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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT. OBJECTIVES To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery. METHODS In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality. MAIN RESULTS We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL. AUTHORS' CONCLUSIONS Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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2
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Olsen F, Hård af Segerstad M, Dalla K, Ricksten SE, Nellgård B. Fractional spinal anesthesia and systemic hemodynamics in frail elderly hip fracture patients. F1000Res 2023; 12:210. [PMID: 37497335 PMCID: PMC10366555 DOI: 10.12688/f1000research.130387.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 07/28/2023] Open
Abstract
Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP <65 mmHg. Results: The incidence of hypotension was 30%. Hypotensive patients (n=5) were treated with low doses of norepinephrine (0.01-0.12 µg/kg/min). MAP showed a maximum reduction of 17% at 10 minutes following the first dose. CI, systemic vascular resistance index and stroke volume index decreased by 10%, 6%, and 7%, respectively, while heart rate was unchanged over time. After the second dose, none of the systemic haemodynamic variables were affected. Conclusions: Fractional spinal anaesthesia administered prior to surgery induced a minor to moderate fall in MAP, mainly caused by a reduction in cardiac output, induced by systemic venodilation, causing a fall in venous return. Our results are contrary to the widely held belief that hypotension is mainly the result of a reduction of systemic vascular resistance.
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Affiliation(s)
- Fredrik Olsen
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Keti Dalla
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bengt Nellgård
- Anesthesia and Critical Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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3
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Yang TX, Tan AY, Leung WH, Chong D, Chow YF. Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review. Cureus 2023; 15:e38238. [PMID: 37261162 PMCID: PMC10226838 DOI: 10.7759/cureus.38238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.
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Affiliation(s)
- Timothy Xianyi Yang
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Adrian Y Tan
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Wesley H Leung
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - David Chong
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
| | - Yu Fat Chow
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong, HKG
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Lorente JV, Reguant F, Arnau A, Borderas M, Prieto JC, Torrallardona J, Carrasco L, Solano P, Pérez I, Farré C, Jiménez I, Ripollés-Melchor J, Monge MI, Bosch J. Effect of goal-directed haemodynamic therapy guided by non-invasive monitoring on perioperative complications in elderly hip fracture patients within an enhanced recovery pathway. Perioper Med (Lond) 2022; 11:46. [PMID: 35945605 PMCID: PMC9364538 DOI: 10.1186/s13741-022-00277-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background Goal-directed haemodynamic therapy (GDHT) has been shown to reduce morbidity and mortality in high-risk surgical patients. However, there is little evidence of its efficacy in patients undergoing hip fracture surgery. This study aims to evaluate the effect of GDHT guided by non-invasive haemodynamic monitoring on perioperative complications in patients undergoing hip fracture surgery. Methods Patients > 64 years undergoing hip fracture surgery within an enhanced recovery pathway (ERP) were enrolled in this single-centre, non-randomized, intervention study with a historical control group and 12-month follow-up. Exclusion criteria were patients with pathological fractures, traffic-related fractures and refractures. Control group (CG) patients received standard care treatment. Intervention group (IG) patients received a GDHT protocol based on achieving an optimal stroke volume, in addition to a systolic blood pressure > 90 mmHg and an individualized cardiac index. No changes were made between groups in the ERP during the study period. Primary outcome was percentage of patients who developed intraoperative haemodynamic instability. Secondary outcomes were intraoperative arrhythmias, postoperative complications (cardiovascular, respiratory, infectious and renal complications), administered fluids, vasopressor requirements, perioperative transfusion, length of hospital stay, readmission and 1-year survival. Results In total, 551 patients (CG=272; IG=279) were included. Intraoperative haemodynamic instability was lower in the IG (37.5% vs 28.0%; p=0.017). GDHT patients had fewer postoperative cardiovascular (18.8% vs 7.2%; p < 0.001), respiratory (15.1% vs 3.6%; p<0.001) and infectious complications (21% vs 3.9%; p<0.001) but not renal (12.1% vs 33.7%; p<0.001). IG patients had less vasopressor requirements (25.5% vs 39.7%; p<0.001) and received less fluids [2.600 ml (IQR 1700 to 2700) vs 850 ml (IQR 750 to 1050); p=0.001] than control group. Fewer patients required transfusion in GDHT group (73.5% vs 44.4%; p<0.001). For IG patients, median length of hospital stay was shorter [11 days (IQR 8 to 16) vs 8 days; (IQR 6 to 11) p < 0.001] and 1-year survival higher [73.4% (95%CI 67.7 to 78.3 vs 83.8% (95%CI 78.8 to 87.7) p<0.003]. Conclusions The use of GDHT decreases intraoperative complications and postoperative cardiovascular, respiratory and infectious but not postoperative renal complications. This strategy was associated with a shorter hospital stay and increased 1-year survival. Trial registration ClinicalTrials.gov NCT02479321. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-022-00277-w.
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Affiliation(s)
- Juan V Lorente
- Anaesthesia and Critical Care Department, Juan Ramón Jiménez Hospital, Ronda Norte s/n, 21590, Huelva, Spain. .,School of Medicine and Health Sciences, International University of Catalonia (UIC), Barcelona, Spain. .,Fluid Therapy and Hemodynamic Group of the Hemostasis, Transfusion Medicine and Fluid Therapy Section, Spanish Society of Anesthesia and Critical Care (SEDAR), Madrid, Spain.
| | - Francesca Reguant
- School of Medicine and Health Sciences, International University of Catalonia (UIC), Barcelona, Spain.,Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Anna Arnau
- School of Medicine and Health Sciences, International University of Catalonia (UIC), Barcelona, Spain.,Central Catalonia Chronicity Research Group (C3RG), Research and Innovation Unit, Althaia Xarxa Assistencial Universitària, Manresa, Spain.,Centre d'Estudis Sanitaris i Socials, (CESS), Universitat de Vic-Universitat Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Marcelo Borderas
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Juan C Prieto
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Jordi Torrallardona
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Laura Carrasco
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Patricia Solano
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Isabel Pérez
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Carla Farré
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | - Ignacio Jiménez
- Fluid Therapy and Hemodynamic Group of the Hemostasis, Transfusion Medicine and Fluid Therapy Section, Spanish Society of Anesthesia and Critical Care (SEDAR), Madrid, Spain.,Clinical Management Anesthesiology Unit, Resuscitation and Pain Therapy, Virgen del Rocio Hospital, Sevilla, Spain
| | - Javier Ripollés-Melchor
- Fluid Therapy and Hemodynamic Group of the Hemostasis, Transfusion Medicine and Fluid Therapy Section, Spanish Society of Anesthesia and Critical Care (SEDAR), Madrid, Spain.,Anesthesia and Critical Care Department, Infanta Leonor Hospital, Madrid, Spain
| | - Manuel I Monge
- Fluid Therapy and Hemodynamic Group of the Hemostasis, Transfusion Medicine and Fluid Therapy Section, Spanish Society of Anesthesia and Critical Care (SEDAR), Madrid, Spain.,Intensive Care Unit, Hospital Universitario SAS, Jerez de la Frontera, Spain
| | - Joan Bosch
- School of Medicine and Health Sciences, International University of Catalonia (UIC), Barcelona, Spain
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5
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Agerskov M, Sørensen H, Højlund J, Secher NH, Foss NB. Fluid-responsiveness, blood volume and perfusion in preoperative haemodynamic optimisation of hip fracture patients; a prospective observational study. Acta Anaesthesiol Scand 2022; 66:660-673. [PMID: 35396854 DOI: 10.1111/aas.14070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preoperative resuscitation strategies in patients with hip fracture (HF) are lacking. We aimed to investigate fluid-responsiveness, peripheral perfusion index (PPI) and blood volume (BV)-status in patients with HF undergoing resuscitation in the preoperative phase. METHODS In a prospective observational study, we evaluated preoperative fluid-responsiveness, indices of perfusion and BV before and after lumbar epidural analgesia in 50 patients with HF shortly after admittance. RESULTS Initially, 18 (36%) patients were fluid-responsive (≥10% increased SV in response to 250 ml fluid bolus) and 13 (26%) presented hypovolaemia (deviation of measured BV from estimated BV ≤ 0.9). According to fluid-responsiveness, no difference in absolute values of cardiac index (CI) (2.7 L [2.1-3.3] vs. 2.8 L [2.3-3.4], p = .5) was seen, but cardiac output (CO) rose significantly in the hypovolaemic patients: 9% [5-18] vs. 1% [-3-7], p = .004. After epidural analgesia, 26 (52%) patients were again fluid-responsive and 15 (30%) were hypovolaemic. CI was now significantly lower in fluid-responsive patients (2.2 L [1.7-2.7] vs. 2.9 L [2.3-3.5], p = .001). Prior to epidural analgesia, no significant trend towards hypovolaemic patients having lower indices of perfusion was seen. After epidural analgesia, more patients with hypovolaemia presented with PPI≤1.5 (8 (53%) vs. 3 (9%), p = .001) and absolute values of PPI were also significantly lower if IBV was low (1.4 [0.9-3.2] vs. 3.2 [2.4-4.8], p = .01). PPI correlated with hypovolaemia after epidural analgesia (rho 0.4 [0.1-0.7], p = .007). CONCLUSIONS Preoperative fluid-responsivity in HF patients might be attributable to elements of hypovolaemia and sympathetic compensatory ability conjointly, confounding the use of SV-guided resuscitation. PPI could be associated with BV, which may support clinicians during perioperative haemodynamic optimisation.
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Affiliation(s)
- Marianne Agerskov
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Henrik Sørensen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Niels H. Secher
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
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6
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Giglio M, Biancofiore G, Corriero A, Romagnoli S, Tritapepe L, Brienza N, Puntillo F. Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2021; 1:26. [PMID: 37386648 DOI: 10.1186/s44158-021-00026-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 11/25/2021] [Indexed: 07/01/2023]
Abstract
BACKGROUND Goal-directed therapy (GDT) aims to assure tissue perfusion, by optimizing doses and timing of fluids, inotropes, and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. Several meta-analyses confirm that GDT can reduce postoperative complications. However, all recent evidences focused on high-risk patients and on major abdominal surgery. OBJECTIVES The aim of the present meta-analysis is to investigate the effect of GDT on postoperative complications (defined as number of patients with a least one postoperative complication) in different kind of surgical procedures. DATA SOURCES Randomized controlled trials (RCTs) on perioperative GDT in adult surgical patients were included. The primary outcome measure was complications, defined as number of patients with at least one postoperative complication. A subgroup-analysis was performed considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery. and so on. STUDY APPRAISAL AND SYNTHESIS METHODS Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS In 52 RCTs, 6325 patients were enrolled. Of these, 3162 were randomized to perioperative GDT and 3153 were randomized to control. In the overall population, 2836 patients developed at least one complication: 1278 (40%) were randomized to perioperative GDT, and 1558 (49%) were randomized to control. Pooled OR was 0.60 and 95% CI was 0.49-0.72. The sensitivity analysis confirmed the main result. The analysis enrolling major abdominal patients showed a significant result (OR 0.72, 95% CI 0.59-0.87, p = 0.0007, 31 RCTs, 4203 patients), both in high- and low-risk patients. A significant effect was observed in those RCTs enrolling exclusively orthopedic procedures (OR 0.53, 95% CI 0.35-0.80, p = 0.002, 7 RCTs, 650 patients. Also neurosurgical procedures seemed to benefit from GDT (OR 0.40, 95% CI 0.21-0.78, p = 0.008, 2 RCTs, 208 patients). In both major abdominal and orthopedic surgery, a strategy adopting fluids and inotropes yielded significant results. The total volume of fluid was not significantly different between the GDT and the control group. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The present meta-analysis, within the limits of the existing data, the clinical and statistical heterogeneity, suggests that GDT can reduce postoperative complication rate. Moreover, the beneficial effect of GDT on postoperative morbidity is significant on major abdominal, orthopedic and neurosurgical procedures. Several well-designed RCTs are needed to further explore the effect of GDT in different kind of surgeries.
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Affiliation(s)
- Mariateresa Giglio
- Anesthesia and Intensive Care Unit, Policlinico di Bari, Piazza G. Cesare, 11, 70124, Bari, Italy.
| | | | - Alberto Corriero
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Stefano Romagnoli
- Anesthesia, Intensive Care Unit and Pain Unit, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Luigi Tritapepe
- Dipartimento di Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Nicola Brienza
- Direttore UOC Anestesia e Rianimazione, AO San Camillo Forlanini-Roma, Rome, Italy
| | - Filomena Puntillo
- Direttore UOC Anestesia e Rianimazione, AO San Camillo Forlanini-Roma, Rome, Italy
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7
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Archunan MW, Subhash S, Attwood J, Kumar S, Choudhry N, Fountain J, Liew I. Nottingham Hip Fracture Score: Does It Predict Mortality in Distal Femoral Fracture Patients? Cureus 2021; 13:e19139. [PMID: 34873498 PMCID: PMC8635683 DOI: 10.7759/cureus.19139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/26/2022] Open
Abstract
Background Patients with distal femur fractures are associated with mortality rates comparable to neck of femur fractures. Identifying high-risk patients is crucial in terms of orthogeriatric input, pre-operative medical optimisation and risk stratification for anaesthetics. The Nottingham Hip Fracture Score (NHFS) is a validated predictor of 30-day mortality in neck of femur fracture patients. In this study, we aim to investigate and evaluate the suitability of the NHFS in predicting 30-day as well as one-year mortality of patients who have sustained distal femur fractures. Methods Patients admitted to a level 1 major trauma centre with distal femur fractures were retrospectively reviewed between June 2012 and October 2017. NHFSs were recorded using parameters immediately pre-operatively. Results Ninety-one patients were included for analysis with a mean follow-up of 32 months. The mean age was 69, 56 (61%) patients were female, 10 (11%) were open fractures and 32 (35%) were peri-prosthetic fractures with 85% of patients being surgically managed. Forty-one patients were found to have an NHFS >4. Overall mortality at 30 days was 7.7% and at 1 year was 21%. Patients with an NHFS of ≤4 had a lower mortality rate at 30 days of 6% compared with those with >4 at 9.8% (p=0.422). On Kaplan-Meier plotting and log-rank test, patients with an NHFS of >4 were associated with a higher mortality rate at 1 year at 36.6% compared to patients with an NHFS of ≤4 at 8% (p=0.001). Conclusion NHFS is a promising tool not only in neck of femur fractures but also distal femur fractures in risk-stratifying patients for pre-operative optimisation as well as a predictor of mortality.
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Affiliation(s)
| | - Sadhin Subhash
- Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Norwich, GBR
| | - Joseph Attwood
- Trauma and Orthopaedics, Aintree University Hospital, Liverpool, GBR
| | - Siddhant Kumar
- Trauma and Orthopaedics, Aintree University Hospital, Liverpool, GBR
| | - Nameer Choudhry
- Trauma and Orthopaedics, Aintree University Hospital, Liverpool, GBR
| | - James Fountain
- Trauma and Orthopaedics, Aintree University Hospital, Liverpool, GBR
| | - Ignatius Liew
- Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Norwich, GBR
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8
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Goal-directed therapy with bolus albumin 5% is not superior to bolus ringer acetate in maintaining systemic and mesenteric oxygen delivery in major upper abdominal surgery: A randomised controlled trial. Eur J Anaesthesiol 2021; 37:491-502. [PMID: 31972601 DOI: 10.1097/eja.0000000000001151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Goal-directed therapy (GDT) is increasingly used in abdominal surgery. Whether crystalloids can exert the same effect as colloid, and how this may affect perfusion, is still unclear. The effect of GDT on the systemic oxygen delivery index (sDO2I) and the mesenteric oxygen delivery index (mDO2I) can be quantified by measuring cardiac index and flow in the superior mesenteric artery, respectively. OBJECTIVE The aim of this study was to test the hypothesis that intra-operative GDT with bolus human albumin 5% is superior to GDT with bolus ringer acetate in maintaining sDO2I and mDO2I in elective major upper gastrointestinal cancer surgery. DESIGN Randomised controlled double blinded trial. SETTING Odense University Hospital, Denmark, from May 2014 to June 2015. PATIENTS A total of 89 adults scheduled for elective major upper gastrointestinal cancer surgery were randomised and data from 60 were analysed. EXCLUSION CRITERIA contraindications for using the LiDCOplus system, known allergy to albumin, pre-operative renal failure, pancreatic cancer and pre-operative down staging using chemotherapy and/or radiation therapy, pregnancy. INTERVENTIONS Patients were randomised to intra-operative GDT with either bolus human albumin or ringer acetate 250 ml, guided by pulse pressure variation and stroke volume. MAIN OUTCOME MEASURES Changes in sDO2I and mDO2I. Secondary outcomes were changes in other haemodynamic variables, fluid balance, blood transfusions, fluid-related complications and length of stay (LOS) in ICU and hospital. RESULTS Median [IQR] sDO2I was 522 [420 to 665] ml min m in the ringer acetate group and 490 [363 to 676] ml min m in the human albumin group, P = 0.36. Median [IQR] mDO2I was 12.1 [5.8 to 28.7] ml min m in the ringer acetate group and 17.0 [7.6 to 27.5] ml min m in the human albumin group, P = 0.17. Other haemodynamic comparisons did not differ significantly. More trial fluid was administered in the ringer acetate group. We found no significant difference in transfusions, complications or LOS. CONCLUSION Bolus human albumin 5% was not superior to bolus ringer acetate in maintaining systemic or mesenteric oxygen delivery in elective major upper gastrointestinal cancer surgery, despite the administration of larger volumes of trial fluid in the ringer acetate group. No significant difference was seen in fluid-related complications or LOS. TRIAL REGISTRATION https://eudract.ema.europa.eu/ Identifier: 2013-002217-36.
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Dushianthan A, Knight M, Russell P, Grocott MP. Goal-directed haemodynamic therapy (GDHT) in surgical patients: systematic review and meta-analysis of the impact of GDHT on post-operative pulmonary complications. Perioper Med (Lond) 2020; 9:30. [PMID: 33072306 PMCID: PMC7560066 DOI: 10.1186/s13741-020-00161-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
Background Perioperative goal-directed haemodynamic therapy (GDHT), defined as the administration of fluids with or without inotropes or vasoactive agents against explicit measured goals to augment blood flow, has been evaluated in many randomised controlled trials (RCTs) over the past four decades. Reported post-operative pulmonary complications commonly include chest infection or pneumonia, atelectasis, acute respiratory distress syndrome or acute lung injury, aspiration pneumonitis, pulmonary embolism, and pulmonary oedema. Despite the substantial clinical literature in this area, it remains unclear whether their incidence is reduced by GDHT. This systematic review aims to determine the effect of GDHT on the respiratory outcomes listed above, in surgical patients. Methods We searched the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, and clinical trial registries up until January 2020. We included all RCTs reporting pulmonary outcomes. The primary outcome was post-operative pulmonary complications and secondary outcomes were specific pulmonary complications and intra-operative fluid input. Data synthesis was performed on Review Manager and heterogeneity was assessed using I2 statistics. Results We identified 66 studies with 9548 participants reporting pulmonary complications. GDHT resulted in a significant reduction in total pulmonary complications (OR 0.74, 95% CI 0.59 to 0.92). The incidence of pulmonary infections, reported in 45 studies with 6969 participants, was significantly lower in the GDHT group (OR 0.72, CI 0.60 to 0.86). Pulmonary oedema was recorded in 23 studies with 3205 participants and was less common in the GDHT group (OR 0.47, CI 0.30 to 0.73). There were no differences in the incidences of pulmonary embolism or acute respiratory distress syndrome. Sub-group analyses demonstrated: (i) benefit from GDHT in general/abdominal/mixed and cardiothoracic surgery but not in orthopaedic or vascular surgery; and (ii) benefit from fluids with inotropes and/or vasopressors in combination but not from fluids alone. Overall, the GDHT group received more colloid (+280 ml) and less crystalloid (−375 ml) solutions than the control group. Due to clinical and statistical heterogeneity, we downgraded this evidence to moderate. Conclusions This systematic review and meta-analysis suggests that the use of GDHT using fluids with inotropes and/or vasopressors, but not fluids alone, reduces the development of post-operative pulmonary infections and pulmonary oedema in general, abdominal and cardiothoracic surgical patients. This evidence was graded as moderate. PROSPERO registry reference: CRD42020170361
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Affiliation(s)
- Ahilanandan Dushianthan
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK.,Anaesthesia Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK.,Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Martin Knight
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
| | - Peter Russell
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
| | - Michael Pw Grocott
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK.,Anaesthesia Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK.,Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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Che L, Zhang XH, Li X, Zhang YL, Xu L, Huang YG. Outcome impact of individualized fluid management during spine surgery: a before-after prospective comparison study. BMC Anesthesiol 2020; 20:181. [PMID: 32698766 PMCID: PMC7376681 DOI: 10.1186/s12871-020-01092-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 07/13/2020] [Indexed: 02/11/2023] Open
Abstract
Background Individualized fluid management (IFM) has been shown to be useful to improve the postoperative outcome of patients undergoing major abdominal surgery. A limited number of clinical studies have been done in orthopaedic patients and have yielded conflicting results. We designed the present study to investigate the clinical impact of IFM in patients undergoing major spine surgery. Methods This is a before-after study done in 300 patients undergoing posterior spine arthrodesis. Postoperative outcomes were compared between control group implementing standard fluid management (n = 150) and IFM group (n = 150) guided by fluid protocol based on continuous stroke volume monitoring and optimization. The primary outcome measure was the proportion of patients who developed one or more complications within 30 days following surgery. Results During surgery, patients received on average the same volume of crystalloids (7.4 vs 7.2 ml/kg/h) and colloids (1.6 vs 1.6 ml/kg/h) before and after the implementation of IFM. During 30 days following surgery, the proportion of patients who developed one or more complications was lower in the IFM group (32 vs 48%, p < 0.01). This difference was mainly explained by a significant decrease in post-operative nausea and vomiting (from 38 to 19%, p < 0.01), urinary tract infections (from 9 to 1%, p < 0.01) and surgical site infections (from 5 to 1%, p < 0.05). Median hospital length of stay was not affected by the implementation of IFM. Conclusion In patients undergoing major spine surgery, the implementation of IFM was associated with a significant decrease in postoperative morbidity. Trial registration ClinicalTrials.gov Identifier: NCT02470221. Prospectively registered on June 12, 2015.
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Affiliation(s)
- Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xiu H Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xu Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yue L Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
| | - Yu G Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
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Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients. J Arthroplasty 2020; 35:1186-1193. [PMID: 31992530 DOI: 10.1016/j.arth.2019.12.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/16/2019] [Accepted: 12/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission. METHODS This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians. RESULTS Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality. CONCLUSIONS Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.
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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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Rocos B, Whitehouse MR, Walsh K, Reeves BC, Kelly MB. Resuscitation in hip fractures: The practicality and clinical effectiveness of pre-operative resuscitation of patients with hip fracture using blood products. J Orthop 2019; 19:93-97. [PMID: 32021044 DOI: 10.1016/j.jor.2019.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 11/03/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction This study aimed to determine the practicality and estimate the effect of administering pre-operative blood product resuscitation to a consecutive, prospectively recruited cohort of 100 patients admitted to a single centre with a hip fracture with all other treatment unchanged. Method 100 patients aged 65 years or over admitted acutely to our unit with unilateral fractured femoral neck during the study period were included in this study, regardless of cognitive function. Patients were excluded only if there were relevant medical comorbidities or consent was declined. Each patient was resuscitated with a single unit of packed red cells in the immediate perioperative period in addition to standard care. The primary outcome was to establish the feasibility of the study protocol employed in using blood products to resuscitate eligible patients and recording reasons for any failures to include eligible patients. Additional data regarding mortality at 30 days following injury, subsequent blood product use, any transfusion related adverse reactions and total blood product use was measured. Results We were able to show that it is safe and practicable to deliver blood as an early resuscitative strategy in the frail elderly hip fracture population. The mortality rate of the study cohort was 3%. No adverse reaction was observed in any of the 99 patients given blood as a result of the resuscitation strategy and no morbidity was seen that could be attributed to the effect of giving blood. The total amount of blood received by comparable cohorts in the study period and the two preceding years were similar. Conclusions The study suggests that in the hip fracture population it is both practical and beneficial to move away from reactive transfusion regimens, and instead centre efforts instead on optimal resuscitation at the initial presentation.
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Affiliation(s)
- Brett Rocos
- Avon Orthopaedic Centre, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Michael R Whitehouse
- Avon Orthopaedic Centre, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Katherine Walsh
- Avon Orthopaedic Centre, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, BS2 8HW, United Kingdom
| | - Michael B Kelly
- Avon Orthopaedic Centre, Brunel Building, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
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Lim BG, Lee IO. Anesthetic management of geriatric patients. Korean J Anesthesiol 2019; 73:8-29. [PMID: 31636241 PMCID: PMC7000283 DOI: 10.4097/kja.19391] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/20/2019] [Indexed: 12/15/2022] Open
Abstract
The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.
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Affiliation(s)
- Byung-Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Il-Ok Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis. Eur J Anaesthesiol 2019; 35:469-483. [PMID: 29369117 DOI: 10.1097/eja.0000000000000778] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Much uncertainty exists as to whether peri-operative goal-directed therapy is of benefit. OBJECTIVES To discover if peri-operative goal-directed therapy decreases mortality and morbidity in adult surgical patients. DESIGN An updated systematic review and random effects meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase and the Cochrane Library were searched up to 31 December 2016. ELIGIBILITY CRITERIA Randomised controlled trials enrolling adult surgical patients allocated to receive goal-directed therapy or standard care were eligible for inclusion. Trauma patients and parturients were excluded. Goal-directed therapy was defined as fluid and/or vasopressor therapy titrated to haemodynamic goals [e.g. cardiac output (CO)]. Outcomes included mortality, morbidity and hospital length of stay. Risk of bias was assessed using Cochrane methodology. RESULTS Ninety-five randomised trials (11 659 patients) were included. Only four studies were at low risk of bias. Modern goal-directed therapy reduced mortality compared with standard care [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.50 to 0.87; number needed to treat = 59; N = 52; I = 0.0%]. In subgroup analysis, there was no mortality benefit for fluid-only goal-directed therapy, cardiac surgery patients or nonelective surgery. Contemporary goal-directed therapy also reduced pneumonia (OR 0.69; 95% CI, 0.51 to 0. 92; number needed to treat = 38), acute kidney injury (OR 0. 73; 95% CI, 0.58 to 0.92; number needed to treat = 29), wound infection (OR 0.48; 95% CI, 0.37 to 0.63; number needed to treat = 19) and hospital length of stay (days) (-0.90; 95% CI, -1.32 to -0.48; I = 81. 2%). No important differences in outcomes were found for the pulmonary artery catheter studies, after accounting for advances in the standard of care. CONCLUSION Peri-operative modern goal-directed therapy reduces morbidity and mortality. Importantly, the quality of evidence was low to very low (e.g. Grading of Recommendations, Assessment, Development and Evaluation scoring), and there was much clinical heterogeneity among the goal-directed therapy devices and protocols. Additional well designed and adequately powered trials on peri-operative goal-directed therapy are necessary.
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Perioperative multi-system optimization protocol in elderly hip fracture patients: a randomized-controlled trial. Can J Anaesth 2019; 66:1472-1482. [PMID: 31531828 DOI: 10.1007/s12630-019-01475-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Hip fractures in elderly patients are associated with increased postoperative morbidity and mortality. We evaluated whether a perioperative multi-system optimization protocol can reduce postoperative complications in these patients. METHODS Immediately after diagnosis of hip fracture, patients ≥ 60 yr were randomized to an intervention or control group. Patients in the intervention group were admitted to our postanesthesia care unit where they were treated with goal-directed hemodynamic management, optimized pain therapy, oxygen therapy, and optimized nutrition. Patients in the control group were managed according to our usual standard of care on a regular ward. Postoperative complications during hospital stay included pre-determined cardiovascular, respiratory, neurologic, renal, or surgical events. RESULTS The incidence of at least one postoperative complication (primary outcome) was seen in 32 of 65 (49%) controls compared with 24 of 62 (39%) in the intervention group (relative risk [RR], 0.79; 95% confidence interval [CI], 0.53 to 1.17; P = 0.23). The secondary unadjusted outcomes showed that patients in the intervention group received more Ringer's acetate compared with controls (median difference, 1.3 L; 95% CI, 0.6 to 2.1 L; P < 0.001), had more frequently a mean arterial pressure > 70 mmHg (57% control vs 75% intervention; median percentage difference, 16%; 95% CI, 7 to 25%; P = 0.001), better pain control (numeric rating scale < 4 at all postoperative measurements; 25% control vs 81% intervention; RR, 0.26; 95% CI, 0.15 to 0.43; P < 0.001), and possibly a lower incidence of acute renal failure (RR, 0.37; 95% CI, 0.14 to 0.98; P = 0.04). CONCLUSIONS The implementation of a perioperative multi-system optimization protocol algorithm did not significantly reduce the risk of postoperative complications. Nevertheless, we likely over-estimated the potential treatment effect in our study design and thus were under-powered to show an effect. TRIAL REGISTRATION Clinicaltrials.gov (NCT01673776). Registered 23 August, 2012.
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Davies SJ, Yates DR, Wilson RJT, Murphy Z, Gibson A, Allgar V, Collyer T. A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185). Perioper Med (Lond) 2019; 8:8. [PMID: 31406569 PMCID: PMC6686254 DOI: 10.1186/s13741-019-0119-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background Hip fracture is a procedure with high mortality and complication rates, and there exists a group especially at risk of these outcomes identified by their Nottingham Hip Fracture Score (NHFS). Meta-analysis suggests a possible benefit to this patient group from intravascular volume optimisation. We investigated whether intraoperative fluid and blood pressure optimisation improved complications in this group. Methods Patients with a NHFS ≥ 5 were enrolled into this multicentre observer-blinded randomised control trial. Patients were allocated to either standard care or a combination of fluid optimisation and blood pressure control using a non-invasive system. The primary outcome was the number of patients with one or more complications in each group. Secondary outcomes included hospital length of stay (LOS), incidence of hypotension and fluid and vasopressor usage. Results Forty-six percent of patients in the intervention group suffered one or more complications compared to the 51% in the control group (OR 0.82 (95% CI 0.49–1.36)). Per-protocol analysis improved the OR to 0.73 (95% CI 0.43–1.24). Median LOS was the same between both groups; however, the mean LOS on a per-protocol analysis was longer in the control group compared to the intervention group (23.2 (18.0) days vs. 18.5 (16.5), p = 0.047). Conclusions Haemodynamic optimisation including blood pressure management in high-risk patients undergoing repair of a hip fracture did not result in a statistically significant reduction in complications; however, a potential reduction in length of stay was seen. Trial registration A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185).
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Affiliation(s)
- S J Davies
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - D R Yates
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - R J T Wilson
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - Z Murphy
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - A Gibson
- Clinical Research Network: Yorkshire and Humber, York Teaching Hospitals Foundation Trust, Wigginton Road, York, UK
| | - V Allgar
- 3Hull York Medical School/Department of Health Sciences, University of York, York, UK
| | - T Collyer
- 4Department of Anaesthesia, Critical Care and Perioperative Medicine, Harrogate and District NHS Foundation Trust, Harrogate, UK
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18
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Giglio M, Dalfino L, Puntillo F, Brienza N. Hemodynamic goal-directed therapy and postoperative kidney injury: an updated meta-analysis with trial sequential analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:232. [PMID: 31242941 PMCID: PMC6593609 DOI: 10.1186/s13054-019-2516-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/13/2019] [Indexed: 12/18/2022]
Abstract
Background Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery, and role of fluids and inotropes. We therefore update a previous analysis, including all studies published in the meanwhile, to clarify the clinical impact of this strategy on acute kidney injury. Main body Randomized controlled trials enrolling adult patients undergoing major surgery were considered. GDT was defined as perioperative monitoring and manipulation of hemodynamic parameters to reach normal or supranormal values by fluids alone or with inotropes. Trials comparing the effects of GDT and standard hemodynamic therapy were considered. Primary outcome was acute kidney injury, whichever definition was used. Meta-analytic techniques (analysis software RevMan, version 5.3) were used to combine studies, using random-effect odds ratios (OR) and 95% confidence intervals (CI). Trial sequential analyses were performed including all trials and considering only low risk of bias trials. Sixty-five trials with an overall sample of 9308 patients were included. OR for the development of renal injury was 0.64 (95% CI, 0.62–0.87; p = 0.0003), with no statistical heterogeneity. Trial sequential analyses and sensitivity analysis including studies with low risk of bias confirmed the main results. A significant decrease in renal injury rate was observed in studies that adopted cardiac output and oxygen delivery as hemodynamic target and that used both fluids and inotropes. The postoperative kidney injury rate was significantly lower in trials enrolling “high-risk” patients and major abdominal and orthopedic surgery. Short conclusion The present meta-analysis suggests that targeting GDT to perioperative systemic oxygen delivery, by means of fluids and inotropes, can be the best way to improve renal perfusion and oxygenation in high-risk patients undergoing major abdominal and orthopedic surgery. Electronic supplementary material The online version of this article (10.1186/s13054-019-2516-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mariateresa Giglio
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy.
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy
| | - Filomena Puntillo
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy
| | - Nicola Brienza
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy
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19
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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20
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Bartha E, Davidson T, Berg HE, Kalman S. A 1-year perspective on goal-directed therapy in elderly with hip fracture: Secondary outcomes. Acta Anaesthesiol Scand 2019; 63:610-614. [PMID: 30656648 DOI: 10.1111/aas.13320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 11/30/2018] [Accepted: 12/14/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND We have previously reported inconclusive results from a randomized controlled trial in elderly with hip-fracture comparing intra-operative goal-directed therapy with routine fluid treatment. Now we aimed to describe and compare secondary outcomes at 4 months and 1 year follow-up and to analyze the cost-effectiveness. METHODS Patients with hip fracture (age ≥70) were randomized for GDT or routine fluid treatment (RFT). The secondary outcomes were long-term survival, complications, number of hospital readmissions, and quality of life (EQ-5D) changes. Additionally, cost effectiveness was analyzed by an analytic tool which combines the clinical effectiveness, quality of life changes and costs. RESULTS Patient data (GDT n = 74; RFT n = 75) were analyzed on an intention to treat basis. Statistically significant differences (GDT vs RFT) were not found considering survival (RR 0.76, 95%CI 0.45-1.28) and complications (RR 0.68, 95% CI 0.4-1.10) at 12 months. No statistically significant difference was found between hospital readmissions and quality of life changes. CONCLUSION The statistical uncertainty of risk reduction of negative outcomes and the large variability of the collected data indicate the need of further research in large sample sizes. To enable future health economic evaluation for decision support surrounding implementation of GDT, we suggest adding patient-oriented outcomes in future trials.
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Affiliation(s)
- Erzsebet Bartha
- Perioperative Medicine and Intensive Care Karolinska University Hospital Huddinge, Stockholm Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institute Stockholm Sweden
| | - Thomas Davidson
- Centre for Medical Technology Assessment, Department of Medical and Health Sciences Linköping University Linköping Sweden
| | - Hans E. Berg
- Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institute Stockholm Sweden
- Department of Orthopedics Karolinska University Hospital Huddinge, Stockholm Sweden
| | - Sigridur Kalman
- Perioperative Medicine and Intensive Care Karolinska University Hospital Huddinge, Stockholm Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institute Stockholm Sweden
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21
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Hofhuizen C, Lemson J, Snoeck M, Scheffer GJ. Spinal anesthesia-induced hypotension is caused by a decrease in stroke volume in elderly patients. Local Reg Anesth 2019; 12:19-26. [PMID: 30881108 PMCID: PMC6404676 DOI: 10.2147/lra.s193925] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Hypotension is common during spinal anesthesia (SA) and is caused by a decrease in systemic vascular resistance (SVR) and/or cardiac output (CO). The effect of the dose of bupivacaine administered intrathecally on the changes in CO in elderly patients is largely unknown. This study investigated the hemodynamic effect of SA in elderly patients by studying the effect of two different dosages of intrathecal bupivacaine. Methods This prospective cohort study included 64 patients aged >65 years scheduled for procedures under SA; the patients received either 15 mg bupivacaine (the medium dose [MD] group) or 10 mg bupivacaine and 5 μg sufentanil (the low dose [LD] group). Blood pressure and CO were monitored throughout the procedure using Nexfin™, a noninvasive continuous monitoring device using a finger cuff. Results Thirty-three patients received MD and 31 received LD and there was no mean difference in baseline hemodynamics between the groups. On an average, the CO decreased 11.6% in the MD group and 10.0 % in the LD group. There was no significant change in SVR. Incidence of a clinically relevant decrease in stroke volume (SV) (>15% from baseline) was 67% in the MD and 45% in the LD groups (P<0.05). Conclusion CO and blood pressure decreased significantly after the onset of SA in elderly patients. This is mainly caused by a decrease in SV and not by a decrease in SVR. There was no difference in CO and blood pressure change between dosages of 10 or 15 mg bupivacaine.
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Affiliation(s)
- Charlotte Hofhuizen
- Department of Critical Care, Radboud University Medical Center, Nijmegen, The Netherlands,
| | - Joris Lemson
- Department of Critical Care, Radboud University Medical Center, Nijmegen, The Netherlands,
| | - Marc Snoeck
- Department of Anesthesia, Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesia, Radboud University Medical Center, Nijmegen, The Netherlands
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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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23
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Kaufmann T, Clement RP, Scheeren TWL, Saugel B, Keus F, Horst ICC. Perioperative goal-directed therapy: A systematic review without meta-analysis. Acta Anaesthesiol Scand 2018; 62:1340-1355. [PMID: 29978454 DOI: 10.1111/aas.13212] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/03/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Perioperative goal-directed therapy aims to optimise haemodynamics by titrating fluids, vasopressors and/or inotropes to predefined haemodynamic targets. Perioperative goal-directed therapy is a complex intervention composed of several independent component interventions. Trials on perioperative goal-directed therapy show conflicting results. We aimed to conduct a systematic review and meta-analysis to investigate the benefits and harms of perioperative goal-directed therapy. METHODS PubMED, EMBASE, Web of Science and Cochrane Library were searched. Trials were included if they had a perioperative goal-directed therapy protocol. The primary outcome was all-cause mortality. The first secondary outcome was serious adverse events excluding mortality. Risk of bias was assessed, and GRADE was used to evaluate quality of evidence. RESULTS One hundred and twelve randomised trials were included of which one trial (1%) had low risk of bias. Included trials varied in patients: types of surgery which was expected due to inclusion criteria; in intervention and comparison: timing of intervention, monitoring devices, haemodynamic variables, target values, use of fluids, vasopressors and/or inotropes as well as combinations of these within protocols; and in outcome: mortality was reported in 87 trials (78%). Due to substantial clinical heterogeneity also within the various types of surgery a meta-analysis of data, including subgroup analyses, as defined in our protocol was considered inappropriate. CONCLUSION Clinical heterogeneity in patients, interventions and outcomes in perioperative goal-directed therapy trials is too large to perform meta-analysis on all trials. Future trials and meta-analyses highly depend on universally agreed definitions on aspects beyond type of surgery of the complex intervention and its evaluation.
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Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Ramon P. Clement
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Thomas W. L. Scheeren
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Bernd Saugel
- Department of Anesthesiology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Frederik Keus
- Department of Critical Care University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Iwan C. C. Horst
- Department of Critical Care University Medical Center Groningen University of Groningen Groningen The Netherlands
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Feng S, Yang S, Xiao W, Wang X, Yang K, Wang T. 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. BMC Anesthesiol 2018; 18:113. [PMID: 30119644 PMCID: PMC6098606 DOI: 10.1186/s12871-018-0564-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 07/20/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Shuai Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuyi Yang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Xiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Department of Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China.
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25
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Zhang L, Dai F, Brackett A, Ai Y, Meng L. Association of conflicts of interest with the results and conclusions of goal-directed hemodynamic therapy research: a systematic review with meta-analysis. Intensive Care Med 2018; 44:1638-1656. [PMID: 30105599 DOI: 10.1007/s00134-018-5345-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE The association between conflicts of interest (COI) and study results or article conclusions in goal-directed hemodynamic therapy (GDHT) research is unknown. METHODS Randomized controlled trials comparing GDHT with usual care were identified. COI were classified as industry sponsorship, author conflict, device loaner, none, or not reported. The association between COI and study results (complications and mortality) was assessed using both stratified meta-analysis and mixed effects meta-regression. The association between COI and an article's conclusion (graded as GDHT-favorable, neutral, or unfavorable) was investigated using logistic regression. RESULTS Of the 82 eligible articles, 43 (53%) had self-reported COI, and 50 (61%) favored GDHT. GDHT significantly reduced complications on the basis of the meta-analysis of studies with any type of COI, studies declaring no COI, industry-sponsored studies, and studies with author conflict but not on studies with a device loaner. However, no significant relationship between COI and the relative risk (GDHT vs. usual care) of developing complications was found on the basis of meta-regression (p = 0.25). No significant effect of GDHT was found on mortality. COI had a significant overall effect (p = 0.016) on the odds of having a GDHT-favorable vs. neutral conclusion based on 81 studies. Eighty-four percent of the industry-sponsored studies had a GDHT-favorable conclusion, while only 27% of the studies with a device loaner had the same conclusion grade. CONCLUSIONS The available evidence does not suggest a close relationship between COI and study results in GDHT research. However, a potential association may exist between COI and an article's conclusion in GDHT research.
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Affiliation(s)
- Lina Zhang
- Department of Critical Care Medicine, Central South University, Xiangya Hospital, Changsha, Hunan Province, China
| | - Feng Dai
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | | | - Yuhang Ai
- Department of Critical Care Medicine, Central South University, Xiangya Hospital, Changsha, Hunan Province, China
| | - Lingzhong Meng
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, New Haven, CT, 208051, USA.
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Molliex S, Passot S, Morel J, Futier E, Lefrant JY, Constantin JM, Le Manach Y, Pereira B. A multicentre observational study on management of general anaesthesia in elderly patients at high-risk of postoperative adverse outcomes. Anaesth Crit Care Pain Med 2018; 38:15-23. [PMID: 29902538 DOI: 10.1016/j.accpm.2018.05.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 05/12/2018] [Accepted: 05/30/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In elderly patients, goal-directed haemodynamic therapy (GDHT), depth of anaesthesia monitoring and lung-protective ventilation have been shown to improve postoperative outcomes. The aim of this study was to evaluate current practices concerning strategies of anaesthesia optimisation in patients aged≥75 years. PATIENTS AND METHODS A multicentre observational study was performed from February to May 2015 in 23 French academic centres. On 30 consecutive days in each centre, patients≥75 years with at least one major comorbidity undergoing elective or emergency procedures (femoral-neck fractures surgery, intraperitoneal abdominal surgery or vascular surgery) were included. Patient characteristics and data related to GHDT, management of hypotension, monitoring of temperature and depth of anaesthesia, lung ventilation, point of care haemoglobin testing were collected. RESULTS In total, 807 patients were included. Only 2% of patients [95% CI: 1-3] received GHDT in full accordance with guidelines. Depth of anaesthesia monitoring was largely performed (53% [95% CI: 50-56]). The multifaceted strategy of lung-protective ventilation combining low tidal volumes (6-8mL/kg), PEEP of 5-8cm cmH2O, and repeated recruitment manoeuvres, was performed in only 4% [95% CI: 3-5] of patients. A centre effect was a major determinant of variation concerning implementation of these strategies. DISCUSSION In patients'≥75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints.
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Affiliation(s)
- Serge Molliex
- Department of Anaesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Université Jean-Monnet Saint-Étienne, 42055 Saint-Étienne, France.
| | - Sylvie Passot
- Department of Anaesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Université Jean-Monnet Saint-Étienne, 42055 Saint-Étienne, France.
| | - Jerome Morel
- Department of Anaesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Université Jean-Monnet Saint-Étienne, 42055 Saint-Étienne, France.
| | - Emmanuel Futier
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Université Clermont-Auvergne, CNRS, Inserm, 63000 Clermont-Ferrand, France.
| | - Jean Yves Lefrant
- Department of Anaesthesiology, Critical Care and Emergency Medicine, Centre Hospitalier Universitaire (CHU) de Nîmes, Université de Montpellier-Nîmes, 30029 Nîmes, France.
| | - Jean Michel Constantin
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, Université Clermont-Auvergne, CNRS, Inserm, 63000 Clermont-Ferrand, France.
| | - Yannick Le Manach
- Departments of Anaesthesia and Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
| | - Bruno Pereira
- Biostatistic Unit, Direction de la Recherche Clinique (DRCI), Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, 63003 Clermont-Ferrand, France.
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White SM, Altermatt F, Barry J, Ben-David B, Coburn M, Coluzzi F, Degoli M, Dillane D, Foss NB, Gelmanas A, Griffiths R, Karpetas G, Kim JH, Kluger M, Lau PW, Matot I, McBrien M, McManus S, Montoya-Pelaez LF, Moppett IK, Parker M, Porrill O, Sanders RD, Shelton C, Sieber F, Trikha A, Xuebing X. International Fragility Fracture Network Delphi consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018; 73:863-874. [DOI: 10.1111/anae.14225] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2018] [Indexed: 01/16/2023]
Affiliation(s)
- S. M. White
- Brighton and Sussex University Hospitals NHS Trust; Brighton East Sussex UK
| | - F. Altermatt
- División de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - J. Barry
- Cairns Hospital; Queensland Australia
| | - B. Ben-David
- University of Pittsburgh Medical Centre; Pittsburgh PA USA
| | - M. Coburn
- Medical Faculty; RWTH Aachen University; Aachen Germany
| | - F. Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies; Sapienza University of Rome; Latina Italy
| | - M. Degoli
- Ospedale Civile di Baggiovara; Azienda Ospedaliero Universitaria di Modena; Modena Italy
| | - D. Dillane
- Anesthesiology and Pain Medicine; University of Alberta; Canada
| | - N. B. Foss
- Department of Anaesthesiology and Intensive Care Medicine; Hvidovre University Hospital; Hvidovre Denmark
| | - A. Gelmanas
- Hospital of Lithuanian University of Health Sciences Kauno klinikos; Lithuania
| | - R. Griffiths
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - G. Karpetas
- General University Hospital of Patras; Rio Greece
| | - J.-H. Kim
- Korea University College of Medicine; Seoul South Korea
| | | | - P.-W. Lau
- University of Hong Kong; Hong Kong China
| | - I. Matot
- Critical Care and Pain; Tel Aviv Medical Center; Sackeler School of Medicine; Tel Aviv Israel
| | | | | | - L. F. Montoya-Pelaez
- Department of Anaesthesia and Perioperative Medicine; Groote Schuur Hospital; University of Cape Town; Cape Town South Africa
| | - I. K. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre Campus; Nottingham University Hospitals NHS Trust; University of Nottingham; Nottingham UK
| | - M. Parker
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - O. Porrill
- New Somerset Hospital; University of Cape Town; South Africa
| | | | - C. Shelton
- Lancaster Medical School and Wythenshawe Hospital; Manchester UK
| | - F. Sieber
- Johns Hopkins Bayview Medical Center; Baltimore MD USA
| | - A. Trikha
- All India Institute of Medical Sciences; New Delhi India
| | - X. Xuebing
- University of Hong Kong-Shenzhen Hospital; Shenzhen China
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Dawe H. Modernising Hip Fracture Anaesthesia. Open Orthop J 2017; 11:1190-1199. [PMID: 29290856 PMCID: PMC5721325 DOI: 10.2174/1874325001711011190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 12/14/2022] Open
Abstract
Hip fracture carries a 30-day mortality of around 8% in the United Kingdom. This figure has remained relatively unchanged despite modern developments in anaesthetic technique. These range from improvements in perioperative analgesia and mortality scoring systems, changes to intra-operative anaesthetic technique and strategies to reduce the requirement for blood transfusion. In this article, we review the current literature on the perioperative management of patients undergoing hip fracture surgery including some of the current controversies.
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Affiliation(s)
- Hannah Dawe
- St. Georges Hospital, Tooting, SW170QT, London, UK
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29
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Guy P, Sheehan KJ, Morin SN, Waddell J, Dunbar M, Harvey E, Sirett S, Sobolev B, Kuramoto L, Tang M. Feasibility of using administrative data for identifying medical reasons to delay hip fracture surgery: a Canadian database study. BMJ Open 2017; 7:e017869. [PMID: 28982835 PMCID: PMC5640061 DOI: 10.1136/bmjopen-2017-017869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/26/2017] [Accepted: 08/23/2017] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Failure to account for medically necessary delays may lead to an underestimation of early surgery benefits. This study investigated the feasibility of using administrative data to identify the National Institute for Health and Care Excellence (NICE) 124 guideline list of conditions that appropriately delay hip fracture surgery. METHODS We assembled a list of diagnosis and procedure codes to reflect the NICE 124 conditions. The list was reviewed and updated by an advanced clinical coder. The list was refined by five clinical experts. We then screened Canadian Institute for Health Information discharge abstracts for 153 918 patients surgically treated for a non-pathological first hip fracture between 1 January 2004 and 31 December 2012 for diagnosis codes present on admission and procedure codes that antedated hip fracture surgery. We classified abstracts as having medical reasons for delaying surgery based on the presence of these codes. RESULTS In total, 10 237 (6.7%; 95% CI 6.5% to 6.8%) patients had diagnostic and procedure codes indicating medical reasons for delay. The most common reasons for medical delay were exacerbation of a chronic chest condition (35.9%) and acute chest infection (23.2%). The proportion of patients with reasons for medical delays increased with time from admission to surgery: 3.9% (95% CI 3.6% to 4.1%) for same day surgery; 4.7% (95% CI 4.5% to 4.8%) for surgery 1 day after admission; 7.1% (95% CI 6.9% to 7.4%) for surgery 2 days after admission; and 15.5% (95% CI 15.1% to 16.0%) for surgery more than 2 days after admission. The trend was seen for admissions on weekday working hours, weekday after hours and on weekends. CONCLUSION Administrative data can be considered to identify conditions that appropriately delay hip fracture surgery. Accounting for medically necessary delays can improve estimates of the effectiveness of early surgery.
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Affiliation(s)
- Pierre Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - Katie J Sheehan
- Academic Department of Physiotherapy, School of Population Health Sciences, Kings College London, London, UK
| | | | - James Waddell
- Division of Orthopaedics, University of Toronto, Toronto, Canada
| | - Michael Dunbar
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, Canada
| | - Edward Harvey
- Division of Orthopaedic Surgery, McGill University, Montreal, Canada
| | - Susan Sirett
- Decision Support, Vancouver Coastal Health Authority, Vancouver, Canada
| | - Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Lisa Kuramoto
- Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Michael Tang
- Vancouver Coastal Health Research Institute, Vancouver, Canada
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Moppett IK, White S, Griffiths R, Buggy D. Tight intra-operative blood pressure control versus standard care for patients undergoing hip fracture repair - Hip Fracture Intervention Study for Prevention of Hypotension (HIP-HOP) trial: study protocol for a randomised controlled trial. Trials 2017; 18:350. [PMID: 28743315 PMCID: PMC5526232 DOI: 10.1186/s13063-017-2066-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/24/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension during anaesthesia for hip fracture surgery is common. Recent data suggest that there is an association between the lowest intra-operative blood pressure and mortality, even when adjusted for co-morbidities. This is consistent with data derived from the wider surgical population, where magnitude and duration of hypotension are associated with mortality and peri-operative complications. However, there are no trial to data to support more aggressive blood pressure control. METHODS/DESIGN We are conducting a three-centre, randomised, double-blinded pilot study in three hospitals in the United Kingdom. The sample size will be 75 patients (25 from each centre). Randomisation will be done using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be aged >70 years, cognitively intact (Abbreviated Mental Test Score 7 or greater), able to give informed consent and admitted directly through the emergency department with a fractured neck of the femur requiring operative repair. Patients randomised to tight blood pressure control or avoidance of intra-operative hypotension will receive active treatment as required to maintain both of the following: systolic arterial blood pressure >80% of baseline pre-operative value and mean arterial pressure >75 mmHg throughout. All participants will receive standard hospital care, including spinal or general anaesthesia, at the discretion of the clinical team. The primary outcome is a composite of the presence or absence of defined cardiovascular, renal and delirium morbidity within 7 days of surgery (myocardial injury, stroke, acute kidney injury, delirium). Secondary endpoints will include the defined individual morbidities, mortality, early mobility and discharge to usual residence. DISCUSSION This is a small-scale pilot study investigating the feasibility of a trial of tight intra-operative blood pressure control in a frail elderly patient group with known high morbidity and mortality. Positive findings will provide the basis for a larger-scale study. TRIAL REGISTRATION ISRCTN Registry identifier: ISRCTN89812075 . Registered on 30 August 2016.
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Affiliation(s)
- Iain Keith Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stuart White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Richard Griffiths
- Department of Anaesthesia, Peterborough & Stamford Hospitals NHS Trust, Peterborough, UK
| | - Donal Buggy
- School of Medicine, Mater Hospital, Eccles Street, Dublin 7, Ireland
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Arterial Pressure Variation in Elective Noncardiac Surgery: Identifying Reference Distributions and Modifying Factors. Anesthesiology 2017; 126:249-259. [PMID: 27906705 DOI: 10.1097/aln.0000000000001460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Assessment of need for intravascular volume resuscitation remains challenging for anesthesiologists. Dynamic waveform indices, including systolic and pulse pressure variation, are demonstrated as reliable measures of fluid responsiveness for mechanically ventilated patients. Despite widespread use, real-world reference distributions for systolic and pulse pressure variation values have not been established for euvolemic intraoperative patients. The authors sought to establish systolic and pulse pressure variation reference distributions and assess the impact of modifying factors. METHODS The authors evaluated adult patients undergoing general anesthetics for elective noncardiac surgery. Median systolic and pulse pressure variations during a 50-min postinduction period were noted for each case. Modifying factors including body mass index, age, ventilator settings, positioning, and hemodynamic management were studied via univariate and multivariable analyses. For systolic pressure variation values, effects of data entry method (manually entered vs. automated recorded) were similarly studied. RESULTS Among 1,791 cases, per-case median systolic and pulse pressure variation values formed nonparametric distributions. For each distribution, median values, interquartile ranges, and reference intervals (2.5th to 97.5th percentile) were, respectively, noted: these included manually entered systolic pressure variation (6.0, 5.0 to 7.0, and 3.0 to 11.0 mmHg), automated systolic pressure variation (4.7, 3.9 to 6.0, and 2.2 to 10.4 mmHg), and automated pulse pressure variation (7.0, 5.0 to 9.0, and 2.0 to 16.0%). Nonsupine positioning and preoperative β blocker were independently associated with altered systolic and pulse pressure variations, whereas ventilator tidal volume more than 8 ml/kg ideal body weight and peak inspiratory pressure more than 16 cm H2O demonstrated independent associations for systolic pressure variation only. CONCLUSIONS This study establishes real-world systolic and pulse pressure variation reference distributions absent in the current literature. Through a consideration of reference distributions and modifying factors, the authors' study provides further evidence for assessing intraoperative volume status and fluid management therapies.
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Sun Y, Chai F, Pan C, Romeiser JL, Gan TJ. Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:141. [PMID: 28602158 PMCID: PMC5467058 DOI: 10.1186/s13054-017-1728-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/22/2017] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Yanxia Sun
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China.
| | - Fang Chai
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China
| | - Chuxiong Pan
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China
| | - Jamie Lee Romeiser
- Department of Surgery, Stony Brook University, Stony Brook, NY, USA.,Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
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Abstract
UNLABELLED To evaluate the evidence for the resuscitation of patients with hip fracture in the preoperative or perioperative phase of their treatment and its impact on mortality. DESIGN We searched MEDLINE, EMBASE, CENTRAL and PROSPERO databases using a systematic search strategy for randomised trials and observational studies investigating the fluid resuscitation of any patient with hip fracture. No language limits were applied to the search, which was complemented by manually screening the reference lists of appropriate studies. OUTCOME MEASURES Mortality at 1 week, 30 days and 1 year following surgery. RESULTS Two hundred and ninety-eight citations were identified, and 12 full manuscripts were reviewed; no studies satisfied the inclusion criteria. The background literature showed that the mortality for these patients at 30 days is approximately 8.5% and that bone cement implantation syndrome is insufficient to explain this. The literature was explored to define the need for an interventional investigation into the preoperative resuscitation of patients with hip fracture. CONCLUSIONS Patients with hip fracture show similar physiological disturbance to major trauma patients. Nineteen per cent of patients presenting with hip fracture are hypoperfused and 50% show preoperative anaemia suggesting that under resuscitation is a common problem that has not been investigated. A properly conducted interventional trial could improve the outcome of these vulnerable patients.
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Affiliation(s)
- Brett Rocos
- Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, UK
| | | | - Michael B Kelly
- Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, UK
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Porter CJ, Moppett IK, Juurlink I, Nightingale J, Moran CG, Devonald MAJ. Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury. BMC Nephrol 2017; 18:20. [PMID: 28088181 PMCID: PMC5237525 DOI: 10.1186/s12882-017-0437-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/04/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Hip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture. METHODS An observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures - development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay. RESULTS Data were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67). CONCLUSIONS Acute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important.
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Affiliation(s)
- Christine J. Porter
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
| | - Iain K. Moppett
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2RD UK
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Irene Juurlink
- Information and Computer Technology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jessica Nightingale
- Department of Orthopaedic Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Christopher G. Moran
- Department of Orthopaedic Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark A. J. Devonald
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
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Meng L, Heerdt P. Perioperative goal-directed haemodynamic therapy based on flow parameters: a concept in evolution. Br J Anaesth 2016; 117:iii3-iii17. [DOI: 10.1093/bja/aew363] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Som A, Maitra S, Bhattacharjee S, Baidya DK. Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials. J Anesth 2016; 31:66-81. [PMID: 27738801 DOI: 10.1007/s00540-016-2261-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/30/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Optimum perioperative fluid administration may improve postoperative outcome after major surgery. This meta-analysis and systematic review has been aimed to determine the effect of dynamic goal directed fluid therapy (GDFT) on postoperative morbidity and mortality in non-cardiac surgical patients. MATERIAL AND METHODS Meta-analysis of published prospective randomized controlled trials where GDFT based on non-invasive flow based hemodynamic measurement has been compared with a standard care. Data from 41 prospective randomized trials have been included in this study. RESULTS Use of GDFT in major surgical patients does not decrease postoperative hospital/30-day mortality (OR 0.70, 95 % CI 0.46-1.08, p = 0.11) length of post-operative hospital stay (SMD -0.14; 95 % CI -0.28, 0.00; p = 0.05) and length of ICU stay (SMD -0.12; 95 % CI -0.28, 0.04; p = 0.14). However, number of patients having at least one postoperative complication is significantly lower with use of GDFT (OR 0.57; 95 % CI 0.43, 0.75; p < 0.0001). Abdominal complications (p = 0.008), wound infection (p = 0.002) and postoperative hypotension (p = 0.04) are also decreased with used of GDFT as opposed to a standard care. Though patients who received GDFT were infused more colloid (p < 0.0001), there is no increased risk of heart failure or pulmonary edema and renal failure. CONCLUSION GDFT in major non- cardiac surgical patients has questionable benefit over a standard care in terms of postoperative mortality, length of hospital stay and length of ICU stay. However, incidence of all complications including wound infection, abdominal complications and postoperative hypotension is reduced.
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Affiliation(s)
- Anirban Som
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Sulagna Bhattacharjee
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
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Marty P, Ferre F, Labaste F, Jacques L, Luzi A, Conil JM, Silva S, Minville V. The Doppler renal resistive index for early detection of acute kidney injury after hip fracture. Anaesth Crit Care Pain Med 2016; 35:377-382. [PMID: 27133237 DOI: 10.1016/j.accpm.2015.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) is linked to an increase in morbidity and mortality, particularly in elderly populations. This study's aim was to assess the accuracy of the Doppler renal resistive index (RI) in detecting AKI at an early stage after hip fracture surgery. METHODS This prospective single-centre study included 48 patients suffering hip fractures requiring surgery and who presented risk factors for the development of AKI. The RI was calculated preoperatively and postoperatively in patients without pain and with haemodynamic and respiratory stability. The occurrence of AKI was determined by measurements of serum creatinine according to AKIN criteria. RESULTS Twenty-nine patients (60%) developed AKI during the first five postoperative days, without need for dialysis. The RI was increased in patients who developed postoperative AKI 0.68 (0.67-0.71) vs. 0.72 (0.7-0.73); P=0.014 for the preoperative index; and 0.6 (0.58-0.68) vs. 0.74 (0.71-0.76); P<0.0001 for the postoperative index. A postoperative index superior or equal to 0.706 is a marker for the early detection of AKI with a high sensitivity and a high specificity (76% and 89%, respectively). CONCLUSION The calculation of the RI during the perioperative periods of hip fracture surgery predicts early and effectively the postoperative occurrence of AKI, thus allowing treatment to be anticipated so as to improve patient prognosis.
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Affiliation(s)
- Philippe Marty
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France
| | - Fabrice Ferre
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France
| | - François Labaste
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France
| | - Loriane Jacques
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France
| | - Aymeric Luzi
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France
| | - Jean-Marie Conil
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France
| | - Stein Silva
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France
| | - Vincent Minville
- Department of Anesthesiology and Intensive Care, Rangueil University Hospital, avenue Jean-Poulhès, 31059 Toulouse, France.
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Bartha E, Arfwedson C, Imnell A, Kalman S. Towards individualized perioperative, goal-directed haemodynamic algorithms for patients of advanced age: observations during a randomized controlled trial (NCT01141894). Br J Anaesth 2016; 116:486-92. [DOI: 10.1093/bja/aew025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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40
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Lewis SR, Butler AR, Brammar A, Nicholson A, Smith AF. Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database Syst Rev 2016; 3:CD003004. [PMID: 26976366 PMCID: PMC7138038 DOI: 10.1002/14651858.cd003004.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Proximal femoral fracture (PFF) is a common orthopaedic emergency that affects mainly elderly people at high risk of complications. Advanced methods for managing fluid therapy during treatment for PFF are available, but their role in reducing risk is unclear. OBJECTIVES To compare the safety and effectiveness of the following methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture: advanced invasive haemodynamic monitoring, such as transoesophageal Doppler and pulse contour analysis; a protocol using standard measures, such as blood pressure, urine output and central venous pressure; and usual care.Comparisons of fluid types (e.g. crystalloid vs colloid) and other methods of optimizing oxygen delivery, such as blood product therapies and pharmacological treatment with inotropes and vasoactive drugs, are considered in other reviews. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9); MEDLINE (October 2012 to September 2015); and EMBASE (October 2012 to September 2015) without language restrictions. We ran forward and backward citation searches on identified trials. We searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for unpublished trials. This is an updated version of a review published originally in 2004 and updated first in 2013 and again in 2015. Original searches were performed in October 2003 and October 2012. SELECTION CRITERIA We included randomized controlled trials (RCTs) in adult participants undergoing surgical treatment for PFF that compared any two of advanced haemodynamic monitoring, protocols using standard measures or usual care, irrespective of blinding, language or publication status. DATA COLLECTION AND ANALYSIS Two review authors assessed the impact of fluid optimization interventions on outcomes of mortality, length of hospital stay, time to medical fitness, whether participants were able to return to pre-fracture accommodation at six months, participant mobility at six months and adverse events in-hospital. We pooled data using risk ratio (RR) or mean difference (MD) for dichotomous or continuous data, respectively, on the basis of random-effects models. MAIN RESULTS We included in this updated review five RCTs with a total of 403 participants, and we added two new trials identified during the 2015 search. One of the included studies was found to have a high risk of bias; no trial featured all pre-specified outcomes. We found two trials for which data are awaited for classification and one ongoing trial.Three studies compared advanced haemodynamic monitoring with a protocol using standard measures; three compared advanced haemodynamic monitoring with usual care; and one compared a protocol using standard measures with usual care. Meta-analyses for the two advanced haemodynamic monitoring comparisons are consistent with both increased and decreased risk of mortality (RR Mantel-Haenszel (M-H) random-effects 0.41, 95% confidence interval (CI) 0.14 to 1.20; 280 participants; RR M-H random-effects 0.45, 95% CI 0.07 to 2.95; 213 participants, respectively). The study comparing a protocol with usual care found no difference between groups for this outcome.Three studies comparing advanced haemodynamic monitoring with usual care reported data for length of stay and time to medical fitness. There was no statistically significant difference between groups for these outcomes in the two studies that we were able to combine (MD IV fixed 0.63, 95% CI -1.70 to 2.96); MD IV fixed 0.01, 95% CI -1.74 to 1.71, respectively) and no statistically significant difference in the third study. One study reported reduced time to medical fitness when comparing advanced haemodynamic monitoring with a protocol, and when comparing protocol monitoring with usual care.The number of participants with one or more complications showed no statistically significant differences in each of the two advanced haemodynamic monitoring comparisons (RR M-H random-effects 0.83, 95% CI 0.59 to 1.17; 280 participants; RR M-H random-effects 0.72, 95% CI 0.40 to 1.31; 173 participants, respectively), nor any differences in the protocol and usual care comparison.Only one study reported the number of participants able to return to normal accommodation after discharge with no statistically significant difference between groups.There were few studies with a small number of participants, and by using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach, we judged the quality of the outcome evidence as low. We had included one study with a high risk of bias, but upon applying GRADE, we downgraded the quality of this outcome evidence to very low. AUTHORS' CONCLUSIONS Five studies including a total of 403 participants provided no evidence that fluid optimization strategies improve outcomes for participants undergoing surgery for PFF. Further research powered to test some of these outcomes is ongoing.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety ResearchPointer Court 1, Ashton RoadLancasterUKLA1 1RP
| | - Andrew R Butler
- University Hospitals of Morecambe Bay NHS Foundation TrustResearch DepartmentRoyal Lancaster InfirmaryAshton RoadLancasterUKLA1 4RP
| | - Andrew Brammar
- University Hospital of South ManchesterDepartment of AnaesthesiaManchesterUK
| | - Amanda Nicholson
- University of LiverpoolLiverpool Reviews and Implementation GroupSecond FloorWhelan Building, The Quadrangle, Brownlow HillLiverpoolUKL69 3GB
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Standardizing endpoints in perioperative research. Can J Anaesth 2016; 63:159-68. [DOI: 10.1007/s12630-015-0565-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/11/2015] [Indexed: 12/21/2022] Open
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Jammer I, Tuovila M, Ulvik A. Stroke volume variation to guide fluid therapy: is it suitable for high-risk surgical patients? A terminated randomized controlled trial. Perioper Med (Lond) 2015. [PMID: 26203353 PMCID: PMC4511544 DOI: 10.1186/s13741-015-0016-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Perioperative goal-directed fluid therapy (GDFT) may improve outcome after high-risk surgery. Minimal invasive measurement of stroke volume variation (SVV) has been recommended to guide fluid therapy. We intended to study how perioperative GDFT with arterial-based continuous SVV monitoring influences postoperative complications in a high-risk surgical population. Methods From February 1st 2012, all ASA 3 and 4 patients undergoing abdominal surgery in two university hospitals were assessed for randomization into a control group or GDFT group. An arterial-line cardiac output monitor was used to measure SVV, and fluid was given after an algorithm in the intervention group. Restrictions of the method excluded patients undergoing laparoscopic surgery, patients with atrial fibrillation and patients with severe mitral/aortal stenosis. To detect a decrease in number of complication from 40 % in the control group to 20 % in the GDFT group, n = 164 patients were needed (power 80 %, alpha 0.05, two-sided test). To include the needed amount of patients, the study was estimated to last for 2 years. Results After 1 year, 30 patients were included and the study was halted due to slow inclusion rate. Of 732 high-risk patients scheduled for abdominal surgery, 391 were screened for randomization. Of those, n = 249 (64 %) were excluded because a laparoscopic technique was preferred and n = 95 (24 %) due to atrial fibrillation. Conclusions Our study was stopped due to a slow inclusion rate. Methodological restrictions of the arterial-line cardiac output monitor excluded the majority of patients. This leaves the question if this method is appropriate to guide fluid therapy in high-risk surgical patients. Trial registration ClinicalTrials.gov: NCT01473446. Electronic supplementary material The online version of this article (doi:10.1186/s13741-015-0016-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ib Jammer
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway ; Department of Anaesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway
| | - Mari Tuovila
- Department of Anesthesiology and Intensive Care, Oulu University Hospital, PL 21, 90029 Oulu, Finland
| | - Atle Ulvik
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway
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Moppett IK, Greenhaff PL, Ollivere BJ, Joachim T, Lobo DN, Rowlands M. Pre-Operative nutrition In Neck of femur Trial (POINT)--carbohydrate loading in patients with fragility hip fracture: study protocol for a randomised controlled trial. Trials 2014; 15:475. [PMID: 25472724 PMCID: PMC4289274 DOI: 10.1186/1745-6215-15-475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/13/2014] [Indexed: 12/20/2022] Open
Abstract
Background Trauma such as hip fracture initiates a neurohumoral stress response that changes the balance between anabolism and catabolism resulting in muscle breakdown and reduced mobilisation. Various studies have demonstrated a reduction in catabolism with pre-operative carbohydrate loading but only in an elective setting. Methods/Design This is a two-centre, randomised double-blinded trial in the United Kingdom. Sample size will be 30 patients (approximately 15 from each centre). Randomisation will be web based using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be >70 years of age, cognitively intact (Abbreviated Mental Score ≥7), able to give informed consent, and admitted directly through the emergency department with fractured neck of femur requiring hemiarthroplasty. Intervention will consist of two carbohydrate drinks (Nutricia pre-Op) given the night before, and the morning of the surgery. The control will receive two placebo drinks of equal volume. All participants will receive standard hospital care at the discretion of the clinical team. The primary outcome is the difference between groups in insulin resistance calculated by a glucose tolerance test administered pre-operatively and 24 hours postoperatively. Secondary endpoints will be changes in muscle carbohydrate metabolism (biopsy), mobility (Cumulative Ambulation Score) and subjective measures of tolerability. Discussion This is a small-scale pilot study, investigating the benefits and tolerability of carbohydrate loading in an emergency setting in a frail elderly group with known high morbidity and mortality. Positive findings will provide the basis for a larger scale study. Trial registration Current Controlled Trials ISRCTN91109766 (7 April 2014); NRES ref: 13/EM/0214 Trial Sponsor: University of Nottingham Ref.13036.
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Affiliation(s)
- Iain K Moppett
- Associate Professor and Honorary Consultant Anaesthetist, Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, UK.
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