1
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Abedi F, Zarei B, Elyasi S. Albumin: a comprehensive review and practical guideline for clinical use. Eur J Clin Pharmacol 2024; 80:1151-1169. [PMID: 38607390 DOI: 10.1007/s00228-024-03664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 03/04/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration. METHODS Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication. RESULTS A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation. CONCLUSION Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.
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Affiliation(s)
- Farshad Abedi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, P.O. Box, Mashhad, 91775-1365, Iran
| | - Batool Zarei
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, P.O. Box, Mashhad, 91775-1365, Iran.
| | - Sepideh Elyasi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, P.O. Box, Mashhad, 91775-1365, Iran.
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2
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Qian M, Zhao J, Zhang K, Zhang W, Jin C, Cai B, Lu Z, Hu Y, Huang J, Ma D, Fang X, Jin Y. High intraoperative fluid load associated with prolonged length of hospital stay and complications after non-cardiac surgery in neonates. Eur J Pediatr 2024:10.1007/s00431-024-05628-x. [PMID: 38856762 DOI: 10.1007/s00431-024-05628-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/11/2024]
Abstract
Inappropriate perioperative fluid load can lead to postoperative complications and death. This retrospective study was designed to investigate the association between intraoperative fluid load and outcomes in neonates undergoing non-cardiac surgery. From April 2020 to September 2022, 940 neonates who underwent non-cardiac surgery were retrospectively enrolled and their perioperative data were harvested for further analysis. According to recorded intraoperative fluid volumes defined as ml.kg-1 h-1, patients were mandatorily divided into quintile with fluid load as restrictive (quintile 1, Q1), moderately restrictive (Q2), moderate (Q3), moderately liberal (Q4), and liberal (Q5). The primary outcomes were defined as prolonged length of hospital stay (LOS) (postoperative LOS ≥ 14 days), complications beyond prolonged LOS, and 30-day mortality. Secondary outcomes included postoperative complications within 14 days of hospital stay. The intraoperative fluid load was in Q1 of 6.5 (5.3-7.3) (median and IQR); Q2: 9.2 (8.7-9.9); Q3: 12.2 (11.4-13.2); Q4: 16.5 (15.4-18.0); and Q5: 26.5 (22.3-32.2) ml.kg-1 h-1. The odd of prolonged LOS was positively correlated with an increase fluid volume (Q5 quintile: OR 2.602 [95% CI 1.444-4.690], P = 0.001), as well as complications beyond prolonged LOS (Q5: OR 3.322 [95% CI 1.656-6.275], P = 0.001). The overall 30-day mortality rate was increased with high intraoperative fluid load but did not reach to a statistical significance after adjusted with confounders. Furthermore, the highest quintile of fluid load (26.5 ml.kg-1 h-1, IQR [22.3-32.2]) (Q5 quintile) was significantly associated with longer postoperative mechanical ventilation time compared with Q1 (Q5: OR 2.212 [95% CI 1.101-4.445], P = 0.026). Conclusion: Restrictive intraoperative fluid load had overall better outcomes, whilst high fluid load was significantly associated with prolonged LOS and complications after non-cardiac surgery in neonates. Trial registration: Chictr.org.cn Identifier: ChiCTR2200066823 (December 19, 2022). What is Known: • Inappropriate perioperative fluid load can lead to postoperative complications and even death. What is New: • High perioperative fluid load was significantly associated with an increased length of stay after non-cardiac surgery in neonates, whilst low fluid load was consistently related to better postoperative outcomes.
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Affiliation(s)
- Minyue Qian
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Jialian Zhao
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Kai Zhang
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310003, China
| | - Wenyuan Zhang
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Chunyi Jin
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Binbin Cai
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Zhongteng Lu
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Yaoqin Hu
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Jinjin Huang
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Daqing Ma
- Perioperative and Systems Medicine Laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Xiangming Fang
- Department of Anesthesiology and Intensive Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310003, China.
| | - Yue Jin
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China.
- Perioperative and Systems Medicine Laboratory, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.
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3
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De Gasperi A, Petrò L, Amici O, Scaffidi I, Molinari P, Barbaglio C, Cibelli E, Penzo B, Roselli E, Brunetti A, Neganov M, Giacomoni A, Aseni P, Guffanti E. Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist. World J Crit Care Med 2024; 13:92751. [PMID: 38855273 PMCID: PMC11155507 DOI: 10.5492/wjccm.v13.i2.92751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/15/2024] [Accepted: 05/07/2024] [Indexed: 06/03/2024] Open
Abstract
Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.
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Affiliation(s)
- Andrea De Gasperi
- Former Head, Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Laura Petrò
- AR1, Ospedale Papa Giovanni 23, Bergamo 24100, Italy
| | - Ombretta Amici
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Ilenia Scaffidi
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Pietro Molinari
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Caterina Barbaglio
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Eva Cibelli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Beatrice Penzo
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Elena Roselli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Andrea Brunetti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Maxim Neganov
- Anestesia e Terapia Intensiva Generale, Istituto Clinico Humanitas, Rozzano 20089, Italy
| | - Alessandro Giacomoni
- Chirurgia Oncologica Miniinvasiva, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Paolo Aseni
- Dipartimento di Medicina d’Urgenza ed Emergenza, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milano 20163, MI, Italy
| | - Elena Guffanti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
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4
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Kehlet H, Lobo DN. Exploring the need for reconsideration of trial design in perioperative outcomes research: a narrative review. EClinicalMedicine 2024; 70:102510. [PMID: 38444430 PMCID: PMC10912044 DOI: 10.1016/j.eclinm.2024.102510] [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] [Received: 11/13/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/07/2024] Open
Abstract
"Enhanced recovery after surgery" is a multimodal effort to control perioperative pathophysiology and improve outcome. However, despite advances in perioperative care, postoperative complications and the need for hospitalisation and prolonged recovery continue to be challenging. This is further complicated by procedure-specific and patient-associated risk factors, given the increase in the number of elderly and frail patients with multiple comorbidities undergoing surgery. This paper is a critical assessment of current methodology for trials in perioperative medicine. We make a plea to reconsider the design of future interventional trials to improve surgical outcome, based upon studies of potentially effective interventions, but often without improvements in recovery. The complexity of perioperative pathophysiology necessitates a procedure- and patient-specific approach whenever outcome is assessed or interventions are planned. With improved understanding of perioperative pathophysiology, the way to improve outcomes looks promising, provided that knowledge and established enhanced recovery programmes are integrated in trial design. Funding None.
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Affiliation(s)
- Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Dileep N. Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- Division of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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5
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Schmidt G, Frieling N, Schneck E, Habicher M, Koch C, Rubarth K, Balzer F, Aßmus B, Sander M. Preoperative routine measurement of NT-proBNP predicts postoperative morbidity after non-cardiac surgery with intermediate or high surgical risk: an observational study. BMC Anesthesiol 2024; 24:113. [PMID: 38521898 PMCID: PMC10960410 DOI: 10.1186/s12871-024-02488-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Chronic heart failure (HF) is a common clinical condition associated with adverse outcomes in elderly patients undergoing non-cardiac surgery. This study aimed to estimate a clinically applicable NT-proBNP cut-off that predicts postoperative 30-day morbidity in a non-cardiac surgical cohort. METHODS One hundred ninety-nine consecutive patients older than 65 years undergoing elective non-cardiac surgery with intermediate or high surgical risk were analysed. Preoperative NT-proBNP was measured, and clinical events were assessed up to postoperative day 30. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection at postoperative day 30. Secondary endpoints included perioperative fluid balance and incidence, duration, and severity of perioperative hypotension. RESULTS NT-proBNP of 443 pg/ml had the highest accuracy in predicting the composite endpoint; a clinical cut-off of 450 pg/ml was implemented to compare clinical endpoints. Although 35.2% of patients had NT-proBNP above the threshold, only 10.6% had a known history of HF. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection. Event rates were significantly increased in patients with NT-proBNP > 450 pg/ml (70.7% vs. 32.4%, p < 0.001), which was due to the incidence of cardiac rehospitalisation (4.4% vs. 0%, p = 0.018), ADHF (20.1% vs. 4.0%, p < 0.001), AKI (39.8% vs. 8.3%, p < 0.001), and infection (46.3% vs. 24.4%, p < 0.01). Perioperative fluid balance and perioperative hypotension were comparable between groups. Preoperative NT-proBNP > 450 pg/ml was an independent predictor of the CME in a multivariable Cox regression model (hazard ratio 2.92 [1.72-4.94]). CONCLUSIONS Patients with NT-proBNP > 450 pg/ml exhibited profoundly increased postoperative morbidity. Further studies should focus on interdisciplinary approaches to improve outcomes through integrated interventions in the perioperative period. TRIAL REGISTRATION German Clinical Trials Register: DRKS00027871, 17/01/2022.
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Affiliation(s)
- Götz Schmidt
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
| | - Nora Frieling
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Christian Koch
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Kerstin Rubarth
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Birgit Aßmus
- Department of Cardiology and Angiology, Justus Liebig University of Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
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6
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Crochemore T, Görlinger K, Lance MD. Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review. Anesth Analg 2024; 138:499-513. [PMID: 37977195 PMCID: PMC10852045 DOI: 10.1213/ane.0000000000006756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 11/19/2023]
Abstract
This is a narrative review of the published evidence for bleeding management in critically ill patients in different clinical settings in the intensive care unit (ICU). We aimed to describe "The Ten Steps" approach to early goal-directed hemostatic therapy (EGDHT) using point-of-care testing (POCT), coagulation factor concentrates, and hemostatic drugs, according to the individual needs of each patient. We searched National Library of Medicine, MEDLINE for publications relevant to management of critical ill bleeding patients in different settings in the ICU. Bibliographies of included articles were also searched to identify additional relevant studies. English-language systematic reviews, meta-analyses, randomized trials, observational studies, and case reports were reviewed. Data related to study methodology, patient population, bleeding management strategy, and clinical outcomes were qualitatively evaluated. According to systematic reviews and meta-analyses, EGDHT guided by viscoelastic testing (VET) has been associated with a reduction in transfusion utilization, improved morbidity and outcome in patients with active bleeding. Furthermore, literature data showed an increased risk of severe adverse events and poor clinical outcomes with inappropriate prophylactic uses of blood components to correct altered conventional coagulation tests (CCTs). Finally, prospective, randomized, controlled trials point to the role of goal-directed fibrinogen substitution to reduce bleeding and the amount of red blood cell (RBC) transfusion with the potential to decrease mortality. In conclusion, severe acute bleeding management in the ICU is still a major challenge for intensive care physicians. The organized and sequential approach to the bleeding patient, guided by POCT allows for rapid and effective bleeding control, through the rational use of blood components and hemostatic drugs, since VET can identify specific coagulation disorders in real time, guiding hemostatic therapy with coagulation factor concentrates and hemostatic drugs with individual goals.
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Affiliation(s)
- Tomaz Crochemore
- From the Department of Critical Care, Hospital Vila Nova Star, São Paulo, Brazil
- Department of Critical Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Werfen LATAM, São Paulo, Brazil
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- TEM Innovations GmbH/Werfen PBM, Munich, Germany
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7
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Ahuja V, Singh K, Thapa D, Mitra S, Attri AK, Kaur J. Effect of lignocaine on postoperative serum lactate dehydrogenase and lactate levels in patients undergoing bowel surgery: A randomised controlled trial. Indian J Anaesth 2024; 68:293-297. [PMID: 38476548 PMCID: PMC10926344 DOI: 10.4103/ija.ija_948_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/21/2023] [Accepted: 12/25/2023] [Indexed: 03/14/2024] Open
Affiliation(s)
- Vanita Ahuja
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Kushagrita Singh
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Deepak Thapa
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Sukanya Mitra
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Ashok K. Attri
- Department of General Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Jasbinder Kaur
- Department of Biochemistry, Government Medical College and Hospital, Chandigarh, India
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8
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Ji JY, Seo YH, Jung HS, Chun HR, Park JS, Kim WJ, Ahn JM, Park YJ, Shin YE, Park CH. Coronary Artery Occlusion with Sharp Blood Pressure Drop during General Anesthesia Induction: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:232. [PMID: 38399520 PMCID: PMC10890261 DOI: 10.3390/medicina60020232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Most anesthetics reduce cardiac functions and lower blood pressure (BP), potentially causing excessive BP reduction in dehydrated patients or those with heart conditions, such as coronary artery disease (CAD). Considering the increased prevalence of cardiovascular disease with age, anesthesiologists must be cautious about BP reduction during general anesthesia in older adults. In the present case, a 76-year-old male patient with undiagnosed CAD in a hypovolemic state experienced a significant drop in systolic BP to the fifties during propofol and sevoflurane anesthesia. Despite the use of vasopressors, excessive hypotension persisted, leading to anesthesia suspension. Subsequent cardiac examinations, including computed tomography heart angio and calcium score, and coronary angiogram, revealed a near total occlusion of the proximal left anterior descending coronary artery (pLAD) and the formation of collateral circulation. After 5 days of hydration and anticoagulation medications and confirmation of normovolemic state, general anesthesia was attempted again and successfully induced; a normal BP was maintained throughout the surgery. Thus, it is important to conduct a thorough cardiac evaluation and maintain normovolemia for general anesthesia in older adults.
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Affiliation(s)
- Jae Young Ji
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Yong Han Seo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ho Soon Jung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Hea Rim Chun
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Jin Soo Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Jae Min Ahn
- Department of Neurosurgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Yu Jun Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ye Eun Shin
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Chan Ho Park
- Department of Radiology, Soonchunhyang University Hospital Cheonan, 31, Sooncheonhyang 6-gil, Donam-gu, Cheonan 31151, Republic of Korea;
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9
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West SJ, Trewren TJ, Stretton B, Kovoor JG, Maddern GJ. What is the optimal approach to perioperative fluid management? J Perioper Pract 2024; 34:4-5. [PMID: 36945830 DOI: 10.1177/17504589231159195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Affiliation(s)
| | | | - Brandon Stretton
- Royal Adelaide Hospital, Adelaide, SA, Australia
- The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
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10
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Lee H, Kim JT. Pediatric perioperative fluid management. Korean J Anesthesiol 2023; 76:519-530. [PMID: 37073521 PMCID: PMC10718623 DOI: 10.4097/kja.23128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 04/20/2023] Open
Abstract
The purpose of perioperative fluid management in children is to maintain adequate volume status, electrolyte level, and endocrine system homeostasis during the perioperative period. Although hypotonic solutions containing glucose have traditionally been used as pediatric maintenance fluids, recent studies have shown that isotonic balanced crystalloid solutions lower the risk of hyponatremia and metabolic acidosis perioperatively. Isotonic balanced solutions have been found to exhibit safer and more physiologically appropriate characteristics for perioperative fluid maintenance and replacement. Additionally, adding 1-2.5% glucose to the maintenance fluid can help prevent children from developing hypoglycemia as well as lipid mobilization, ketosis, and hyperglycemia. The fasting time should be as short as possible without compromising safety; recent guidelines have recommended that the duration of clear fluid fasting be reduced to 1 h. The ongoing loss of fluid and blood as well as the free water retention induced by antidiuretic hormone secretion are unique characteristics of postoperative fluid management that must be considered. Reducing the infusion rate of the isotonic balanced solution may be necessary to avoid dilutional hyponatremia during the postoperative period. In summary, perioperative fluid management in pediatric patients requires careful attention because of the limited reserve capacity in this population. Isotonic balanced solutions appear to be the safest and most beneficial choice for most pediatric patients, considering their physiology and safety concerns.
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Affiliation(s)
- Hyungmook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Chandramohan D, Mohamed F, Vikram S, Damodaran D, Shamsudeen S, Rahman F, Alapatt JJ, Krishnan GR, Dayananda R, Shahid MP, Das AP, Varghese J, Bhatt A, Damodaran D. Standardised Critical Care Strategies Improve Outcomes Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in an Indian Peritoneal Malignancy Centre. Indian J Surg Oncol 2023; 14:920-927. [PMID: 38187832 PMCID: PMC10766987 DOI: 10.1007/s13193-023-01803-y] [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: 03/29/2023] [Accepted: 07/14/2023] [Indexed: 01/09/2024] Open
Abstract
Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major undertaking with profound peri-operative metabolic and haemodynamic alterations. It requires standardised protocols for immediate postoperative intensive care management to improve patient-related outcomes. A retrospective analysis of a prospectively maintained data-base of 244 patients who underwent CRS and HIPEC between June 2017 and July 2022 in our institute was done. Based on the audit, six strategies were implemented, namely, (1) dynamic multiparameter-based IVF therapy to aggressively correct the hyperlactatemia, (2) initiation of IV 20% human albumin infusion from POD-0, (3) correction of serum iCa2+ levels, (4) initiation of diuresis from POD-1, (5) prophylactic use of HFNO immediately post-extubation and (6) serum procalcitonin level-based empiric escalation of IV antibiotics. Patients were divided into two cohorts, pre-protocol group of 145 patients (from June 2017 to December 2020) and post-protocol group comprising of 99 patients (from January 2021 to July 2022), and were analysed for compliance and patient-related outcomes. Implementation of these strategies improved the patient-related outcomes among the two cohorts with significant reduction of Clavien-Dindo grade III/IV complications and improvement in failure to rescue (FTR) index (p < 0.05). There was highly significant reduction in median ICU and hospital stay among the two cohorts (p < 0.001). The formulated protocols of management strategies especially multiparameter-based dynamic fluid therapy, planned diuresis and prophylactic HFNO have improved the outcomes in our patients undergoing CRS and HIPEC.
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Affiliation(s)
- Deepa Chandramohan
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Faheez Mohamed
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Syam Vikram
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Deepak Damodaran
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Shafeek Shamsudeen
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Faslu Rahman
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - John J. Alapatt
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Gokul R. Krishnan
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - R Dayananda
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Muhammed P. Shahid
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Arun P. Das
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Jinu Varghese
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Aditi Bhatt
- Department of Surgical Oncology, KD Hospital, Ahmedabad, Gujarat India
| | - Dileep Damodaran
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
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12
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Labadie KP, Melstrom LG, Lewis AG. Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience. J Surg Oncol 2023; 128:1347-1352. [PMID: 37781938 DOI: 10.1002/jso.27455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023]
Abstract
Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.
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Affiliation(s)
- Kevin P Labadie
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
| | - Aaron G Lewis
- Department of Surgery, City of Hope National Medical Center, Division of Surgical Oncology, Duarte, California, USA
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13
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Xing J, Loh SKN. Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists. PROCEEDINGS OF SINGAPORE HEALTHCARE 2023. [DOI: 10.1177/20101058231163406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Background Among the different types of perioperative organ injury, acute kidney injury (AKI) occurs frequently and is consistently associated with increased rates of mortality and mortality. Despite development of many clinical trials to assess perioperative interventions, reliable means to prevent or reverse AKI are still lacking. Objectives This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and potential directions for future research. Methods A Pubmed search with the relevant keywords was done for articles published in the last 10 years. Results New insights into preoperative identification and optimisation, intraoperative strategies, including the choice of anaesthetic, haemodynamic and fluid management, have been made, with the aim of preventing perioperative AKI. Conclusion A patient-centric multidisciplinary approach is essential to protect kidney function of patients going for surgery. Much can be done by anaesthesiologists perioperatively, to reduce the risk of development of AKI, especially in susceptible patients. There is a need for further multicentred trials to enhance the currently generic perioperative recommendations.
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Affiliation(s)
- Jieyin Xing
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Samuel Kent Neng Loh
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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14
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Lu W, Liu C, He J, Wang R, Gao D, Cheng R. Surgical and medical co-management optimizes surgical outcomes in older patients with chronic diseases undergoing robot-assisted laparoscopic radical prostatectomy. Aging Male 2023; 26:2159368. [PMID: 36974926 DOI: 10.1080/13685538.2022.2159368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION While robotic-assisted laparoscopic radical prostatectomy (RRP) is a standard mode for localized prostate cancer (PC), the risk of complications in older patients with chronic diseases and complex medical conditions can be a deterrent to surgery. Surgical and medical co-management (SMC) is a new strategy to improve patients' healthcare outcomes in surgical settings. METHODS We reviewed the clinical data of older patients with chronic diseases who were cared for with SMC undergoing RRP in our hospital in the past 3 years and compared them with the clinical data from the general urology ward. Preoperative conditions and related indicators of recovery, and incidence of postoperative complications with the Clavien Grade System were compared between these two groups. RESULTS The indicators of recovery were significantly better, and the incidence rates of complications were significantly reduced in the SMC group at grades I-IV (p < 0.05), as compared to the general urology ward group. CONCLUSIONS The provision of care by SMC for older patients focused on early identification, comorbidity management, preoperative optimization, and collaborative management would significantly improve surgical outcomes. The SMC strategy is worthy of further clinical promotion in RRP treatment in older men with chronic diseases and complex medical conditions.
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Affiliation(s)
- Wenning Lu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Dewei Gao
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rui Cheng
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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15
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Ripollés-Melchor J, Colomina MJ, Aldecoa C, Clau-Terre F, Galán-Menéndez P, Jiménez-López I, Jover-Pinillos JL, Lorente JV, Monge García MI, Tomé-Roca JL, Yanes G, Zorrilla-Vaca A, Escaraman D, García-Fernández J. A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:458-466. [PMID: 37669701 DOI: 10.1016/j.redare.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/22/2022] [Indexed: 09/07/2023]
Abstract
In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.
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Affiliation(s)
| | - M J Colomina
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario de Bellvitge, Universidad de Barcelona, Barcelona, Spain
| | - C Aldecoa
- Grupo Español de Rehabilitación Multimodal (ReDGERM), Zaragoza, Spain; Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Río Hortega, Valladolid, Spain
| | - F Clau-Terre
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - P Galán-Menéndez
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - I Jiménez-López
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J L Jover-Pinillos
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen de los Lirios, Alcoy, Spain
| | - J V Lorente
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - M I Monge García
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Jerez de la Frontera, Cádiz, Spain
| | - J L Tomé-Roca
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - G Yanes
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - A Zorrilla-Vaca
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Brigham and Women's Hospital, Boston, MA, United States
| | - D Escaraman
- Centro Médico Nacional La Raza, Mexico City, Mexico
| | - J García-Fernández
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Puerta de Hierro, Majadahonda, Spain
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Hristovska AM, Uldall-Hansen B, Mehlsen J, Andersen LB, Kehlet H, Foss NB. Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study. Can J Anaesth 2023; 70:1587-1599. [PMID: 37752379 PMCID: PMC10600298 DOI: 10.1007/s12630-023-02556-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 09/28/2023] Open
Abstract
PURPOSE Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids. METHODS This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation. RESULTS Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia. CONCLUSION We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain. STUDY REGISTRATION ClinicalTrials.gov (NCT04499664); registered 5 August 2020.
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Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark.
| | - Bodil Uldall-Hansen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Jesper Mehlsen
- Department of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
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Malbrain MLNG, Caironi P, Hahn RG, Llau JV, McDougall M, Patrão L, Ridley E, Timmins A. Multidisciplinary expert panel report on fluid stewardship: perspectives and practice. Ann Intensive Care 2023; 13:89. [PMID: 37747558 PMCID: PMC10519908 DOI: 10.1186/s13613-023-01177-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
Although effective and appropriate fluid management is a critical aspect of quality care during hospitalization, the widespread adoption of consistent policies that ensure adequate fluid stewardship has been slow and heterogenous. Despite evidence-based guidelines on fluid management being available, clinical opinions continue to diverge on important aspects of care in this setting, and the consistency of guideline implementation is far from ideal. A multidisciplinary panel of leading practitioners and experts convened to discuss best practices for ongoing staff education, intravenous fluid therapy, new training technologies, and strategies to track the success of institutional fluid stewardship efforts. Fluid leads should be identified in every hospital to ensure consistency in fluid administration and monitoring. In this article, strategies to communicate the importance of effective fluid stewardship for the purposes of education, training, institutional support, and improvement of patient outcomes are reviewed and recommendations are summarized.
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Affiliation(s)
- Manu L N G Malbrain
- First Department Anaesthesiology and Intensive Therapy, Medical University Lublin, Lublin, Poland.
- International Fluid Academy, Lovenjoel, Belgium.
- Medical Data Management, Medaman, Geel, Belgium.
- Medical Management, AZ Oudenaarde Hospital, Oudenaarde, Belgium.
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
| | - Robert G Hahn
- Anesthesia and Intensive Care, Karolinska Institute, Stockholm, Sweden
| | - Juan V Llau
- Anaesthesiology and Post-Surgical Critical Care, University Hospital Doctor Peset, Valencia, Spain
- Anaesthesiology, Department of Surgery, University of Valencia, Valencia, Spain
| | - Marcia McDougall
- Anaesthetics and Intensive Care, Victoria Hospital, Kirkcaldy, Fife, Scotland
| | - Luís Patrão
- Intensive Care Unit, Centro HospitalarTondela-Viseu, EPE, Viseu, Portugal
- UpHill Health, Lisbon, Portugal
| | - Emily Ridley
- Fluid Management lead, Department of Nursing, Victoria Hospital, Kirkcaldy, Fife, Scotland
| | - Alan Timmins
- Pharmacy Department, Victoria Hospital, Kirkcaldy, Fife, Scotland
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Gopal J, Srivastava S, Singh N, Haldar R, Verma R, Gupta D, Mishra P. Pulse Pressure Variance (PPV)-Guided Fluid Management in Adult Patients Undergoing Supratentorial Tumor Surgeries: A Randomized Controlled Trial. Asian J Neurosurg 2023; 18:508-515. [PMID: 38152505 PMCID: PMC10749863 DOI: 10.1055/s-0043-1771364] [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] [Indexed: 12/29/2023] Open
Abstract
Objective Appropriate fluid management in neurosurgery is critical due to the risk of secondary brain injury. Determination of volume status is challenging with static variables being unreliable. Goal-directed fluid therapy with dynamic variables allows reliable determination of fluid responsiveness and promises better outcomes. We aimed to compare the intraoperative fluid requirement between conventional central venous pressure (CVP)-guided and pulse pressure variance (PPV)-guided fluid management in supratentorial tumor surgeries. Materials and Methods This prospective, randomized, double-blind, single-center trial was conducted with 72 adults undergoing supratentorial tumor surgery in a supine position. Patients were divided into two groups of 36 patients each receiving CVP- and PPV-guided fluid therapy. The CVP-guided group received boluses to target CVP greater than 8 mm Hg along with hourly replacement of intraoperative losses and maintenance fluids. The PPV-guided group received boluses to target PPV less than 13% in addition to maintenance fluids. Total intraoperative fluids administered and the incidence of hypotension was recorded along with the brain relaxation score. Postoperatively, serum lactate levels, periorbital and conjunctival edema, as well as postoperative nausea and vomiting were assessed. Statistical Analyses All statistical analyses were performed with Statistical Package for Social Sciences, version-20 (SPSS-20, IBM, Chicago, Illinois, United States). To compare the means between the two groups (CVP vs. PPV), independent samples t -test was used for normal distribution data and Mann-Whitney U test for nonnormal distribution data. The chi-square test or Fischer's exact test was used for categorical variables. Results The CVP group received significantly more intraoperative fluids than the PPV group (4,340 ± 1,010 vs. 3,540 ± 740 mL, p < 0.01). Incidence of hypotension was lower in the PPV group (4 [11.1%] vs. 0 [0%], p = 0.04). Brain relaxation scores, serum lactate levels, periorbital and conjunctival edema, and incidence of postoperative nausea and vomiting were comparable between the groups. Conclusion The requirement for intraoperative fluids was less in PPV-guided fluid management with better hemodynamic stability, adequate brain conditions, and no compromise of perfusion.
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Affiliation(s)
- Janani Gopal
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shashi Srivastava
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nidhi Singh
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rudrashish Haldar
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ruchi Verma
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Devendra Gupta
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhakar Mishra
- Department of Biostatistics & Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Vignarajah M, Berg A, Abdallah Z, Arora N, Javidan A, Pitre T, Fernando SM, Spence J, Centofanti J, Rochwerg B. Intraoperative use of balanced crystalloids versus 0.9% saline: a systematic review and meta-analysis of randomised controlled studies. Br J Anaesth 2023; 131:463-471. [PMID: 37455198 DOI: 10.1016/j.bja.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/29/2023] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The evidence regarding optimal crystalloid use in the perioperative period remains unclear. As the primary aim of this study, we sought to summarise the data from RCTs examining whether use of balanced crystalloids compared with 0.9% saline (saline) leads to differences in patient-important outcomes. METHODS We searched Ovid MEDLINE, Embase, the Cochrane library, and Clinicaltrials.gov, from inception until December 15, 2022, and included RCTs that intraoperatively randomised adult participants to receive either balanced fluids or saline. We pooled data using a random-effects model and present risk ratios (RRs) or mean differences (MDs), along with 95% confidence intervals (CIs). We assessed individual study risk of bias using the modified Cochrane tool, and certainty of evidence using GRADE. RESULTS Of 5959 citations, we included 38 RCTs (n=3776 patients). Pooled analysis showed that intraoperative use of balanced fluids compared with saline had an uncertain effect on postoperative mortality analysed at the longest point of follow-up (RR 1.51, 95% CI: 0.42-5.36) and postoperative need for renal replacement therapy (RR 0.95, 95% CI: 0.56-1.59), both very low certainty. Furthermore, use of balanced crystalloids probably leads to a higher postoperative serum pH (MD 0.05, 95% CI: 0.04-0.06), moderate certainty. CONCLUSIONS Use of balanced crystalloids, compared with saline, in the perioperative setting has an uncertain effect on mortality and need for renal replacement therapy but probably improves postoperative acid-base status. Further research is needed to determine whether balanced crystalloid use affects patient-important outcomes. CLINICAL TRIAL REGISTRATION CRD42022367593.
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Affiliation(s)
| | - Annie Berg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zahra Abdallah
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Naman Arora
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arshia Javidan
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Spence
- Department of Anaesthesia, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John Centofanti
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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ABDULLAH T, GÖKDUMAN HC, ENİŞTE İA, ATASEVER AG, ALİ A, GÜMÜŞ ÖZCAN F. Novel parameters for predicting fluid responsiveness during the mini fluid challenge and ability of the cardiac power index: an observational cohort study. Turk J Med Sci 2023; 53:1224-1233. [PMID: 38813019 PMCID: PMC10763793 DOI: 10.55730/1300-0144.5688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 10/26/2023] [Accepted: 08/26/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim The percentage change in the stroke volume index (SVI) due to the mini fluid challenge (MFC) (MFC-ΔSVI%) is used commonly in daily practice. However, up to 20% of patients remain in the gray zone of this variable. Thus, it was aimed to compare the MFC-ΔSVI% and the percentage change in the cardiac power index (CPI) due to the MFC (MFC-ΔCPI%) with the baseline values of the pulse pressure variation (PPV) and stroke volume variation (SVV) in terms of their abilities to predict fluid responsiveness. Materials and methods The SVI, CPI, SVV, and PPV were recorded before 100 mL of isotonic saline was infused (MFC), after MFC was completed, and after an additional 400 mL of isotonic saline was infused to complete 500 mL of fluid loading (FL). Patients whose SVI increased more than 15% after the FL were defined as fluid responders. Results Sixty-seven patients completed the study and 35 (52%) of them were responders.The areas under the receiver operating characteristics curves for the MFC-ΔSVI% and MFC-ΔCPI% (0.94; 95% CI: 0.86-0.99 and 0.89; 95% CI: 0.79-0.95, respectively) were significantly higher than those for the SVV and PPV (0.63; 95% CI: 0.50-0.75 and 0.55; 95% CI: 0.42-0.67, respectively) (p < 0.001 for all of the comparisons). The gray zone analysis revealed that the MFC-ΔSVI% values of 12 patients were in the gray zone. Of the 12, the MFC-ΔCPI% values of 7 patients were outside of the gray zone. Conclusion Fluid responsiveness can be predicted more accurately using the MFC-ΔSVI% and MFC-ΔCPI% than using the SVV and PPV. Additionally, concomitant use of the MFC-ΔSVI% and MFC-ΔCPI% is recommended, as this approach diminishes the number of patients in the gray zone.
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Affiliation(s)
- Taner ABDULLAH
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
| | - Hürü Ceren GÖKDUMAN
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
| | - İşbara Alp ENİŞTE
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
| | - Ayşe Gülşah ATASEVER
- Department of Anesthesiology, University Hospitals of the KU Leuven, Leuven,
Belgium
| | - Achmet ALİ
- Department of Anesthesiology and Reanimation, İstanbul Medical Faculty, İstanbul University, İstanbul,
Turkiye
| | - Funda GÜMÜŞ ÖZCAN
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
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21
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Kehlet H. Perioperative optimisation programmes - Much evidence but still challenges for implementation. Anaesth Crit Care Pain Med 2023; 42:101265. [PMID: 37290696 DOI: 10.1016/j.accpm.2023.101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Henrik Kehlet
- Section of Surgical Pathophysiology 7621, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
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22
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Basumatary K, Dey S, Neema PK, Mujahid OM, Arora P, Kalbande J. Incidence of postoperative pulmonary congestion as diagnosed by lung ultrasound in surgeries performed under general anaesthesia: A prospective, observational study. Indian J Anaesth 2023; 67:628-632. [PMID: 37601941 PMCID: PMC10436713 DOI: 10.4103/ija.ija_598_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 08/22/2023] Open
Abstract
Background and Aims Administering liberal fluid raises concerns about pulmonary congestion postoperatively. Bedside ultrasonography is a valuable tool for the early detection of pulmonary congestion. In this study, we have used it to ascertain the impact of the duration of surgery and intraoperative fluid volume on the causation of pulmonary congestion. Our objective was to determine the incidence of pulmonary congestion as diagnosed by lung ultrasound in patients undergoing general anaesthesia with varied fluid administration. Methods Seventy participants of American Society of Anesthesiologists physical status I and II, aged between 18 and 60 years, undergoing elective extrathoracic surgeries of over 3 h under general anaesthesia were included. Preoperative lung ultrasound was carried out in all patients, and a postoperative lung ultrasound was carried out at 1 h after extubation. The appearance of three or more "B"-lines was considered positive for lung congestion. Results Significant differences (P < 0.001) were found in the duration of surgery and the appearance of B-lines in the postoperative period. Participants who developed B lines received, on average, 150% more fluid (1148.16 ± 291.79 ml) than those who did not (591.29 ± 398.42 ml) (P = 0.0240). Net fluid balance was also significantly different in patients who developed B lines (P = 0.0014). None of the patients developed symptoms of lung congestion postoperatively. Conclusion Long duration of surgery under general anaesthesia (>3 h) with the administration of large volumes of intraoperative fluid and a large net fluid balance are associated with lung congestion as diagnosed by lung ultrasound.
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Affiliation(s)
- Kartik Basumatary
- Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Samarjit Dey
- Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Praveen K. Neema
- Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Omer M. Mujahid
- Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Prateek Arora
- Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Jitendra Kalbande
- Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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23
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Laou E, Papagiannakis N, Ntalarizou N, Choratta T, Angelopoulou Z, Annousis K, Sakellakis M, Kyriakaki A, Ragias D, Michou A, Chalkias A. The Relation of Calculated Plasma Volume Status to Sublingual Microcirculatory Blood Flow and Organ Injury. J Pers Med 2023; 13:1085. [PMID: 37511698 PMCID: PMC10381119 DOI: 10.3390/jpm13071085] [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: 05/21/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The calculated plasma volume status (cPVS) was validated as a surrogate of intravascular filling. The aim of this study is to assess the cPVS in relation to sublingual perfusion and organ injury. METHODS Pre- and postoperative cPVS were obtained by determining the actual and ideal plasma volume levels in surgical patients. The sublingual microcirculation was assessed using SDF imaging, and we determined the De Backer score, the Consensus Proportion of Perfused Vessels (Consensus PPV), and the Consensus PPV (small). Our primary outcome was the assessment of the distribution of cPVS and its association with intraoperative sublingual microcirculation and postoperative complications. RESULTS The median pre- and postoperative cPVS were -7.25% (IQR -14.29--1.88) and -0.4% (IQR -5.43-6.06), respectively (p < 0.001). The mean intraoperative administered fluid volume was 2.5 ± 2.5 L (1.14 L h-1). No statistically significant correlation was observed between the pre- or postoperative cPVS and sublingual microcirculation variables. Higher preoperative (OR = 1.04, p = 0.098) and postoperative cPVS (OR = 1.057, p = 0.029) were associated with postoperative organ injury and complications (sepsis (30%), anemia (24%), respiratory failure (13%), acute kidney injury (6%), hypotension (6%), stroke (3%)). CONCLUSIONS The calculated PVS was associated with an increased risk of organ injury and complications in this cohort.
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Affiliation(s)
- Eleni Laou
- Department of Anesthesiology, Agia Sophia Children's Hospital, 11527 Athens, Greece
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Nicoletta Ntalarizou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Theodora Choratta
- First Department of Surgery, Metaxa Cancer Hospital, 18537 Piraeus, Greece
| | - Zacharoula Angelopoulou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | | | - Minas Sakellakis
- Department of Medical Oncology, Metropolitan Hospital, 10461 Piraeus, Greece
| | - Aikaterini Kyriakaki
- High Dependency Unit, General Hospital of Syros Vardakeio and Proio, 84100 Syros, Greece
| | - Dimitrios Ragias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Anastasia Michou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Institute for Translational Medicine and Therapeutics, School of Medicine, University of Pennsylvania Perelman, Philadelphia, PA 19104, USA
- Outcomes Research Consortium, Cleveland, OH 44195, USA
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24
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Malbon-Harris R. Perioperative fluid therapy. Br J Hosp Med (Lond) 2023; 84:1-2. [PMID: 37127414 DOI: 10.12968/hmed.2022.0524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Fluids are usually administered perioperatively to maintain euvolaemia and adequate oxygen delivery, but administration of too little or too much fluid can cause problems. This article summarises the current evidence on the type of fluid and volume best administered in the perioperative period.
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Affiliation(s)
- Rupert Malbon-Harris
- Anaesthetic Department, Manchester University NHS Foundation Trust, Manchester, UK
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25
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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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26
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Choi C, Lemmink G, Humanez J. Postoperative Respiratory Failure and Advanced Ventilator Settings. Anesthesiol Clin 2023; 41:141-159. [PMID: 36871996 DOI: 10.1016/j.anclin.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Postoperative respiratory failure has a multifactorial etiology, of which atelectasis is the most common mechanism. Its injurious effects are magnified by surgical inflammation, high driving pressures, and postoperative pain. Chest physiotherapy and noninvasive ventilation are good options to prevent progression of respiratory failure. Acute respiratory disease syndrome is a late and severe finding, which is associated with high morbidity and mortality. If present, proning is a safe, effective, and underutilized therapy. Extracorporeal membrane oxygenation is an option only when traditional supportive measures have failed.
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Affiliation(s)
- Christopher Choi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068, USA.
| | - Gretchen Lemmink
- Department of Anesthesiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0531, USA
| | - Jose Humanez
- Department of Anesthesiology, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, C72, Jacksonville, FL 32209, USA
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27
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Ripollés-Melchor J, Zorrilla-Vaca A, Lorente JV, Weiss R. Is it time to incorporate Kidney Disease Improving Global Outcomes (KDIGO) bundles into Enhanced Recovery After Surgery (ERAS) protocols for colorectal surgery? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:125-128. [PMID: 36842696 DOI: 10.1016/j.redare.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/30/2021] [Indexed: 02/28/2023]
Affiliation(s)
- J Ripollés-Melchor
- Department of Anesthesia and Critical Care, Hospital Universitario Infanta Leonor, Madrid, Spain; Spanish Perioperative Audit and Research Network (REDGERM); Fluid Therapy and Hemodynamic Group of the Hemostasis, Transfusion Medicine and Fluid Therapy Section, Spanish Society of Anesthesia and Critical Care (SEDAR).
| | - A Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J V Lorente
- Fluid Therapy and Hemodynamic Group of the Hemostasis, Transfusion Medicine and Fluid Therapy Section, Spanish Society of Anesthesia and Critical Care (SEDAR); Department of Anesthesia and Critical Care, Juan Ramón Jiménez Hospital, Huelva, Spain
| | - R Weiss
- Department of Anesthesia and Critical Care, Juan Ramón Jiménez Hospital, Huelva, Spain; Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany; Renal Protection Network, RAPNET
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28
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Muangman S, Raksakietisak M, Akavipat P, Rushatamukayanunt P, Akkaworakit S, Romkespikun N, Mahatnirunkul P. Effects of Low versus Intermediate Doses of Dexmedetomidine Infusion on Blood Loss, Hemodynamics, and Operative Time in Transsphenoidal Pituitary Tumor Removal: A Prospective Randomized Study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2023. [DOI: 10.1055/s-0042-1758747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background Dexmedetomidine, an alpha-2 agonist, has been widely used as an anesthetic adjunct for transsphenoidal pituitary resection. However, there is no consensus on the appropriate infusion dosage. This study aimed to compare the effects of low (0.2 mcg/kg/h) and intermediate (0.5 mcg/kg/h) dexmedetomidine infusions during anesthetic maintenance on blood loss, hemodynamics, and operating time.
Methods A randomized controlled trial involving two centers was conducted. Between December 2015 and November 2019, 80 patients (40 in each group) who underwent elective transsphenoidal pituitary tumor resection were recruited. Dexmedetomidine was administered to group I at a loading dose of 0.5 mcg/kg, followed by 0.2 mcg/kg/h, and to group II at the same loading dose, followed by 0.5 mcg/kg/h. Comparative analyses were performed using the Student's t-test, repeated-measures analysis of variance, and Mann–Whitney U test; p-values < 0.05 were considered statistically significant.
Results Eighty patients were analyzed. Patient demographics were comparable. The difference in intraoperative blood loss between both groups (320 [220–525] vs. 250 [100-487] mL, p = 0.070) was not statistically significant. There were no differences in blood pressure or heart rate between the groups. In group II, the procedure took significantly less time (179 vs. 142 minutes, p = 0.018), with more episodes of transient hypotension (p = 0.034).
Conclusion When maintaining anesthesia for transsphenoidal pituitary resection, dexmedetomidine infusions of 0.2 and 0.5 mcg/kg/h showed the same effect on blood loss and hemodynamics; however, significantly more episodes of transient hypotension and shorter operating times were noted with the latter.
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Affiliation(s)
- Saipin Muangman
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manee Raksakietisak
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phuping Akavipat
- Department of Anesthesiology, Neurological Institute of Thailand, Bangkok, Thailand
| | - Pranee Rushatamukayanunt
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirinuttakul Akkaworakit
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natthaporn Romkespikun
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Porntip Mahatnirunkul
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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29
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Rubio-López JD, Durán-Martínez M, Moreno-Blázquez A, Rodríguez-Ortiz L, Rufián-Andújar B, Valenzuela-Molina F, Adam ÁC, Sánchez-Hidalgo JM, Rufián-Peña S, Romero-Ruiz A, Briceño-Delgado J, Arjona-Sánchez Á. Intraoperative metabolic changes associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Langenbecks Arch Surg 2023; 408:34. [PMID: 36648571 PMCID: PMC9845164 DOI: 10.1007/s00423-023-02770-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/01/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) causes considerable hemodynamic, respiratory, and metabolic changes during the perioperative period. OBJECTIVES To evaluate metabolic changes associated with this procedure. Understanding perioperative factors and their association with morbidity may improve the perioperative management of patients undergoing this treatment. METHODS A retrospective review of a prospectively maintained database was performed. All consecutive unselected patients who underwent CRS plus HIPEC between January 2018 and December 2020 (n = 219) were included. RESULTS The mean age was 58 ± 11.7 years and 167 (76.3%) were female. The most frequent histology diagnosis was serous ovarian carcinoma 49.3% (n = 108) and colon carcinoma 36.1% (n = 79). Mean peritoneal cancer index was 14.07 ± 10.47. There were significant variations in pH, lactic acid, sodium, potassium, glycemia, bicarbonate, excess bases, and temperature (p < 0.05) between the pre-HIPEC and post-HIPEC periods. The closed HIPEC technique resulted in higher levels of temperature than the open technique (p < 0.05). Age, potassium level post-HIPEC potassium level, and pre-HIPEC glycemia were identified as prognostic factors for morbidity in multivariate analysis. CONCLUSION The administration of HIPEC after CRS causes significant changes in internal homeostasis. Although the closed technique causes a greater increase in temperature, it is not related to higher morbidity rates. The patient's age, post-HIPEC potassium level, and pre-HIPEC glycemia are predictive factors for morbidity.
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Affiliation(s)
| | - Manuel Durán-Martínez
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain.
| | - Andrea Moreno-Blázquez
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Lidia Rodríguez-Ortiz
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Blanca Rufián-Andújar
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain
| | - Francisca Valenzuela-Molina
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain
| | - Ángela Casado Adam
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Juan M Sánchez-Hidalgo
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Sebastián Rufián-Peña
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Antonio Romero-Ruiz
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - J Briceño-Delgado
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain
| | - Álvaro Arjona-Sánchez
- Unit of Surgical Oncology, Department of Surgery, Reina Sofia University Hospital, Menendez Pidal Av. 14004, Cordoba, Spain.
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain.
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30
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Cihoric M, Kehlet H, Højlund J, Lauritsen ML, Kanstrup K, Foss NB. Perioperative changes in fluid distribution and haemodynamics in acute high-risk abdominal surgery. Crit Care 2023; 27:20. [PMID: 36647120 PMCID: PMC9841944 DOI: 10.1186/s13054-023-04309-9] [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] [Received: 11/02/2022] [Accepted: 01/07/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Understanding the pathophysiology of fluid distribution in acute high-risk abdominal (AHA) surgery is essential in optimizing fluid management. There is currently no data on the time course and haemodynamic implications of fluid distribution in the perioperative period and the differences between the surgical pathologies. METHODS Seventy-three patients undergoing surgery for intestinal obstruction, perforated viscus, and anastomotic leakage within a well-defined perioperative regime, including intraoperative goal-directed therapy, were included in this prospective, observational study. From 0 to 120 h, we measured body fluid volumes and hydration status by bioimpedance spectroscopy (BIA), fluid balance (input vs. output), preload dependency defined as a > 10% increase in stroke volume after preoperative fluid challenge, and post-operatively evaluated by passive leg raise. RESULTS We observed a progressive increase in fluid balance and extracellular volume throughout the study, irrespective of surgical diagnosis. BIA measured variables indicated post-operative overhydration in 36% of the patients, increasing to 50% on the 5th post-operative day, coinciding with a progressive increase of preload dependency, from 12% immediately post-operatively to 58% on the 5th post-operative day and irrespective of surgical diagnosis. Patients with overhydration were less haemodynamically stable than those with normo- or dehydration. CONCLUSION Despite increased fluid balance and extracellular volumes, preload dependency increased progressively during the post-operative period. Our observations indicate a post-operative physiological incoherence between changes in the extracellular volume compartment and inadequate physiological preload control in patients undergoing AHA surgery. Considering the increasing overhydration during the observational period, our findings show that an indiscriminate correction of preload dependency with intravenous fluid bolus could lead to overhydration. Trial registration clinicaltrials.gov. (NCT03997721), Registered 23 May 2019, first participant enrolled 01 June 2019.
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Affiliation(s)
- Mirjana Cihoric
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Henrik Kehlet
- grid.475435.4Section for Surgical Pathophysiology, JMC, Rigshospitalet, Copenhagen, Capital Region of Denmark Denmark
| | - Jakob Højlund
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Morten Laksáfoss Lauritsen
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Katrine Kanstrup
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Nicolai Bang Foss
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
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Lin YJ, Lu LY, Tao DQ, Yang ZM. Anesthetic management for cytoreductive surgery of pseudomyxoma peritonei with high intra-abdominal pressure: A case report. Front Surg 2023; 9:1017500. [PMID: 36726956 PMCID: PMC9885852 DOI: 10.3389/fsurg.2022.1017500] [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] [Received: 08/12/2022] [Accepted: 10/25/2022] [Indexed: 01/18/2023] Open
Abstract
Anesthetic management for patients of pseudomyxoma peritonei (PMP) is challenging. This case report describes a patient of PMP with high intra-abdominal pressure. Intubation was performed in lateral position; the intraabdominal pressure was relieved slowly to prevent significant hemodynamic changes. Additionally, positive pressure ventilation was performed to reduce the risk of re-expansion pulmonary edema. During the operation, transfusion and infusion therapy was performed with target-mediated fluid therapy according to stroke volume variation (SVV) and cardiac index (CI) and blood gas analysis.
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Impact of the fluid challenge infusion rate on cardiac stroke volume during major spinal neurosurgery: a prospective single center randomized interventional trial. BMC Anesthesiol 2022; 22:400. [PMID: 36564704 PMCID: PMC9783430 DOI: 10.1186/s12871-022-01945-6] [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] [Received: 09/01/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Fluid therapy, including the choice of a crystalloid or colloid infusion, the execution time of a volume bolus, and the expected volume need of a patient during surgery, varies greatly in clinical practice. Different goal directed fluid protocols have been developed, where fluid boluses guided by dynamic preload parameters are administered within a specific period. OBJECTIVE To study the efficacy of two fluid bolus infusion rates measured by the response of hemodynamic parameters. DESIGN Monocentric randomized controlled interventional trial. SETTING University hospital. PATIENTS Forty patients undergoing elective major spinal neurosurgery in prone position were enrolled, thirty-one were finally analyzed. INTERVENTIONS Patients were randomly assigned to receive 250 ml crystalloid and colloid boluses within 5 min (group 1) or 20 min (group 2) when pulse pressure variation (PPV) exceeded 14%. MAIN OUTCOME MEASURES Changes in stroke volume (SV), mean arterial pressure (MAP), and catecholamine administration. RESULTS Group 1 showed a greater increase in SV (P = 0.031), and MAP (P = 0.014), while group 2 still had higher PPV (P = 0.005), and more often required higher dosages of noradrenalin after fluid administration (P = 0.033). In group 1, fluid boluses improved CI (P < 0.01), SV (P < 0.01), and MAP (P < 0.01), irrespective of whether crystalloids or colloids were used. In group 2, CI and SV did not change, while MAP was slightly increased (P = 0.011) only after colloid infusion. CONCLUSIONS A fluid bolus within 5 min is more effective than those administered within 20 min and should therefore be the primary treatment option. Furthermore, bolus infusions administered within 20 min may result in volume overload without achieving relevant hemodynamic improvements. TRIAL REGISTRATION German Clinical Trials Register: DRKS00022917.
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The Impact of Individualized Hemodynamic Management on Intraoperative Fluid Balance and Hemodynamic Interventions during Spine Surgery in the Prone Position: A Prospective Randomized Trial. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111683. [PMID: 36422222 PMCID: PMC9698539 DOI: 10.3390/medicina58111683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Background and Objectives: The effect of individualized hemodynamic management on the intraoperative use of fluids and other hemodynamic interventions in patients undergoing spinal surgery in the prone position is controversial. This study aimed to evaluate how the use of individualized hemodynamic management based on extended continuous non-invasive hemodynamic monitoring modifies intraoperative hemodynamic interventions compared to conventional hemodynamic monitoring with intermittent non-invasive blood pressure measurements. Methods: Fifty adult patients (American Society of Anesthesiologists physical status I−III) who underwent spinal procedures in the prone position and were then managed with a restrictive fluid strategy were prospectively randomized into intervention and control groups. In the intervention group, individualized hemodynamic management followed a goal-directed protocol based on continuously non-invasively measured blood pressure, heart rate, cardiac output, systemic vascular resistance, and stroke volume variation. In the control group, patients were monitored using intermittent non-invasive blood pressure monitoring, and the choice of hemodynamic intervention was left to the discretion of the attending anesthesiologist. Results: In the intervention group, more hypotensive episodes (3 (2−4) vs. 1 (0−2), p = 0.0001), higher intraoperative dose of ephedrine (0 (0−10) vs. 0 (0−0) mg, p = 0.0008), and more positive fluid balance (680 (510−937) vs. 270 (196−377) ml, p < 0.0001) were recorded. Intraoperative norepinephrine dose and postoperative outcomes did not differ between the groups. Conclusions: Individualized hemodynamic management based on data from extended non-invasive hemodynamic monitoring significantly modified intraoperative hemodynamic management and was associated with a higher number of hemodynamic interventions and a more positive fluid balance.
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Shin J, Suh SW. Influence of fluid balance on postoperative outcomes after hepatic resection in patients with left ventricular diastolic dysfunction. Front Surg 2022; 9:1036850. [PMID: 36468074 PMCID: PMC9709119 DOI: 10.3389/fsurg.2022.1036850] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/31/2022] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE The maintenance of low central venous pressure (CVP) during hepatic resection is associated with a reduction in estimated blood loss. After completion of the hepatic parenchymal transection, fluid is rapidly administered to replace the surgical blood loss and fluid deficit to prevent subsequent organ injury risk. However, this perioperative fluid strategy may influence on the postoperative outcomes of patients with left ventricular diastolic dysfunction (LVDD) who cannot tolerate volume adjustment. METHOD A total of 206 patients with who underwent hepatic resection between March 2015 and February 2021 were evaluated. LVDD was defined according to the American Society of Echocardiography and the European Association of Cardiovascular Imaging 2016 recommendations as LVDD (group A, n = 39), or normal LV diastolic function and indeterminate decision (group B, n = 153). We compared the clinical outcomes of patients between two groups, and then analyzed the risk factors for postoperative complications. RESULT Postoperative acute kidney injury (AKI, 10.3% vs. 1.3%, P = 0.004) and pleural effusion or edema (51.3% vs. 30.1%, P = 0.013) were more common in group A than in group B. Further, creatinine levels from postoperative day 1 to day 7 were significantly higher and daily urine outputs at postoperative day 1 (P = 0.038) and day 2 (P = 0.025) were significantly lower in group A than in group B. LVDD was the only significant risk factor for postoperative AKI after hepatic resection (odds ratio, 10.181; 95% confidence interval, 1.570-66.011, P = 0.015). CONCLUSIONS The rates of renal dysfunction and pulmonary complications after hepatic resection are higher in patients with LVDD than in those with normal LV diastolic function. Thus, these patients require individualized fluid management.
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Affiliation(s)
- Jungho Shin
- Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Suk-Won Suh
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
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Navarro E Lima LH, Papa FDV, Amorim CGD, Guimarães GMN, Alves RL. Perioperative fluid therapy: more questions than definitive answers. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:683-684. [PMID: 36167160 PMCID: PMC9659978 DOI: 10.1016/j.bjane.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Lais Helena Navarro E Lima
- University of Manitoba, Department of Anesthesiology, Pain and Perioperative Medicine, Manitoba, Canada; Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Programa de Pós-Graduação em Anestesiologia, Botucatu, SP, Brazil.
| | - Fábio de Vasconcelos Papa
- St. Michael's Hospital, Department of Anesthesia, Toronto, Canada; University of Toronto, Department of Anesthesiology & Pain Medicine, Toronto, Canada
| | | | | | - Rodrigo Leal Alves
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Programa de Pós-Graduação em Anestesiologia, Botucatu, SP, Brazil; Hospital São Rafael, Salvador, BA, Brazil; Universidade Federal da Bahia, Salvador, BA, Brazil
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Palomba H, Treml RE, Caldonazo T, Katayama HT, Gomes BC, Malbouisson LMS, Silva Junior JM. Intraoperative fluid balance and cardiac surgery-associated acute kidney injury: a multicenter prospective study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:688-694. [PMID: 35917847 PMCID: PMC9659999 DOI: 10.1016/j.bjane.2022.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 05/16/2023]
Abstract
BACKGROUND Recent data suggest the regime of fluid therapy intraoperatively in patients undergoing major surgeries may interfere in patient outcomes. The development of postoperative Acute Kidney Injury (AKI) has been associated with both Restrictive Fluid Balance (RFB) and Liberal Fluid Balance (LFB) during non-cardiac surgery. In patients undergoing cardiac surgery, this influence remains unclear. The study objective was to evaluate the relationship between intraoperative RFB vs. LFB and the incidence of Cardiac-Surgery-Associated AKI (CSA-AKI) and major postoperative outcomes in patients undergoing on-pump Coronary Artery Bypass Grafting (CABG). METHODS This prospective, multicenter, observational cohort study was set at two high-complexity university hospitals in Brazil. Adult patients who required postoperative intensive care after undergoing elective on-pump CABG were allocated to two groups according to their intraoperative fluid strategy (RFB or LFB) with no intervention. RESULTS The primary endpoint was CSA-AKI. The secondary outcomes were in-hospital mortality, cardiovascular complications, ICU Length of Stay (ICU-LOS), and Hospital LOS (H-LOS). After propensity score matching, 180 patients remained in each group. There was no difference in risk of CSA-AKI between the two groups (RR = 1.15; 95% CI, 0.85-1.56, p = 0.36). The in-hospital mortality, H-LOS and cardiovascular complications were higher in the LFB group. ICU-LOS was not significantly different between the two groups. ROCcurve analysis determined a fluid balance above 2500 mL to accurately predict in-hospital mortality. CONCLUSION Patients undergoing on-pump CABG with LFB when compared with patients with RFB present similar CSA-AKI rates and ICU-LOS, but higher in-hospital mortality, cardiovascular complications, and H-LOS.
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Affiliation(s)
- Henrique Palomba
- Hospital Alemão Oswaldo Cruz, Departamento de Medicina Intensiva, São Paulo, SP, Brazil
| | - Ricardo E Treml
- Friedrich-Schiller-University, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
| | - Tulio Caldonazo
- Friedrich-Schiller-University, Department of Cardiothoracic Surgery, Jena, Germany
| | - Henrique T Katayama
- Universidade de São Paulo, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - Brenno C Gomes
- Universidade Federal do Paraná, Departamento de Medicina Integrada, Setor de Ciências da Saúde, Curitiba, PR, Brazil
| | - Luiz M S Malbouisson
- Universidade de São Paulo, Departamento de Anestesiologia, São Paulo, SP, Brazil
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Tankel J, Chayen D, Einav S. Fluid balance following laparotomy for hollow viscus perforation: A study of morbidity and mortality. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Li Q, Dong S, Yan T, Zhao H. Association between intraoperative fluid overload and postoperative debridement in major sacrum tumor resection: A propensity score matching study. Medicine (Baltimore) 2022; 101:e30947. [PMID: 36221393 PMCID: PMC9542569 DOI: 10.1097/md.0000000000030947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Intra-aortic balloon occlusion (IABO) is used to reduce intraoperative bleeding and facilitate successful sacrum tumor resection. Up to 20% of patients experience postoperative wound healing problems, but the risk factors related to this complication have not been clearly defined. The anesthetic database of Peking University People's Hospital, Beijing, China, was searched for all patients (aged 14-70 years old) who underwent sacrum tumor surgery with the application of IABO from 2014 to 2017. Data from 278 patients with an aortic occlusion duration of 72 ± 33 minutes were collected. Fifty-six patients required postoperative debridement because of wound infection. The independent risk factor identified by logistic regression was fluid excess (calculated as volume infused minus blood loss and urine output divided by body weight [kg]), and decision tree analysis revealed that the cutoff point for fluid excess was 38.5 mL/kg. Then patients were then divided into high fluid excess group (fluid excess > 38.5 mL/kg) and low fluid excess group (fluid excess ≤ 38.5 mL/kg) and 91 pairs of patients were generated through propensity score matching (PSM). Fluid excess was significantly higher in the high fluid excess group (46 vs 30 mL/kg, P < .001), and more patients required postoperative debridement than in the low fluid excess group (24 (26.3%) vs 12 (13.1%), P < .001). In this retrospective PSM study on sacrum tumor resection, fluid overload was related to postoperative debridement and further studies are needed to improve the clinical prognosis.
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Affiliation(s)
- Qi Li
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
| | - Sen Dong
- Musculoskeletal Tumor Center, Peking University People’s Hospital, Beijing, China
| | - Taiqiang Yan
- Musculoskeletal Tumor Center, Peking University People’s Hospital, Beijing, China
| | - Hong Zhao
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
- * Correspondence: Hong Zhao, Department of Anesthesiology, Peking University People’s Hospital, #11 Xizhimen South Street, Beijing 100044, China (e-mail: )
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Esfahanian M, Marcott SC, Hopkins E, Burkart B, Khosla RK, Lorenz HP, Wang E, De Souza E, Algaze-Yojay C, Caruso TJ. Enhanced recovery after cleft palate repair: A quality improvement project. Paediatr Anaesth 2022; 32:1104-1112. [PMID: 35929340 DOI: 10.1111/pan.14541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery. AIMS The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery. METHODS A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts. RESULTS Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p < .0001) relative to our historical cohort (n = 63), with a mean difference of -0.33 ± 0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p = .002), with a mean difference of -0.27 ± 0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p = .02) relative to our historical cohort, with a mean difference of -3.81 ± 1.56 h (95% CI -6.9 to -0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes. CONCLUSION Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.
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Affiliation(s)
- Mohammad Esfahanian
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Stephen Craig Marcott
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elena Hopkins
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA
| | - Brendan Burkart
- Center for Pediatric & Maternal Value (CPMV), Lucile Packard Children's Hospital Stanford, Analytics & Clinical Effectiveness, Palo Alto, California, USA
| | - Rohit Kumar Khosla
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA.,Division of Plastic & Reconstructive Surgery, Department of Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - H Peter Lorenz
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA.,Division of Plastic & Reconstructive Surgery, Department of Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ellen Wang
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth De Souza
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Claudia Algaze-Yojay
- Center for Pediatric & Maternal Value (CPMV), Lucile Packard Children's Hospital Stanford, Analytics & Clinical Effectiveness, Palo Alto, California, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Thomas J Caruso
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
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Cunningham C, Tapking C, Salter M, Seeton R, Kramer GC, Prough DS, Sheffield-Moore M, Kinsky MP. The physiologic responses to a fluid bolus administration in old and young healthy adults. Perioper Med (Lond) 2022; 11:30. [PMID: 35971161 PMCID: PMC9380305 DOI: 10.1186/s13741-022-00266-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Organ function is known to decline with age. Optimizing cardiac, pulmonary and renal function in older adults has led to significant improvements in perioperative care. However, when substantial blood loss and fluid shifts occur, perioperative outcomes still remains poor, especially in older adults. We suspect that this could be due to age-related changes in endothelial function-an organ controlling the transport of fluid and solutes. The capillary filtration coefficient (CFC) is an important determinant of fluid transport. The CFC can be measured in vivo, which provides a tool to estimate endothelial barrier function. We have previously shown that the CFC increases when giving a fluid bolus resulting in increased vascular and extravascular volume expansion, in young adults. This study aimed to compare the physiologic determinants of fluid distribution in young versus older adults so that clinicians can best optimize perioperative fluid therapy. METHODS Ten healthy young volunteers (ages 21-35) and nine healthy older volunteers (ages 60-75) received a 10 mL/kg fluid bolus over the course of twenty minutes. Hemodynamics, systolic and diastolic heart function, fluid volumetrics and microcirculatory determinants were measured before, during, and after the fluid bolus. RESULTS Diastolic function was reduced in older versus younger adults before and after fluid bolus (P < 0.01). Basal CFC and plasma oncotic pressure were lower in the older versus younger adults. Further, CFC did not increase in older adults following the fluid bolus, whereas it did in younger adults (p < 0.05). Cumulative urinary output, while lower in older adults, was not significantly different (p = 0.059). Mean arterial pressure and systemic vascular resistance were elevated in the older versus younger adults (p < 0.05). CONCLUSION Older adults show a less reactive CFC to a fluid bolus, which could reduce blood to tissue transport of fluid. Diastolic dysfunction likely contributes to fluid maldistribution in older adults.
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Affiliation(s)
- Cordell Cunningham
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Christian Tapking
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Unfallklinik Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Michael Salter
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Roger Seeton
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - George C Kramer
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Donald S Prough
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | | | - Michael P Kinsky
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA.
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Liu L, McCluskey SA, Law M, Abrahamyan L, Peer M, Tait G, Rao V, Wijeysundera DN, Scales DC, Callum J, Karkouti K, Bartoszko J. Albumin use for fluid resuscitation in cardiac surgical patients: a survey of Canadian perioperative care providers. Can J Anaesth 2022; 69:818-831. [PMID: 35378686 DOI: 10.1007/s12630-022-02237-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/02/2022] [Accepted: 01/26/2022] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the perceptions and practices of Canadian cardiovascular anesthesiologists and intensivists towards intravenous albumin as a resuscitation fluid in patients undergoing cardiac surgery. METHODS We conducted a cross-sectional survey of cardiac anesthesiologists and intensivists involved in the care of cardiac surgical patients. The 22-item survey included seven open-ended questions and assessed practice patterns and attitudes towards albumin. Descriptive statistics were analyzed using counts and proportions. Qualitative data were analyzed to identify themes describing albumin use patterns in Canada. RESULTS A total of 133 respondents from seven provinces participated, with 83 (62%) using albumin perioperatively. The majority of respondents (77%) felt a low fluid balance in cardiac surgical patients was important, and that supplementing crystalloids with albumin was helpful for this objective (67%). There was poor agreement among survey respondents regarding the role of albumin for faster vasopressor weaning or intensive care discharge, and ≥ 90% did not feel albumin reduced mortality, renal injury, or coagulopathy. Nevertheless, cardiac surgical patients were identified as a distinct population where albumin may help to minimize fluid balance. There was an acknowledged paucity of formal evidence supporting possible benefits. Fewer than 10% of respondents could identify institutional or national guidelines for albumin use. A lack of evidence supporting albumin use in cardiac surgical patients, especially those at highest risk of complications, was a frequently identified concern. CONCLUSIONS The majority of Canadian anesthesiologists and intensivists (62%) use albumin in cardiac surgical patients. There is clinical equipoise regarding its utility, and an acknowledged need for higher quality evidence to guide practice.
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Affiliation(s)
- Laura Liu
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael Law
- Department of Anesthesia, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, Royal Columbian Hospital, Fraser Health Authority, Vancouver, BC, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Miki Peer
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Gordon Tait
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivek Rao
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queens University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
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Hahn RG, Olsson J. Diuretic response to Ringer's solution is normal shortly after awakening from general anaesthesia: a retrospective kinetic analysis. BJA OPEN 2022; 2:100013. [PMID: 37588273 PMCID: PMC10430821 DOI: 10.1016/j.bjao.2022.100013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/21/2022] [Indexed: 08/18/2023]
Abstract
Background The elimination of Ringer's solution is severely depressed during general anaesthesia, but the degree to which this continues postoperatively is poorly established. Methods An intravenous infusion of Ringer's acetate solution 20 ml kg-1 was administered over 60 min in 12 patients undergoing laparoscopic cholecystectomy. Population kinetic analysis was performed based on repeated measurements of blood haemoglobin concentration and urinary excretion over 240 min regardless of when the operations were finished. The analysis contrasted the periods before and after awakening from general anaesthesia and compared them with data from 18 volunteers who received the same fluid at the same rate. Results Patients were monitored for approximately 2 h after awakening from general anaesthesia. The rate constant for redistribution of fluid from the extravascular space to the plasma (k21) and the rate constant for urinary excretion (k10) were significantly higher postoperatively than during the surgical period. Computer simulations indicated that urinary excretion after surgery was almost restored to the rate found in the volunteers. In contrast, the redistribution of fluid from the extravascular space to the plasma, which was almost nil during the surgery, showed only limited recovery during the postoperative phase, and was only approximately 10% of the flow rate found in the volunteers. The combination of nearly normalised urinary excretion and lack of adequate return of distributed fluid to the plasma promoted postoperative hypovolaemia. Conclusion The kinetic analysis indicates that plasma volume support should be given during the first 2 h after laparoscopic cholecystectomy.
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Affiliation(s)
- Robert G. Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden
- Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Joel Olsson
- Department of Anaesthesia, Sundsvalls sjukhus, Sundsvall, Sweden
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial. Acta Anaesthesiol Scand 2022; 66:640-650. [PMID: 35124808 DOI: 10.1111/aas.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/10/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction. AIM To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV. METHODS AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol. DISCUSSION The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Rigshospitalet Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
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Sucher R, Schiemanck T, Hau HM, Laudi S, Stehr S, Sucher E, Rademacher S, Seehofer D, Jahn N. Influence of Intraoperative Hemodynamic Parameters on Outcome in Simultaneous Pancreas-Kidney Transplant Recipients. J Clin Med 2022; 11:jcm11071966. [PMID: 35407575 PMCID: PMC8999645 DOI: 10.3390/jcm11071966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 12/19/2022] Open
Abstract
Objectives: Adequate organ perfusion, as well as appropriate blood pressure levels at the time of unclamping, is crucial for early and long-term graft function and outcome in simultaneous pancreas−kidney transplantation (SPKT). However, the optimal intraoperative mean arterial pressure (MAP) level has not well been defined. Methods: From a prospectively collected database, the medical data of 105 patients undergoing SPKT at our center were retrospectively analyzed. A receiver operating characteristic (ROC) analysis was preliminarily performed for optimal cut-off value for MAP at reperfusion, to predict early pancreatic graft function. Due to these results, we divided the patients according to their MAP values at reperfusion into <91 mmHg (n = 47 patients) and >91 mmHg (n = 58 patients) groups. Clinicopathological characteristics and outcomes, as well as early graft function and long-term survival, were retrospectively analyzed. Results: Donor and recipient characteristics were comparable between both groups. Rates of postoperative complications were significantly higher in the <91 mmHg group than those in the >91 mmHg group (vascular thrombosis of the pancreas: 7 (14%) versus 2 (3%); p = 0.03; pancreatitis/intraabdominal abscess: 10 (21%) versus 4 (7%); p = 0.03; renal delayed graft function (DGF): 11 (23%) versus 5 (9%); p = 0.03; postreperfusion urine output: 106 ± 50 mL versus 195 ± 45 mL; p = 0.04). There were no significant differences in intraoperative volume repletion, central venous pressure (CVP), use of vasoactive inotropic agents, and the metabolic outcome. Five-year pancreas graft survival was significantly higher in the >91 mmHg group (>91 mmHg: 82% versus <91 mmHg: 61%; p < 0.01). No significant differences were observed in patient and kidney graft survival at 5 years between both groups. Multivariate Cox regression analysis affirmed MAP < 91 mmHg as an independent prognostic predictor for renal DGF (HR 3.49, 1.1−10.8, p = 0.03) and pancreas allograft failure (HR 2.26, 1.0−4.8, p = 0.01). Conclusions: A MAP > 91 mmHg at the time point of reperfusion was associated with a reduced rate of postoperative complications, enhancing and recovering long-term graft function and outcome and thus increasing long-term survival in SPKT recipients.
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Affiliation(s)
- Robert Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (R.S.); (T.S.); (H.M.H.); (S.R.); (D.S.)
| | - Tina Schiemanck
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (R.S.); (T.S.); (H.M.H.); (S.R.); (D.S.)
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany; (S.L.); (S.S.)
| | - Hans Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (R.S.); (T.S.); (H.M.H.); (S.R.); (D.S.)
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine Carl Gustav Carus, University Hospital, Technische Universität Dresden, 01307 Dresden, Germany
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany; (S.L.); (S.S.)
| | - Sebastian Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany; (S.L.); (S.S.)
| | - Elisabeth Sucher
- Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectiology, University Hospital of Leipzig, 04103 Leipzig, Germany;
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (R.S.); (T.S.); (H.M.H.); (S.R.); (D.S.)
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (R.S.); (T.S.); (H.M.H.); (S.R.); (D.S.)
| | - Nora Jahn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany; (S.L.); (S.S.)
- Correspondence: ; Tel.: +49-(0)341-97-10759; Fax: +49-(0)341-97-17709
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Agerskov M, Sørensen H, Højlund J, Kjær S, Secher NH, Foss NB. The effect of vasoconstriction on intestinal perfusion is determined by preload dependency: A prospective observational study. Acta Anaesthesiol Scand 2022; 66:713-721. [PMID: 35338646 DOI: 10.1111/aas.14059] [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: 10/07/2021] [Revised: 02/21/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effects of vasoconstriction on cardiac stroke volume (SV) and indices of peripheral and intestinal perfusion are insufficiently described. METHODS In a non-randomized clinical study, 30 patients undergoing elective rectal surgery were exposed to modulation of preload. The primary endpoint was intestinal perfusion (flux), measured by single-point laser Doppler flowmetry. Secondary endpoints were central cardiovascular variables obtained by the LiDCO rapid monitor, the peripheral perfusion index (PPI) derived from the pulse oximetry signal and muscle (StO2 ) and cerebral oxygenation (ScO2 ) determined by near-infrared spectroscopy. RESULTS For the whole cohort (n = 30), administration of Phenylephrine during HUT induced a median [IQR] increase in SV by 22% [14-41], p = .003 and in mean arterial pressure (MAP) by 54% [31-62], p < .001, with no change in PPI, StO2 and ScO2 or flux. In patients who were preload dependent during HUT (stroke volume variation; SSV >10%; n = 23), administration of phenylephrine increased SV by 29% [12-43], p = .01 and MAP by 54% [33-63], p < .001, followed by an increase in intestinal perfusion flux by 60% [15-289], p = .05, while PPI, StO2 and ScO2 remained unchanged. For non-preload dependent patients (SSV <10%; n = 7), no changes in hemodynamic indices were seen besides an increase in MAP by 54% [33-58], p = .002. CONCLUSION The reflection of vasoconstrictive modulation of preload in systemic cardiovascular variables and indices of perfusion was dependent on preload responsiveness. Administration of phenylephrine to increase preload did not appear to compromise organ perfusion.
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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
| | - Søren Kjær
- Gastroenterology Surgical Section 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 B. Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
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Abstract
The idea that perioperative outcomes may be improved through the implementation of measures that modify the surgical stress response has been around for several decades. Many techniques have been trialled with varying success. In addition, how the response to modification is measured, what constitutes a positive result and how this translates into clinical practice is the subject of debate. Modification of the stress response is the principal tenet behind the enhanced recovery after surgery (ERAS) movement which has seen the development of guidelines for perioperative care across a variety of surgical specialties bringing with them significant improvements in outcomes.
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Affiliation(s)
- Leigh J S Kelliher
- Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7AS, UK.
| | - Michael Scott
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Surgical Outcomes Research Centre, University College London, London, UK
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French WB, Scott M. Fluid and Hemodynamics. Anesthesiol Clin 2022; 40:59-71. [PMID: 35236583 DOI: 10.1016/j.anclin.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Several components of an Enhanced Recovery After Surgery (ERAS) pathway act to improve and simplify perioperative fluid and hemodynamic therapy. Modern perioperative fluid management has shifted away from the liberal fluid therapy and toward more individualized approaches. Clinical evidence has also emphasized the importance of maintaining adequate mean arterial pressure and avoiding intraoperative hypotension. Goal-directed hemodynamic therapy (GDHT), or the use of cardiac output monitoring to guide fluid and vasopressor use, has been shown to reduce complications, but its role within ERAS pathways is likely best-suited to high-risk patients or those undergoing high-risk procedures. This article reviews the mechanisms by which ERAS pathways aid the provider in hemodynamic management, reviews trends, and evidence regarding fluid and hemodynamic therapy approaches, and provides guidance on the practical implementation of these concepts within ERAS pathways.
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Affiliation(s)
- W Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1250 E Marshall Street, Richmond, VA 23219, USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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van Stein RM, Lok CA, Aalbers AG, H.J.T. de Hingh I, Houwink AP, Stoevelaar HJ, Sonke GS, van Driel WJ. Standardizing HIPEC and perioperative care for patients with ovarian cancer in the Netherlands using a Delphi-based consensus. Gynecol Oncol Rep 2022; 39:100945. [PMID: 35252523 PMCID: PMC8894234 DOI: 10.1016/j.gore.2022.100945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022] Open
Abstract
Implementation of HIPEC for ovarian cancer is ongoing, aiming to offer this treatment to all eligible patients in the Netherlands. Standardization reduces unwanted variation in clinical treatment. We intend to standardize patient selection, technical aspects, and perioperative care of CRS and HIPEC. This consensus study comprised a two-phase modified Delphi approach. Consensus was reached on 82% of items.
Objective Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is standard of care in the Netherlands in patients with stage III epithelial ovarian cancer following interval cytoreductive surgery (CRS). Differences in patient selection, technical aspects, and perioperative management exist between centers performing HIPEC. Standardization aims to reduce unwanted variation in clinical practice. As part of an implementation process, we aimed to standardize perioperative care for patients treated with CRS and HIPEC using a Delphi-based consensus approach. Methods We performed a two-phase modified Delphi method involving a multidisciplinary panel of 40 experts who completed a survey on CRS and HIPEC. During a consensus meeting, survey outcomes and available scientific evidence was discussed. Items without consensus (<75% agreement) were adjusted and evaluated in a second survey. Results Consensus was reached in the first round on 51% of items. After two rounds, consensus was reached on the majority of items (82%) including patient selection, preoperative workup, technical aspects of CRS and HIPEC, and postoperative care. No consensus was reached on the role of HIPEC in rare ovarian cancer types, preoperative bowel preparation, timing to create bowel anastomoses, and manipulation of the perfusate. Conclusions Dutch experts reached consensus on most items regarding interval CRS and HIPEC for ovarian cancer. This consensus study may help to align treatment protocols and to minimize practice variation. Topics without consensus may be put on the research agenda of HIPEC for ovarian cancer.
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