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Wu QR, Zhao ZZ, Fan KM, Cheng HT, Wang B. Pulse pressure variation guided goal-direct fluid therapy decreases postoperative complications in elderly patients undergoing laparoscopic radical resection of colorectal cancer: a randomized controlled trial. Int J Colorectal Dis 2024; 39:33. [PMID: 38436757 PMCID: PMC10912221 DOI: 10.1007/s00384-024-04606-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The use of goal-directed fluid therapy (GDFT) has been shown to reduce complications and improve prognosis in high-risk abdominal surgery patients. However, the utilization of pulse pressure variation (PPV) guided GDFT in laparoscopic surgery remains a subject of debate. We hypothesized that utilizing PPV guidance for GDFT would optimize short-term prognosis in elderly patients undergoing laparoscopic radical resection for colorectal cancer compared to conventional fluid therapy. METHODS Elderly patients undergoing laparoscopic radical resection of colorectal cancer were randomized to receive either PPV guided GDFT or conventional fluid therapy and explore whether PPV guided GDFT can optimize the short-term prognosis of elderly patients undergoing laparoscopic radical resection of colorectal cancer compared with conventional fluid therapy. RESULTS The incidence of complications was significantly lower in the PPV group compared to the control group (32.8% vs. 57.1%, P = .009). Additionally, the PPV group had a lower occurrence of gastrointestinal dysfunction (19.0% vs. 39.3%, P = .017) and postoperative pneumonia (8.6% vs. 23.2%, P = .033) than the control group. CONCLUSION Utilizing PPV as a monitoring index for GDFT can improve short-term prognosis in elderly patients undergoing laparoscopic radical resection of colorectal cancer. REGISTRATION NUMBER ChiCTR2300067361; date of registration: January 5, 2023.
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Affiliation(s)
- Qiu-Rong Wu
- Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zi-Zuo Zhao
- Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ke-Ming Fan
- Department of Anesthesiology, Yongchuan District People's Hospital of Chongqing, Chongqing, 400016, China
| | - Hui-Ting Cheng
- Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Bin Wang
- Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Trauzeddel RF, Nordine M, Fucini GB, Sander M, Dreger H, Stangl K, Treskatsch S, Habicher M. Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis. Braz J Cardiovasc Surg 2024; 39:e20220470. [PMID: 38426709 PMCID: PMC10903543 DOI: 10.21470/1678-9741-2022-0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/19/2023] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes. METHODS Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch. RESULTS Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ. CONCLUSION GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.
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Affiliation(s)
- Ralf Felix Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine,
Charité - Universitätsmedizin Berlin, Corporate Member of Freie
Universität Berlin and Humboldt-Universität zu Berlin, Campus Benjamin
Franklin, Berlin, Germany
| | - Michael Nordine
- Department of Anesthesiology, Intensive Care Medicine, and Pain
Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt,
Hessen, Germany
| | - Giovanni B. Fucini
- Institute of Hygiene and Environmental Medicine and National
Reference Center for the Surveillance of Nosocomial Infections, Charité -
Universitätsmedizin Berlin, Corporate Member of Freie Universität
Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine,
and Pain Therapy, Justus Liebig University of Giessen, Hessen, Germany
| | - Henryk Dreger
- Department of Cardiology, Angiology, and Intensive Care Medicine,
Deutsches Herzzentrum der Charité - Medical Heart Center of Charité
and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Karl Stangl
- Department of Cardiology and Angiology, Deutsches Herzzentrum der
Charité - Medical Heart Center of Charité and German Heart Institute
Berlin, Campus Charité Mitte, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine,
Charité - Universitätsmedizin Berlin, Corporate Member of Freie
Universität Berlin and Humboldt-Universität zu Berlin, Campus Benjamin
Franklin, Berlin, Germany
| | - Marit Habicher
- Department of Anesthesiology, Operative Intensive Care Medicine,
and Pain Therapy, Justus Liebig University of Giessen, Hessen, Germany
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Choo CL, Law LS, How WJ, Goh BY, Ashokka B. A systematic review and meta-analysis on the effect of goal-directed fluid therapy on postoperative outcomes in renal transplantation surgeries. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:679-694. [PMID: 38920161 DOI: 10.47102/annals-acadmedsg.202367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction This systematic review and meta-analysis investigated the impact of intraoperative goal-directed therapy (GDT) compared with conventional fluid therapy on postoperative outcomes in renal transplantation recipients, addressing this gap in current literature. Method A systematic search of patients aged ≥18 years who have undergone single-organ primary renal transplantations up to June 2022 in PubMed, Embase, Scopus and CINAHL Plus was performed. Primary outcome examined was postoperative renal function. Secondary outcomes assessed were mean arterial pressure at graft reperfusion, intraoperative fluid volume and other postoperative complications. Heterogeneity was tested using I² test. The study protocol was registered on PROSPERO. Results A total of 2459 studies were identified. Seven eligible studies on 607 patients were included. Subgroup assessments revealed potential renal protective benefits of GDT, with patients receiving cadaveric grafts showing lower serum creatinine on postoperative days 1 and 3, and patients monitored with arterial waveform analysis devices experiencing lower incidences of postoperative haemodialysis. Overall analysis found GDT resulted in lower incidence of tissue oedema (risk ratio [RR] 0.34, 95% CI 0.15-0.78, P=0.01) and respiratory complications (RR 0.39, 95% CI 0.17-0.90, P=0.03). However, quality of data was deemed low given inclusion of non-randomised studies, presence of heterogeneities and inconsistencies in defining outcomes measures. Conclusion While no definitive conclusions can be ascertained given current limitations, this review highlights potential benefits of using GDT in renal transplantation recipients. It prompts the need for further standardised studies to address limitations discussed in this review.
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Affiliation(s)
- Caitlin Lmc Choo
- Department of Anaesthesia, National University Hospital, Singapore
| | - Lawrence Sc Law
- Department of Medicine, National University Hospital, Singapore
| | - Wen Jie How
- Department of Anaesthesia, National University Hospital, Singapore
| | - Benjamin Ys Goh
- National University Centre for Organ Transplantation, National University Hospital, Singapore
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Miegoń J, Zacha S, Skonieczna-Żydecka K, Wiczk-Bratkowska A, Andrzejewska A, Jarosz K, Deptuła-Jarosz M, Biernawska J. Optimising Intraoperative Fluid Management in Patients Treated with Adolescent Idiopathic Scoliosis-A Novel Strategy for Improving Outcomes. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1371. [PMID: 37628370 PMCID: PMC10453073 DOI: 10.3390/children10081371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023]
Abstract
Scoliosis surgery is a challenge for the entire team in terms of safety, and its accomplishment requires the utilization of advanced monitoring technologies. A prospective, single centre, non-randomised controlled cohort study, was designed to assess the efficacy of protocolised intraoperative haemodynamic monitoring and goal-directed therapy in relation to patient outcomes following posterior fusion surgery for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure management during the surgical procedure, whereas the intervention group (n = 35, mean age: 14 years) underwent minimally invasive haemodynamic monitoring. Arterial pulse contour analysis (APCO) devices were employed, along with goal-directed therapy protocol centered on achieving target mean arterial pressure and stroke volume. This was facilitated through the application of crystalloid boluses, ephedrine, and noradrenaline. The intervention group was subjected to a comprehensive protocol following Enhanced Recovery After Surgery (ERAS) principles. Remarkably, the intervention group exhibited notable advantages (p < 0.05), including reduced hospital stay durations (median 7 days vs. 10), shorter episodes of hypotension (mean arterial pressure < 60 mmHg-median 8 vs. 40 min), lesser declines in postoperative haemoglobin levels (-2.36 g/dl vs. -3.83 g/dl), and quicker extubation times. These compelling findings strongly imply that the integration of targeted interventions during the intraoperative care of AIS patients undergoing posterior fusion enhance a set of treatment outcomes.
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Affiliation(s)
- Jakub Miegoń
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Sławomir Zacha
- Department of Paediatric Orthopaedics and Oncology of the Musculoskeletal System, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | | | - Agata Wiczk-Bratkowska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Agata Andrzejewska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University in Szczecin, 71-210 Szczecin, Poland
| | - Monika Deptuła-Jarosz
- Department of Neurosurgery and Paediatric Neurosurgery, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
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Andrzejewska A, Miegoń J, Zacha S, Skonieczna-Żydecka K, Jarosz K, Zacha W, Biernawska J. The Impact of Intraoperative Haemodynamic Monitoring, Prediction of Hypotension and Goal-Directed Therapy on the Outcomes of Patients Treated with Posterior Fusion Due to Adolescent Idiopathic Scoliosis. J Clin Med 2023; 12:4571. [PMID: 37510686 PMCID: PMC10380250 DOI: 10.3390/jcm12144571] [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: 06/14/2023] [Revised: 07/04/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
A prospective, single-centre, non-randomised, case-control study aimed to evaluate the effectiveness of intraoperative haemodynamic monitoring, prediction of hypotension and goal-directed therapy on the outcomes of patients undergoing posterior fusion for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure control during surgery, while the intervention group (n = 24, mean age: 14 years) underwent minimally invasive haemodynamic monitoring and goal-directed therapy. The intervention group showed significantly shorter durations of hypotension (mean arterial pressure < 60 mmHg), reduced hospital stays and smaller decreases in post-surgery haemoglobin levels. Additionally, the intervention group experienced shorter times from the end of surgery to extubation. These findings suggest that incorporating targeted interventions during intraoperative care for AIS patients undergoing posterior fusion can lead to improved outcomes.
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Affiliation(s)
- Agata Andrzejewska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Jakub Miegoń
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Sławomir Zacha
- Department of Paediatric Orthopaedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, 71-252 Szczecin, Poland
| | | | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University, 71-210 Szczecin, Poland
| | - Wojciech Zacha
- Department of Paediatric Orthopaedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, 71-252 Szczecin, Poland
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Trauzeddel RF, Leitner M, Dehé L, Nordine M, Piper SK, Habicher M, Sander M, Perka C, Treskatsch S. Goal-directed fluid therapy using uncalibrated pulse contour analysis and balanced crystalloid solutions during hip revision arthroplasty: a quality implementation project. J Orthop Surg Res 2023; 18:281. [PMID: 37024966 PMCID: PMC10078091 DOI: 10.1186/s13018-023-03738-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND To implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study. METHODS Adult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction. RESULTS Sixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54-74 ml; colloids: 67.5 (60-75.25 ml) and total volume infused (crystalloids: 2575 (2000-4210) ml; colloids: 2435 (1760-3480) ml; and controls: 2210 (1658-3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3-55.2%) for crystalloids and 49.2% (95%CI 40.4-58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1-74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6-42.9); colloids: 43% (95%CI 34.4-52.0); and controls: 62% (95%CI 52.6-69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay. CONCLUSIONS Perioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01753050.
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Affiliation(s)
- R F Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Leitner
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - L Dehé
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Nordine
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - S K Piper
- Institute of Medical Informatics, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - M Habicher
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - M Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte and Virchow-Klinikum, Charitéplatz 1, 10117, Berlin, Germany
| | - S Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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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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Dmytriiev D, Nazarchuk O, Melnychenko M, Levchenko B. Optimization of the target strategy of perioperative infusion therapy based on monitoring data of central hemodynamics in order to prevent complications. Front Med (Lausanne) 2022; 9:935331. [PMID: 36262276 PMCID: PMC9573976 DOI: 10.3389/fmed.2022.935331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are increasingly used in the perioperative period around the world. The concept of goal-directed fluid therapy (GDT) is a key element of the ERAS protocols. Inadequate perioperative infusion therapy can lead to a number of complications, including the development of an infectious process, namely surgical site infections, pneumonia, urinary tract infections. Optimal infusion therapy is difficult to achieve with standard parameters (e.g., heart rate, blood pressure, central venous pressure), so there are various methods of monitoring central hemodynamics - from invasive, minimally invasive to non-invasive. The latter are increasingly used in clinical practice. The current evidence base shows that perioperative management, specifically the use of GDT guided by real-time, continuous hemodynamic monitoring, helps clinicians maintain a patient's optimal fluid balance. The manuscript presents the analytical data, which describe the benefits and basic principles of perioperative targeted infusion therapy based on central hemodynamic parameters to reduce the risk of complications.
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Affiliation(s)
- Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Oleksandr Nazarchuk
- Department of Microbiology, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Mykola Melnychenko
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Bohdan Levchenko
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
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Meoli A, Ciavola L, Rahman S, Masetti M, Toschetti T, Morini R, Dal Canto G, Auriti C, Caminiti C, Castagnola E, Conti G, Donà D, Galli L, La Grutta S, Lancella L, Lima M, Lo Vecchio A, Pelizzo G, Petrosillo N, Simonini A, Venturini E, Caramelli F, Gargiulo GD, Sesenna E, Sgarzani R, Vicini C, Zucchelli M, Mosca F, Staiano A, Principi N, Esposito S. Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention. Antibiotics (Basel) 2022; 11:antibiotics11070863. [PMID: 35884117 PMCID: PMC9311619 DOI: 10.3390/antibiotics11070863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 12/04/2022] Open
Abstract
A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.
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Affiliation(s)
- Aniello Meoli
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Lorenzo Ciavola
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Sofia Rahman
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Marco Masetti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Tommaso Toschetti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Riccardo Morini
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Giulia Dal Canto
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Cinzia Auriti
- Neonatology and Neonatal Intensive Care Unit, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, 43126 Parma, Italy;
| | - Elio Castagnola
- Infectious Diseases Unit, IRCCS Giannina Gaslini, 16147 Genoa, Italy;
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00165 Rome, Italy;
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, 35100 Padua, Italy;
| | - Luisa Galli
- Infectious Disease Unit, Meyer Children’s Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Stefania La Grutta
- Institute of Translational Pharmacology IFT, National Research Council, 90146 Palermo, Italy;
| | - Laura Lancella
- Paediatric Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Mario Lima
- Pediatric Surgery, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy; (A.L.V.); (A.S.)
| | - Gloria Pelizzo
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy;
| | - Nicola Petrosillo
- Infection Prevention and Control—Infectious Disease Service, Foundation University Hospital Campus Bio-Medico, 00128 Rome, Italy;
| | - Alessandro Simonini
- Pediatric Anesthesia and Intensive Care Unit, Salesi Children’s Hospital, 60123 Ancona, Italy;
| | - Elisabetta Venturini
- Infectious Disease Unit, Meyer Children’s Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Gaetano Domenico Gargiulo
- Department of Cardio-Thoracic and Vascular Medicine, Adult Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Enrico Sesenna
- Maxillo-Facial Surgery Unit, Head and Neck Department, University Hospital of Parma, 43126 Parma, Italy;
| | - Rossella Sgarzani
- Servizio di Chirurgia Plastica, Centro Grandi Ustionati, Ospedale M. Bufalini, AUSL Romagna, 47521 Cesena, Italy;
| | - Claudio Vicini
- Head-Neck and Oral Surgery Unit, Department of Head-Neck Surgery, Otolaryngology, Morgagni Piertoni Hospital, 47121 Forli, Italy;
| | - Mino Zucchelli
- Pediatric Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40138 Bologna, Italy;
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Mother, Child and Infant, 20122 Milan, Italy;
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy; (A.L.V.); (A.S.)
| | | | - Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
- Correspondence: ; Tel.: +39-0521-903524
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10
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Zhao CC, Ye Y, Li ZQ, Wu XH, Zhao C, Hu ZJ. Effect of goal-directed fluid therapy on renal function in critically ill patients: a systematic review and meta-analysis. Ren Fail 2022; 44:777-789. [PMID: 35535511 PMCID: PMC9103701 DOI: 10.1080/0886022x.2022.2072338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate whether goal-directed fluid therapy (GDFT) reduces the risk of renal injury in critical illness. Methods MEDLINE via PubMed, EMBASE, CENTRAL and CBM was searched from inception to 13 March 2022, for studies comparing the effect of GDFT with usual care on renal function in critically ill patients. GDFT was defined as a protocolized intervention based on hemodynamic and/or oxygen delivery parameters. A fixed or random effects model was applied to calculate the pooled odds ratio (OR) based on heterogeneity through the included studies. Results A total of 28 studies with 9,019 patients were included. The pooled data showed that compared with usual care, GDFT reduced the incidence of acute kidney injury (AKI) in critical illness (OR 0.62, 95% confidence interval (CI) 0.47 to 0.80, p< 0.001). Sensitivity analysis with only low risk of bias studies showed the same result. Subgroup analyses found that GDFT was associated with a lower AKI incidence in both postoperative and medical patients. The reduction was significant in GDFT aimed at dynamic indicators. However, no significant difference was found between groups in RRT support (OR 0.88, 95% CI 0.74 to 1.05, p= 0.17). GDFT tended to increase fluid administration within the first 6 h, decrease fluid administration after 24 h, and was associated with more vasopressor requirements. Conclusions This meta-analysis suggests that GDFT aimed at dynamic indicators may be an effective way to prevent AKI in critical illness. This may indicate a benefit from early adequate fluid resuscitation and the combined effect of vasopressors.
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Affiliation(s)
- Cong-Cong Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Ye
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-Qiang Li
- Department of Intensive Care Unit, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Xin-Hui Wu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chai Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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11
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Jessen MK, Vallentin MF, Holmberg MJ, Bolther M, Hansen FB, Holst JM, Magnussen A, Hansen NS, Johannsen CM, Enevoldsen J, Jensen TH, Roessler LL, Lind PC, Klitholm MP, Eggertsen MA, Caap P, Boye C, Dabrowski KM, Vormfenne L, Høybye M, Henriksen J, Karlsson CM, Balleby IR, Rasmussen MS, Pælestik K, Granfeldt A, Andersen LW. Goal-directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis. Br J Anaesth 2022; 128:416-433. [PMID: 34916049 PMCID: PMC8900265 DOI: 10.1016/j.bja.2021.10.046] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/28/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND During general anaesthesia for noncardiac surgery, there remain knowledge gaps regarding the effect of goal-directed haemodynamic therapy on patient-centred outcomes. METHODS Included clinical trials investigated goal-directed haemodynamic therapy during general anaesthesia in adults undergoing noncardiac surgery and reported at least one patient-centred postoperative outcome. PubMed and Embase were searched for relevant articles on March 8, 2021. Two investigators performed abstract screening, full-text review, data extraction, and bias assessment. The primary outcomes were mortality and hospital length of stay, whereas 15 postoperative complications were included based on availability. From a main pool of comparable trials, meta-analyses were performed on trials with homogenous outcome definitions. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). RESULTS The main pool consisted of 76 trials with intermediate risk of bias for most outcomes. Overall, goal-directed haemodynamic therapy might reduce mortality (odds ratio=0.84; 95% confidence interval [CI], 0.64 to 1.09) and shorten length of stay (mean difference=-0.72 days; 95% CI, -1.10 to -0.35) but with low certainty in the evidence. For both outcomes, larger effects favouring goal-directed haemodynamic therapy were seen in abdominal surgery, very high-risk surgery, and using targets based on preload variation by the respiratory cycle. However, formal tests for subgroup differences were not statistically significant. Goal-directed haemodynamic therapy decreased risk of several postoperative outcomes, but only infectious outcomes and anastomotic leakage reached moderate certainty of evidence. CONCLUSIONS Goal-directed haemodynamic therapy during general anaesthesia might decrease mortality, hospital length of stay, and several postoperative complications. Only infectious postoperative complications and anastomotic leakage reached moderate certainty in the evidence.
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Affiliation(s)
- Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Maria Bolther
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Johanne M Holst
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niklas S Hansen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Thomas H Jensen
- Department of Internal Medicine, University Hospital of North Norway, Narvik, Norway
| | - Lara L Roessler
- Department of Emergency Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peter C Lind
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Maibritt P Klitholm
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mark A Eggertsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Philip Caap
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Caroline Boye
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karol M Dabrowski
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lasse Vormfenne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeppe Henriksen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Carl M Karlsson
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Ida R Balleby
- National Hospital of the Faroe Islands, Torshavn, Faroe Islands, Denmark
| | - Marie S Rasmussen
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Kim Pælestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lars W Andersen
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.
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12
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Early Goal-directed Therapy During Endovascular Coiling Procedures Following Aneurysmal Subarachnoid Hemorrhage: A Pilot Prospective Randomized Controlled Study. J Neurosurg Anesthesiol 2022; 34:35-43. [PMID: 32496448 DOI: 10.1097/ana.0000000000000700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/30/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Maintenance of euvolemia and cerebral perfusion are recommended for the prevention of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). We conducted a pilot randomized controlled study to assess the feasibility and efficacy of goal-directed therapy (GDT) to correct fluid and hemodynamic derangements during endovascular coiling in patients with aSAH. METHODS This study was conducted between November 2015 and February 2019 at a single tertiary center in Canada. Adult patients with aSAH within 5 days of aneurysm rupture were randomly assigned to receive either GDT or standard therapy during endovascular coiling. The incidence of dehydration at presentation and the efficacy of GDT were evaluated. RESULTS Forty patients were allocated to receive GDT (n=21) or standard therapy (n=19). Sixty percent of all patients were found to have dehydration before the coiling procedure commenced. Compared with standard therapy, GDT reduced the duration of intraoperative hypovolemia (mean difference 37.6 [95% confidence interval, 6.2-37.4] min, P=0.006) and low cardiac index (mean difference 30.7 [95% confidence interval, 9.5-56.9] min, P=0.035). There were no differences between the 2 treatment groups with respect to the incidence of vasospasm, stroke, death, and other complications up to postoperative day 90. CONCLUSIONS A high proportion of aSAH patients presented at the coiling procedure with dehydration and a low cardiac output state; these derangements were more likely to be corrected if the GDT algorithm was used. Compared with standard therapy, use of the GDT algorithm resulted in earlier recognition and more consistent treatment of dehydration and hemodynamic derangement during endovascular coiling.
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Leisy PJ, Barnes RD, Weavind LM. Are Surgical Site Infections an Anesthesiologist's Problem? Adv Anesth 2021; 39:1-15. [PMID: 34715969 DOI: 10.1016/j.aan.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Philip J Leisy
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
| | - Robert D Barnes
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Liza M Weavind
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
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Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial. Br J Anaesth 2021; 127:521-531. [PMID: 34389168 DOI: 10.1016/j.bja.2021.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group). METHODS In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications. RESULTS In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found. CONCLUSION Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay. CLINICAL TRIAL REGISTRATION EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).
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15
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Tegegne BA, Lema GF, Fentie DY, Bizuneh YB. Perioperative risk stratification and strategies for reducing postoperative pulmonary complications following major surgery in resource limited areas: A systematic review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Giglioli C, Cecchi E, Stefàno PL, Spini V, Fortini G, Chiostri M, Marchionni N, Romano SM. Six-month prognostic impact of hemodynamic profiling by short minimally invasive monitoring after cardiac surgery. J Cardiovasc Thorac Res 2020; 12:313-320. [PMID: 33510881 PMCID: PMC7828750 DOI: 10.34172/jcvtr.2020.62] [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: 08/31/2020] [Accepted: 11/02/2020] [Indexed: 11/09/2022] Open
Abstract
Introduction: Studies have shown that a hemodynamic-guided therapy improves the post operative outcomes of high-risk patients.This study, evaluated if a short period through minimally invasive hemodynamic monitoring, pressure recording analytical method (PRAM), on admission to a post-cardiac surgery step-down unit (SDU), may identify patients at higher risk of 6-month adverse events after cardiac surgery. Methods: From December 2016-May 2017,173 patients were admitted in SDU within 24-48 hours of major cardiac surgery procedure, and submitted to clinical, laboratoristic and echocardiographic evaluation and a 1-hour PRAM recording to obtain a "biohumoral snapshot" of individual patient's.156 173 patients (17 patients were lost at follow-up) were phone interviewed six months after surgery,to evaluate, as a composite end-point, the adverse events during follow-up. A multivariable logistic regression analysis was used to identify a model clinical-biohumoral (CBM) and clinical-biohumoral hemodynamics (CBHM). Results: No data from past clinical history and no conventional risk score (EuroScore II, STS score)independently predicted the risk of 6-month major events in our study. The risk of adverse events at six-month follow-up was directly related, in the CBM, to sustained post-operative cardiac arrhythmias, higher values of NT-proBNP and of arterial pH; inversely related to values of hs-C-reactive protein (hs-CRP) and, in the CBHM, to low values of cardiac cycle efficiency (CCE) and dP/dtmax. Conclusion: Our study although limited by its observational nature and by the limited number of patients enrolled, showed that a short period of minimally invasive hemodynamic monitoring increased the accuracy to identify patients at major risk of mid-term events after cardiac surgery.
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Affiliation(s)
- Cristina Giglioli
- Division of General Cardiology, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Emanuele Cecchi
- Division of General Cardiology, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Pier Luigi Stefàno
- Division of Cardiosurgery, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Valentina Spini
- Division of General Cardiology, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giacomo Fortini
- Division of General Cardiology, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Chiostri
- Department of Experimental and Clinical Medicine, Unit of Internal Medicine and Cardiology, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Division of General Cardiology, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.,Department of Experimental and Clinical Medicine, Unit of Internal Medicine and Cardiology, University of Florence, Florence, Italy
| | - Salvatore Mario Romano
- Division of General Cardiology, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.,Department of Experimental and Clinical Medicine, Unit of Internal Medicine and Cardiology, University of Florence, Florence, Italy
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Zhao X, Zhang L, Brackett A, Dai F, Xu J, Meng L. Hemodynamic management and surgical site infection: Network meta-analysis of randomized controlled trials. J Clin Anesth 2020; 67:110021. [PMID: 32927235 DOI: 10.1016/j.jclinane.2020.110021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/28/2020] [Accepted: 07/30/2020] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To investigate which hemodynamic management strategy is most effective in reducing surgical site infection (SSI). DESIGN Network meta-analysis of randomized controlled trials. SETTING Perioperative setting. PATIENTS Surgical patients. INTERVENTIONS Usual care vs. optimized hemodynamic management, including goal-directed hemodynamic therapy (GDHT) and liberal/restrictive fluid therapy. MEASUREMENTS The primary outcome was SSI arising within postoperative 30 days. The secondary outcomes included postoperative respiratory and urinary system infectious complications and sepsis/septic shock. The effect and ranking were assessed using network meta-analysis and the surface under the cumulative ranking curve (SUCRA) scores, respectively. MAIN RESULTS We systematically searched Ovid MEDLINE, Ovid Embase, and Web of Science for eligible randomized controlled trials from inception to October 11, 2019. Fifty-three eligible studies reported SSI and comprised of 56 GDHT groups (patients, n = 4205) and 51 usual care groups (patients, n = 3895). Comparing with usual care, GDHTs aimed at intravascular volume and stroke volume optimization (odds ratio (OR), 0.28 [95% credible interval (CrI), 0.13 to 0.56]; moderate quality), stroke volume and cardiac output optimization (OR, 0.34 [95% CrI, 0.16 to 0.70]; moderate quality), and intravascular volume and cardiac output optimization (OR, 0.51 [95% CrI, 0.24 to 0.99]; low quality) significantly reduced SSI. GDHT strategy aimed at intravascular volume and stroke volume optimization was likely most effective (SUCRA = 80%). Certain GDHTs significantly reduced respiratory infectious complications; however, no GDHT significantly reduced urinary infectious complications and sepsis/septic shock. GDHT strategy aimed at intravascular volume, stroke volume, and cardiac output optimization was likely most effective for reducing respiratory infectious complications (SUCRA = 88%). CONCLUSIONS Different hemodynamic managements exert different effectiveness for SSI reduction. GDHTs aimed at intravascular volume, stroke volume, and cardiac output optimization are likely most effective based on the overall evidence.
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Affiliation(s)
- Xu Zhao
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, United States of America; Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Huanan Province, China
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, United States of America
| | - Feng Dai
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, United States of America
| | - Junmei Xu
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China.
| | - Lingzhong Meng
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, United States of America.
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Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial. Br J Anaesth 2020; 125:122-132. [PMID: 32711724 DOI: 10.1016/j.bja.2020.04.094] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity. METHODS In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3. RESULTS The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care. CLINICAL TRIAL REGISTRATION NCT02834377.
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Ongaigui C, Fiorda-Diaz J, Dada O, Mavarez-Martinez A, Echeverria-Villalobos M, Bergese SD. Intraoperative Fluid Management in Patients Undergoing Spine Surgery: A Narrative Review. Front Surg 2020; 7:45. [PMID: 32850944 PMCID: PMC7403195 DOI: 10.3389/fsurg.2020.00045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 06/17/2020] [Indexed: 12/29/2022] Open
Abstract
Fluid management has been widely recognized as an important component of the perioperative care in patients undergoing major procedures including spine surgeries. Patient- and surgery-related factors such as age, length of the surgery, massive intraoperative blood loss, and prone positioning, may impact the intraoperative administration of fluids. In addition, the type of fluid administered may also affect post-operative outcomes. Published literature describing intraoperative fluid management in patients undergoing major spine surgeries is limited and remains controversial. Therefore, we reviewed current literature on intraoperative fluid management and its association with post-operative complications in spine surgery.
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Affiliation(s)
- Corinna Ongaigui
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Olufunke Dada
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ana Mavarez-Martinez
- Department of Anesthesiology, School of Medicine, Stony Brook University, Health Sciences Center, Stony Brook, NY, United States
| | | | - Sergio D Bergese
- Department of Anesthesiology, School of Medicine, Stony Brook University, Health Sciences Center, Stony Brook, NY, United States
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Che L, Zhang XH, Li X, Zhang YL, Xu L, Huang YG. Outcome impact of individualized fluid management during spine surgery: a before-after prospective comparison study. BMC Anesthesiol 2020; 20:181. [PMID: 32698766 PMCID: PMC7376681 DOI: 10.1186/s12871-020-01092-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 07/13/2020] [Indexed: 02/11/2023] Open
Abstract
Background Individualized fluid management (IFM) has been shown to be useful to improve the postoperative outcome of patients undergoing major abdominal surgery. A limited number of clinical studies have been done in orthopaedic patients and have yielded conflicting results. We designed the present study to investigate the clinical impact of IFM in patients undergoing major spine surgery. Methods This is a before-after study done in 300 patients undergoing posterior spine arthrodesis. Postoperative outcomes were compared between control group implementing standard fluid management (n = 150) and IFM group (n = 150) guided by fluid protocol based on continuous stroke volume monitoring and optimization. The primary outcome measure was the proportion of patients who developed one or more complications within 30 days following surgery. Results During surgery, patients received on average the same volume of crystalloids (7.4 vs 7.2 ml/kg/h) and colloids (1.6 vs 1.6 ml/kg/h) before and after the implementation of IFM. During 30 days following surgery, the proportion of patients who developed one or more complications was lower in the IFM group (32 vs 48%, p < 0.01). This difference was mainly explained by a significant decrease in post-operative nausea and vomiting (from 38 to 19%, p < 0.01), urinary tract infections (from 9 to 1%, p < 0.01) and surgical site infections (from 5 to 1%, p < 0.05). Median hospital length of stay was not affected by the implementation of IFM. Conclusion In patients undergoing major spine surgery, the implementation of IFM was associated with a significant decrease in postoperative morbidity. Trial registration ClinicalTrials.gov Identifier: NCT02470221. Prospectively registered on June 12, 2015.
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Affiliation(s)
- Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xiu H Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xu Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yue L Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
| | - Yu G Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
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Molnar Z, Benes J, Saugel B. Intraoperative hypotension is just the tip of the iceberg: a call for multimodal, individualised, contextualised management of intraoperative cardiovascular dynamics. Br J Anaesth 2020; 125:419-423. [PMID: 32690244 DOI: 10.1016/j.bja.2020.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/16/2020] [Accepted: 05/16/2020] [Indexed: 01/25/2023] Open
Affiliation(s)
- Zsolt Molnar
- Department of Translational Medicine, Medical School, University of Pecs, Pecs, Hungary; Department of Anaesthesiology and Intensive Therapy, Poznan University for Medical Sciences, Poznan, Poland
| | - Jan Benes
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Pilsen, Pilsen, Czech Republic; Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
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22
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Carsetti A, Amici M, Bernacconi T, Brancaleoni P, Cerutti E, Chiarello M, Cingolani D, Cola L, Corsi D, Forlini G, Giampieri M, Iuorio S, Principi T, Tappatà G, Tempesta M, Adrario E, Donati A. Estimated oxygen extraction versus dynamic parameters of fluid-responsiveness for perioperative hemodynamic optimization of patients undergoing non-cardiac surgery: a non-inferiority randomized controlled trial. BMC Anesthesiol 2020; 20:87. [PMID: 32305061 PMCID: PMC7165409 DOI: 10.1186/s12871-020-01011-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 04/15/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Goal directed therapy (GDT) is able to improve mortality and reduce complications in selected high-risk patients undergoing major surgery. The aim of this study is to compare two different strategies of perioperative hemodynamic optimization: one based on optimization of preload using dynamic parameters of fluid-responsiveness and the other one based on estimated oxygen extraction rate (O2ER) as target of hemodynamic manipulation. METHODS This is a multicenter randomized controlled trial. Adult patients undergoing elective major open abdominal surgery will be allocated to receive a protocol based on dynamic parameters of fluid-responsiveness or a protocol based on estimated O2ER. The hemodynamic optimization will be continued for 6 h postoperatively. The primary outcome is difference in overall postoperative complications rate between the two protocol groups. Fluids administered, fluid balance, utilization of vasoactive drugs, hospital length of stay and mortality at 28 day will also be assessed. DISCUSSION As a predefined target of cardiac output (CO) or oxygen delivery (DO2) seems to be not adequate for every patient, a personalized therapy is likely more appropriate. Following this concept, dynamic parameters of fluid-responsiveness allow to titrate fluid administration aiming CO increase but avoiding fluid overload. This approach has the advantage of personalized fluid therapy, but it does not consider if CO is adequate or not. A protocol based on O2ER considers this second important aspect. Although positive effects of perioperative GDT have been clearly demonstrated, currently studies comparing different strategies of hemodynamic optimization are lacking. TRIAL REGISTRATION ClinicalTrials.gov, NCT04053595. Registered on 12/08/2019.
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Affiliation(s)
- Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Mirco Amici
- Pediatric Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Tonino Bernacconi
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 2, Jesi, Italy
| | - Paolo Brancaleoni
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 1, Urbino, Italy
| | - Elisabetta Cerutti
- Anesthesia and Post-operative Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Marco Chiarello
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 3, Camerino, Italy
| | - Diego Cingolani
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 2, Senigallia, Italy
| | - Luisanna Cola
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 4, Fermo, Italy
| | - Daniela Corsi
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 3, Civitanova Marche, Italy
| | - Giorgio Forlini
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 5, Ascoli Piceno, Italy
| | | | | | - Tiziana Principi
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 5, San Benedetto del Tronto, Italy
| | - Giuseppe Tappatà
- Anesthesia and Intensive Care Unit, ASUR Marche, area vasta n. 3, Macerata, Italy
| | - Michele Tempesta
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Marche Nord, Pesaro, Italy
| | - Erica Adrario
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
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Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, Zarbock A, Stoppe C, Meineri M, Grocott HP, Ghadimi K, Gutsche JT, Patel PA, Denault A, Shaw A, Fletcher N, Levy JH. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step-But There Is Much Work to Be Done. J Cardiothorac Vasc Anesth 2020; 34:39-47. [PMID: 31570245 DOI: 10.1053/j.jvca.2019.09.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/02/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Anesthesiology, Perioperative and Pain Medicine, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Albert T Cheung
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Herzzentrum Leipzig, Leipzig, Germany
| | - Michael Sander
- Department of Anaesthesiology and Intensive Care Medicine, UKGM University Hospital Gießen, Justus-Liebig-University Giessen, Gießen, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Aachen, Germany
| | | | - Hilary P Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine and Department of Surgery, University of Manitoba, Winnipeg, Canada
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
| | - Jacob T Gutsche
- Division of Cardiac Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Andre Denault
- Département d'Anesthésiologie et de Médecine de la Douleur, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Division des Soins Intensifs, Département de Chirurgie Cardiaque, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Département de Pharmacologie et de Physiologie, Institut de Cardiologie de Montréal, Montréal, Quebec Canada
| | - Andrew Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nick Fletcher
- Department of Cardiothoracic Anesthesia and Critical Care, St. Georges University Hospital, London, United Kingdom; Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
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Ling ML, Apisarnthanarak A, Abbas A, Morikane K, Lee KY, Warrier A, Yamada K. APSIC guidelines for the prevention of surgical site infections. Antimicrob Resist Infect Control 2019; 8:174. [PMID: 31749962 PMCID: PMC6852795 DOI: 10.1186/s13756-019-0638-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/31/2019] [Indexed: 01/25/2023] Open
Abstract
Background The Asia Pacific Society of Infection Control (APSIC) launched the APSIC Guidelines for the Prevention of Surgical Site Infections in 2018. This document describes the guidelines and recommendations for the setting prevention of surgical site infections (SSIs). It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities at Asia Pacific region in achieving high standards in preoperative, perioperative and postoperative practices. Method The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section. Results It recommends that healthcare facilities review specific risk factors and develop effective prevention strategies, which would be cost effective at local levels. Gaps identified are best closed using a quality improvement process. Surveillance of SSIs is recommended using accepted international methodology. The timely feedback of the data analysed would help in the monitoring of effective implementation of interventions. Conclusions Healthcare facilities should aim for excellence in safe surgery practices. The implementation of evidence-based practices using a quality improvement process helps towards achieving effective and sustainable results.
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Affiliation(s)
- Moi Lin Ling
- Infection Prevention & Epidemiology, Singapore General Hospital, Singapore, 169608 Singapore
| | - Anucha Apisarnthanarak
- Infectious Diseases, Division of Infectious Diseases, Thammasat University Hospital, Khlong Nueng, Thailand
| | - Azlina Abbas
- Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpor, Malaysia
| | - Keita Morikane
- Division of Clinical Laboratory and Infection Control Yamagata University Hospital, Yamagata, Japan
| | - Kil Yeon Lee
- Surgery, Medical College, Kyung Hee University Center, Gangdong-gu, South Korea
| | - Anup Warrier
- Infectious Diseases and Infection Control, Aster Medcity, Kochi, India
| | - Koji Yamada
- Orthopaedic Surgery, Kanto Rosai Hospital, Kawasaki, Japan
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Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery. JAMA Surg 2019; 154:755-766. [DOI: 10.1001/jamasurg.2019.1153] [Citation(s) in RCA: 347] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel T. Engelman
- Heart and Vascular Program, Baystate Medical Center, Springfield, Massachusetts
| | | | | | | | - V. Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rakesh C. Arora
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
- Now with Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, Los Angeles, California
| | - Marc Gerdisch
- Franciscan Health Heart Center, Indianapolis, Indiana
| | | | - Kevin Lobdell
- Atrium Health, Department of Cardiovascular and Thoracic Surgery, North Carolina
| | - Nick Fletcher
- St Georges University of London, London, United Kingdom
| | - Matthias Kirsch
- Centre Hospitalier Universitaire Vaudois Cardiac Surgery Centre, Lausanne, Switzerland
| | | | | | | | - Edward M. Boyle
- Department of Cardiac Surgery, St Charles Medical Center, Bend, Oregon
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Goal-Directed Fluid Resuscitation Protocol Based on Arterial Waveform Analysis of Major Burn Patients in a Mass Burn Casualty. Ann Plast Surg 2019; 80:S21-S25. [PMID: 29389698 DOI: 10.1097/sap.0000000000001288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adequate fluid titration during the initial resuscitation period of major burn patients is crucial. This study aimed to evaluate the feasibility and efficacy of a goal-directed fluid resuscitation protocol that used hourly urine output plus the arterial waveform analysis FloTrac (Edwards LifeSciences, Irvine, Calif) system for major burns to avoid fluid overload. METHODS We conducted a retrospective cohort study of 43 major burn patients at the Tri-Service General Hospital after the Formosa Fun Coast Dust Explosion on June 27, 2015. Because of the limited capacity of intensive care units (ICUs), 23 intubated patients were transferred from the burn wards or emergency department to the ICU within 24 hours. Fluid administration was adjusted to achieve a urine output of 30 to 50 mL/h, cardiac index greater than 2.5 L/min/m, and stroke volume variation (SVV) less than 12%. The hourly crystalloid fluid infusion rate was titrated based on SVV and hourly urine output. RESULTS Of the 23 critically burned patients admitted to the ICU, 13 patients who followed the goal-directed fluid resuscitation protocol within 12 hours postburn were included in the analysis. The mean age (years) was 21.8, and the mean total body surface area (TBSA) burned (%) was 68.0. The mean Revised Baux score was 106.8. All patients sustained inhalation injury. The fluid volumes administered to patients in the first 24 hours and the second 24 hours (mL/kg/% total body surface area) were 3.62 ± 1.23 and 2.89 ± 0.79, respectively. The urine outputs in the first 24 hours and the second 24 hours (mL/kg/h) were 1.13 ± 0.66 and 1.53 ± 0.87, respectively. All patients achieved the established goals within 32 hours postburn. In-hospital mortality rate was 0%. CONCLUSIONS The SVV-based goal-directed fluid resuscitation protocol leads to less unnecessary fluid administration during the early resuscitation phase. Clinicians can efficaciously manage the dynamic body fluid changes in major burn patients under the guidance of the protocol.
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Brienza N, Biancofiore G, Cavaliere F, Corcione A, De Gasperi A, De Rosa RC, Fumagalli R, Giglio MT, Locatelli A, Lorini FL, Romagnoli S, Scolletta S, Tritapepe L. Clinical guidelines for perioperative hemodynamic management of non cardiac surgical adult patients. Minerva Anestesiol 2019; 85:1315-1333. [PMID: 31213042 DOI: 10.23736/s0375-9393.19.13584-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.
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Affiliation(s)
- Nicola Brienza
- Unit of Anesthesia and Resuscitation, Department of Emergencies and Organ Transplantations, Aldo Moro University, Bari, Italy -
| | | | - Franco Cavaliere
- Unit of Cardiac Anesthesia and Cardiosurgical Intensive Therapy, A. Gemelli University Polyclinic, Sacred Heart Catholic University, Rome, Italy
| | - Antonio Corcione
- Operative Unit of Anesthesia and Intensive Postoperative Therapy, Department of Critical Area, Colli-Monaldi Hospital, Naples, Italy
| | - Andrea De Gasperi
- Operative Unit of Anesthesia and Resuscitation II, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Rosanna C De Rosa
- Operative Unit of Anesthesia and Intensive Postoperative Therapy, Department of Critical Area, Colli-Monaldi Hospital, Naples, Italy
| | - Roberto Fumagalli
- Operative Unit of Anesthesia and Resuscitation I, Milano Bicocca University, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Maria T Giglio
- Unit of Anesthesia and Resuscitation, Department of Emergencies and Organ Transplantations, Aldo Moro University, Bari, Italy
| | - Alessandro Locatelli
- Service of Anesthesia and Cardiovascular Intensive Therapy, Department of Emergency and Critical Area, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Ferdinando L Lorini
- Department of Emergency, Urgency and Critical Area, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Resuscitation, University of Florence, Careggi University Hospital, Florence, Italy
| | - Sabino Scolletta
- Unit of Resuscitation and Critical Medicine, Department of Medicine, Surgery and Neurosciences, University Hospital of Siena, Siena, Italy
| | - Luigi Tritapepe
- Operative Unit of Anesthesia and Intensive Therapy in Cardiosurgery, Department of Emergency and Admission, Anesthesia and Critical Areas, Umberto I Policlinic, Sapienza University, Rome, Italy
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Impact of a new balanced gelatine on electrolytes and pH in the perioperative care. PLoS One 2019; 14:e0213057. [PMID: 31034525 PMCID: PMC6488052 DOI: 10.1371/journal.pone.0213057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 10/13/2018] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Balanced fluid replacement solutions can possibly reduce the risks for electrolyte imbalances, for acid-base imbalances, and thus for renal failure. To assess the intraoperative change of base excess (BE) and chloride in serum after treatment with either a balanced gelatine/electrolyte solution or a non-balanced gelatine/electrolyte solution, a prospective, controlled, randomized, double-blind, dual centre phase III study was conducted in two tertiary care university hospitals in Germany. MATERIAL AND METHODS 40 patients of both sexes, aged 18 to 90 years, who were scheduled to undergo elective abdominal surgery with assumed intraoperative volume requirement of at least 15 mL/kg body weight gelatine solution were included. Administration of study drug was performed intravenously according to patients need. The trigger for volume replacement was a central venous pressure (CVP) minus positive end-expiratory pressure (PEEP) <10 mmHg (CVP <10 mmHg). The crystalloid:colloid ratio was 1:1 intra- and postoperatively. The targets for volume replacement were a CVP between 10 and 14 mmHg minus PEEP after treatment with vasoactive agent and mean arterial pressure (MAP) > 65 mmHg. RESULTS The primary endpoints, intraoperative changes of base excess -2.59 ± 2.25 (median: -2.65) mmol/L (balanced group) and -4.79 ± 2.38 (median: -4.70) mmol/L (non-balanced group)) or serum chloride 2.4 ± 1.9 (median: 3.0) mmol/L and 5.2 ± 3.1 (median: 5.0) mmol/L were significantly different (p = 0.0117 and p = 0.0045, respectively). In both groups (each n = 20) the investigational product administration in terms of volume and infusion rate was comparable throughout the course of the study, i.e. before, during and after surgery. DISCUSSION Balanced gelatine solution 4% combined with a balanced electrolyte solution demonstrated significant smaller impact on blood gas analytic parameters in the primary endpoints BE and serum chloride when compared to a non-balanced gelatine solution 4% combined with NaCl 0.9%. No marked treatment differences were observed with respect to haemodynamics, coagulation and renal function. TRIAL REGISTRATION ClinicalTrials.gov (NCT01515397) and clinicaltrialsregister.eu, EudraCT number 2010-018524-58.
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Klevebro F, Boshier PR, Low DE. Application of standardized hemodynamic protocols within enhanced recovery after surgery programs to improve outcomes associated with anastomotic leak and conduit necrosis in patients undergoing esophagectomy. J Thorac Dis 2019; 11:S692-S701. [PMID: 31080646 PMCID: PMC6503292 DOI: 10.21037/jtd.2018.11.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
Esophagectomy for cancer is associated with high risk for postoperative morbidity. The most serious regularly encountered complication is anastomotic leak and the most feared individual complication is conduit necrosis. Both of these complications affect the length of stay, mortality, quality of life, and survival for patients undergoing esophageal resection. The maintenance of conduit viability is of primary importance in the perioperative care of patients following esophageal resection. It has been shown that restrictive fluid management may be associated with improved postoperative outcomes in abdominal and other types of surgery, but many factors can affect the incidence of anastomotic leak and the viability of the gastric conduit. We have performed a comprehensive review with the aim to give an overview of the available evidence for the use of standardized hemodynamic protocols (SHPs) for esophagectomy and review the hemodynamic protocol, which has been applied within a standardized clinical pathway (SCP) at the Department of Thoracic surgery at the Virginia Mason Medical Center between 2004-2018 where the anastomotic leak rate over the period has been 5.2% and the incidence of conduit necrosis requiring surgical management is zero. The literature review demonstrates that there are few high quality studies that provide scientific evidence for the use of a SHP. The evidence indicates that the use of goal-directed hemodynamic monitoring might be associated with a reduced risk for postoperative complications, shortened length of stay, and decreased need for intensive care unit stay. We propose that the routine application of a SHP can provide a uniform infrastructure to optimize conduit perfusion and decrease the incidence of anastomotic leak.
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Affiliation(s)
- Fredrik Klevebro
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Piers R Boshier
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
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Zhang LM, Li R, Zhao XC, Wang ML, Fu Y. The Relationship Between Colloid Transfusion During Surgical Decompression Hemicraniectomy Period and Postoperative Pneumonia or Long-Term Outcome After Space-Occupying Cerebral Infarction: A Retrospective Study. World Neurosurg 2018; 122:e1312-e1320. [PMID: 30448584 DOI: 10.1016/j.wneu.2018.11.041] [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] [Received: 05/25/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Colloid transfusion during surgical decompressive hemicraniectomy (DHC) to treat space-occupying cerebral infarction induced by middle cerebral artery (MCA) is controversial. A multicenter retrospective study was conducted to determine whether an increased colloid transfusion during surgery is associated with a lower incidence of postoperative pneumonia and better long-term outcomes after space-occupying cerebral infarction. METHODS Data from surgical DHC within 48 hours to treat space-occupying cerebral infarction that took place between November 30, 2013, and March 30, 2016, were collected in a multicenter chart. Univariate analysis, Spearman correlation, χ2 test, and bivariate and multivariate logistic regression were performed to account for the associations between colloid transfusion and postoperative pneumonia or long-term outcomes (indicated by modified Rankin Scale [mRS] scores). RESULTS Univariate analysis showed that surgical duration and mRS were significantly different between the subjects older and younger than 60 years who underwent surgical DHC (P < 0.05). In the entire population studied, increased National Institutes of Health Stroke Scale was associated with a greater incidence of postoperative pneumonia (odds ratio [OR] 1.255, P = 0.003) and increased mRS (OR 1.229, P = 0.014). In the population older than 60 years, it was revealed that increased colloid transfusion was associated with a lower incidence of postoperative pneumonia (OR 0.761, P = 0.030) or better outcomes, as indicated with lower mRS (OR 0.837, P = 0.045). CONCLUSIONS Our retrospective study demonstrated that there is a robust association between increased perioperative colloid transfusion and lower incidence of postoperative pneumonia and better outcomes among the patients older than 60 years after space-occupying cerebral infarction.
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Affiliation(s)
- Li-Min Zhang
- Department of Anesthesiology, Cangzhou Central Hospital, Cangzhou, China.
| | - Rui Li
- Department of Anesthesiology, Cangzhou Central Hospital, Cangzhou, China
| | - Xiao-Chun Zhao
- Department of Anesthesiology, Shengjing Hospital, Shenyang, China
| | - Ming-Li Wang
- Department of Anesthesiology, Cangzhou People's Hospital, Cangzhou, China
| | - Yue Fu
- Department of Anesthesiology, Cangzhou Second People's Hospital, Cangzhou, China
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Voldby AW, Aaen AA, Møller AM, Brandstrup B. Goal-directed fluid therapy in urgent GAstrointestinal Surgery-study protocol for A Randomised multicentre Trial: The GAS-ART trial. BMJ Open 2018; 8:e022651. [PMID: 30429144 PMCID: PMC6252645 DOI: 10.1136/bmjopen-2018-022651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/05/2018] [Accepted: 09/12/2018] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Intravenous fluid therapy during gastrointestinal surgery is a life-saving part of the perioperative care. Too little fluid may lead to hypovolaemia, decreased organ perfusion and circulatory shock. Excessive fluid administration increases postoperative complications, worsens pulmonary and cardiac function as well as the healing of surgical wounds. Intraoperative individualised goal-directed fluid therapy (GDT) and zero-balance therapy (weight adjusted) has shown to reduce postoperative complications in elective surgery, but studies in urgent gastrointestinal surgery are sparse. The aim of the trial is to test whether zero-balance GDT reduces postoperative mortality and major complications following urgent surgery for obstructive bowel disease or perforation of the gastrointestinal tract compared with a protocolled standard of care. METHODS/ANALYSIS This study is a multicentre, randomised controlled trial with planned inclusion of 310 patients. The randomisation procedure is stratified by hospital and by obstructive bowel disease and perforation of the gastrointestinal tract. Patients are allocated into either 'the standard group' or 'the zero-balance GDT group'. The latter receive intraoperative GDT (guided by a stroke volume algorithm) and postoperative zero-balance fluid therapy based on body weight and fluid charts. The protocolled treatment continues until free oral intake or the seventh postoperative day.The primary composite outcome is death, unplanned reoperations, life-threatening thromboembolic and bleeding complications, a need for mechanical ventilation or dialysis. Secondary outcomes are additional complications, length of hospital stay, length of stay in the intensive care unit, length of mechanical ventilation, readmissions and time to death. Follow-up is 90 days.We plan intention-to-treat analysis of the primary outcome. ETHICS AND DISSEMINATION The Danish Scientific Ethics Committee approved the GAS-ART trial before patient enrolment (J: SJ-436). Enrolment of patients began in August 2015 and is proceeding. We expect to publish the GAS-ART results in Summer 2019. TRIAL REGISTRATION NUMBER EudraCT 2015-000563-14.
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Affiliation(s)
| | - Anne Albers Aaen
- Department of Anaesthesiology, Holbaek University Hospital, Holbaek, Denmark
| | - Ann Merete Møller
- Department of Anaesthesiology and Intensive Care Medicine, Herlev University Hospital, Holbaek, Denmark
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Yin K, Ding J, Wu Y, Peng M. Goal-directed fluid therapy based on noninvasive cardiac output monitor reduces postoperative complications in elderly patients after gastrointestinal surgery: A randomized controlled trial. Pak J Med Sci 2018; 34:1320-1325. [PMID: 30559778 PMCID: PMC6290223 DOI: 10.12669/pjms.346.15854] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective: Goal-directed fluid therapy (GDFT) was associated with improved outcomes after surgery. Noninvasive Cardiac Output Monitoring (NICOM) has proved to be a good choice for guiding GDFT. This study evaluated the effect of GDFT based on NICOM on prognosis in elderly patients undergoing resection of gastrointestinal tumor. Methods: Fifty patients scheduled for elective laparoscopic radical resection for stomach, colon or rectal cancer in Yongchuan Hospital of Chongqing Medical University between November 2014 and December 2015 were included and randomly divided into two groups: conventional fluid therapy (group C, n=25) and goal-directed fluid therapy (group G, n=25). The primary outcome was moderate or severe postoperative complications within 30 days. Results: Finally, 45 patients successfully completed the study (group G, n=22; group C, n=23). There were no difference of the duration of surgery, the requirement of vasoactive agents and the bleeding volume between two groups (P>0.05). Total fluids infused were 2956±629 ml (group C) and 2259±454 ml (group G) (P<0.05), while the requirement of colloid was increased in group G (1103±285ml vs 855±226ml) (P<0.05). The MAP and the mean CI were higher in group G (P<0.05). Compared with group C, the time when the patients passed the flatus and the length of hospital stay after operation were shortened in group G (12.6±2.4day vs17.2±2.6day), the incidence of postoperative complications were significantly lower in group G (P<0.05). Conclusions: Goal-directed fluid therapy based on NICOM was significantly associated with improvement of prognosis in elderly patients undergoing resection of gastrointestinal tumor which reduced postoperative complications.
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Affiliation(s)
- Kaiyu Yin
- Kaiyu Yin, Department of Anesthesiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, China
| | - Jiahui Ding
- Jiahui Ding, Department of Anesthesiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, China
| | - You Wu
- You Wu, Department of Anesthesiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, China
| | - Mingqing Peng
- Mingqing Peng, Department of Anesthesiology, Yongchuan Hospital of Chongqing Medical University, Chongqing, 402160, China
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Outcome impact of hemodynamic and depth of anesthesia monitoring during major cancer surgery: a before–after study. J Clin Monit Comput 2018; 33:365-371. [DOI: 10.1007/s10877-018-0190-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/30/2018] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW For the past 15 years, there has been a strong push to use goal-directed protocols for resuscitating critically ill patients and to manage perioperative patients. However, recent large clinical trials have failed to find evidence of improved outcome with this approach. RECENT FINDINGS A striking feature in the recent three large prospective randomized trials of septic patients and the one in high-risk perioperative patients is that outcomes in the control groups have markedly improved. This implies improvement in care and clinical acumen. Perhaps the clinical approach should be more toward further helping clinicians with their clinical choices. A good example is cardiac output. The objective of most hemodynamic interventions is to increase cardiac output. It would thus make sense to assess what happened to cardiac output after the intervention to determine if the intervention actually increased cardiac output. If it did not, another therapy should be chosen. I call this a flow-directed responsive protocol. SUMMARY A clinical approach that uses monitored values such as cardiac output as a feedback tool to evaluate the response to therapeutic interventions in individual patients may be better than protocols that set fixed targets for all study participants.
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Calvo-Vecino J, Ripollés-Melchor J, Mythen M, Casans-Francés R, Balik A, Artacho J, Martínez-Hurtado E, Serrano Romero A, Fernández Pérez C, Asuero de Lis S, Errazquin AT, Gil Lapetra C, Motos AA, Reche EG, Medraño Viñas C, Villaba R, Cobeta P, Ureta E, Montiel M, Mané N, Martínez Castro N, Horno GA, Salas RA, Bona García C, Ferrer Ferrer ML, Franco Abad M, García Lecina AC, Antón JG, Gascón GH, Peligro Deza J, Pascual LP, Ruiz Garcés T, Roberto Alcácer AT, Badura M, Terrer Galera E, Fernández Casares A, Martínez Fernández MC, Espinosa Á, Abad-Gurumeta A, Feldheiser A, López Timoneda F, Zuleta-Alarcón A, Bergese S. Effect of goal-directed haemodynamic therapy on postoperative complications in low–moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial). Br J Anaesth 2018; 120:734-744. [DOI: 10.1016/j.bja.2017.12.018] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 11/20/2017] [Accepted: 12/11/2017] [Indexed: 02/06/2023] Open
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Yan T, Liang XQ, Wang T, Li WO, Li HJ, Zhu SN, Wang DX. Prophylactic penehyclidine inhalation for prevention of postoperative pulmonary complications in high-risk patients: study protocol of a randomized controlled trial. Trials 2017; 18:571. [PMID: 29183393 PMCID: PMC5706155 DOI: 10.1186/s13063-017-2315-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 11/06/2017] [Indexed: 11/20/2022] Open
Abstract
Background Postoperative pulmonary complications (PPCs) are major causes of morbidity, mortality, and prolonged hospital stay in patients after surgery. Using effective strategies to prevent its occurrence is essential to improve outcome. However, despite various efforts, the incidence of PPCs remains elevated in high-risk patients. Anticholinergic inhalation is used to reduce high airway resistance and improve pulmonary function; it may be helpful to decrease the risk of PPCs. Penehyclidine is a long-acting anticholinergic agent which selectively blocks M1 and M3 receptors. We hypothesize that, in high-risk patients, prophylactic penehyclidine inhalation may decrease the incidence of PPCs. Methods This is a randomized, double-blind, placebo-controlled trial with two parallel arms. A total of 864 patients at high risk of PPCs will be enrolled and randomized to receive prophylactic inhalation of either penehyclidine or placebo (water for injection). Study drug inhalation will be administered from the night (7 pm) before surgery until the second day after surgery, in an interval of every 12 hours. The primary outcome is the incidence of PPCs within 30 days after surgery. Secondary outcomes include the time to onset of PPCs (from end of surgery to first diagnosis of PPCs), the number of PPCs (indicates the number of diagnosed individual PPCs), the incidence of postoperative extrapulmonary complications, the length of stay in hospital after surgery, and the 30-day all-cause mortality. Discussion Results of the present study will provide evidence to guide clinical practice in using prophylactic inhalation of an anticholinergic to prevent PPCs in high-risk patients. Trial registration The study was registered prospectively in Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR-IPC-15006603) on 14 May 2015 and retrospectively in ClinicalTrials.gov (NCT02644876) on 30 December 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2315-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ting Yan
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Xin-Quan Liang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Tong Wang
- Department of Anesthesiology, Aerospace Central Hospital, No.15 Yuquan Street, Haidian District, Beijing, 100049, China
| | - Wei-Ou Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Sai-Nan Zhu
- Department of Biostatistics, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China.
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Prasad V, Guerrisi M, Dauri M, Coniglione F, Tisone G, De Carolis E, Cillis A, Canichella A, Toschi N, Heldt T. Prediction of postoperative outcomes using intraoperative hemodynamic monitoring data. Sci Rep 2017; 7:16376. [PMID: 29180647 PMCID: PMC5703992 DOI: 10.1038/s41598-017-16233-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/08/2017] [Indexed: 12/13/2022] Open
Abstract
Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of which patient might be at risk for such events may help guide peri- and postoperative care. We show how archiving and mining of intraoperative hemodynamic data in orthotopic liver transplantation (OLT) can aid in the prediction of postoperative 180-day mortality and acute renal failure (ARF), improving upon predictions that rely on preoperative information only. From 101 patient records, we extracted 15 preoperative features from clinical records and 41 features from intraoperative hemodynamic signals. We used logistic regression with leave-one-out cross-validation to predict outcomes, and incorporated methods to limit potential model instabilities from feature multicollinearity. Using only preoperative features, mortality prediction achieved an area under the receiver operating characteristic curve (AUC) of 0.53 (95% CI: 0.44–0.78). By using intraoperative features, performance improved significantly to 0.82 (95% CI: 0.56–0.91, P = 0.001). Similarly, including intraoperative features (AUC = 0.82; 95% CI: 0.66–0.94) in ARF prediction improved performance over preoperative features (AUC = 0.72; 95% CI: 0.50–0.85), though not significantly (P = 0.32). We conclude that inclusion of intraoperative hemodynamic features significantly improves prediction of postoperative events in OLT. Features strongly associated with occurrence of both outcomes included greater intraoperative central venous pressure and greater transfusion volumes.
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Affiliation(s)
- Varesh Prasad
- Harvard-MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, MA, USA. .,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Maria Guerrisi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy.,Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Filadelfo Coniglione
- Department of Clinical Science and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy.,Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy.,University "Our Lady of Good Counsel", Tirana, Albania
| | - Giuseppe Tisone
- Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
| | - Elisa De Carolis
- Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Annagrazia Cillis
- Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Antonio Canichella
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Nicola Toschi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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Futier E, Lefrant JY, Guinot PG, Godet T, Lorne E, Cuvillon P, Bertran S, Leone M, Pastene B, Piriou V, Molliex S, Albanese J, Julia JM, Tavernier B, Imhoff E, Bazin JE, Constantin JM, Pereira B, Jaber S. Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery: A Randomized Clinical Trial. JAMA 2017; 318:1346-1357. [PMID: 28973220 PMCID: PMC5710560 DOI: 10.1001/jama.2017.14172] [Citation(s) in RCA: 463] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
IMPORTANCE Perioperative hypotension is associated with an increase in postoperative morbidity and mortality, but the appropriate management strategy remains uncertain. OBJECTIVE To evaluate whether an individualized blood pressure management strategy tailored to individual patient physiology could reduce postoperative organ dysfunction. DESIGN, SETTING, AND PARTICIPANTS The Intraoperative Norepinephrine to Control Arterial Pressure (INPRESS) study was a multicenter, randomized, parallel-group clinical trial conducted in 9 French university and nonuniversity hospitals. Adult patients (n = 298) at increased risk of postoperative complications with a preoperative acute kidney injury risk index of class III or higher (indicating moderate to high risk of postoperative kidney injury) undergoing major surgery lasting 2 hours or longer under general anesthesia were enrolled from December 4, 2012, through August 28, 2016 (last follow-up, September 28, 2016). INTERVENTIONS Individualized management strategy aimed at achieving a systolic blood pressure (SBP) within 10% of the reference value (ie, patient's resting SBP) or standard management strategy of treating SBP less than 80 mm Hg or lower than 40% from the reference value during and for 4 hours following surgery. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of systemic inflammatory response syndrome and dysfunction of at least 1 organ system of the renal, respiratory, cardiovascular, coagulation, and neurologic systems by day 7 after surgery. Secondary outcomes included the individual components of the primary outcome, durations of ICU and hospital stay, adverse events, and all-cause mortality at 30 days after surgery. RESULTS Among 298 patients who were randomized, 292 patients completed the trial (mean [SD] age, 70 [7] years; 44 [15.1%] women) and were included in the modified intention-to-treat analysis. The primary outcome event occurred in 56 of 147 patients (38.1%) assigned to the individualized treatment strategy vs 75 of 145 patients (51.7%) assigned to the standard treatment strategy (relative risk, 0.73; 95% CI, 0.56 to 0.94; P = .02; absolute risk difference, -14%, 95% CI, -25% to -2%). Sixty-eight patients (46.3%) in the individualized treatment group and 92 (63.4%) in the standard treatment group had postoperative organ dysfunction by day 30 (adjusted hazard ratio, 0.66; 95% CI, 0.52 to 0.84; P = .001). There were no significant between-group differences in severe adverse events or 30-day mortality. CONCLUSIONS AND RELEVANCE Among patients predominantly undergoing abdominal surgery who were at increased postoperative risk, management targeting an individualized systolic blood pressure, compared with standard management, reduced the risk of postoperative organ dysfunction. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01536470.
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Affiliation(s)
- Emmanuel Futier
- Département de Médecine Périopératoire, Université Clermont Auvergne, Centre national de la recherche scientifique, Inserm, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Yves Lefrant
- Section d’Anesthésie and Département Anesthésie et Réanimation, Centre Hospitalier Universitaire Nîmes, Nîmes, France
| | - Pierre-Gregoire Guinot
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire Amiens, Amiens, France
| | - Thomas Godet
- Département de Médecine Périopératoire, Université Clermont Auvergne, Centre national de la recherche scientifique, Inserm, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Lorne
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire Amiens, Amiens, France
| | - Philippe Cuvillon
- Section d’Anesthésie and Département Anesthésie et Réanimation, Centre Hospitalier Universitaire Nîmes, Nîmes, France
| | - Sebastien Bertran
- Section d’Anesthésie and Département Anesthésie et Réanimation, Centre Hospitalier Universitaire Nîmes, Nîmes, France
| | - Marc Leone
- Service Anesthésie et Réanimation, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Université Aix Marseille, Marseille, France
| | - Bruno Pastene
- Service Anesthésie et Réanimation, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Université Aix Marseille, Marseille, France
| | - Vincent Piriou
- Service d’Anesthésie-Réanimation, Université Claude Bernard Lyon-1, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - Serge Molliex
- Département Anesthésie-Réanimation, Centre Hospitalier Universitaire Saint-Etienne, Saint-Étienne, France
| | - Jacques Albanese
- Service Anesthésie et Réanimation, Assistance Publique Hôpitaux de Marseille, Hôpital de la Conception, Marseille, France
| | - Jean-Michel Julia
- Anesthésie et Réanimation, Clinique du Parc, Castelnau-Le-Lez, France
| | - Benoit Tavernier
- Pôle Anesthésie-Réanimation, Centre Hospitalier Universitaire Lille, Lille, France
| | - Etienne Imhoff
- Service d’Anesthésie-Réanimation, Université Claude Bernard Lyon-1, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - Jean-Etienne Bazin
- Département de Médecine Périopératoire, Université Clermont Auvergne, Centre national de la recherche scientifique, Inserm, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Département de Médecine Périopératoire, Université Clermont Auvergne, Centre national de la recherche scientifique, Inserm, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistic Unit, Centre Hospitalier Universitaire Clermont-Ferrand, Direction de la Recherche Clinique, Clermont-Ferrand, France
| | - Samir Jaber
- Département Anesthésie et Réanimation B, Centre Hospitalier Universitaire Montpellier, Hôpital Saint-Eloi, and INSERM U-1046, Montpellier, France
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Cata JP, Lasala J, Mena GE, Mehran JR. Anesthetic Considerations for Mediastinal Staging Procedures for Lung Cancer. J Cardiothorac Vasc Anesth 2017; 32:893-900. [PMID: 29174661 DOI: 10.1053/j.jvca.2017.08.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Indexed: 12/25/2022]
Abstract
Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.
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Affiliation(s)
- J P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Texas, USA.
| | - J Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Texas, USA; Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Texas, USA
| | - G E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Texas, USA
| | - J R Mehran
- Anesthesiology and Surgical Oncology Research Group, Houston, Texas, USA
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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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Michard F, Giglio M, Brienza N. Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome. Br J Anaesth 2017; 119:22-30. [DOI: 10.1093/bja/aex138] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Landais A, Morel M, Goldstein J, Loriau J, Fresnel A, Chevalier C, Rejasse G, Alfonsi P, Ecoffey C. Evaluation of financial burden following complications after major surgery in France: Potential return after perioperative goal-directed therapy. Anaesth Crit Care Pain Med 2017; 36:151-155. [DOI: 10.1016/j.accpm.2016.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 10/05/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023]
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Ripollés-Melchor J, Chappell D, Aya HD, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part III: Goal directed hemodynamic therapy. Rationale for maintaining vascular tone and contractility. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:348-359. [PMID: 28343682 DOI: 10.1016/j.redar.2017.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 06/06/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - H D Aya
- Departamento de Cuidados Intensivos, St George's University Hospitals, NHS Foundation Trust, Londres, Reino Unido
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, España
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Mahmoudi N, Eslahi N, Mehdipour A, Mohammadi M, Akbari M, Samadikuchaksaraei A, Simchi A. Temporary skin grafts based on hybrid graphene oxide-natural biopolymer nanofibers as effective wound healing substitutes: pre-clinical and pathological studies in animal models. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:73. [PMID: 28361280 DOI: 10.1007/s10856-017-5874-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 02/28/2017] [Indexed: 06/07/2023]
Abstract
In recent years, temporary skin grafts (TSG) based on natural biopolymers modified with carbon nanostructures have received considerable attention for wound healing. Developments are required to improve physico-mechanical properties of these materials to match to natural skins. Additionally, in-deep pre-clinical examinations are necessary to ensure biological performance and toxicity effect in vivo. In the present work, we show superior acute-wound healing effect of graphene oxide nanosheets embedded in ultrafine biopolymer fibers (60 nm) on adult male rats. Nano-fibrous chitosan-based skin grafts crosslinked by Genepin with physico-mechanical properties close to natural skins were prepared by electrospinning of highly concentrated chitosan- polyvinylpyrrolidone solutions containing graphene oxide (GO) nanosheets. No surfactants and organic solvents were utilized to ensure high biocompatibility of the fibrous structure. In vitro evaluations by human skin fibroblast cells including live and dead assay and MTT results show that GO promote cell viability of porous nanofibrous membrane while providing enhanced bactericidal capacity. In vivo studies on rat's skin determine accelerated healing effect, i.e. a large open wound (1.5 × 1.5 cm2) is fully regenerated after 14-day of post operation while healing is observed for sterile gauze sponge (as the control). Pathological studies support thick dermis formation and complete epithelialization in the presence of 1.5 wt% GO nanosheets. Over 99% wound healing occurs after 21 days for the injury covered with TSG containing 1.5 wt% GO while this would takes weeks for the control. Therefore, the developed materials have a high potential to be used as TSG as pre-clinical testing has shown.
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Affiliation(s)
- N Mahmoudi
- Department of Materials Science and Engineering, Sharif University of Technology, P.O. Box11155-9161, Azadi Avenue, Tehran, 14588, Iran
| | - N Eslahi
- Department of Textile Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - A Mehdipour
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - M Mohammadi
- Department of Materials Science and Engineering, Sharif University of Technology, P.O. Box11155-9161, Azadi Avenue, Tehran, 14588, Iran
| | - M Akbari
- Department of Mechanical Engineering, University of Victoria, Victoria, BC, Canada
| | - A Samadikuchaksaraei
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Tissue Engineering & Regenerative Medicine, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - A Simchi
- Department of Materials Science and Engineering, Sharif University of Technology, P.O. Box11155-9161, Azadi Avenue, Tehran, 14588, Iran.
- Institute for Nanoscience and Nanotechnology, Sharif University of Technology, P. O. Box 11365-9466, Azadi Avenue, Tehran, 14588, Iran.
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Veelo DP, van Berge Henegouwen MI, Ouwehand KS, Geerts BF, Anderegg MCJ, van Dieren S, Preckel B, Binnekade JM, Gisbertz SS, Hollmann MW. Effect of goal-directed therapy on outcome after esophageal surgery: A quality improvement study. PLoS One 2017; 12:e0172806. [PMID: 28253353 PMCID: PMC5333843 DOI: 10.1371/journal.pone.0172806] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/09/2017] [Indexed: 12/21/2022] Open
Abstract
Background Goal-directed therapy (GDT) can reduce postoperative complications in high-risk surgery patients. It is uncertain whether GDT has the same benefits in patients undergoing esophageal surgery. Goal of this Quality Improvement study was to evaluate the effects of a stroke volume guided GDT on post-operative outcome. Methods and findings We compared the postoperative outcome of patients undergoing esophagectomy before (99 patients) and after (100 patients) implementation of GDT. There was no difference in the proportion of patients with a complication (56% vs. 54%, p = 0.82), hospital stay and mortality. The incidence of prolonged ICU stay (>48 hours) was reduced (28% vs. 12, p = .005) in patients treated with GDT. Secondary analysis of complication rate showed a decrease in pneumonia (29 vs. 15%, p = .02), mediastinal abscesses (12 vs. 3%, p = .02), and gastric tube necrosis (5% vs. 0%, p = .03) in patients treated with GDT. Patients in the GDT group received significantly less fluids but received more colloids. Conclusions The implementation of GDT during esophagectomy was not associated with reductions in overall morbidity, mortality and hospital length of stay. However, we observed a decrease in pneumonia, mediastinal abscesses, gastric tube necrosis, and ICU length of stay.
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Affiliation(s)
- Denise P. Veelo
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Kirsten S. Ouwehand
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Bart F. Geerts
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | | | - Susan van Dieren
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan M. Binnekade
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Markus W. Hollmann
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
Acute kidney injury (AKI) has been associated with an increased risk of death and morbidity in many clinical scenarios. The prevention and treatment of AKI therefore has been advocated as a high-priority research focus. However, nearly all strategies tested in this setting have failed to prevent or cure AKI and fluid loading remains a cornerstone of preventive and curative treatment of AKI. Concerns have been raised, however, regarding both the efficacy and safety of fluid loading to prevent or reverse AKI. In this review, we address the question of the best use of fluid loading based on current preclinical and clinical data in a mechanistically guided approach. Impacts of fluid resuscitation on renal hemodynamics, from macrocirculation to microcirculation, with physiological end points as well as renal consequences of different fluids available are discussed. Finally, the complex relationship between renal hemodynamics is discussed.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesiology and Critical Care and Burn Unit, Assitance Publique Hôpitaux de Paris, Hôpital St-Louis, Paris, France; Unité mixte de recherche INSERM 942, Institut National de la Santé et de la Recherche Médicale, Lariboisière Hospital, Paris, France; University Paris Diderot, Paris, France
| | - Can Ince
- Department of Intensive Care, Erasmus Medical Center University Hospital, Rotterdam, The Netherlands; Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Uña Orejón R, Del Huercio Martinez I, Casinello Ogea C, Del Prado Ureta Tolsada M, Uña Orejon S. Intraoperatorive hydroxyethyl starch: A safe therapy or a poison? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:588-593. [PMID: 27129792 DOI: 10.1016/j.redar.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/22/2016] [Accepted: 03/02/2016] [Indexed: 06/05/2023]
Affiliation(s)
- R Uña Orejón
- Jefe de Sección Bloque Quirúrgico, Servicio de Anestesiología, Hospital "La Paz", Madrid, Spain.
| | | | - C Casinello Ogea
- FEA Servicio de Anestesiología, Hospital "Miguel Servet", Zaragoza, Spain
| | | | - S Uña Orejon
- FEA Servicio de Anestesiología, Hospital General de Albacete, Spain
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Ripollés-Melchor J, Casans-Francés R, Espinosa A, Abad-Gurumeta A, Feldheiser A, López-Timoneda F, Calvo-Vecino JM. Goal directed hemodynamic therapy based in esophageal Doppler flow parameters: A systematic review, meta-analysis and trial sequential analysis. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:384-405. [PMID: 26873025 DOI: 10.1016/j.redar.2015.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/14/2015] [Accepted: 07/18/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Numerous studies have compared perioperative esophageal doppler monitoring (EDM) guided intravascular volume replacement strategies with conventional clinical volume replacement in surgical patients. The use of the EDM within hemodynamic algorithms is called 'goal directed hemodynamic therapy' (GDHT). METHODS Meta-analysis of the effects of EDM guided GDHT in adult non-cardiac surgery on postoperative complications and mortality using PRISMA methodology. A systematic search was performed in Medline, PubMed, EMBASE, and the Cochrane Library (last update, March 2015). INCLUSION CRITERIA Randomized clinical trials (RCTs) in which perioperative GDHT was compared to other fluid management. PRIMARY OUTCOMES Overall complications. SECONDARY OUTCOMES Mortality; number of patients with complications; cardiac, renal and infectious complications; incidence of ileus. Studies were subjected to quantifiable analysis, pre-defined subgroup analysis (stratified by surgery, type of comparator and risk); pre-defined sensitivity analysis and trial sequential analysis (TSA). RESULTS Fifty six RCTs were initially identified, 15 fulfilling the inclusion criteria, including 1,368 patients. A significant reduction was observed in overall complications associated with GDHT compared to other fluid therapy (RR=0.75; 95%CI: 0.63-0.89; P=0.0009) in colorectal, urological and high-risk surgery compared to conventional fluid therapy. No differences were found in secondary outcomes, neither in other subgroups. The impact on preventing the development of complications in patients using EDM is high, causing a relative risk reduction (RRR) of 50% for a number needed to treat (NNT)=6. CONCLUSIONS GDHT guided by EDM decreases postoperative complications, especially in patients undergoing colorectal surgery and high-risk surgery. However, no differences versus restrictive fluid therapy and in intermediate-risk patients were found.
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Affiliation(s)
- J Ripollés-Melchor
- Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid. Servicio de Anestesia, Hospital Universitario Infanta Leonor, Madrid, España.
| | - R Casans-Francés
- Facultad de Medicina, Universidad de Zaragoza. Servicio de Anestesia, Hospital Universitario Lozano Blesa, Zaragoza, España
| | - A Espinosa
- Department of Anesthesia, Center of Vascular and Thoracic Surgery and Intensive Care, Örebro University Hospital, Örebro, Suecia
| | - A Abad-Gurumeta
- Servicio de Anestesia, Hospital Universitario La Paz, Madrid, España
| | - A Feldheiser
- Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte and Campus Charité Virchow-Klinikum, Berlín, Alemania
| | - F López-Timoneda
- Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid. Servicio de Anestesia, Hospital Clínico Universitario San Carlos, Madrid, España
| | - J M Calvo-Vecino
- Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid. Servicio de Anestesia, Hospital Universitario Infanta Leonor, Madrid, España
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