0.73, p < 0.001).

CONCLUSION

GDT reduces the length of hospital stay compared with the standard of care. Further studies are necessary to continually assess the benefit of GDT following major surgery. Key Messages The results of this analysis revealed no significant difference between cardiac surgery patients receiving goal-directed hemodynamic therapy (GDT) or conventional fluid therapy in terms of the all-cause mortality, duration of mechanical intervention, and length of ICU-stay. The length of hospital stay was significantly reduced in patients treated with GDT compare to conventional fluid therapy. GDT may have limited benefit in reducing mortality; however, the association to shorter length of hospital stay may suggest that better hemodynamic balance can facilitate postoperative recovery.

Excessive intravenous fluid therapy in head and neck cancer surgery

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.