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Wirkus JM, Goss F, David M, Hartmann EK, Fukui K, Schmidtmann I, Wittenmeier E, Pestel GJ, Griemert EV. Changes of pulse wave transit time after haemodynamic manoeuvres in healthy adults: a prospective randomised observational trial (PWTT volunteer study). BJA OPEN 2024; 11:100291. [PMID: 39027721 PMCID: PMC11255098 DOI: 10.1016/j.bjao.2024.100291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/19/2024] [Indexed: 07/20/2024]
Abstract
Background Pulse wave transit time (PWTT) shows promise for monitoring intravascular fluid status intraoperatively. Presently, it is unknown how PWTT mirrors haemodynamic variables representing preload, inotropy, or afterload. Methods PWTT was measured continuously in 24 adult volunteers. Stroke volume was assessed by transthoracic echocardiography. Volunteers underwent four randomly assigned manoeuvres: 'Stand-up' (decrease in preload), passive leg raise (increase in preload), a 'step-test' (adrenergic stimulation), and a 'Valsalva manoeuvre' (increase in intrathoracic pressure). Haemodynamic measurements were performed before and 1 and 5 min after completion of each manoeuvre. Correlations between PWTT and stroke volume were analysed using the Pearson correlation coefficient. Results 'Stand-up' caused an immediate increase in PWTT (mean change +55.9 ms, P-value <0.0001, 95% confidence interval 46.0-65.7) along with an increase in mean arterial pressure and heart rate and a drop in stroke volume (P-values <0.0001). Passive leg raise caused an immediate drop in PWTT (mean change -15.4 ms, P-value=0.0024, 95% confidence interval -25.2 to -5.5) along with a decrease in mean arterial pressure (P-value=0.0052) and an increase in stroke volume (P-value=0.001). After 1 min, a 'step-test' caused no significant change in PWTT measurements (P-value=0.5716) but an increase in mean arterial pressure and heart rate (P-values <0.0001), without changes in stroke volume (P-value=0.1770). After 5 min, however, PWTT had increased significantly (P-value <0.0001). Measurements after the Valsalva manoeuvre caused heterogeneous results. Conclusion Noninvasive assessment of PWTT shows promise to register immediate preload changes in healthy adults. The clinical usefulness of PWTT may be hampered by late changes because of reasons different from fluid shifts. Clinical trial registration German clinical trial register (DRKS, ID: DRKS00031978, https://www.drks.de/DRKS00031978).
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Affiliation(s)
- Johannes M. Wirkus
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Fabienne Goss
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Matthias David
- Department of Anaesthesiology, Marienhaus Hospital, Mainz, Germany
| | - Erik K. Hartmann
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Kimiko Fukui
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Eva Wittenmeier
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Gunther J. Pestel
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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Niu W, Li J, Wang S. The Effect of Colloids versus Crystalloids for Goal-Directed Fluid Therapy on Prognosis in Patients Undergoing Noncardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. Anesthesiol Res Pract 2024; 2024:4386447. [PMID: 38938262 PMCID: PMC11211012 DOI: 10.1155/2024/4386447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 06/29/2024] Open
Abstract
Background Goal-directed fluid therapy (GDFT) contributes to improvements in intraoperative fluid infusion based on objective parameters and has been widely recommended in clinical practice. In addition, increasing evidence reveals that GDFT can improve the prognosis of surgical patients. However, considering the individual characteristics of colloids and crystalloids in clinical use, it is uncertain as to which type of fluids administered is associated with better outcomes in the condition of GDFT. Objectives To evaluate the effect of colloids versus crystalloids under GDFT on prognosis in patients undergoing noncardiac surgery. Data Sources. Randomized controlled trials (RCTs) from PubMed, EMBASE, Ovid MEDLINE, CNKI, Cochrane library, and reference lists of relevant articles. Methods Two investigators independently screened and reviewed studies for inclusion and performed data extraction. Our primary outcome was a composite of postoperative complications. The secondary outcomes were (1) mortality at the follow-up duration; (2) postoperative complications of several organ systems, including cardiac, pulmonary, digestive, urinary, nervous system, and postoperative infection events; and (3) hospital and ICU length of stay. Heterogeneity was assessed by the I 2 and chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data. Results Of 332 articles retrieved, 15 RCTs (involving 2,956 patients undergoing noncardiac surgery) were included in the final analysis. When the data were pooled, patients in the colloids and crystalloids group revealed no difference in postoperative composite complications (OR = 0.84, 95% CI = 0.51-1.38, P=0.49) under GDFT. Regarding the secondary outcomes, patients in the colloids group were associated with fewer digestive system complications (OR = 0.64, 95% CI = 0.41-0.98, P=0.04). However, no difference was found in mortality (OR = 1.37, 95% CI = 0.72-2.58, P=0.34), complications of the cardiac system (OR = 1.49, 95% CI = 0.66-3.37, P=0.34), pulmonary system (OR = 0.89, 95% CI = 0.62-1.28, P=0.53), urinary system (OR = 1.05, 95% CI = 0.61-1.80, P=0.87), nervous system (OR = 1.04, 95% CI = 0.55-1.98, P=0.90), postoperative infection events (OR = 0.89, 95% CI = 0.75-1.07, P=0.22), length of hospital stay (difference in mean = -0.71, 95% CI = -1.49-0.07, P=0.07), and ICU stay (difference in mean = -0.01, 95% CI = -0.20-0.18, P=0.95) between patients receiving GDFT with colloids or crystalloids. Conclusion There is no evidence of a benefit in using colloids over crystalloids under GDFT in patients undergoing noncardiac surgery, despite its use resulting in lower digestive system complications.
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Affiliation(s)
- Wang Niu
- Department of Anesthesiology, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Junyi Li
- Department of Anesthesia Operating Center, West China Hospital, Sichuan University, West China School of Nursing, Chengdu, China
| | - Shouping Wang
- Department of Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, China
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Mladinov D, Isaza E, Gosling AF, Clark AL, Kukreja J, Brzezinski M. Perioperative Fluid Management. Anesthesiol Clin 2023; 41:613-629. [PMID: 37516498 DOI: 10.1016/j.anclin.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the elderly are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the elderly. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, CWN-L1, Boston, MA 02115, USA
| | - Erin Isaza
- University of California, San Francisco, School of Medicine, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Andre F Gosling
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845D, Birmingham, AL 35249, USA
| | - Adrienne L Clark
- Department of Anesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Marek Brzezinski
- Department of Anesthesia and Perioperative Care, University of California, VA Medical Center-San Francisco, 4150 Clement Street, San Francisco CA 94121, USA.
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Fukui K, Wirkus JM, Hartmann EK, Schmidtmann I, Pestel GJ, Griemert EV. Non-invasive assessment of Pulse Wave Transit Time (PWTT) is a poor predictor for intraoperative fluid responsiveness: a prospective observational trial (best-PWTT study). BMC Anesthesiol 2023; 23:60. [PMID: 36849887 PMCID: PMC9969649 DOI: 10.1186/s12871-023-02016-0] [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: 10/31/2022] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Aim of this study is to test the predictive value of Pulse Wave Transit Time (PWTT) for fluid responsiveness in comparison to the established fluid responsiveness parameters pulse pressure (ΔPP) and corrected flow time (FTc) during major abdominal surgery. METHODS Forty patients undergoing major abdominal surgery were enrolled with continuous monitoring of PWTT (LifeScope® Modell J BSM-9101 Nihon Kohden Europe GmbH, Rosbach, Germany) and stroke volume (Esophageal Doppler Monitoring CardioQ-ODM®, Deltex Medical Ltd, Chichester, UK). In case of hypovolemia (difference in pulse pressure [∆PP] ≥ 9%, corrected flow time [FTc] ≤ 350 ms) a fluid bolus of 7 ml/kg ideal body weight was administered. Receiver operating characteristics (ROC) curves and corresponding areas under the curve (AUCs) were used to compare different methods of determining PWTT. A Wilcoxon test was used to discriminate fluid responders (increase in stroke volume of ≥ 10%) from non-responders. The predictive value of PWTT for fluid responsiveness was compared by testing for differences between ROC curves of PWTT, ΔPP and FTc using the methods by DeLong. RESULTS AUCs (area under the ROC-curve) to predict fluid responsiveness for PWTT-parameters were 0.61 (raw c finger Q), 0.61 (raw c finger R), 0.57 (raw c ear Q), 0.53 (raw c ear R), 0.54 (raw non-c finger Q), 0.52 (raw non-c finger R), 0.50 (raw non-c ear Q), 0.55 (raw non-c ear R), 0.63 (∆ c finger Q), 0.61 (∆ c finger R), 0.64 (∆ c ear Q), 0.66 (∆ c ear R), 0.59 (∆ non-c finger Q), 0.57 (∆ non-c finger R), 0.57 (∆ non-c ear Q), 0.61 (∆ non-c ear R) [raw measurements vs. ∆ = respiratory variation; c = corrected measurements according to Bazett's formula vs. non-c = uncorrected measurements; Q vs. R = start of PWTT-measurements with Q- or R-wave in ECG; finger vs. ear = pulse oximetry probe location]. Hence, the highest AUC to predict fluid responsiveness by PWTT was achieved by calculating its respiratory variation (∆PWTT), with a pulse oximeter attached to the earlobe, using the R-wave in ECG, and correction by Bazett's formula (AUC best-PWTT 0.66, 95% CI 0.54-0.79). ∆PWTT was sufficient to discriminate fluid responders from non-responders (p = 0.029). No difference in predicting fluid responsiveness was found between best-PWTT and ∆PP (AUC 0.65, 95% CI 0.51-0.79; p = 0.88), or best-PWTT and FTc (AUC 0.62, 95% CI 0.49-0.75; p = 0.68). CONCLUSION ΔPWTT shows poor ability to predict fluid responsiveness intraoperatively. Moreover, established alternatives ΔPP and FTc did not perform better. TRIAL REGISTRATION Prior to enrolement on clinicaltrials.gov (NC T03280953; date of registration 13/09/2017).
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Affiliation(s)
- Kimiko Fukui
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Johannes M Wirkus
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Erik K Hartmann
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics Medical (IMBEI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Gunther J Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany.
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Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review. J Clin Med 2022; 11:jcm11123435. [PMID: 35743505 PMCID: PMC9225521 DOI: 10.3390/jcm11123435] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 02/01/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.
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Teixeira-Neto FJ, Valverde A. Clinical Application of the Fluid Challenge Approach in Goal-Directed Fluid Therapy: What Can We Learn From Human Studies? Front Vet Sci 2021; 8:701377. [PMID: 34414228 PMCID: PMC8368984 DOI: 10.3389/fvets.2021.701377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Resuscitative fluid therapy aims to increase stroke volume (SV) and cardiac output (CO) and restore/improve tissue oxygen delivery in patients with circulatory failure. In individualized goal-directed fluid therapy (GDFT), fluids are titrated based on the assessment of responsiveness status (i.e., the ability of an individual to increase SV and CO in response to volume expansion). Fluid administration may increase venous return, SV and CO, but these effects may not be predictable in the clinical setting. The fluid challenge (FC) approach, which consists on the intravenous administration of small aliquots of fluids, over a relatively short period of time, to test if a patient has a preload reserve (i.e., the relative position on the Frank-Starling curve), has been used to guide fluid administration in critically ill humans. In responders to volume expansion (defined as individuals where SV or CO increases ≥10–15% from pre FC values), FC administration is repeated until the individual no longer presents a preload reserve (i.e., until increases in SV or CO are <10–15% from values preceding each FC) or until other signs of shock are resolved (e.g., hypotension). Even with the most recent technological developments, reliable and practical measurement of the response variable (SV or CO changes induced by a FC) has posed a challenge in GDFT. Among the methods used to evaluate fluid responsiveness in the human medical field, measurement of aortic flow velocity time integral by point-of-care echocardiography has been implemented as a surrogate of SV changes induced by a FC and seems a promising non-invasive tool to guide FC administration in animals with signs of circulatory failure. This narrative review discusses the development of GDFT based on the FC approach and the response variables used to assess fluid responsiveness status in humans and animals, aiming to open new perspectives on the application of this concept to the veterinary field.
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Affiliation(s)
- Francisco José Teixeira-Neto
- Departmento de Cirurgia Veterinária e Reprodução Animal, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, Brazil
| | - Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Semiz B, Carek AM, Johnson JC, Ahmad S, Heller JA, Vicente FG, Caron S, Hogue CW, Etemadi M, Inan OT. Non-Invasive Wearable Patch Utilizing Seismocardiography for Peri-Operative Use in Surgical Patients. IEEE J Biomed Health Inform 2021; 25:1572-1582. [PMID: 33090962 PMCID: PMC8189504 DOI: 10.1109/jbhi.2020.3032938] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Optimizing peri-operative fluid management has been shown to improve patient outcomes and the use of stroke volume (SV) measurement has become an accepted tool to guide fluid therapy. The Transesophageal Doppler (TED) is a validated, minimally invasive device that allows clinical assessment of SV. Unfortunately, the use of the TED is restricted to the intra-operative setting in anesthetized patients and requires constant supervision and periodic adjustment for accurate signal quality. However, post-operative fluid management is also vital for improved outcomes. Currently, there is no device regularly used in clinics that can track patient's SV continuously and non-invasively both during and after surgery. METHODS In this paper, we propose the use of a wearable patch mounted on the mid-sternum, which captures the seismocardiogram (SCG) and electrocardiogram (ECG) signals continuously to predict SV in patients undergoing major surgery. In a study of 12 patients, hemodynamic data was recorded simultaneously using the TED and wearable patch. Signal processing and regression techniques were used to derive SV from the signals (SCG and ECG) captured by the wearable patch and compare it to values obtained by the TED. RESULTS The results showed that the combination of SCG and ECG contains substantial information regarding SV, resulting in a correlation and median absolute error between the predicted and reference SV values of 0.81 and 7.56 mL, respectively. SIGNIFICANCE This work shows promise for the proposed wearable-based methodology to be used as an alternative to TED for continuous patient monitoring and guiding peri-operative fluid management.
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2021; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
- Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Mukai A, Suehiro K, Kimura A, Tanaka K, Yamada T, Mori T, Nishikawa K. Effect of Systemic Vascular Resistance on the Reliability of Noninvasive Hemodynamic Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1782-1791. [PMID: 33279380 DOI: 10.1053/j.jvca.2020.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/31/2020] [Accepted: 11/06/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the effect of systemic vascular resistance (SVR) on the reliability of the ClearSight system (Edwards Lifesciences, Irvine, CA) for measuring blood pressure (BP) and cardiac output (CO). DESIGN Observational study. SETTING University hospital. PARTICIPANTS Twenty-five patients undergoing cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS BP, measured using ClearSight and an arterial line, and CO, measured using ClearSight and a pulmonary artery catheter, were recorded before (T1) and two minutes after phenylephrine or ephedrine administration. Bland-Altman analysis was used to compare BP and CO measurements at T1. A polar plot was used to assess trending abilities. Patients were divided into the following three groups according to the SVR index (SVRI) at T1: low (<1,200 dyne s/cm5/m2), normal (1,200-25,00 dyne s/cm5/m2), and high (>2,500 dyne s/cm5/m2). The bias in BP and CO was -4.8 ± 8.9 mmHg and 0.10 ± 0.81 L/min, respectively, which was correlated significantly with SVRI (p < 0.05). The percentage error in CO was 40.6%, which was lower in the normal SVRI group (33.3%) than the low and high groups (46.3% and 47.7%, respectively). The angular concordance rate was 96.3% and 95.4% for BP and 87.0% and 92.5% for CO after phenylephrine and ephedrine administration, respectively. There was a low tracking ability for CO changes after phenylephrine administration in the low-SVRI group (angular concordance rate 33.3%). CONCLUSION The ClearSight system showed an acceptable accuracy in measuring BP and tracking BP changes in various SVR states; however, the accuracy of CO measurement and its trending ability in various SVR states was poor.
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Affiliation(s)
- Akira Mukai
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan
| | - Koichi Suehiro
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan.
| | - Aya Kimura
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan
| | - Katsuaki Tanaka
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan
| | - Tokuhiro Yamada
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan
| | - Takashi Mori
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan
| | - Kiyonobu Nishikawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan
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Heming N, Moine P, Coscas R, Annane D. Perioperative fluid management for major elective surgery. Br J Surg 2020; 107:e56-e62. [PMID: 31903587 DOI: 10.1002/bjs.11457] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adequate fluid balance before, during and after surgery may reduce morbidity. This review examines current concepts surrounding fluid management in major elective surgery. METHOD A narrative review was undertaken following a PubMed search for English language reports published before July 2019 using the terms 'surgery', 'fluids', 'fluid therapy', 'colloids', 'crystalloids', 'albumin', 'starch', 'saline', 'gelatin' and 'goal directed therapy'. Additional reports were identified by examining the reference lists of selected articles. RESULTS Fluid therapy is a cornerstone of the haemodynamic management of patients undergoing major elective surgery. Both fluid overload and hypovolaemia are deleterious during the perioperative phase. Zero-balance fluid therapy should be aimed for. In high-risk patients, individualized haemodynamic management should be titrated through the use of goal-directed therapy. The optimal type of fluid to be administered during major surgery remains to be determined. CONCLUSION Perioperative fluid management is a key challenge during major surgery. Individualized volume optimization by means of goal-directed therapy is warranted during high-risk surgery. In most patients, balanced crystalloids are the first choice of fluids to be used in the operating theatre. Additional research on the optimal type of fluid for use during major surgery is needed.
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Affiliation(s)
- N Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
| | - P Moine
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
| | - R Coscas
- Department of Vascular Surgery, Ambroise Paré Hospital, GHU APHP University Paris-Saclay, Boulogne-Billancourt, France.,U1018, Centre de Recherche en Épidémiologie et Santé des Populations, UVSQ and University Paris-Saclay, Villejuif, France
| | - D Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
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Porhomayon J, Pourafkari L, Mahmoodpoor A, Nader ND. The utilization spectrum of cardiac output monitoring devices among anesthesiology programs across Veterans Health Administration in the United States. Ann Card Anaesth 2020; 22:199-203. [PMID: 30971603 PMCID: PMC6489392 DOI: 10.4103/aca.aca_107_18] [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: 11/04/2022] Open
Abstract
Background Electronic monitoring of physiologic variables has gained widespread support over the past decade for critical patients in the intensive care setting. Specifically, anesthesiologists have increased the emphasis and practice of hemodynamic control through monitoring cardiac output (CO). However, these physicians are presented with several options in terms of how they wish to study the trend of this physiologic parameter. Materials and Methods A survey was distributed to 250 general and subspecialty-trained anesthesiologists. A series of questions were presented in terms of preference of patient monitoring methods requiring yes or no answers. Anesthesiologists were asked about subspecialty training, years since residency graduation, and preferences toward specific hemodynamic monitoring tools. Nonparametric statistical analysis and Chi-squared tests were used to analyze both normal and nonnormally distributed data. Results CO monitoring devices were implemented by 106 out of 133 anesthesiologists, with 98 of these physicians utilizing CO monitoring for fluid and vasopressors response. Of the physicians implementing a monitoring device, 48 out of 107 physicians preferred pulmonary artery catheter, while pulse contour analysis was preferred by 17 anesthesiologists. An echocardiography unit was available to the department for 90 anesthesiologists, and 77 anesthesiologists were trained to use this technology for monitoring cardiac function. Conclusion Many anesthesiologists have placed emphasis on the importance of CO monitoring within the intensive care setting. However, physicians are still faced with multiple options in terms of how they wish to specifically monitor this hemodynamic variable. Factors that influence such decisions include the time of physician's residency training along with patient and clinical case characteristics.
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Affiliation(s)
| | | | - Ata Mahmoodpoor
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nader D Nader
- Department of Anesthesiology, SUNY-Buffalo, Buffalo, NY, USA
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Milam AJ, Ghoddoussi F, Lucaj J, Narreddy S, Kumar N, Reddy V, Hakim J, Krishnan SH. Comparing the Mutual Interchangeability of ECOM, FloTrac/Vigileo, 3D-TEE, and ITD-PAC Cardiac Output Measuring Systems in Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2020; 35:514-529. [PMID: 32622708 DOI: 10.1053/j.jvca.2020.03.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study was to compare the mutual interchangeability of 4 cardiac output measuring devices by comparing their accuracy, precision, and trending ability. DESIGN A single-center prospective observational study. DESIGN Nonuniversity teaching hospital, single center. PARTICIPANTS Forty-four consecutive patients scheduled for elective, nonemergent coronary artery bypass grafting (CABG). INTERVENTIONS The cardiac output was measured for each participant using 4 methods: intermittent thermodilution via pulmonary artery catheter (ITD-PAC), Endotracheal Cardiac Output Monitor (ECOM), FloTrac/Vigileo System (FLOTRAC), and 3-dimensional transesophageal echocardiography (3D-TEE). MEASUREMENTS AND MAIN RESULTS Measurements were performed simultaneously at 5 time points: presternotomy, poststernotomy, before cardiopulmonary bypass, after cardiopulmonary bypass, and after sternal closure. A series of statistical and comparison analyses including ANOVA, Pearson correlation, Bland-Altman plots, quadrant plots, and polar plots were performed, and inherent precision for each method and percent errors for mutual interchangeability were calculated. For the 6 two-by-two comparisons of the methods, the Pearson correlation coefficients (r), the percentage errors (% error), and concordance ratios (CR) were as follows: ECOM_versus_ITD-PAC (r = 0.611, % error = 53%, CR = 75%); FLOTRAC_versus_ITD-PAC (r = 0.676, % error = 49%, CR = 77%); 3D-TEE versus ITD-PAC (r = 0.538, % error = 64%, CR = 67%); FLOTRAC_versus_ECOM (r = 0.627, % error = 51%, CR = 75%); 3D-TEE_versus ECOM (r = 0.423, % error = 70%, CR = 60%), and 3D-TEE_versus_FLOTRAC (r = 0.602, % error = 59%, CR = 61%). CONCLUSIONS Based on the recommended statistical measures of interchangeability, ECOM, FLOTRAC, and 3D-TEE are not interchangeable with each other or to the reference standard invasive ITD-PAC method in patients undergoing nonemergent cardiac bypass surgery. Despite the negative result in this study and the majority of previous studies, these less-invasive methods of CO have continued to be used in the hemodynamic management of patients. Each device has its own distinct technical features and inherent limitations; it is clear that no single device can be used universally for all patients. Therefore, different methods or devices should be chosen based on individual patient conditions, including the degree of invasiveness, measurement performance, and the ability to provide real-time, continuous CO readings.
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Affiliation(s)
- Adam J Milam
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Farhad Ghoddoussi
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI
| | - Jon Lucaj
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Spurthy Narreddy
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Nakul Kumar
- Department of Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Vennela Reddy
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Joffer Hakim
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Sandeep H Krishnan
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI.
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Kobe J, Mishra N, Arya VK, Al-Moustadi W, Nates W, Kumar B. Cardiac output monitoring: Technology and choice. Ann Card Anaesth 2020; 22:6-17. [PMID: 30648673 PMCID: PMC6350438 DOI: 10.4103/aca.aca_41_18] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The accurate quantification of cardiac output (CO) is given vital importance in modern medical practice, especially in high-risk surgical and critically ill patients. CO monitoring together with perioperative protocols to guide intravenous fluid therapy and inotropic support with the aim of improving CO and oxygen delivery has shown to improve perioperative outcomes in high-risk surgical patients. Understanding of the underlying principles of CO measuring devices helps in knowing the limitations of their use and allows more effective and safer utilization. At present, no single CO monitoring device can meet all the clinical requirements considering the limitations of diverse CO monitoring techniques. The evidence for the minimally invasive CO monitoring is conflicting; however, different CO monitoring devices may be used during the clinical course of patients as an integrated approach based on their invasiveness and the need for additional hemodynamic data. These devices add numerical trend information for anesthesiologists and intensivists to use in determining the most appropriate management of their patients and at present, do not completely prohibit but do increasingly limit the use of the pulmonary artery catheter.
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Affiliation(s)
- Jeff Kobe
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Nitasha Mishra
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra K Arya
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Waiel Al-Moustadi
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Wayne Nates
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Bhupesh Kumar
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Perioperative Fluid Administration in Pancreatic Surgery: a Comparison of Three Regimens. J Gastrointest Surg 2020; 24:569-577. [PMID: 30945088 DOI: 10.1007/s11605-019-04166-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Optimization of perioperative fluid management is a controversial issue. Weight-adjusted, fixed fluid strategies do not take into account patient hemodynamic status, so that individualized strategies guided by relevant variables may be preferable. We studied this issue in patients undergoing pancreatic surgery within our institution. METHODS All patients who underwent a laparotomy for pancreatic cancer during a 5-month period at our hospital (AOUI of Verona, Italy) were eligible to be included in this prospective, observational study. According to the responsible anesthesiologist's free choice, patients received, during surgery, either liberal (12 ml/kg/h) or restricted (4 ml/kg/h) fixed-volume weight-guided replacement fluids or goal-directed (GD) fluid replacement using stroke volume variation (SVV) determined by the FloTrac Vigileo device. RESULTS Eighty-six patients were included: 29 in the liberal group, 23 in the restricted group, and 34 in the GD group. The mean duration of surgery was 6 [4-7] h. Patients in the liberal group received more perioperative fluid than those in the GD and restricted groups. Nearly one third of all patients had a major complication, including delayed enteral feeding, and presented a longer duration of hospital stay. Despite the biases related to our limited cohort, there were significantly fewer postoperative complications (such as postoperative fistula, abdominal collection, and hemorrhage) in the restricted and GD groups of patients than in the liberal one. CONCLUSION In patients undergoing pancreatic surgery, a restricted or individually guided GD strategy for management of perioperative fluids can result in fewer complications than a liberal fluid strategy. Larger and randomized investigations are warranted to confirm these data on this domain.
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Pestel G, Fukui K, Higashi M, Schmidtmann I, Werner C. [Meta-analyses on measurement precision of non-invasive hemodynamic monitoring technologies in adults]. Anaesthesist 2019; 67:409-425. [PMID: 29789877 DOI: 10.1007/s00101-018-0452-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An ideal non-invasive monitoring system should provide accurate and reproducible measurements of clinically relevant variables that enables clinicians to guide therapy accordingly. The monitor should be rapid, easy to use, readily available at the bedside, operator-independent, cost-effective and should have a minimal risk and side effect profile for patients. An example is the introduction of pulse oximetry, which has become established for non-invasive monitoring of oxygenation worldwide. A corresponding non-invasive monitoring of hemodynamics and perfusion could optimize the anesthesiological treatment to the needs in individual cases. In recent years several non-invasive technologies to monitor hemodynamics in the perioperative setting have been introduced: suprasternal Doppler ultrasound, modified windkessel function, pulse wave transit time, radial artery tonometry, thoracic bioimpedance, endotracheal bioimpedance, bioreactance, and partial CO2 rebreathing have been tested for monitoring cardiac output or stroke volume. The photoelectric finger blood volume clamp technique and respiratory variation of the plethysmography curve have been assessed for monitoring fluid responsiveness. In this manuscript meta-analyses of non-invasive monitoring technologies were performed when non-invasive monitoring technology and reference technology were comparable. The primary evaluation criterion for all studies screened was a Bland-Altman analysis. Experimental and pediatric studies were excluded, as were all studies without a non-invasive monitoring technique or studies without evaluation of cardiac output/stroke volume or fluid responsiveness. Most studies found an acceptable bias with wide limits of agreement. Thus, most non-invasive hemodynamic monitoring technologies cannot be considered to be equivalent to the respective reference method. Studies testing the impact of non-invasive hemodynamic monitoring technologies as a trend evaluation on outcome, as well as studies evaluating alternatives to the finger for capturing the raw signals for hemodynamic assessment, and, finally, studies evaluating technologies based on a flow time measurement are current topics of clinical research.
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Affiliation(s)
- G Pestel
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - K Fukui
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - M Higashi
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - I Schmidtmann
- Institut für Medizinische Biometrie, Epidemiologie und Informatik (IMBEI), Universitätsmedizin Mainz, Mainz, Deutschland
| | - C Werner
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis. Eur J Anaesthesiol 2019; 35:469-483. [PMID: 29369117 DOI: 10.1097/eja.0000000000000778] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Much uncertainty exists as to whether peri-operative goal-directed therapy is of benefit. OBJECTIVES To discover if peri-operative goal-directed therapy decreases mortality and morbidity in adult surgical patients. DESIGN An updated systematic review and random effects meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase and the Cochrane Library were searched up to 31 December 2016. ELIGIBILITY CRITERIA Randomised controlled trials enrolling adult surgical patients allocated to receive goal-directed therapy or standard care were eligible for inclusion. Trauma patients and parturients were excluded. Goal-directed therapy was defined as fluid and/or vasopressor therapy titrated to haemodynamic goals [e.g. cardiac output (CO)]. Outcomes included mortality, morbidity and hospital length of stay. Risk of bias was assessed using Cochrane methodology. RESULTS Ninety-five randomised trials (11 659 patients) were included. Only four studies were at low risk of bias. Modern goal-directed therapy reduced mortality compared with standard care [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.50 to 0.87; number needed to treat = 59; N = 52; I = 0.0%]. In subgroup analysis, there was no mortality benefit for fluid-only goal-directed therapy, cardiac surgery patients or nonelective surgery. Contemporary goal-directed therapy also reduced pneumonia (OR 0.69; 95% CI, 0.51 to 0. 92; number needed to treat = 38), acute kidney injury (OR 0. 73; 95% CI, 0.58 to 0.92; number needed to treat = 29), wound infection (OR 0.48; 95% CI, 0.37 to 0.63; number needed to treat = 19) and hospital length of stay (days) (-0.90; 95% CI, -1.32 to -0.48; I = 81. 2%). No important differences in outcomes were found for the pulmonary artery catheter studies, after accounting for advances in the standard of care. CONCLUSION Peri-operative modern goal-directed therapy reduces morbidity and mortality. Importantly, the quality of evidence was low to very low (e.g. Grading of Recommendations, Assessment, Development and Evaluation scoring), and there was much clinical heterogeneity among the goal-directed therapy devices and protocols. Additional well designed and adequately powered trials on peri-operative goal-directed therapy are necessary.
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Best practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring. Best Pract Res Clin Anaesthesiol 2019; 33:139-153. [PMID: 31582094 DOI: 10.1016/j.bpa.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.
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Omesiete N, Martinez C, Pandit V, Villalvazo Y, Jecius H, Thompson E, Norcera M, Nfonsam V. Restricting Intraoperative Fluid Volume Allows Earlier Return of Bowel Function After Colon and Rectal Surgery. J Surg Res 2019; 244:130-135. [PMID: 31284142 DOI: 10.1016/j.jss.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/17/2019] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Return of bowel function (ROBF) after abdominal surgery is an important determinant of patient outcomes. The role of intraoperative fluids (IOFs) in colon surgery remains unclear. The aim of this study was to assess the impact of IOF on ROBF in patients undergoing colon surgery. We hypothesized that minimizing IOFs allows earlier ROBF. METHODS A 2-year (2016-2017) retrospective analysis of all patients undergoing elective colon resection was performed at our tertiary hospital using a protocol limiting IOF and postoperative narcotics. Patients were divided into two groups: preprotocol (2016) and postprotocol (PoP) (2017). Patients were matched using propensity score matching for age, gender, comorbidities, Anesthesiology Severity Score, indication for procedure, and procedure type. The outcome measured was ROBF. Secondary outcome measures were complication rates and hospital length of stay. RESULTS A total of 360 patients were analyzed. After propensity matching, 90 patients (preprotocol: 45; PoP: 45) were included. The mean age was 62.2 ± 14.8 y, 43.3% male, and 44.4% of procedures were performed laparoscopically. There was no difference in demographics and comorbidities between groups. PoP patients received lower IOF (P = 0.036, 2016: 1198.8 ± 1096.5 mL, 2017: 2176.7 ± 1458.3 mL) and lower postoperative narcotics (P = 0.042). PoP patients had earlier ROBF 2[2-4], 4[3-5] (odds ratio: 1.18 [1.05-1.52], P = 0.04), shorter length of stay 3[2-5] d versus 5[4-7] (odds ratio: 1.11 [1.09-1.89], P = 0.043), and trended toward lower complication rates (P = 0.09). CONCLUSIONS IOF volume independently impacts ROBF after colon surgery. Restricting IOF allows for earlier bowel function and shorter hospital stay. Further studies defining optimum fluid management impacting ROBF may help optimize patient care.
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Affiliation(s)
| | | | - Viraj Pandit
- Department of Surgery, University of Arizona, Tucson, Arizona
| | | | - Hunter Jecius
- College of Medicine, University of Arizona, Tucson, Arizona
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Intraoperative Fluid Administration and Surgical Outcomes Following Pancreaticoduodenectomy: External Validation at a Tertiary Referral Center. World J Surg 2019; 43:929-936. [PMID: 30377724 DOI: 10.1007/s00268-018-4842-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND While intraoperative fluid overload is associated with higher complication rates following surgery, data for pancreaticoduodenectomy are scarce and heterogeneous. We evaluated multiple prior definitions of restrictive and liberal fluid regimens and analyzed whether these affected surgical outcomes at our tertiary referral center. METHODS Studies evaluating different intraoperative fluid regimens on outcomes after pancreatic resections were retrieved. After application of all prior definitions of restrictive and liberal fluid regimens to our patient cohort, relative risks of each outcome were calculated using all reported infusion regimens. RESULTS Five hundred and seven pancreaticoduodenectomies were included. Nine different fluid regimens were evaluated. Two regimens utilized absolute volume cutoffs, and the remaining evaluated various infusion rates, ranging from 5 to 15 mL/kg/h. Total volume administration of >5000 mL and >6000 mL was associated with increased complications (RR 1.25 and RR 1.17, respectively) and >6000 mL with increased sepsis (RR 2.14). Conversely, a rate of <5 mL/kg/h was associated with increased risk of postoperative pancreatic fistula (POPF, RR 3.16) and sepsis (RR 3.20), <6.8 mL/kg/h with increased major morbidity (RR 1.64) and sepsis (RR 2.27), and <8.2 mL/kg/h with increased POPF (RR 2.16). No effects were observed on pulmonary complications, surgical site infections, length of stay, or mortality. CONCLUSIONS In an uncontrolled setting with no standard intraoperative or postoperative care map, the volume of intraoperative fluid administration appears to have limited impact on early postoperative outcomes following pancreaticoduodenectomy, with adverse outcomes only seen at extreme values.
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Kaufmann T, Saugel B, Scheeren TWL. Perioperative goal-directed therapy - What is the evidence? Best Pract Res Clin Anaesthesiol 2019; 33:179-187. [PMID: 31582097 DOI: 10.1016/j.bpa.2019.05.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/08/2019] [Indexed: 01/27/2023]
Abstract
Perioperative goal-directed therapy aims at optimizing global hemodynamics during the perioperative period by titrating fluids, vasopressors, and/or inotropes to predefined hemodynamic goals. There is evidence on the benefit of perioperative goal-directed therapy, but its adoption into clinical practice is slow and incomprehensive. Current evidence indicates that treating patients according to perioperative goal-directed therapy protocols reduces morbidity and mortality, particularly in patients having high-risk surgery. Perioperative goal-directed therapy protocols need to be started early, should include vasoactive agents in addition to fluids, and should target blood flow related variables. Future promising developments in the field of perioperative goal-directed therapy include personalized hemodynamic management and closed-loop system management.
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Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands.
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands.
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Goal directed fluid optimization using Pleth variability index versus corrected flow time in cirrhotic patients undergoing major abdominal surgeries. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2011.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Dhawan R, Shahul S, Roberts JD, Smith ND, Steinberg GD, Chaney MA. Prospective, randomized clinical trial comparing use of intraoperative transesophageal echocardiography to standard care during radical cystectomy. Ann Card Anaesth 2019; 21:255-261. [PMID: 30052211 PMCID: PMC6078029 DOI: 10.4103/aca.aca_183_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose: Our prospective, randomized clinical study aims to evaluate the utility of intraoperative transesophageal echocardiography (TEE) in patients undergoing radical cystectomy. Materials and Methods: Eighty patients were randomized to a standard of care group or the intervention group that received continuous intraoperative TEE. Data are presented as means ± standard deviations, median (25th percentile, 75th percentile), or numbers and percentages. Characteristics were compared between groups using independent sample t-tests, Wilcoxon–Mann–Whitney tests or Chi-square tests, as appropriate. All tests were two-sided and P < 0.05 was considered to indicate statistical significance. Results: Both groups had similar preoperative demographic characteristics. There was a significant difference between central line insertion with all insertions in the control group (15%, 6 vs. 0%, 0; P < 0.003). Of all the perioperative complications, 80% occurred in the control group versus 20% in the TEE group, with 21% of controls experiencing a cardiac or pulmonary complication compared to 5% in the TEE group (8 vs. 2, P < 0.04). The control group patients were more likely to have adverse cardiac complications than the TEE group (15%, 6 vs. 3%, 1; P < 0.040). Postoperative cardiac arrhythmia was observed only in the control group (13%, 5 vs. 0%, 0; P <.007). Prolonged intubation was only observed in the control group (10%, 4 vs. 0%, 0; P < 0.017). Conclusion: TEE can be a useful monitoring tool in patients undergoing radical cystectomy, limiting the use of central line insertion and potentially translating into earlier extubation and decreased postoperative cardiac morbidities.
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Affiliation(s)
- Richa Dhawan
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL, USA
| | - Sajid Shahul
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL, USA
| | - Joseph Devin Roberts
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL, USA
| | - Norm D Smith
- Department of Surgery/Section of Urology, University of Chicago Medical Center, Chicago, IL, USA
| | - Gary D Steinberg
- Department of Surgery/Section of Urology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL, USA
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Minimally Invasive and Robotic Esophagectomy: A Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 13:391-403. [PMID: 30543576 DOI: 10.1097/imi.0000000000000572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.
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Holzer A, Sitter B, Kimberger O, Wenzl R, Fleischmann E, Marhofer D, Kabon B. Body Mass Index does not affect intraoperative goal-directed fluid requirements. Minerva Anestesiol 2019; 85:1071-1079. [PMID: 30994313 DOI: 10.23736/s0375-9393.19.13396-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Perioperative normovolemia is a major determinant of tissue oxygen availability and postoperative outcome. Thus, adequate volume replacement therapy remains an essential part of perioperative management. Nevertheless, volume optimization in overweight and obese surgical patients with alterations in cardiovascular function, peripheral perfusion, and body composition remains challenging. We, therefore, tested the hypothesis that Body Mass Index (BMI) correlates with fluid requirements during goal-directed management. Furthermore, we evaluated subcutaneous tissue oxygen tension (PsqO2) as an indicator of intravascular volume status and peripheral perfusion. METHODS Ninety women, undergoing open gynecologic surgery, were assigned to three groups according to their BMI, (lean: BMI 18.5 to 24.9 kg/m2, overweight: BMI 25 to 29.9 kg/m2, obese: BMI>30 kg/m2). Esophageal Doppler monitoring guided intraoperative crystalloid administration. Tissue oxygen tension was measured with a polarographic electrode in the subcutaneous tissue of the upper arm and served as a secondary outcome parameter. RESULTS BMI and fluid requirements did not correlate (r=0.093, P=0.384). Total amounts of administered crystalloids were comparable. Lean patients received 2223±1811 mL in total, while overweight patients received 1866±1261 mL. Obese patients required 2416±1143 mL of total crystalloids (P=0.327). Intra- and postoperative PsqO2 did not differ significantly (97.3 vs. 86.8 vs. 79.6 mmHg, P=0.06 and 74.5 vs. 83 vs. 81.5 mmHg, P=0.63, respectively). CONCLUSIONS BMI did not affect intraoperative fluid requirements. Doppler-guided intravascular volume optimization was associated with well-maintained subcutaneous tissue oxygen availability in all BMI groups.
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Affiliation(s)
- Andrea Holzer
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Barbara Sitter
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Oliver Kimberger
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - René Wenzl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria -
| | - Daniela Marhofer
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
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Bruce RM, Crockett DC, Morgan A, Tran MC, Formenti F, Phan PA, Farmery AD. Noninvasive cardiac output monitoring in a porcine model using the inspired sinewave technique: a proof-of-concept study. Br J Anaesth 2019; 123:126-134. [PMID: 30954237 PMCID: PMC6676057 DOI: 10.1016/j.bja.2019.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/10/2019] [Accepted: 02/11/2019] [Indexed: 11/25/2022] Open
Abstract
Background Cardiac output (Q˙) monitoring can support the management of high-risk surgical patients, but the pulmonary artery catheterisation required by the current ‘gold standard’—bolus thermodilution (Q˙T)—has the potential to cause life-threatening complications. We present a novel noninvasive and fully automated method that uses the inspired sinewave technique to continuously monitor cardiac output (Q˙IST). Methods Over successive breaths the inspired nitrous oxide (N2O) concentration was forced to oscillate sinusoidally with a fixed mean (4%), amplitude (3%), and period (60 s). Q˙IST was determined in a single-compartment tidal ventilation lung model that used the resulting amplitude/phase of the expired N2O sinewave. The agreement and trending ability of Q˙IST were compared with Q˙T during pharmacologically induced haemodynamic changes, before and after repeated lung lavages, in eight anaesthetised pigs. Results Before lung lavage, changes in Q˙IST and Q˙T from baseline had a mean bias of –0.52 L min−1 (95% confidence interval [CI], –0.41 to –0.63). The concordance between Q˙IST and Q˙T was 92.5% as assessed by four-quadrant analysis, and polar plot analysis revealed a mean angular bias of 5.98° (95% CI, –24.4°–36.3°). After lung lavage, concordance was slightly reduced (89.4%), and the mean angular bias widened to 21.8° (–4.2°, 47.6°). Impaired trending ability correlated with shunt fraction (r=0.79, P<0.05). Conclusions The inspired sinewave technique provides continuous and noninvasive monitoring of cardiac output, with a ‘marginal–good’ trending ability compared with cardiac output based on thermodilution. However, the trending ability can be reduced with increasing shunt fraction, such as in acute lung injury.
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Affiliation(s)
- Richard M Bruce
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Sciences, King's College London, London, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Douglas C Crockett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Anna Morgan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Minh Cong Tran
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Sciences, King's College London, London, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Department of Biomechanics, University of Nebraska, Omaha, NE, USA
| | - Phi Anh Phan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andrew D Farmery
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Weil G, Motamed C, Eghiaian A, Monnet X, Suria S. Comparison of Proaqt/Pulsioflex® and oesophageal Doppler for intraoperative haemodynamic monitoring during intermediate-risk abdominal surgery. Anaesth Crit Care Pain Med 2019; 38:153-159. [DOI: 10.1016/j.accpm.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
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Zhu ACC, Agarwala A, Bao X. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clin Colon Rectal Surg 2019; 32:114-120. [PMID: 30833860 DOI: 10.1055/s-0038-1676476] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Fluid management is an essential component of the Enhanced Recovery after Surgery (ERAS) pathway. Optimal management begins in the preoperative period and continues through the intraoperative and postoperative phases. In this review, we outline current evidence-based practices for fluid management through each phase of the perioperative period. Preoperatively, patients should be encouraged to hydrate until 2 hours prior to the induction of anesthesia with a carbohydrate-containing clear liquid. When mechanical bowel preparation is necessary, with modern isoosmotic solutions, fluid repletion is not necessary. Intraoperatively, fluid therapy should aim to maintain euvolemia with an individualized approach. While some patients may benefit from goal-directed fluid therapy, a restrictive, zero-balance approach to intraoperative fluid management may be reasonable. Postoperatively, early initiation of oral intake and cessation of intravenous therapy are recommended.
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Affiliation(s)
- Alyssa Cheng-Cheng Zhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aalok Agarwala
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Decreasing the Surgical Stress Response and an Initial Experience from the Enhanced Recovery After Surgery Colorectal Surgery Program at an Academic Institution. Int Anesthesiol Clin 2019; 55:163-178. [PMID: 28901989 DOI: 10.1097/aia.0000000000000162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Boyle MS, Bennett M, Keogh GW, O'Brien M, Flynn G, Collins DW, Biharih D. Central venous Oxygen Saturation during High-Risk General Surgical Procedures—Relationship to Complications and Clinical Outcomes. Anaesth Intensive Care 2019; 42:28-36. [DOI: 10.1177/0310057x1404200107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M. S. Boyle
- Intensive Care Unit and Wales Anaesthesia, Prince of Wales Hospital, Randwick, New South Wales
| | - M. Bennett
- Intensive Care Unit and Wales Anaesthesia, Prince of Wales Hospital, Randwick, New South Wales
- Wales Anaesthesia and University of New South Wales, Prince of Wales Hospital, Randwick, New South Wales
| | - G. W. Keogh
- Intensive Care Unit and Wales Anaesthesia, Prince of Wales Hospital, Randwick, New South Wales
- Department of Surgery
| | - M. O'Brien
- Intensive Care Unit and Wales Anaesthesia, Prince of Wales Hospital, Randwick, New South Wales
| | - G. Flynn
- Intensive Care Unit and Wales Anaesthesia, Prince of Wales Hospital, Randwick, New South Wales
| | - D. W. Collins
- Intensive Care Unit and Wales Anaesthesia, Prince of Wales Hospital, Randwick, New South Wales
| | - D. Biharih
- Intensive Care Unit and Wales Anaesthesia, Prince of Wales Hospital, Randwick, New South Wales
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Torregiani G, Claroni C, Covotta M, Naccarato A, Canfora M, Giannarelli D, Grazi GL, Tribuzi S, Forastiere E. Impact of a goal-directed fluid therapy on length of hospital stay and costs of hepatobiliarypancreatic surgery: a prospective observational study. J Comp Eff Res 2018; 7:1171-1179. [PMID: 30450955 DOI: 10.2217/cer-2018-0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
AIM The effectiveness of goal-directed fluid therapy (GDFT) algorithms in improving postoperative outcomes has extensively been suggested. Nevertheless, there is a lack of strong evidence regarding both the clinical impact and the cost-effectiveness of the GDFT protocols. The aim of this study is to evaluate the costs of patients undergoing hepatobiliopancreatic surgery when a GDFT protocol is applied. Materials & methods: Consecutive ASA I-III patients undergoing hepatobiliopancreatic surgery were included in this prospective observational study. Depending on device availability, patients were handled either by fluid therapy guided by Vigileo monitor-derived hemodynamic variables (Vigileo-GDFT group) or by standard fluid treatment (standard group). Postoperative length of stay and economic costs were analyzed. RESULTS In total, 147 patients were included (71 in the Vigileo-GDFT group and 76 in the standard group). The total hospital length of stay was 13 (median, 1st-3rd quartile, 9-20) days for the Vigileo-GDFT group and 14 (8-21) days for the standard group (p = 0.58); no statistically significant differences between the two groups emerged regarding costs and postoperative complications. In both groups, complications were the main contributor to total cost sustained. CONCLUSION The application of a GDFT algorithm did not reduce the total length of hospital stay and the global costs, which were mainly influenced by the number of complications.
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Affiliation(s)
- Giulia Torregiani
- Department of Anesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Claudia Claroni
- Department of Anesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Marco Covotta
- Department of Anesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Alessia Naccarato
- Department of Anesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Marco Canfora
- Scientific Direction, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Diana Giannarelli
- Scientific Direction, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Gian L Grazi
- Department of Hepatobiliarypancreatic Surgery, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Susanna Tribuzi
- Department of Anesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
| | - Ester Forastiere
- Department of Anesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144 Rome, Italy
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Zhang X, Zheng W, Chen C, Kang X, Zheng Y, Bao F, Gan S, Zhu S. Goal-directed fluid therapy does not reduce postoperative ileus in gastrointestinal surgery: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e13097. [PMID: 30407319 PMCID: PMC6250561 DOI: 10.1097/md.0000000000013097] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Perioperative goal-directed fluid therapy (GDFT) aiming to maintain individual fluid balance based on sensitive parameters was prevalent in major surgery, especially in enhanced recovery after surgery (ERAS) pathway. This meta-analysis was conducted for the purpose of evaluating whether GDFT impacts on occurrence of postoperative ileus and whether its application is worthwhile in gastrointestinal surgery. METHODS A systematic search of RCTs compared GDFT with other fluid management in patients undergoing gastrointestinal surgery from the PubMed, Web of Science, Embase, Cochrane Library databases was implemented. The primary outcome is incidence of postoperative ileus. Other outcome measures were length of hospital stay (LOS), postoperative morbidity and mortality. Subgroup analysis was planed a prior to verify the definite role of GDFT. RESULTS 12 trials consisted of 1836 patients were included in the final analysis. GDFT did not influence the occurrence of postoperative ileus (relative risk, RR 0.71, 95% confidence interval, CI 0.47-1.07, P = .10), with moderate heterogeneity (I = 29%, P = .16). No difference was found between GDFT and control groups in LOS (mean difference -0.17 days, 95% CI -0.73 to 0.39, P = .55), total complication rate (RR 0.92, 95% CI 0.81-1.05, P = .23), and 30-day mortality (RR 0.91, 95% CI 0.47-1.75, P = .77). In other secondary outcomes, only wound infection rate was lower in the GDFT group (RR 0.68, 95% CI 0.50-0.93, P = .02). When performed subgroup analysis, GDFT was superior in reduction ileus only when compared with standard therapy or in those outside ERAS. CONCLUSIONS It is possible that GDFT dose not affect the occurrence of postoperative ileus in gastrointestinal surgery. It scarcely influences postoperative morbidity and mortality as well. However, lower incidence of ileus is observed in GDFT group either outside ERAS or compared with standard fluid therapy. Probably, GDFT may not be necessary in the ERAS pathway or if a hybrid approach is adopted.
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Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS, Scott M, Mark Smithers B, Addor V, Ljungqvist O. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2018; 43:299-330. [DOI: 10.1007/s00268-018-4786-4] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fathi EM, Narchi H, Chedid F. Noninvasive hemodynamic monitoring of septic shock in children. World J Methodol 2018; 8:1-8. [PMID: 29988909 PMCID: PMC6033738 DOI: 10.5662/wjm.v8.i1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/10/2018] [Accepted: 05/11/2018] [Indexed: 02/06/2023] Open
Abstract
Septic shock in children is associated with high mortality and morbidity. Its management is time-sensitive and must be aggressive and target oriented. The use of clinical assessment alone to differentiate between cold and warm shock and to select the appropriate inotropic and vasoactive medications is fraught with errors. Semi-quantitative and quantitative assessment of the preload, contractility and afterload using non-invasive tools has been suggested, in conjunction with clinical and laboratory assessment, to direct shock management and select between vasopressors, vasodilators and inotropes or a combination of these drugs. This review aims to describe non-invasive tools to assess the hemodynamic status in septic shock including echocardiography, trans-thoracic/trans-esophageal Doppler and electrical cardiometry. As septic shock is a dynamic condition that changes markedly overtime, frequent or continuous measurement of the cardiac output (CO), systemic vascular resistance (SVR) and other hemodynamic parameters using the above-mentioned tools is essential to personalize the treatment and adapt it over time. The different combinations of blood pressure, CO and SVR serve as a pathophysiological framework to manage fluid therapy and titrate inotropic and vasoactive drugs. Near infrared spectroscopy is introduced as a non-invasive method to measure end organ perfusion and assess the response to treatment.
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Affiliation(s)
- Emad Mohamed Fathi
- Department of Critical Care, Al Jalila Children’s Specialty Hospital, Dubai 7662, United Arab Emirates
| | - Hassib Narchi
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 17666, United Arab Emirates
| | - Fares Chedid
- Neonatal Intensive Care Unit, Oasis Hospital, Al Ain 1016, United Arab Emirates
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Le Guen M, Follin A, Gayat E, Fischler M. The plethysmographic variability index does not predict fluid responsiveness estimated by esophageal Doppler during kidney transplantation: A controlled study. Medicine (Baltimore) 2018; 97:e10723. [PMID: 29768341 PMCID: PMC5976303 DOI: 10.1097/md.0000000000010723] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Research is ongoing to find a noninvasive method of monitoring, which can predict fluid responsiveness in patients undergoing kidney transplantation.To compare the responses to fluid challenges with the Pleth Variability Index, a noninvasive dynamic index derived from plethysmographic variability (Radical 7 pulse oximeter; Masimo Corporation, Irvine, CA), and the esophageal Doppler, the criterion standard.Observational study.University hospital; study from May 2011 and May 2012.Forty-eight patients with end-renal function were included and 44 analyzed. Patients with cardiac failure were not eligible.Fluid challenges were administered during maintenance of general anesthesia but before skin incision and repeated if the patient was deemed to be a "responder" (increase in stroke volume ≥10%).The primary endpoint was to assess if the Pleth Variability Index is an accurate predictor of fluid responsiveness.Among 76 fluid challenges, 38 were considered as positive (increase in stroke volume measured by Doppler ≥10%). Pleth Variability Index was similar at baseline between responders and nonresponder patients. Fluid challenges were associated with a significant decrease in Pleth Variability Index in overall cases (12 [8-14] vs 10 [6-17], P = .050), but it was not able to discriminate between responders (12 [8-15] vs 10 [5-15], P = .650) and nonresponders (11 [6-16] vs 8 [5-14], P = .047). The area under the Receiver Operating Characteristic curve for Pleth Variability Index was 0.49 (0.36-0.62).Pleth Variability Index is not an accurate predictor of fluid responsiveness during kidney transplantation.
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Affiliation(s)
- Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch
- Université Versailles Saint-Quentin en Yvelines, Suresnes
| | - Arnaud Follin
- Department of Anesthesiology, Hôpital Foch
- Université Versailles Saint-Quentin en Yvelines, Suresnes
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis-Lariboisière-Fernand Widal
- UMR-S 942, INSERM, University Paris 7 Diderot, Paris, France
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch
- Université Versailles Saint-Quentin en Yvelines, Suresnes
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Currently, there is no consensus about the optimum intraoperative fluid therapy strategy. There is growing body of evidence supports the beneficial effects of adopting “Goal-directed therapy” over either the “liberal” or “restrictive” fluid therapy strategies. In this narrative review, we have presented the evidence to support the optimum strategy for intraoperative therapy. In conclusion, whatever the intravenous fluid replacement strategy used, the anesthesiologist must be prepared to adjust the composition and rate of the fluids administered to provide sufficient intravascular fluid volume for adequate perfusion of vital organs without overwhelming the glycocalyx function with fluid overloads.
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Abstract
Advanced primary and recurrent colorectal cancer can be successfully treated by experienced, dedicated centers delivering good outcomes with low mortality and morbidity. Development and implementation of a comprehensive referral pathway is to be encouraged. Multidisciplinary team management is essential in the management of this complex group of patients and is associated with significantly more complete preoperative evaluation and more accurate provision of patient information, as well as improved access to the most appropriate individualized management plan. A structured selection process can improve outcomes through standardized approaches to service delivery to provide the highest quality of care.
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Affiliation(s)
- Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Paris Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
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Fayed NA, Yassen KA, Abdulla AR. Comparison Between 2 Strategies of Fluid Management on Blood Loss and Transfusion Requirements During Liver Transplantation. J Cardiothorac Vasc Anesth 2017; 31:1741-1750. [DOI: 10.1053/j.jvca.2017.02.177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Indexed: 12/16/2022]
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Manning MW, Dunkman WJ, Miller TE. Perioperative fluid and hemodynamic management within an enhanced recovery pathway. J Surg Oncol 2017; 116:592-600. [DOI: 10.1002/jso.24828] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/11/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Michael W. Manning
- Division of Cardiothroacic Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
- Division of General, Vascular, and Transplant Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
| | - William Jonathan Dunkman
- Division of General, Vascular, and Transplant Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
| | - Timothy E. Miller
- Division of General, Vascular, and Transplant Anesthesia, Department of Anesthesiology; Duke University; Durham North Carolina
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Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg 2017; 139:1056e-1071e. [PMID: 28445352 DOI: 10.1097/prs.0000000000003242] [Citation(s) in RCA: 203] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol. METHODS A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society. RESULTS High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery. CONCLUSION Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Demirel İ, Bolat E, Altun AY, Özdemir M, Beştaş A. Efficacy of Goal-Directed Fluid Therapy via Pleth Variability Index During Laparoscopic Roux-en-Y Gastric Bypass Surgery in Morbidly Obese Patients. Obes Surg 2017; 28:358-363. [DOI: 10.1007/s11695-017-2840-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Sun Y, Chai F, Pan C, Romeiser JL, Gan TJ. Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:141. [PMID: 28602158 PMCID: PMC5467058 DOI: 10.1186/s13054-017-1728-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/22/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Goal-directed hemodynamic therapy (GDHT) has been used in the clinical setting for years. However, the evidence for the beneficial effect of GDHT on postoperative recovery remains inconsistent. The aim of this systematic review and meta-analysis was to evaluate the effect of perioperative GDHT in comparison with conventional fluid therapy on postoperative recovery in adults undergoing major abdominal surgery. METHODS Randomized controlled trials (RCTs) in which researchers evaluated the effect of perioperative use of GDHT on postoperative recovery in comparison with conventional fluid therapy following abdominal surgery in adults (i.e., >16 years) were considered. The effect sizes with 95% CIs were calculated. RESULTS Forty-five eligible RCTs were included. Perioperative GDHT was associated with a significant reduction in short-term mortality (risk ratio [RR] 0.75, 95% CI 0.61-0.91, p = 0.004, I 2 = 0), long-term mortality (RR 0.80, 95% CI 0.64-0.99, p = 0.04, I 2 = 4%), and overall complication rates (RR 0.76, 95% CI 0.68-0.85, p < 0.0001, I 2 = 38%). GDHT also facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 0.4 days (95% CI -0.72 to -0.08, p = 0.01, I 2 = 74%) and the time to toleration of oral diet by 0.74 days (95% CI -1.44 to -0.03, p < 0.0001, I 2 = 92%). CONCLUSIONS This systematic review of available evidence suggests that the use of perioperative GDHT may facilitate recovery in patients undergoing major abdominal surgery.
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Affiliation(s)
- Yanxia Sun
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China.
| | - Fang Chai
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China
| | - Chuxiong Pan
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China
| | - Jamie Lee Romeiser
- Department of Surgery, Stony Brook University, Stony Brook, NY, USA.,Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY, USA
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Stens J, Hering JP, van der Hoeven CWP, Boom A, Traast HS, Garmers LE, Loer SA, Boer C. The added value of cardiac index and pulse pressure variation monitoring to mean arterial pressure-guided volume therapy in moderate-risk abdominal surgery (COGUIDE): a pragmatic multicentre randomised controlled trial. Anaesthesia 2017; 72:1078-1087. [PMID: 28543041 DOI: 10.1111/anae.13834] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 02/06/2023]
Abstract
There is disagreement regarding the benefits of goal-directed therapy in moderate-risk abdominal surgery. Therefore, we tested the hypothesis that the addition of non-invasive cardiac index and pulse pressure variation monitoring to mean arterial pressure-based goal-directed therapy would reduce the incidence of postoperative complications in patients having moderate-risk abdominal surgery. In this pragmatic multicentre randomised controlled trial, we randomly allocated 244 patients by envelope drawing in a 1:1 fashion, stratified per centre. All patients had mean arterial pressure, cardiac index and pulse pressure variation measured continuously. In one group, healthcare professionals were blinded to cardiac index and pulse pressure variation values and were asked to guide haemodynamic therapy only based on mean arterial pressure (control group). In the second group, cardiac index and pulse pressure variation values were displayed and kept within target ranges following a pre-defined algorithm (CI-PPV group). The primary endpoint was the incidence of postoperative complications within 30 days. One hundred and seventy-five patients were eligible for final analysis. Overall complication rates were similar (42/94 (44.7%) vs. 38/81 (46.9%) in the control and CI-PPV groups, respectively; p = 0.95). The CI-PPV group had lower mean (SD) pulse pressure variation values (9.5 (2.0)% vs. 11.9 (4.6)%; p = 0.003) and higher mean (SD) cardiac indices (2.76 (0.62) l min-1 .m-2 vs. 2.53 (0.66) l min-1 .m-2 ; p = 0.004) than the control group. In moderate-risk abdominal surgery, we observed no additional value of cardiac index and pulse pressure variation-guided haemodynamic therapy to mean arterial pressure-guided volume therapy with regard to postoperative complications.
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Affiliation(s)
- J Stens
- Department of Anaesthesiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - J-P Hering
- Department of Anaesthesiology, Westfriesgasthuis, Hoorn, the Netherlands
| | | | - A Boom
- Department of Anaesthesiology, Spaarneziekenhuis, Hoofddorp, the Netherlands
| | - H S Traast
- Department of Anaesthesiology, Medical Center Alkmaar, Alkmaar, the Netherlands
| | - L E Garmers
- Department of Anaesthesiology, Medical Center Alkmaar, Alkmaar, the Netherlands
| | - S A Loer
- Department of Anaesthesiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - C Boer
- Department of Anaesthesiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
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45
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Ellis CN. Discharge criteria after colon resection: Is return of bowel function necessary? Am J Surg 2017; 213:544-547. [DOI: 10.1016/j.amjsurg.2016.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/28/2016] [Accepted: 11/05/2016] [Indexed: 12/25/2022]
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46
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Heinink TP, Read DJ, Mitchell WK, Bhalla A, Lund JN, Phillips BE, Williams JP. Oesophageal Doppler guided optimization of cardiac output does not increase visceral microvascular blood flow in healthy volunteers. Clin Physiol Funct Imaging 2017; 38:213-219. [PMID: 28168868 DOI: 10.1111/cpf.12401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 10/14/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oesophageal Doppler monitoring (ODM) is used clinically to optimize cardiac output (CO) and guide fluid therapy. Despite limited experimental evidence, it is assumed that increasing CO increases visceral microvascular blood flow (MBF). We used contrast-enhanced ultrasound (CEUS) to assess whether ODM-guided optimization of CO altered MBF. METHODS Sixteen healthy male volunteers (62 ± 3·4 years) were studied. Baseline measurements of CO were recorded via ODM. Hepatic and renal MBF was assessed via CEUS. Saline 0·9% was administered to optimize CO according to a standard protocol and repeat CEUS performed. Time-intensity curves were constructed, allowing organ perfusion calculation via time to 5% perfusion (TT5). MBF was assessed via organ perfusion rise time (RT) (5-95%). RESULTS CO increased (4535 ± 241 ml/min versus 5442 ± 329 ml/min, P<0·0001) following fluid administration, whilst time to renal (22·48 ± 1·19 s versus 20·79 ± 1·31 s; P = 0·03), but not hepatic (28·13 ± 4·48 s versus 26·83 ± 1·53 s; P = 0·15) perfusion decreased. Time to renal perfusion was related to CO (renal: r = -0·43, P = 0·01). Hepatic nor renal RT altered following fluid administration (renal: 9·03 ± 0·86 versus 8·93 ± 0·85 s P = 0·86; hepatic: 27·86 ± 1·60 s versus 30·71 ± 2·19 s, P = 0·13). No relationship was observed between changes in CO and MBF in either organ (renal: r = -0·17, P = 0·54; hepatic: r = -0·07, P = 0·80). CONCLUSIONS ODM-optimized CO reduces time to renal perfusion but does not alter renal or hepatic MBF. A lack of relationship between microvascular visceral perfusion and CO following ODM-guided optimization may explain the absence of improved clinical outcome with ODM monitoring.
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Affiliation(s)
- Thomas P Heinink
- Department of Anaesthesia and Critical Care, Royal Derby Hospital, Derby, UK.,Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK
| | - David J Read
- Department of Anaesthesia and Critical Care, Royal Derby Hospital, Derby, UK.,Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK
| | - William K Mitchell
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK.,MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Derby, UK
| | - Ashish Bhalla
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK.,MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Derby, UK
| | - Jonathan N Lund
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK.,MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Derby, UK.,University of Nottingham, Derby, UK
| | - Bethan E Phillips
- MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Derby, UK.,University of Nottingham, Derby, UK
| | - John P Williams
- Department of Anaesthesia and Critical Care, Royal Derby Hospital, Derby, UK.,Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK.,MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Derby, UK.,University of Nottingham, Derby, UK
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47
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Watson X, Cecconi M. Haemodynamic monitoring in the peri-operative period: the past, the present and the future. Anaesthesia 2017; 72 Suppl 1:7-15. [DOI: 10.1111/anae.13737] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 12/17/2022]
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48
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Abstract
IMPORTANCE Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology. OBJECTIVE The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology. EVIDENCE ACQUISITION Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed. RESULTS Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life. CONCLUSIONS AND RELEVANCE High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.
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Detweiler BN, Kollmorgen LE, Umberham BA, Hedin RJ, Vassar BM. Risk of bias and methodological appraisal practices in systematic reviews published in anaesthetic journals: a meta-epidemiological study. Anaesthesia 2016; 71:955-68. [DOI: 10.1111/anae.13520] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 11/28/2022]
Affiliation(s)
- B. N. Detweiler
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - L. E. Kollmorgen
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - B. A. Umberham
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - R. J. Hedin
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
| | - B. M. Vassar
- Institutional Research and Analytics; Oklahoma State University Center for Health Sciences; Tulsa Oklahoma USA
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50
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Marx G, Schindler AW, Mosch C, Albers J, Bauer M, Gnass I, Hobohm C, Janssens U, Kluge S, Kranke P, Maurer T, Merz W, Neugebauer E, Quintel M, Senninger N, Trampisch HJ, Waydhas C, Wildenauer R, Zacharowski K, Eikermann M. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33:488-521. [PMID: 27043493 PMCID: PMC4890839 DOI: 10.1097/eja.0000000000000447] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gernot Marx
- From the Department of Cardiothoracic and Vascular Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz (JA); Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena (MB); Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne (ME); Institute of Nursing Science and Practice, Paracelsus Private Medical University, Salzburg, Austria (IG); Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Leibzig (CH); Department of Cardiology, St Antonius Hospital, Eschweiler (UJ); Centre for Intensive Care Medicine, Universitätsklinikum, Hamburg-Eppendorf (SK); Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Würzburg (PK); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (GM); Urological Unit and Outpatient Clinic, University Hospital rechts der Isar, Munich (TM); Department of Obstetrics and Gynaecology, Bonn University Hospital, Bonn (WM); Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne (CM, EN); Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen (MQ); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (AWS); Department of General and Visceral Surgery, Münster University Hospital, Münster (NS); Department of Health Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum (HJT); Department of Trauma Surgery, Essen University Hospital, Essen (CW); Department of General Surgery, University Hospital of Würzburg, Würzburg (RW); and Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany (KZ)
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