Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study

Pilot Study to Optimize Goal-directed Hemodynamic Management During Pancreatectomy

INTRODUCTION

Intraoperative goal-directed hemodynamic therapy (GDHT) is a cornerstone of enhanced recovery protocols. We hypothesized that use of an advanced noninvasive intraoperative hemodynamic monitoring system to guide GDHT may decrease intraoperative hypotension (IOH) and improve perfusion during pancreatic resection.

METHODS

The monitor uses machine learning to produce the Hypotension Prediction Index to predict hypotensive episodes. A clinical decision-making algorithm uses the Hypotension Prediction Index and hemodynamic data to guide intraoperative fluid versus pressor management. Pre-implementation (PRE), patients were placed on the monitor and managed per usual. Post-implementation (POST), anesthesia teams were educated on the algorithm and asked to use the GDHT guidelines. Hemodynamic data points were collected every 20 s (8942 PRE and 26,638 POST measurements). We compared IOH (mean arterial pressure <65 mmHg), cardiac index >2, and stroke volume variation <12 between the two groups.

RESULTS

10 patients were in the PRE and 24 in the POST groups. In the POST group, there were fewer minimally invasive resections (4.2% versus 30.0%, P = 0.07), more pancreaticoduodenectomies (75.0% versus 20.0%, P < 0.01), and longer operative times (329.0 + 108.2 min versus 225.1 + 92.8 min, P = 0.01). After implementation, hemodynamic parameters improved. There was a 33.3% reduction in IOH (5.2% ± 0.1% versus 7.8% ± 0.3%, P < 0.01, a 31.6% increase in cardiac index >2.0 (83.7% + 0.2% versus 63.6% + 0.5%, P < 0.01), and a 37.6% increase in stroke volume variation <12 (73.2% + 0.3% versus 53.2% + 0.5%, P < 0.01).

CONCLUSIONS

Advanced intraoperative hemodynamic monitoring to predict IOH combined with a clinical decision-making tree for GDHT may improve intraoperative hemodynamic parameters during pancreatectomy. This warrants further investigation in larger studies.

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Influence of different intraoperative fluid management on postoperative outcome after abdominal tumours resection

BACKGROUND

Intraoperative fluid management is a crucial aspect of cancer surgery, including colorectal surgery and pancreatoduodenectomy. The study tests if intraoperative multimodal monitoring reduces postoperative morbidity and duration of hospitalisation in patients undergoing major abdominal surgery treated by the same anaesthetic protocols with epidural analgesia.

PATIENTS AND METHODS

A prospective study was conducted in 2 parallel groups. High-risk surgical patients undergoing major abdominal surgery were randomly selected in the control group (CG), where standard monitoring was applied (44 patients), and the protocol group (PG), where cerebral oxygenation and extended hemodynamic monitoring were used with the protocol for intraoperative interventions (44 patients).

RESULTS

There were no differences in the median length of hospital stay, CG 9 days (interquartile range [IQR] 8 days), PG 9 (5.5), p = 0.851. There was no difference in postoperative renal of cardiac impairment. Procalcitonin was significantly higher (highest postoperative value in the first 3 days) in CG, 0.75 mcg/L (IQR 3.19 mcg/L), than in PG, 0.3 mcg/L (0.88 mcg/L), p = 0.001. PG patients received a larger volume of intraoperative fluid; median intraoperative fluid balance +1300 ml (IQR 1063 ml) than CG; +375 ml (IQR 438 ml), p < 0.001.

CONCLUSIONS

There were significant differences in intraoperative fluid management and vasopressor use. The median postoperative value of procalcitonin was significantly higher in CG, suggesting differences in immune response to tissue trauma in different intraoperative fluid status, but there was no difference in postoperative morbidity or hospital stay.

The management of goal-directed fluid therapy during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Cytoreductive surgery is a surgical treatment approach that has been applied over the last 3 decades in patients with peritoneal metastases originating from intraabdominal organs. Goal-directed fluid therapy (GDFT) is an approach in which a patient fluid therapy during a medical procedure or surgery is carefully managed based on a specific goal. In this study, we aimed to present the results of GDFT in patients who underwent cytoreductive surgery for peritoneal carcinomatosis (PC) during the perioperative period. This retrospective study included 398 patients patient who underwent cytoreductive surgery + hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) due to PC originating from intraabdominal malignancies. Of the cases, 233 (58.6%) were female, and 165 (41.4%) were male patients. The mean age was 58.9. Perioperative findings revealed an average PC score of 12 (3-24), average lactate levels of 3 (2-7) mmol/L, Pao2/fio2 of 3.3 (2.4-4.1) mm Hg, mean arterial pressure (MAP) of 60 (55-70), average surgery duration of 6.5 hours (3-14), and average blood loss of 400 (200-4000) cc. The mean intraoperative fluid rate was 6.4 mL/kg/h (IQR 5.8-7.1). Sixteen (16.3%) patients experienced Clavien-Dindo Grade 3-4 adverse events. Within 30 days, 25 patients (6.3%) died. CRS + HIPEC procedures utilizing perioperative GDFT along with advanced anesthesia monitoring devices have shown successful application, offering an alternative to traditional and restrictive fluid management approaches.

Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

OBJECTIVE

To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE.

RESULTS

We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%).

CONCLUSION

Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.

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

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.

Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).

Analysis of Intraoperative Variables Responsible for the Increase in Lactic Acid in Patients Undergoing Debulking Surgery

Background: Cytoreductive surgery (CRS) is a complex procedure with a high incidence of perioperative complications. Elevated lactacidaemia levels have been associated with complications and perioperative morbidity and mortality. This study aims to analyse the intraoperative variables of patients undergoing CRS and their relationship with lactacidaemia levels. Methods: This retrospective, observational study included 51 patients with peritoneal carcinomatosis who underwent CRS between 2014 and 2016 at the Abdomino-Pelvic Oncological Surgery Reference Unit (URCOAP) of the General University Hospital of Castellón (HGUCS). The main variable of interest was the level of lactic acid at the end of surgery. Intraoperative variables, including preoperative haemoglobin, duration of surgery, intraoperative bleeding, fluid therapy administered, administration of blood products, and intraoperative peritoneal cancer index (PCI), were analysed. Results: Positive correlations were found between lactic acid levels and PCI, duration of intervention, fluid therapy, intraoperative bleeding, and transfusion of blood products. Additionally, a negative correlation was observed between haemoglobin levels and lactic acid levels. Notably, the strongest correlations were found with operative PCI (ρ = 0.532; p-value < 0.001) and duration of surgery (ρ = 0.518; p-value < 0.001). Conclusions: PCI and duration of surgery are decisive variables in determining the prognosis of patients undergoing debulking surgery. This study suggests that, for each minute of surgery, lactic acid levels increase by 0.005 mmol/L, and for each unit increase in PCI, lactic acid levels increase by 0.060 mmol/L.

Effects of goal-directed fluid management guided by a non-invasive device on the incidence of postoperative complications in neurosurgery: a pilot and feasibility randomized controlled trial

BACKGROUND

The positive effects of goal-directed hemodynamic therapy (GDHT) on patient-orientated outcomes have been demonstrated in various clinical scenarios; however, the effects of fluid management in neurosurgery remain unclear. Therefore, this study was aimed at assessing the safety and feasibility of GDHT using non-invasive hemodynamic monitoring in elective neurosurgery. The incidence of postoperative complications was compared between GDHT and control groups.

METHODS

We conducted a single-center randomized pilot study with an enrollment target of 34 adult patients scheduled for elective neurosurgery. We randomly assigned the patients equally into control and GDHT groups. The control group received standard therapy during surgery and postoperatively, whereas the GDHT group received therapy guided by an algorithm based on non-invasive hemodynamic monitoring. In the GDHT group, we aimed to achieve and sustain an optimal cardiac index by using non-invasive hemodynamic monitoring and bolus administration of colloids and vasoactive drugs. The number of patients with adverse events, feasibility criteria, perioperative parameters, and incidence of postoperative complications was compared between groups.

RESULTS

We successfully achieved all feasibility criteria. The GDHT protocol was safe, because no patients in either group had unsatisfactory brain tissue relaxation after surgery or brain edema requiring therapy during surgery or 24 h after surgery. Major complications occurred in two (11.8%) patients in the GDHT group and six (35.3%) patients in the control group (p = 0.105).

CONCLUSIONS

Our results suggested that a large randomized trial evaluating the effects of GDHT on the incidence of postoperative complications in elective neurosurgery should be safe and feasible. The rate of postoperative complications was comparable between groups.

TRIAL REGISTRATION

Trial registration: ClininalTrials.gov, registration number: NCT04754295, date of registration: February 15, 2021.

Accuracy of hemodynamic parameters derived by GE E-PiCCO in comparison with PiCCO® in patients admitted to the intensive care unit

To evaluate the agreement and accuracy of a novel advanced hemodynamic monitoring (AHM) device, the GE E-PiCCO module, with the well-established PiCCO® device in intensive care patients using pulse contour analysis (PCA) and transpulmonary thermodilution (TPTD). A total of 108 measurements were performed in 15 patients with AHM. Each of the 27 measurement sequences (one to four per patient) consisted of a femoral and a jugular indicator injection via central venous catheters (CVC) and measurement using both PiCCO (PiCCO® Jug and Fem) and GE E-PiCCO (GE E-PiCCO Jug and Fem) devices. For statistical analysis, Bland-Altman plots were used to compare the estimated values derived from both devices. The cardiac index measured via PCA (CIpc) and TPTD (CItd) was the only parameter that fulfilled all a priori-defined criteria based on bias and the limits of agreement (LoA) by the Bland-Altman method as well as the percentage error by Critchley and Critchley for all three comparison pairs (GE E-PiCCO Jug vs. PiCCO® Jug, GE E-PiCCO Fem vs. PiCCO® Fem, and GE E-PiCCO Fem vs. GE E-PiCCO Jug), while the GE E-PiCCO did not accurately estimate EVLWI, SVRI, SVV, and PPV values measured via the jugular and femoral CVC compared with values assessed by PiCCO®. Consequently, measurement discrepancy should be considered on evaluation and interpretation of the hemodynamic status of patients admitted to the ICU when using the GE E-PiCCO module instead of the PiCCO® device.

Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review

Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Reliability of bioreactance and pulse power analysis in measuring cardiac index during cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)

PURPOSE

Various malignancies with peritoneal carcinomatosis are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). The hemodynamic instability resulting from fluid balance alterations during the procedure necessitates reliable hemodynamic monitoring. The aim of the study was to compare the accuracy, precision and trending ability of two less invasive hemodynamic monitors, bioreactance-based Starling SV and pulse power device LiDCOrapid with bolus thermodilution technique with pulmonary artery catheter in the setting of cytoreductive surgery with HIPEC.

METHODS

Thirty-one patients scheduled for cytoreductive surgery were recruited. Twenty-three of them proceeded to HIPEC and were included to the study. Altogether 439 and 430 intraoperative bolus thermodilution injections were compared to simultaneous cardiac index readings obtained with Starling SV and LiDCOrapid, respectively. Bland-Altman method, four-quadrant plots and error grids were used to assess the agreement of the devices.

RESULTS

Comparing Starling SV with bolus thermodilution, the bias was acceptable (0.13 l min^- 1 m^- 2, 95% CI 0.05 to 0.20), but the limits of agreement were wide (- 1.55 to 1.71 l min^- 1 m^- 2) and the percentage error was high (60.0%). Comparing LiDCOrapid with bolus thermodilution, the bias was acceptable (- 0.26 l min^- 1 m^- 2, 95% CI - 0.34 to - 0.18), but the limits of agreement were wide (- 1.99 to 1.39 l min^- 1 m^- 2) and the percentage error was high (57.1%). Trending ability was inadequate with both devices.

CONCLUSION

Starling SV and LiDCOrapid were not interchangeable with bolus thermodilution technique limiting their usefulness in the setting of cytoreductive surgery with HIPEC.

Do Cerebral Cortex Perfusion, Oxygen Delivery, and Oxygen Saturation Responses Measured by Near-Infrared Spectroscopy Differ Between Patients Who Fail or Succeed in a Spontaneous Breathing Trial? A Prospective Observational Study

BACKGROUND

Alterations in perfusion to the brain during the transition from mechanical ventilation (MV) to a spontaneous breathing trial (SBT) remain poorly understood. The aim of the study was to determine whether changes in cerebral cortex perfusion, oxygen delivery (DO₂), and oxygen saturation (%StiO₂) during the transition from MV to an SBT differ between patients who succeed or fail an SBT.

METHODS

This was a single-center prospective observational study conducted in a 16-bed medical intensive care unit of the University Hospital Leuven, Belgium. Measurements were performed in 24 patients receiving MV immediately before and at the end of a 30-min SBT. Blood flow index (BFI), DO₂, and %StiO₂ in the prefrontal cortex, scalene, rectus abdominis, and thenar muscle were simultaneously assessed by near-infrared spectroscopy using the tracer indocyanine green dye. Cardiac output, arterial blood gases, and systemic oxygenation were also recorded.

RESULTS

During the SBT, prefrontal cortex BFI and DO₂ responses did not differ between SBT-failure and SBT-success groups (p > 0.05). However, prefrontal cortex %StiO₂ decreased in six of eight patients (75%) in the SBT-failure group (median [interquartile range 25-75%]: MV = 57.2% [49.1-61.7] vs. SBT = 51.0% [41.5-62.5]) compared to 3 of 16 patients (19%) in the SBT-success group (median [interquartile range 25-75%]: MV = 65.0% [58.6-68.5] vs. SBT = 65.1% [59.5-71.1]), resulting in a significant differential %StiO₂ response between groups (p = 0.031). Similarly, a significant differential response in thenar muscle %StiO₂ (p = 0.018) was observed between groups. A receiver operating characteristic analysis identified a decrease in prefrontal cortex %StiO₂ > 1.6% during the SBT as an optimal cutoff, with a sensitivity of 94% and a specificity of 75% to predict SBT failure and an area under the curve of 0.79 (95% CI: 0.55-1.00). Cardiac output, systemic oxygenation, scalene, and rectus abdominis BFI, DO₂, and %StiO₂ responses did not differ between groups (p > 0.05); however, during the SBT, a significant positive association in prefrontal cortex BFI and partial pressure of arterial carbon dioxide was observed only in the SBT-success group (SBT success: Spearman's ρ = 0.728, p = 0.002 vs. SBT failure: ρ = 0.048, p = 0.934).

CONCLUSIONS

This study demonstrated a reduced differential response in prefrontal cortex %StiO₂ in the SBT-failure group compared with the SBT-success group possibly due to the insufficient increase in prefrontal cortex perfusion in SBT-failure patients. A > 1.6% drop in prefrontal cortex %StiO₂ during SBT was sensitive in predicting SBT failure. Further research is needed to validate these findings in a larger population and to evaluate whether cerebral cortex %StiO₂ measurements by near-infrared spectroscopy can assist in the decision-making process on liberation from MV.

Accuracy of Estimated Continuous Cardiac Output Monitoring Using Pulse Wave Transit Time Compared to Arterial Pressure-based CO Measurement during Major Surgeries

Background

Pulse wave transit time is a novel method of estimating continuous cardiac output (esCCO). Since there are not many studies evaluating esCCO, we compared it with arterial pressure based cardiac output (APCO) method (FloTrac).

Methods

In this prospective single-center observational study, we included 50 adult patients planned to undergo supramajor oncosurgeries, where major blood loss and extensive fluid shifts were expected. Cardiac output (CO) measurements were obtained by both methods at five distinct time points, giving us 250 paired readings of stroke volume index (SVI) and cardiac index (CI). We analyzed these readings using Pearson's correlation coefficient and Bland–Altman plots, along with other appropriate statistical tests.

Results

There was significant correlation between CI and SVI measured by the esCCO and APCO. Bland–Altman plot analysis for CI showed a bias of −0.44 L/minute/m², precision of 0.74, and the limits of agreement of −1.89 and +1.01, while the percentage error was 46.29%. Bland–Altman analysis for SVI showed a bias −5.07 mL with a precision of 9.36, and the limits of agreement to be −23.4 to +13.28. The percentage error was 46.56%.

Conclusion

This study demonstrated that esCCO tended to underestimate the CI to a large degree, particularly while estimating the cardiac output in the lower range. We found that the limits of agreement between two methods were wide, which are not likely to be clinically acceptable. Further studies with larger number of data points, obtained in a similar subset of patients, for cardiac output measurement in the perioperative period will certainly help determine if pulse wave transit time (PWTT) is here to stay (CTRI No.: CTRI/2019/08/020543).

How to cite this article

Joshi M, Rathod R, Bhosale SJ, Kulkarni AP. Accuracy of Estimated Continuous Cardiac Output Monitoring (esCCO) Using Pulse Wave Transit Time (PWTT) Compared to Arterial Pressure-based CO (APCO) Measurement during Major Surgeries. Indian J Crit Care Med 2022;26(4):496–500.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of a Perioperative Hypotension-Avoidance Strategy Versus a Hypertension-Avoidance Strategy on the Risk of Acute Kidney Injury: A Clinical Research Protocol for a Substudy of the POISE-3 Randomized Clinical Trial

Background:

Most patients who take antihypertensive medications continue taking them on the morning of surgery and during the perioperative period. However, growing evidence suggests this practice may contribute to perioperative hypotension and a higher risk of complications. This protocol describes an acute kidney injury substudy of the Perioperative Ischemic Evaluation-3 (POISE-3) trial, which is testing the effect of a perioperative hypotension-avoidance strategy versus a hypertension-avoidance strategy in patients undergoing noncardiac surgery.

Objective:

To conduct a substudy of POISE-3 to determine whether a perioperative hypotension-avoidance strategy reduces the risk of acute kidney injury compared with a hypertension-avoidance strategy.

Design:

Randomized clinical trial with 1:1 randomization to the intervention (a perioperative hypotension-avoidance strategy) or control (a hypertension-avoidance strategy).

Intervention:

If the presurgery systolic blood pressure (SBP) is <130 mmHg, all antihypertensive medications are withheld on the morning of surgery. If the SBP is ≥130 mmHg, some medications (but not angiotensin receptor blockers [ACEIs], angiotensin receptor blockers [ARBs], or renin inhibitors) may be continued in a stepwise manner. During surgery, the patients’ mean arterial pressure (MAP) is maintained at ≥80 mmHg. During the first 48 hours after surgery, some antihypertensive medications (but not ACEIs, ARBs, or renin inhibitors) may be restarted in a stepwise manner if the SBP is ≥130 mmHg.

Control:

Patients receive their usual antihypertensive medications before and after surgery. The patients’ MAP is maintained at ≥60 mmHg from anesthetic induction until the end of surgery.

Setting:

Recruitment from 108 centers in 22 countries from 2018 to 2021.

Patients:

Patients (~6800) aged ≥45 years having noncardiac surgery who have or are at risk of atherosclerotic disease and who routinely take antihypertensive medications.

Measurements:

The primary outcome of the substudy is postoperative acute kidney injury, defined as an increase in serum creatinine concentration of either ≥26.5 μmol/L (≥0.3 mg/dL) within 48 hours of randomization or ≥50% within 7 days of randomization.

Methods:

The primary analysis (intention-to-treat) will examine the relative risk and 95% confidence interval of acute kidney injury in the intervention versus control group. We will repeat the primary analysis using alternative definitions of acute kidney injury and examine effect modification by preexisting chronic kidney disease, defined as a prerandomization estimated glomerular filtration rate <60 mL/min/1.73 m².

Results:

Substudy results will be analyzed in 2022.

Limitations:

It is not possible to mask patients or providers to the intervention; however, objective measures will be used to assess acute kidney injury.

Conclusions:

This substudy will provide generalizable estimates of the effect of a perioperative hypotension-avoidance strategy on the risk of acute kidney injury.

Central Venous-to-Arterial CO2 Difference-Assisted Goal-Directed Hemodynamic Management During Major Surgery-A Randomized Controlled Trial

BACKGROUND

Different goals have guided goal-directed therapy (GDT). Protocols aiming for central venous-to-arterial carbon dioxide gap (DCO2) <6 mm Hg have improved organ function in septic shock. Evidence for use of DCO2 in the perioperative period is scarce. We aimed to determine if a GDT protocol using central venous saturation of oxygen (SCvo2) and DCO2 reduced organ dysfunction and intensive care unit (ICU) stay in American Society of Anesthesiologist (ASA) I and II patients undergoing major surgeries compared to pragmatic goal-directed care.

METHODS

One hundred patients were randomized. Arterial and venous blood-gas values were recorded every 2 hours perioperatively for all patients. Intervention group (GrI) with access to both values was managed per protocol based on DCO2 and SCvo2. Dobutamine infusion 3 to 5 µg/kg/min started if DCO2 >6 mm Hg after correcting all macrocirculatory end points. Control group (GrC) had access only to arterial-gas values and managed per "conventional" goals without DCO2 or SCvo2. Patients were followed for 48 hours after surgery. Organ dysfunction, sequential organ failure assessment (SOFA) scores-primary outcome, length of stay in ICU, and duration of postoperative mechanical ventilation and hospital stay were recorded. The patient, surgeons, ICU team, and analyzer were blinded to group allocation.

RESULTS

The groups (44 each) did not significantly differ with respect to baseline characteristics. Perioperative fluids, blood products, and vasopressors used did not significantly differ. The GrI had less organ dysfunction although not significant (79% vs 66%; P = .2). Length of ICU stay in the GrI was significantly less (1.52; standard deviation [SD], 0.82 vs 2.18; SD, 1.08 days; P = .002). Mechanical ventilation duration (0.9 days in intervention versus 0.6 days in control; P = .06) and length of hospital stay did not significantly differ between the groups. Perioperative DCO2 (5.8 vs 8.4 mm Hg; P < .001) and SCvo2 (73.5 vs 68.4 mm Hg; P < .001) were significantly better in the GrI.

CONCLUSIONS

GDT guided by DCO2 did not improve organ function in our cohort. It resulted in greater use of dobutamine, improved tissue oxygen parameters, and decreased length of ICU stay. More evidence is needed for the routine use of DCO2 in sicker patients. In the absence of cardiac output monitors, it may be a readily available, less-expensive, and underutilized parameter for major surgical procedures.

The impact of Enhanced Recovery after Surgery (ERAS) pathways with regard to perioperative outcome in patients with ovarian cancer

Purpose

Major surgery for ovarian cancer is associated with significant morbidity. Recently, guidelines for perioperative care in gynecologic oncology with a structured “Enhanced Recovery after Surgery (ERAS)” program were presented. Our aim was to evaluate if implementation of ERAS reduces postoperative complications in patients undergoing extensive cytoreductive surgery for ovarian cancer.

Methods

134 patients with ovarian cancer (FIGO I-IV) were included. 47 patients were prospectively studied after implementation of a mandatory ERAS protocol (ERAS group) and compared to 87 patients that were treated before implementation (pre-ERAS group). Primary endpoints of this study were the effects of the ERAS protocol on postoperative complications and length of stay in hospital.

Results

Preoperative and surgical data were comparable in both groups. Only the POSSUM score was higher in the ERAS group (11.8% vs. 9.3%, p < 0.001), indicating a higher surgical risk in the ERAS group. Total number of postoperative complications (ERAS: 29.8% vs. pre-ERAS: 52.8%, p = 0.011), and length of hospital stay (ERAS: 11 (6–23) vs pre-ERAS: 13 (6–50) days; p < 0.001) differed significantly. A lower fraction of patients of the ERAS group (87.2%) needed postoperative admission to the ICU compared to the pre-ERAS group (97.7%), p = 0.022). Mortality within the ERAS group was 0% vs. 3.4% (p = 0.552) in the pre-ERAS group.

Conclusion

The implementation of a mandatory ERAS protocol was associated with a lower rate of postoperative complications and a reduced length of stay in hospital. If ERAS has influence on long-term outcome needs to be further evaluated.

Perioperative goal-directed therapy and postoperative complications in different kind of surgical procedures: an updated meta-analysis

BACKGROUND

Goal-directed therapy (GDT) aims to assure tissue perfusion, by optimizing doses and timing of fluids, inotropes, and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. Several meta-analyses confirm that GDT can reduce postoperative complications. However, all recent evidences focused on high-risk patients and on major abdominal surgery.

OBJECTIVES

The aim of the present meta-analysis is to investigate the effect of GDT on postoperative complications (defined as number of patients with a least one postoperative complication) in different kind of surgical procedures.

DATA SOURCES

Randomized controlled trials (RCTs) on perioperative GDT in adult surgical patients were included. The primary outcome measure was complications, defined as number of patients with at least one postoperative complication. A subgroup-analysis was performed considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery. and so on.

STUDY APPRAISAL AND SYNTHESIS METHODS

Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

In 52 RCTs, 6325 patients were enrolled. Of these, 3162 were randomized to perioperative GDT and 3153 were randomized to control. In the overall population, 2836 patients developed at least one complication: 1278 (40%) were randomized to perioperative GDT, and 1558 (49%) were randomized to control. Pooled OR was 0.60 and 95% CI was 0.49-0.72. The sensitivity analysis confirmed the main result. The analysis enrolling major abdominal patients showed a significant result (OR 0.72, 95% CI 0.59-0.87, p = 0.0007, 31 RCTs, 4203 patients), both in high- and low-risk patients. A significant effect was observed in those RCTs enrolling exclusively orthopedic procedures (OR 0.53, 95% CI 0.35-0.80, p = 0.002, 7 RCTs, 650 patients. Also neurosurgical procedures seemed to benefit from GDT (OR 0.40, 95% CI 0.21-0.78, p = 0.008, 2 RCTs, 208 patients). In both major abdominal and orthopedic surgery, a strategy adopting fluids and inotropes yielded significant results. The total volume of fluid was not significantly different between the GDT and the control group.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The present meta-analysis, within the limits of the existing data, the clinical and statistical heterogeneity, suggests that GDT can reduce postoperative complication rate. Moreover, the beneficial effect of GDT on postoperative morbidity is significant on major abdominal, orthopedic and neurosurgical procedures. Several well-designed RCTs are needed to further explore the effect of GDT in different kind of surgeries.

Ultrasound and Other Advanced Hemodynamic Monitoring Techniques in the Intensive Care Unit

The ideal device for hemodynamic monitoring of critically ill patients in the intensive care unit (ICU) or the operating room has not yet been developed. This would need to be affordable, consistent, have a very low margin of error (<30%), be minimally or noninvasive, and allow the clinician to make a reasonable therapeutic decision that consistently led to better outcomes. Such a device does not yet exist. This article will describe the distinct options we, as critical care physicians, currently possess for this Herculean endeavor.

Changes in stroke volume variation and cardiac index during open major bowel surgery

Background

Stroke volume variation (SVV) is a dynamic indicator of preload, which is a determinant of cardiac output. Aims: Aim of this study was to evaluate the relationship between changes in SVV and cardiac index (CI) in patients with normal left ventricular function undergoing major open abdominal surgery.

Patients and Methods

Patients undergoing major open abdominal surgery were monitored continuously with FloTrac® to measure SVV and CI along with standard monitoring. Both SVV and CI were noted at baseline and every 10 min thereafter till the end of surgery and were observed for concurrence between the measurements.

Results

1800 pairs of measurement of SVV and CI were obtained from 60 patients. Mean SVV and CI (of all patients) measured at different time points of measurement showed that as SVV increased with time, the CI dropped correspondingly. When individual readings of CI and SVV were plotted against each other, the scatter was found to be wide, reiterating the lack of agreement between the two parameters (R² = 0.035). SVV >13% suggesting hypovolemia was found at 207 time points. Of these, 175 had a CI >2.5 L/min/m² and only 32 patients had a CI <2.5 L/min/m².

Conclusion

SVV, a dynamic index of fluid responsiveness can be used to monitor patients expected to have large fluid shifts during major abdominal surgery. It is very specific and has a high negative predictive value. When SVV increases, CI is usually maintained. Since many factors affect SVV and CI, any increase in SVV >13%, must be correlated with other parameters before administration of the fluid challenge.

Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial

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).

Bioreactance and fourth-generation pulse contour methods in monitoring cardiac index during off-pump coronary artery bypass surgery

The pulmonary artery catheter (PAC) is considered the gold standard for cardiac index monitoring. Recently new and less invasive methods to assess cardiac performance have been developed. The aim of our study was to assess the reliability of a non-invasive monitor utilizing bioreactance (Starling SV) and a non-calibrated mini-invasive pulse contour device (FloTrac/EV1000, fourth-generation software) compared to bolus thermodilution technique with PAC (TDCO) during off-pump coronary artery bypass surgery (OPCAB). In this prospective study, 579 simultaneous intra- and postoperative cardiac index measurements obtained with Starling SV, FloTrac/EV1000 and TDCO were compared in 20 patients undergoing OPCAB. The agreement of data was investigated by Bland-Altman plots, while trending ability was assessed by four-quadrant plots with error grids. In comparison with TDCO, Starling SV was associated with a bias of 0.13 L min^-1 m^-2 (95% confidence interval, 95% CI, 0.07 to 0.18), wide limits of agreement (LOA, - 1.23 to 1.51 L min^-1 m^-2), a percentage error (PE) of 60.7%, and poor trending ability. In comparison with TDCO, FloTrac was associated with a bias of 0.01 L min^-1 m^-2 (95% CI - 0.05 to 0.06), wide LOA (- 1.27 to 1.29 L min^-1 m^-2), a PE of 56.8% and poor trending ability. Both Starling SV and fourth-generation FloTrac showed acceptable mean bias but imprecision due to wide LOA and high PE, and poor trending ability. These findings indicate limited reliability in monitoring cardiac index in patients undergoing OPCAB.

Preoperative carbohydrate loading and intraoperative goal-directed fluid therapy for elderly patients undergoing open gastrointestinal surgery: a prospective randomized controlled trial

Background

The effect of a combination of a goal-directed fluid protocol and preoperative carbohydrate loading on postoperative complications in elderly patients still remains unknown. Therefore, we designed this trial to evaluate the relative impact of preoperative carbohydrate loading and intraoperative goal-directed fluid therapy versus conventional fluid therapy (CFT) on clinical outcomes in elderly patients following gastrointestinal surgery.

Methods

This prospective randomized controlled trial with 120 patients over 65years undergoing gastrointestinal surgery were randomized into a CFT group (n=60) with traditional methods of fasting and water-deprivation, and a GDFT group (n=60) with carbohydrate (200ml) loading 2h before surgery. The CFT group underwent routine monitoring during surgery, however, the GDFT group was conducted by a Vigileo/FloTrac monitor with cardiac index (CI), stroke volume variation (SVV), and mean arterial pressure (MAP). For all patients, demographic data, intraoperative parameters and postoperative outcomes were recorded.

Results

Patients in the GDFT group received significantly less crystalloids fluid (1111442.9ml vs 1411412.6ml; p<0.001) and produced significantly less urine output (200ml [150300] vs 400ml [290500]; p<0.001) as compared to the CFT group. Moreover, GDFT was associated with a shorter average time to first flatus (5614.1h vs 6422.3h; p=0.002) and oral intake (7216.9h vs 8526.8h; p=0.011), as well as a reduction in the rate of postoperative complications (15 (25.0%) vs 29 (48.3%) patients; p=0.013). However, postoperative hospitalization or hospitalization expenses were similar between groups (p>0.05).

Conclusions

Focused on elderly patients undergoing open gastrointestinal surgery, we found perioperative fluid optimisation may be associated with improvement of bowel function and a lower incidence of postoperative complications.

Trial registration

ChiCTR, ChiCTR1800018227. Registered 6 September 2018 - Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01377-8.

Feasibility and beneficial effects of an early goal directed therapy after cardiac arrest: evaluation by conductance method

Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids (P < 0.05) and less epinephrine administration (P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.

Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery

Background

Appropriate perioperative fluid management is of pivotal importance to reduce postoperative complications, which impact on early and long-term patient outcome. The so-called perioperative goal-directed therapy (GDT) approach aims at customizing perioperative fluid management on the individual patients’ hemodynamic response. Whether or not the overall amount of perioperative volume infused in the context of GDT could influence postoperative surgical outcomes is unclear.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of GDT approach between study population and control group in reducing postoperative complications and perioperative mortality, using MEDLINE, EMBASE and the Cochrane Controlled Clinical trials register. The enrolled studies were grouped considering the amount infused intraoperatively and during the first 24 h after the admission in the critical care unit (perioperative fluid).

Results

The metanalysis included 21 RCTs enrolling 2729 patients with a median amount of perioperative fluid infusion of 4500 ml. In the studies reporting an overall amount below or above this threshold, the differences in postoperative complications were not statically significant between controls and GDT subgroup [43.4% vs. 34.2%, p value = 0.23 and 54.8% vs. 39.8%; p value = 0.09, respectively].

Overall, GDT reduced the overall rate of postoperative complications, as compared to controls [pooled risk difference (95% CI) = − 0.10 (− 0.14, − 0.07); Chi₂ = 30.97; p value < 0.0001], but not to a reduction of perioperative mortality [pooled risk difference (95%CI) = − 0.016 (− 0.0334; 0.0014); p value = 0.07]. Considering the rate of organ-related postoperative events, GDT did not reduce neither renal (p value = 0.52) nor cardiovascular (p value = 0.86) or pulmonary (p value = 0.14) or neurological (p value = 0.44) or infective (p value = 0.12) complications.

Conclusions

Irrespectively to the amount of perioperative fluid administered, GDT strategy reduces postoperative complications, but not perioperative mortality.

Trial Registration

CRD42020168866; Registration: February 2020

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866

Cardiac output estimation using pulse wave analysis-physiology, algorithms, and technologies: a narrative review

Pulse wave analysis (PWA) allows estimation of cardiac output (CO) based on continuous analysis of the arterial blood pressure (AP) waveform. We describe the physiology of the AP waveform, basic principles of PWA algorithms for CO estimation, and PWA technologies available for clinical practice. The AP waveform is a complex physiological signal that is determined by interplay of left ventricular stroke volume, systemic vascular resistance, and vascular compliance. Numerous PWA algorithms are available to estimate CO, including Windkessel models, long time interval or multi-beat analysis, pulse power analysis, or the pressure recording analytical method. Invasive, minimally-invasive, and noninvasive PWA monitoring systems can be classified according to the method they use to calibrate estimated CO values in externally calibrated systems, internally calibrated systems, and uncalibrated systems.

Minimally Invasive Hemodynamic Assessment during Obstetric Hysterectomy for Invasive Placentation with Epidural Anesthesia

Background

The present study aimed to describe the evolution of hemodynamic parameters over time of patients with invasive placentation during their third trimester who were delivered via cesarean section and subsequently underwent obstetric hysterectomy under epidural anesthesia.

Methods

A prospective, descriptive, longitudinal, 11-month cohort study of 43 patients aged between 18 and 37 years who presented with invasive placentation. Minimal invasive monitoring was placed before the administration of epidural anesthesia for hemodynamic parameter tracking during the cesarean section. After delivery, the patients underwent an obstetric hysterectomy. Blood loss, hemodynamic parameters, and coagulation were managed via goal-directed therapy. Parameters were compared via repeated measures ANOVA and effect size estimation (Cohen's d).

Results

The mean age of the patients was 29.2 ± 3.4 years and was moderately overweight. They had minor cardiac index variance (P=NS, no significance), vascular systemic resistance index (NS), heart rate (P=NS), and median arterial pressure (P=NS). Differences were observed in the stroke volume index (P=0.015) due to moderately higher values (d = 0.3, P=0.016) in the middle of the surgery. Patients had lower cardiac index (d = -0.36, NS) and cardiac workload requirements (d = -0.29, P=0.034) toward the completion of surgery.

Conclusion

Patients who are in their third trimester and who subsequently underwent obstetric hysterectomy under epidural anesthesia had modest surgical hemodynamic variance and reduced cardiac workload requirements toward the end of the surgery.

Goal-directed haemodynamic therapy (GDHT) in surgical patients: systematic review and meta-analysis of the impact of GDHT on post-operative pulmonary complications

Background

Perioperative goal-directed haemodynamic therapy (GDHT), defined as the administration of fluids with or without inotropes or vasoactive agents against explicit measured goals to augment blood flow, has been evaluated in many randomised controlled trials (RCTs) over the past four decades. Reported post-operative pulmonary complications commonly include chest infection or pneumonia, atelectasis, acute respiratory distress syndrome or acute lung injury, aspiration pneumonitis, pulmonary embolism, and pulmonary oedema. Despite the substantial clinical literature in this area, it remains unclear whether their incidence is reduced by GDHT. This systematic review aims to determine the effect of GDHT on the respiratory outcomes listed above, in surgical patients.

Methods

We searched the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, and clinical trial registries up until January 2020. We included all RCTs reporting pulmonary outcomes. The primary outcome was post-operative pulmonary complications and secondary outcomes were specific pulmonary complications and intra-operative fluid input. Data synthesis was performed on Review Manager and heterogeneity was assessed using I² statistics.

Results

We identified 66 studies with 9548 participants reporting pulmonary complications. GDHT resulted in a significant reduction in total pulmonary complications (OR 0.74, 95% CI 0.59 to 0.92). The incidence of pulmonary infections, reported in 45 studies with 6969 participants, was significantly lower in the GDHT group (OR 0.72, CI 0.60 to 0.86). Pulmonary oedema was recorded in 23 studies with 3205 participants and was less common in the GDHT group (OR 0.47, CI 0.30 to 0.73). There were no differences in the incidences of pulmonary embolism or acute respiratory distress syndrome. Sub-group analyses demonstrated: (i) benefit from GDHT in general/abdominal/mixed and cardiothoracic surgery but not in orthopaedic or vascular surgery; and (ii) benefit from fluids with inotropes and/or vasopressors in combination but not from fluids alone. Overall, the GDHT group received more colloid (+280 ml) and less crystalloid (−375 ml) solutions than the control group. Due to clinical and statistical heterogeneity, we downgraded this evidence to moderate.

Conclusions

This systematic review and meta-analysis suggests that the use of GDHT using fluids with inotropes and/or vasopressors, but not fluids alone, reduces the development of post-operative pulmonary infections and pulmonary oedema in general, abdominal and cardiothoracic surgical patients. This evidence was graded as moderate.

PROSPERO registry reference: CRD42020170361

Four different methods of measuring cardiac index during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are high-risk extensive abdominal surgery. During high-risk surgery, less invasive methods for cardiac index (CI) measurement have been widely used in operating theater. We investigated the accuracy of CI derived from different methods (FroTrac, ProAQT, ClearSight, and arterial pressure waveform analysis [APWA], from PICCO) and compared them to transpulmonary thermodilution (TPTD) during CRS and HIPEC in the operative room and intensive care unit (ICU).

Methods

Twenty-five patients scheduled for CRS-HIPEC were enrolled. During nine predefined time-points, simultaneous hemodynamic measurements were performed in the operating room and ICU. Absolute and relative changes of CI were analyzed using a Bland-Altman plot, four-quadrant plot, and interchangeability.

Results

The mean bias was −0.1 L/min/m² for ClearSight, ProAQT, and APWA and was −0.2 L/min/m² for FloTrac compared with TPTD. All devices had large limits of agreement (LoA). The percentage of errors and interchangeabilities for ClearSight, FloTrac, ProAQT, and APWA were 50%, 50%, 54%, 36% and 36%, 47%, 40%, 72%, respectively. Trending capabilities expressed as concordance using clinically significant CI changes were −7º ± 39º, −19º ± 38º, −13º ± 41º, and −15º ± 39º. Interchangeability in trending showed low percentages of interchangeable and gray zone data pairs for all devices.

Conclusions

During CRS-HIPEC, ClearSight, FloTrac and ProAQT systems were not able to reliably measure CI compared to TPTD. Reproducibility of changes over time using concordance, angular bias, radial LoA, and interchangeability in trending of all devices was unsatisfactory.

Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial

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.

Estimation of pulse pressure variation and cardiac output in patients having major abdominal surgery: a comparison between a mobile application for snapshot pulse wave analysis and invasive pulse wave analysis

Pulse pressure variation (PPV) and cardiac output (CO) can guide perioperative fluid management. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a mobile application for snapshot pulse wave analysis (PWAsnap) and estimates PPV and CO using pulse wave analysis of a snapshot of the arterial blood pressure waveform displayed on any patient monitor. We evaluated the PPV and CO measurement performance of PWAsnap in adults having major abdominal surgery. In a prospective study, we simultaneously measured PPV and CO using PWAsnap installed on a tablet computer (PPV_PWAsnap, CO_PWAsnap) and using invasive internally calibrated pulse wave analysis (ProAQT; Pulsion Medical Systems, Feldkirchen, Germany; PPV_ProAQT, CO_ProAQT). We determined the diagnostic accuracy of PPV_PWAsnap in comparison to PPV_ProAQT according to three predefined PPV categories and by computing Cohen’s kappa coefficient. We compared CO_ProAQT and CO_PWAsnap using Bland-Altman analysis, the percentage error, and four quadrant plot/concordance rate analysis to determine trending ability. We analyzed 190 paired PPV and CO measurements from 38 patients. The overall diagnostic agreement between PPV_PWAsnap and PPV_ProAQT across the three predefined PPV categories was 64.7% with a Cohen’s kappa coefficient of 0.45. The mean (± standard deviation) of the differences between CO_PWAsnap and CO_ProAQT was 0.6 ± 1.3 L min^− 1 (95% limits of agreement 3.1 to − 1.9 L min^− 1) with a percentage error of 48.7% and a concordance rate of 45.1%. In adults having major abdominal surgery, PPV_PWAsnap moderately agrees with PPV_ProAQT. The absolute and trending agreement between CO_PWAsnap with CO_ProAQT is poor. Technical improvements are needed before PWAsnap can be recommended for hemodynamic monitoring.

Impact of Goal-Directed Therapy on Delayed Ischemia After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose:

Delayed cerebral ischemia (DCI) is the most important cause for a poor clinical outcome after a subarachnoid hemorrhage. The aim of this study was to assess whether goal-directed hemodynamic therapy (GDHT), as compared to standard clinical care, reduces the rate of DCI after subarachnoid hemorrhage.

Methods:

We conducted a prospective randomized controlled trial. Patients >18 years of age with an aneurysmal subarachnoid hemorrhage were enrolled and randomly assigned to standard therapy or GDHT. Advanced hemodynamic monitoring and predefined GDHT algorithms were applied in the GDHT group. The primary end point was the occurrence of DCI. Functional outcome was assessed using the Glasgow Outcome Scale (GOS) 3 months after discharge.

Results:

In total, 108 patients were randomized to the control (n=54) or GDHT group (n=54). The primary outcome (DCI) occurred in 13% of the GDHT group and in 32% of the control group patients (odds ratio, 0.324 [95% CI, 0.11–0.86]; P =0.021). Even after adjustment for confounding parameters, GDHT was found to be superior to standard therapy (hazard ratio, 2.84 [95% CI, 1.18–6.86]; P =0.02). The GOS was assessed 3 months after discharge in 107 patients; it showed more patients with a low disability (GOS 5, minor or no deficits) than patients with higher deficits (GOS 1–4) in the GDHT group compared with the control group (GOS 5, 66% versus 44%; GOS 1–4, 34% versus 56%; P =0.025). There was no significant difference in mortality between the groups.

Conclusions:

GDHT reduced the rate of DCI after subarachnoid hemorrhage with a better functional outcome (GOS=5) 3 months after discharge.

Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01832389.

Outcome impact of individualized fluid management during spine surgery: a before-after prospective comparison study

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.

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

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.

Impact of Age on Short- and Long-Term Outcomes after Pancreatoduodenectomy for Periampullary Neoplasms

Background

Although mortality and morbidity of pancreatoduodenectomy (PD) have improved significantly over the past years, the impact of age for patients undergoing PD is still debated. This study is aimed at analyzing short- and long-term outcomes of PD in elderly patients.

Methods

124 consecutive patients who have undergone PD for pancreas neoplasms in our center between 2012 and 2017 were analyzed. Patients were divided into two groups: group I (<75 years) and group II (≥75 years). Demographic features and intraoperative and clinical-pathological data were collected. Primary endpoints were perioperative morbidity and mortality; complications were classified according to the Clavien-Dindo Score. Secondary endpoints included feasibility of adjuvant treatment and overall survival rates.

Results

A total of 106 patients were included in this study. There were 73 (68.9%) patients in group I and 33 (31.1%) in group II. Perioperative deceases were 4 (3.6%), and postoperative pancreatic fistulas were 34 (32.1%). Significant difference between two groups was demonstrated for the ASA Score (p = 0.004), Karnofsky Score (p = 0.025), preoperative jaundice (p = 0.004), and pulmonary complications (p = 0.034). No significance was shown for diabetes, radicality of resection, stage of disease, operative time, length of stay, postoperative complications according to the Clavien-Dindo Score, postoperative mortality, pancreatic fistula, and reoperation rates. 69.9% of the patients in group I underwent adjuvant treatment vs. 39.4% of the older ones (p = 0.012). Mean overall survival was 28.5 months in group I vs. 22 months in group II (p = 0.909).

Conclusion

PD can be performed safely in elderly patients. Advanced age should not be an absolute contraindication for PD, even if greater frailty should be considered. The outcome of elderly patients who have undergone PD is similar to that of younger patients, even though adjuvant treatment administration is significantly lower, demonstrating that surgery remains the main therapeutic option.

Early Postoperative Use of Diuretics After Kidney Transplantation Showed Increase in Delayed Graft Function

PURPOSE

In acute renal injury, diuretics are widely considered to be harmful. Nevertheless, they are used frequently after kidney transplantation. We hypothesized that diuretics administered in the early postoperative treatment after kidney transplantation increase the incidence of delayed graft function (DGF).

METHODS

In this monocentric, retrospective cohort analysis, we screened the closed files of all consecutive patients who underwent kidney transplantation from 2011 to 2017. The outcome variable was DGF, defined as at least 1 hemodialysis within 7 days postoperatively. To stratify for baseline characteristics such as waiting time or cold ischemic period, we employed a propensity score-matched analysis. Further statistical processing included basic descriptive statistics, Mann-Whitney U test, and binary logistic regression analysis.

RESULTS

The unmatched cohort included 445 patients and showed a significantly increased rate of DGF for patients who received either furosemide or mannitol or a combination of both (5% vs 25%; P < .001). Mannitol (odds ratio [OR]: 4.094) and furosemide (OR: 2.915) showed a significant correlation with DGF in the multivariate regression analysis. Propensity score-based matching resulted in a matched cohort of 214 patients with balanced baseline risk variables. In this matched cohort, the rate of DGF was significantly increased in patients who received diuretics in the early postoperative treatment (7% vs 16%; P = .031).

CONCLUSION

Our results show that postoperatively administered diuretics are associated with an increased rate of DGF even in a cohort with balanced preoperative risk variables. This study supports recently published reviews, which call diuretics in the transplantation process into question.

Intraoperative fluid therapy and postoperative complications during minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study

PURPOSE

Compared with open thoracotomy, minimally invasive esophagectomy (MIE) methods, such as transhiatal or thoracoscopic esophagectomy, likely have lower morbidity. However, the relationship between intraoperative fluid management and postoperative complications after MIE remains unclear. Thus, we investigated the association of cumulative intraoperative fluid balance and postoperative complications in patients undergoing MIE.

METHODS

This single-center retrospective cohort study examined patients undergoing thoracoscopic esophagectomy for esophageal cancer in the prone position. Postoperative complications included pneumonia, arrhythmia, thrombotic events and acute kidney injury (AKI). We compared patients with higher and lower intraoperative fluid balance (higher and lower than the median). Multivariable logistic regression analyses were performed to estimate the odds ratio of intraoperative fluid balance status on the incidence of postoperative complications.

RESULTS

In total, 135 patients were included in the study. Postoperative complications occurred in 43 (32%), including cardiac arrhythmia (n = 12, 9%), thrombosis (n = 20, 15%), pneumonia (n = 13, 10%), and AKI required hemodialysis (n = 1, 1%). Patients with a higher fluid balance had higher incidence of complications than those with a lower fluid balance (46% vs. 18%, p < 0.001). After adjusting for age, ASA-PS ≥ III, blood loss, and the use of radical surgery, the higher intraoperative fluid balance group was significantly and independently associated with postoperative complications (adjusted OR 5.31, 95% CI 2.26-13.6, p < 0.0001).

CONCLUSIONS

In patients undergoing thoracoscopic esophagectomy in the prone position, a greater intraoperative positive fluid balance was independently associated with a higher incidence of complications.

Impact of perioperative hemodynamic optimization therapies in surgical patients: economic study and meta-analysis

Background

Several studies suggest that hemodynamic optimization therapies can reduce complications, the length of hospital stay and costs. However, Brazilian data are scarce. Therefore, the objective of this analysis was to evaluate whether the improvement demonstrated by hemodynamic optimization therapy in surgical patients could result in lower costs from the perspective of the Brazilian public unified health system.

Methods

A meta-analysis was performed comparing surgical patients who underwent hemodynamic optimization therapy (intervention) with patients who underwent standard therapy (control) in terms of complications and hospital costs. The cost-effectiveness analysis evaluated the clinical and financial benefits of hemodynamic optimization protocols for surgical patients. The analysis considered the clinical outcomes of randomized studies published in the last 20 years that involved surgeries and hemodynamic optimization therapy. Indirect costs (equipment depreciation, estate and management activities) were not included in the analysis.

Results

A total of 21 clinical trials with a total of 4872 surgical patients were selected. Comparison of the intervention and control groups showed lower rates of infectious (RR = 0.66; 95% CI = 0.58–0.74), renal (RR = 0.68; 95% CI = 0.54–0.87), and cardiovascular (RR = 0.87; 95% CI = 0.76–0.99) complications and a nonstatistically significant lower rate of respiratory complications (RR = 0.82; 95% CI = 0.67–1.02). There was no difference in mortality (RR = 1.02; 95% CI = 0.80–1.3) between groups. In the analysis of total costs, the intervention group showed a cost reduction of R$396,024.83-BRL ($90,161.38-USD) for every 1000 patients treated compared to the control group. The patients in the intervention group showed greater effectiveness, with 1.0 fewer days in the intensive care unit and hospital. In addition, there were 333 fewer patients with complications, with a consequent reduction of R$1,630,341.47-BRL ($371,173.27-USD) for every 1000 patients treated.

Conclusions

Hemodynamic optimization therapy is cost-effective and would increase the efficiency of and decrease the burden of the Brazilian public health system.

Systematic review and meta-analysis of the perioperative use of vasoactive drugs on postoperative outcomes after major abdominal surgery

BACKGROUND

The perioperative use of vasoactive drugs is ubiquitous in clinical anaesthesia; yet, the drugs, doses, and haemodynamic targets used are highly variable. Our objectives were to determine whether the perioperative administration of vasoactive drugs reduces mortality, morbidity, and length of stay in adult patients (aged 16 yr or older) undergoing major abdominal surgery.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for peer-reviewed RCTs with no language or date restrictions. Studies that assessed the intraoperative use of vasoactive drugs were included. Title, abstract, and full-text screening was performed. Risk of bias for each outcome measure was conducted. We calculated the risk ratio (RR) using the Mantel-Haenszel random-effects model with corresponding 95% confidence interval (CI) for dichotomous outcomes, and mean difference using the inverse variance random-effects model with corresponding 95% CI for continuous outcomes.

RESULTS

Twenty-six studies (5561 participants) were included. There was no difference in mortality at the longest follow-up with an RR of 0.84 (95% CI: 0.63-1.12; P=0.23). The intervention significantly reduced the number of patients with one or more postoperative complications; RR: 0.76 (95% CI: 0.66-0.88; P=0.0002). Hospital length of stay was reduced by 0.91 days in the intervention group.

CONCLUSIONS

This review is limited by the quality and sample size of individual studies, and the heterogeneity of the settings, interventions, and outcome measures. Perioperative administration of vasoactive drugs may reduce postoperative complications and hospital length of stay in adult patients having major abdominal surgery.

[Perioperative fluid management]

An appropriate perioperative infusion management is pivotal for the perioperative outcome of the patient. Optimization of the perioperative fluid treatment often results in enhanced postoperative outcome, reduced perioperative complications and shortened hospitalization. Hypovolemia as well as hypervolemia can lead to an increased rate of perioperative complications. The main goal is to maintain perioperative euvolemia by goal-directed therapy (GDT), a combination of fluid management and inotropic medication, to optimize perfusion conditions in the perioperative period; however, perioperative fluid management should also include the preoperative and postoperative periods. This encompasses the preoperative administration of carbohydrate-rich drinks up to 2 h before surgery. In the postoperative period, patients should be encouraged to start per os hydration early and excessive i.v. fluid administration should be avoided. Implementation of a comprehensive multimodal, goal-directed fluid management within an enhanced recovery after surgery (ERAS) protocol is efficient but the exact status of indovodual items remains unclear at present.

Management of perioperative volume therapy - monitoring and pitfalls

Over 300 million surgical procedures are performed every year worldwide. Anesthesiologists play an important role in the perioperative process by assessing the overall risk of surgery and aim to reduce the risk of complications. Perioperative hemodynamic and volume management can help to improve outcomes in perioperative patients. There has been ongoing discussion about goal-directed therapy. However, there is a consensus that fluid overload and severe fluid depletion in the perioperative period are harmful and can lead to adverse outcomes. This article provides an overview of how to evaluate the fluid responsiveness of patients, details which parameters could be used, and what limitations should be noted.

Validation study of the dynamic parameters of pulse wave in pulmonary resection surgery

INTRODUCTION

In lung resection surgery, restrictive fluid therapy is recommended due to the risk of acute lung injury. In contrast, this recommendation increases the risk of hypoperfusion. Guided fluid therapy allows individualization of fluid intake. The use of dynamic volume response parameters is not validated during one-lung ventilation. The main objective is the validation of dynamic parameters, stroke volume variation (SVV) and pulse pressure variation (PPV), during lung resection surgery as fluid response predictors, after the administration of 250ml crystalloid volume loads, if IC<2.5ml/min/m² and if SVV≥8% and/or PPV≥10%.

MATERIAL AND METHODS

Pilot, prospective, observational and single centre study. Twenty-five patients monitored with the PiCCO system were included during open lung resection surgery with the patient in a lateral position, one lung ventilation with tidal volume (TV): 6ml/kg and open chest. Hemodynamic variables were collected before and after volume loading. The results were classified into two groups: volume responders (increase IC≥10% and/or VSI≥10% after volume loading) and non-responders (no increase or increase IC<10% and/or VSI<10% after volume loading). We assess the diagnostic efficacy of SVV and PPV by analyzing the AUC (area under curve) in the ROC curves.

RESULTS

In the analysis of ROC curves, SVV and PPV did not reach a discriminative value (AUCSVV: 0.47; AUCPPV: 0.50), despite the decrease in the threshold value of SVV and PPV to initiate an overload of volume during one-lung ventilation, in lateral position and open chest.

CONCLUSIONS

The results obtained show that the values of the dynamic parameters of volume response (SVV≥8% and PPV≥10%) do not discriminate against responders patients and non-responders during open lung resection surgery.