Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial

A sub-study of the POISE-3 randomized trial examined effects of a perioperative hypotension-avoidance strategy versus a hypertension-avoidance strategy on the risk of acute kidney injury

In this pre-specified sub-study of the POISE-3 trial, we examined the effect of a perioperative hypotension-avoidance strategy versus a hypertension-avoidance strategy on the risk of postoperative acute kidney injury (AKI). Altogether, 7307 patients were included from 110 hospitals in 22 countries. Patients were 45 years and older, had or were at risk of atherosclerotic disease, took at least one antihypertensive medication, and were scheduled for noncardiac surgery. Hypotension-avoidance strategy: (i) target intraoperative mean arterial pressure (MAP) 80 mm Hg or over, (ii) on day of surgery and for two days after, hold renin-angiotensin-aldosterone system inhibitors and use other antihypertensives in stepwise fashion if systolic blood pressure (SBP) 130 mm Hg or more. Hypertension-avoidance strategy: (i) target intraoperative MAP 60 mm Hg or more, (ii) continue all antihypertensives before and after surgery. Primary outcome: postoperative AKI, an increase in serum creatinine concentration of either 26.5 μmol/L or more (0.3 mg/dL or more) within 48 hours of randomization or 50% or more within seven days of randomization. The hypotension-avoidance group (3654 patients) used fewer antihypertensive medications than the hypertension-avoidance group (3653 patients); specifically, 6% vs. 38% used an ACEI or ARB on the day of surgery, and 6% vs. 47% and 7% vs. 50% one and two days after surgery, respectively. Patients also spent about half as much intraoperative time with a MAP under 80 mm Hg (27 vs. 60 minutes, respectively), but had little difference in average BP before or after surgery. There was no significant difference in AKI risk (15.1% vs. 14.4%). Results were consistent with other definitions of AKI and in patients with preexisting chronic kidney disease. Thus, a hypotension-avoidance strategy targeting a MAP greater than 80 mm Hg in the operating room and discontinued blood pressure medication during the perioperative period did not confer a lower risk of AKI compared to a hypertension avoidance strategy. Clinical trial registration number: NCT03505723.

Intraoperative goal-directed hemodynamic therapy targeting both arterial pressure and flow parameters using uncalibrated pulse contour techniques: A meta-analysis of randomized controlled trials

BACKGROUND

Goal-directed haemodynamic therapy (GDHT) aims to optimize haemodynamic variables. However, its effectiveness in reducing postoperative complications in major abdominal surgery, particularly when targeting both arterial pressure and flow variables, remains unclear. This meta-analysis addresses this by evaluating GDHT using uncalibrated pulse contour (uPC) methods.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCT) in adult patients undergoing major abdominal surgery who received GDHT using uncalibrated pulse contour (uPC) methods for cardiac output monitoring, with predefined targets for both blood flow and blood pressure. The primary outcome was postoperative complications; secondary outcomes included postoperative acute kidney injury (AKI), hospital length of stay (EH), intraoperative fluid administration and mortality.

RESULTS

Initial search retrieved 860 reports, with 12 RCTs (1367 patients) meeting the inclusion criteria. Our meta-analysis showed a significant reduction in postoperative complications (RR 0.78, 95% CI 0.68-0.90), AKI (RR 0.7, 95% CI 0.51-0.97), and hospital LOS (SMD -0.30, 95% CI -0.54 to -0.06) with uPC-guided GDHT. No significant differences were observed in intraoperative fluid volume and mortality.

CONCLUSIONS

Implementing GDHT in major abdominal surgery with predefined arterial pressure and blood flow targets significantly reduces postoperative morbidity and hospital EH without increasing intraoperative fluid administration.

Goal-directed fluid therapy on the postoperative complications of laparoscopic hepatobiliary or pancreatic surgery: An interventional comparative study

BACKGROUND

Intraoperative fluid balance significantly affects patients' outcomes. Goal-directed fluid therapy (GDFT) has reduced the incidence of major postoperative complications by 20% for 30 days after open abdominal surgery. Little is known about GDFT during laparoscopic surgery.

AIM

We investigated whether GDFT affects the postoperative outcomes in laparoscopic hepatobiliary or pancreatic surgery compared with conventional fluid management.

METHODS

This interventional comparative study with a historical control group was performed in the tertiary care center. Patients were allocated to one of two groups. The GDFT (n = 147) was recruited prospectively and the conventional group (n = 228) retrospectively. In the GDFT group, fluid management was guided by the stroke volume (SV) and cardiac index (CI), whereas it had been performed based on vital signs in the conventional group. Propensity score (PS) matching was performed to reduce selection bias (n = 147 in each group). Postoperative complications were evaluated as primary outcome measures.

RESULTS

The amount of crystalloid used during surgery was less in the GDFT group than in the conventional group (5.1 ± 1.1 vs 6.3 ± 1.8 ml/kg/h, respectively; P <0.001), whereas the amount of colloid was comparable between the two groups. The overall proportion of patients who experienced any adverse events was 57.8% in the GDFT group and 70.1% in the conventional group (P = 0.038), of which the occurrence of pleural effusion was significantly lower in the GDFT group than in the conventional group (9.5% vs. 19.7%; P = 0.024). During the postoperative period, the proportion of patients admitted to the intensive care unit (ICU) was lower in the GDFT group than that in the conventional group after PS matching (4.1% vs 10.2%; P = 0.049).

CONCLUSIONS

GDFT based on SV and CI resulted in a lower net fluid balance than conventional fluid therapy. The overall complication rate in laparoscopic hepatobiliary or pancreatic surgery decreased after GDFT, and the frequency of pleural effusion was the most affected.

Intraoperative Fluid Balance and Perioperative Complications in Ovarian Cancer Surgery

BACKGROUND

Fluid overload and hypovolemia promote postoperative complications in patients undergoing cytoreductive surgery for ovarian cancer. In the present study, postoperative complications and anastomotic leakage were investigated before and after implementation of pulse pressure variation-guided fluid management (PPVGFM) during ovarian cancer surgery.

PATIENTS AND METHODS

A total of n = 243 patients with ovarian cancer undergoing cytoreductive surgery at the University Hospital Bonn were retrospectively evaluated. Cohort A (CA; n = 185 patients) was treated before and cohort B (CB; n = 58 patients) after implementation of PPVGFM. Both cohorts were compared regarding postoperative complications.

RESULTS

Ultrasevere complications (G4/G5) were exclusively present in CA (p = 0.0025). No difference between cohorts was observed regarding severe complications (G3-G5) (p = 0.062). Median positive fluid excess was lower in CB (p = 0.001). This was independent of tumor load [peritoneal cancer index] (p = 0.001) and FIGO stage (p = 0.001). Time to first postoperative defecation was shorter in CB (CB: d2 median versus CA: d3 median; p = 0.001). CB had a shorter length of hospital stay (p = 0.003), less requirement of intensive medical care (p = 0.001) and postoperative ventilation (p = 0.001). CB received higher doses of noradrenalin (p = 0.001). In the combined study cohort, there were more severe complications (G3-G5) in the case of a PFE ≥ 3000 ml (p = 0.034) and significantly more anastomotic leakage in the case of a PFE ≥ 4000 ml (p = 0.006).

CONCLUSIONS

Intraoperative fluid reduction in ovarian cancer surgery according to a PPVGFM is safe and significantly reduces ultrasevere postoperative complications. PFEs of ≥ 3000 ml and ≥ 4000 ml were identified as cutoffs for significantly more severe complications and anastomotic leakage, respectively.

Systematic review and meta-analysis of goal-directed haemodynamic therapy algorithms during surgery for the prevention of surgical site infection

Background

Surgical site infection (SSI) is the most common postoperative complication. Goal-directed haemodynamic therapy (GDHT) may help to prevent SSI, but recommendations for its use initially have been set at conditional because of low-certainty evidence at the time. An updated systematic review with SSI as the primary endpoint has not been performed since 2011, and important new evidence has emerged. We assessed the influence of GDHT on SSI and other postoperative outcomes.

Methods

We searched Ovid/MEDLINE, Excerpta Medica Database (Embase.com), and Cochrane library from inception up to September 2024 for randomised controlled trials comparing the effect of any GDHT algorithm to conventional fluid therapy on SSI incidence in adult patients undergoing surgery and analysed eligible data using random effects. We conducted several subgroup analyses, including the risk of bias (RoB), and a trial sequential analysis (TSA). We evaluated the certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluations. This study is registered with PROSPERO, CRD42022277535.

Findings

We found 75 studies that met the inclusion criteria with an incidence of 1,478 SSI among 13,010 patients (11.4%). The incidence of SSI was reduced from 13.3% in the conventional fluid therapy to 9.4% after GDHT (absolute risk reduction 3.9%); pooled relative risk 0.71 (95% CI 0.62-0.81). Subgroup analysis for the low RoB studies revealed comparable results. Meta-regression indicated no strong evidence for individual subgroup effects. In the TSA, the cumulative z-line crossed the boundary for effect.

Interpretation

High-certainty evidence indicates that GDHT reduces the risk of SSI when compared to conventional fluid therapy in adults undergoing surgery. New studies are unlikely to change this outcome. These findings justify a stronger recommendation for the use of GDHT.

Funding

Dutch Association for Quality Funds Medical Specialists.

Effects of dynamic versus static parameter-guided fluid resuscitation in patients with sepsis: A randomized controlled trial

Background

Fluid resuscitation is an essential component for sepsis treatment. Although several studies demonstrated that dynamic variables were more accurate than static variables for prediction of fluid responsiveness, fluid resuscitation guidance by dynamic variables is not standard for treatment. The objectives were to determine the effects of dynamic inferior vena cava (IVC)-guided versus (vs.) static central venous pressure (CVP)-guided fluid resuscitation in septic patients on mortality; and others, i.e., resuscitation targets, shock duration, fluid and vasopressor amount, invasive respiratory support, length of stay and adverse events.

Methods

A single-blind randomized controlled trial was conducted at Thammasat University Hospital between August 2016 and April 2020. Septic patients were stratified by acute physiologic and chronic health evaluation II (APACHE II) <25 or ≥25 and randomized by blocks of 2 and 4 to fluid resuscitation guidance by dynamic IVC or static CVP.

Results

Of 124 patients enrolled, 62 were randomized to each group, and one of each was excluded from mortality analysis. Baseline characteristics were comparable. The 30-day mortality rates between dynamic IVC vs. static CVP groups were not different (34.4% vs. 45.9%, p=0.196). Relative risk for 30-day mortality of dynamic IVC group was 0.8 (95%CI=0.5-1.2, p=0.201). Different outcomes were median (interquartile range) of shock duration (0.8 (0.4-1.6) vs. 1.5 (1.1-3.1) days, p=0.001) and norepinephrine (NE) dose (6.8 (3.9-17.8) vs. 16.1 (7.6-53.6) milligrams, p=0.008 and 0.1 (0.1-0.3) vs. 0.3 (0.1-0.8) milligram⋅kilogram -1, p=0.017). Others were not different.

Conclusions

Dynamic IVC-guided fluid resuscitation does not affect mortality of septic patients. However, this may reduce shock duration and NE dose, compared with static CVP guidance.

Intraoperative goal-directed fluid therapy in adult patients undergoing craniotomies under general anaesthesia: A systematic review and meta-analysis with trial sequential analysis

Background and Aims

Goal-directed fluid therapy (GDFT) has conflicting evidence regarding outcomes in neurosurgical patients. This meta-analysis aimed to compare the effect of GDFT and conventional fluid therapy on various perioperative outcomes in patients undergoing neurosurgical procedures.

Methods

A comprehensive literature search was conducted using PubMed, EMBASE, Scopus, ProQuest, Web of Science, EBSCOhost, Cochrane and preprint servers. The search was conducted up until 16 October 2023, following PROSPERO registration. The search strategy included terms related to GDFT, neurosurgery and perioperative outcomes. Only randomised controlled trials involving adult humans and comparing GDFT with standard/liberal/traditional/restricted fluid therapy were included. The studies were evaluated for risk of bias (RoB), and pooled estimates of the outcomes were measured in terms of risk ratio (RR) and mean difference (MD).

Results

No statistically significant difference was observed in neurological outcomes between GDFT and conventional fluid therapy [RR with 95% confidence interval (CI) was 1.10 (0.69, 1.75), two studies, 90 patients, low certainty of evidence using GRADEpro]. GDFT reduced postoperative complications [RR = 0.67 (0.54, 0.82), six studies, 392 participants] and intensive care unit (ICU) and hospital stay [MD (95% CI) were -1.65 (-3.02, -0.28) and -0.94 (-1.47, -0.42), respectively] with high certainty of evidence. The pulmonary complications were significantly lower in the GDFT group [RR (95% CI) = 0.55 (0.38, 0.79), seven studies, 442 patients, high certainty of evidence]. Other outcomes, including total intraoperative fluids administered and blood loss, were comparable in GDFT and conventional therapy groups [MD (95% CI) were -303.87 (-912.56, 304.82) and -14.79 (-49.05, 19.46), respectively].

Conclusion

The perioperative GDFT did not influence the neurological outcome. The postoperative complications and hospital and ICU stay were significantly reduced in the GDFT group.

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.

The Use of Pressure Recording Analytical Method in Patients Undergoing Endovascular Repair for Abdominal Aortic Aneurysm: The Impact on Clinical Decisions for the Appropriate Postoperative Setting and Cost-effective Analysis

OBJECTIVE

To analyze the use of the Pressure Recording Analytical Method (PRAM), an hemodynamic monitoring system, in evaluating intraoperative and postoperative hemodynamic instability in patients undergoing endovascular repair for abdominal aortic aneurysm, and to evaluate if the decision to refer patients to a ordinary ward or to a Cardiac Step-Down Unit (CSDU) after the intervention on the basis of intraoperative hemodynamic monitoring could be more cost-effective.

MATERIALS AND METHODS

After preoperative clinical evaluation, 44 patients were divided in this non-randomised study into two groups according to their postoperative destination: Group 1-ward (N=22) and Group 2-CSDU (N=22). All patients underwent monitoring with PRAM during the intervention and in the 24 postoperative hours, measuring several indices of myocardial contractility and other hemodynamic variables.

RESULTS

According to the variability of two parameters, Stroke Volume Variation and Pulse Pressure Variation, patients were classified as stable or unstable. Unstable patients showed a significant alteration in several hemodynamic indices, in comparison to stable ones. According to the intraoperative monitoring, eight high risk patients could have been sent to an ordinary ward due to their stability, with a reduction in the improper use of CSDU and, consequently, in costs.

CONCLUSIONS

Hemodynamic monitoring with PRAM can be useful in these patients, both for intraoperative management and for the choice of the more appropriate postoperative setting, possibly reducing the improper use of CSDU for hemodynamically stable patients who are judged to be at high risk preoperatively, and re-evaluating low surgical risk patients with an unstable intraoperative pattern, with a possible reduction in costs.

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.

Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis

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.

A systematic review and meta-analysis on the effect of goal-directed fluid therapy on postoperative outcomes in renal transplantation surgeries

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.

Goal-directed fluid therapy using stroke volume variation on length of stay and postoperative gastrointestinal function after major abdominal surgery-a randomized controlled trial

BACKGROUND AND OBJECTIVE

The effectiveness of goal-directed fluid therapy (GDFT) in promoting postoperative recovery remains unclear, the aim of this study was to evaluate the effect of GDFT on length of hospital stay and postoperative recovery of GI function in patients undergoing major abdominal oncologic surgery.

METHODS

In this randomized, double- blinded, controlled trial, adult patients scheduled for elective major abdominal surgery with general anesthesia, were randomly divided into the GDFT protocol (group G) or conventional fluid therapy group (group C). Patients in group C underwent conventional fluid therapy based on mean arterial pressure (MAP) and central venous pressure (CVP) whereas those in group G received GDFT protocol associated with the SVV less than 12% and the cardiac index (CI) was controlled at a minimum of 2.5 L/min/m2. The primary outcomes were the length of hospital stay and postoperative GI function.

RESULTS

One hundred patients completed the study protocol. The length of hospital stay was significantly shorter in group G compared with group C [9.0 ± 5.8 days versus 12.0 ± 4.6 days, P = 0.001]. Postoperative gastrointestinal dysfunction (POGD) occurred in two of 50 patients (4%) in group G and 16 of 50 patients (32%) in the control group (P < 0.001). GDFT significantly also shorten time to first flatus by 11 h (P = 0.009) and time to first tolerate oral diet by 2 days (P < 0.001).

CONCLUSIONS

Guided by SVV and CI, the application of GDFT has the potential to expedite postoperative recovery of GI function and reduce hospitalization duration after major abdominal surgery.

TRIAL REGISTRATION

This study was registered on www.

CLINICALTRIALS

gov on 07/05/2019 with registration number: NCT03940144.

Stroke volume variation and dynamic arterial elastance predict fluid responsiveness even in thoracoscopic esophagectomy: a prospective observational study

PURPOSE

It remains unknown whether stroke volume variation (SVV), pulse pressure variation (PPV), and dynamic arterial elastance (Eadyn) are suitable for monitoring fluid management during thoracoscopic esophagectomy (TE) in the prone position with one-lung ventilation and artificial pneumothorax. Our study aimed to evaluate the accuracy of SVV, PVV, and Eadyn in predicting the fluid responsiveness in these patients.

METHODS

We recruited 24 patients who had undergone TE. Patients with a mean arterial blood pressure ≤ 65 mmHg received a 200-ml bolus of 6% hydroxyethyl starch over 10 min. Fluid responders showed the stroke volume index ≥ 15% 5 min after the fluid bolus. Receiver operating characteristic (ROC) curves were generated and area under the ROC curve (AUROC) was calculated.

RESULTS

We obtained 61 fluid bolus data points, of which 20 were responders and 41 were non-responders. The median SVV before the fluid bolus in responders was significantly higher than that in non-responders (18% [interquartile range (IQR) 13-21] vs. 12% [IQR 8-15], P = 0.001). Eadyn was significantly lower in responders than in non-responders (0.55 [IQR 0.45-0.78] vs. 0.91 [IQR 0.67-1.00], P < 0.001). There was no difference in the PPV between the groups. The AUROC was 0.76 for SVV (95% confidence interval [CI] 0.62-0.89, P = 0.001), 0.56 for PPV (95% CI 0.41-0.71, P = 0.44), and 0.82 for Eadyn (95% CI 0.69-0.95, P < 0.001).

CONCLUSIONS

SVV and Eadyn are reliable parameters for predicting fluid responsiveness in patients undergoing TE.

Prediction of postoperative complications after hepatectomy with dynamic monitoring of central venous oxygen saturation

BACKGROUND

The usefulness of static monitoring using central venous pressure has been reported for anesthetic management in hepatectomy. It is unclear whether intra-hepatectomy dynamic monitoring can predict the postoperative course. We aimed to investigate the association between intraoperative dynamic monitoring and post-hepatectomy complications. Furthermore, we propose a novel anesthetic management strategy to reduce postoperative complication.

METHODS

From 2018 to 2021, 93 patients underwent hepatectomy at our hospital. Fifty-three patients who underwent dynamic monitoring during hepatectomy were enrolled. Flo Trac system was used for dynamic monitoring. The baseline central venous oxygen saturation (ScvO2) was defined as the average ScvO2 for 30 min after anesthesia induction. ScvO2 fluctuation (ΔScvO2) was defined as the difference between the baseline and minimum ScvO2. Postoperative complications were evaluated using the comprehensive complication index (CCI).

RESULTS

Patients with ΔScvO2 ≥ 10% had significantly higher CCI scores (0 vs. 20.9: p = 0.043). In univariate analysis, patients with higher CCI scores demonstrated significantly higher preoperative C-reactive protein-to-lymphocyte ratio (7.51 vs. 24.49: p = 0.039), intraoperative bleeding (105 vs. 581 ml: p = 0.008), number of patients with major hepatectomy (4/45 vs. 3/8: p = 0.028), and number of patients with ΔScvO2 ≥ 10% (11/45 vs. 6/8; p = 0.010). Multivariate logistic regression analysis revealed that ΔScvO2 ≥ 10% (odds ratio: 9.53, p = 0.016) was the only independent predictor of elevated CCI.

CONCLUSIONS

Central venous oxygen saturation fluctuation during hepatectomy is a predictor of postoperative complications. Anesthetic management based on intraoperative dynamic monitoring and minimizing the change in ScvO2 is a potential strategy for decreasing the risk of post-hepatectomy complications.

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.

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.

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.

Prospective comparison of the effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy on complications in thoracoscopic lobectomy

Objective

Restrictive fluid therapy is recommended in thoracoscopic lobectomy to reduce postoperative pulmonary complications, but it may contribute to hypovolemia. Goal-directed fluid therapy (GDFT) regulates fluid infusion to an amount required to avoid dehydration. We compared the effects of GDFT versus restrictive fluid therapy on postoperative complications after thoracoscopic lobectomy.

Methods

In total, 124 patients who underwent thoracoscopic lobectomy were randomized into the GDFT group (group G, n = 62) or restrictive fluid therapy group (group R, n = 62). The fluid volume and postoperative complications within 30 days of surgery were recorded.

Results

The total fluid volume in groups G and R was 1332 ± 364 and 1178 ± 278 mL, respectively. Group R received a smaller colloid fluid volume (523 ± 120 vs. 686 ± 180 mL), had a smaller urine output (448 ± 98 vs. 491 ± 101 mL), and received more norepinephrine (120 ± 66 vs. 4 ± 18 µg) than group G. However, there were no significant differences in postoperative pulmonary complications, acute kidney injury, length of hospital stay, or in-hospital mortality between the two groups.

Conclusion

Restrictive fluid therapy performs similarly to GDFT in thoracoscopic lobectomy but is a simpler fluid strategy than GDFT.

Trial registration: This study has been registered at the Chinese Clinical Trial Registry (ChiCTR2100051339) (http://www.chictr.org.cn/index.aspx).

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.

Application of perioperative hemodynamics today and potentials for tomorrow

Hemodynamic (HD) monitoring remains integral to the assessment and management of perioperative and critical care patients. This review article seeks to provide an update on the different types of flow-guided HD monitoring technologies available, highlight their limitations, and review the therapies associated with the application of these technologies. Additionally, we will also comment on the expanding roles of HD monitoring in the future.

Efficacy of Intraoperative Hemodynamic Optimization Using FloTrac/EV1000 Platform for Early Goal-Directed Therapy to Improve Postoperative Outcomes in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Randomized Controlled Trial

Purpose

Early goal-directed therapy (EGDT) using the FloTrac system reportedly improved postoperative outcomes among high-risk patients undergoing non-cardiac surgery. This study's objective was to evaluate the FloTrac/EV1000 platform's efficacy for improving postoperative outcomes in cardiac surgery.

Patients and Methods

Eighty-six adults undergoing coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) in 2 tertiary referral centers were randomized to the EGDT or Control group. The Control group was managed with standard care to achieve the following goals: mean arterial pressure 65-90 mmHg; central venous pressure 8-12 mmHg; urine output ≥0.5 mL·kg^-1·h^-1; oxygen saturation >95%; and hematocrit 26-30%. The EGDT group was managed to reach similar goals using information from the FloTrac/EV1000 monitor. The targets were stroke volume variation <13%; stroke volume index 33-65 mL·beat^-1·m^-2; cardiac index 2.2-4.0 L·min^-1·m^-2; and systemic vascular resistance index 1600-2500 dynes·s·cm^-5·m^-2.

Results

The intensive care unit (ICU) stay of the EGDT group was significantly shorter (mean difference -29.5 h; 95% CI -17.2 to -41.8, P < 0.001). The mechanical ventilation time was also shorter in the EGDT group (mean difference -11.3 h; 95% CI -2.7 to -19.9, P = 0.011). The hospital LOS was shorter in the EGDT group (mean difference -1.1 d; 95% CI -0.1 to -2.1, P = 0.038).

Conclusion

EGDT using FloTrac/EV1000 can be applied in CABG with CPB to improve postoperative outcomes.

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.

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

Comparison of the Efficacy of Different Arterial Waveform-derived Variables (Pulse Pressure Variation, Stroke Volume Variation, Systolic Pressure Variation) for Fluid Responsiveness in Hemodynamically Unstable Mechanically Ventilated Critically Ill Patients

Introduction

This study was conducted to assess fluid responsiveness in critically ill patients to avoid various complications of fluid overload.

Material and methods

This study was done in an ICU of a tertiary care hospital after approval from the institute ethical committee over 18 months. A total of 54 consenting adult patients were included in the study. Patients were hemodynamically unstable requiring mechanical ventilation, had acute circulatory failure, or those with at least one clinical sign of inadequate tissue perfusion. All patients were ventilated using tidal volume of 6–8 mL/kg, RR—12–15/minutes, positive end expiratory pressure (PEEP)—5 cm of water, and plateau pressure was kept below 30 cm water. They were sedated throughout the study. The arterial line and the central venous catheter were placed and connected to Vigileo-FloTrac transducer (Edward Lifesciences). Patients were classified into responder and nonresponder groups on the basis of the cardiac index (CI) after fluid challenge of 10 mL/kg of normal saline over 30 minutes. Pulse pressure variation (PPV), stroke volume variation (SVV), and systolic pressure variation (SPV) were assessed and compared at baseline, 30 minutes, and 60 minutes.

Results

In our study we found that PPV and SVV were significantly lower among responders than nonresponders at 30 minutes and insignificant at 60 minutes. Stroke volume variation was 10.28 ± 1.76 in the responder compared to 12.28 ± 4.42 (p = 0.02) at 30 minutes and PPV was 15.28 ± 6.94 in responders while it was 20.03 ± 4.35 in nonresponders (p = 0.01). We found SPV was insignificant at all time periods among both groups.

Conclusion

We can conclude that initial assessment for fluid responsiveness in critically ill mechanically ventilated patients should be based on PPV and SVV to prevent complications of fluid overload and their consequences.

How to cite this article

Kumar N, Malviya D, Nath SS, Rastogi S, Upadhyay V. Comparison of the Efficacy of Different Arterial Waveform-derived Variables (Pulse Pressure Variation, Stroke Volume Variation, Systolic Pressure Variation) for Fluid Responsiveness in Hemodynamically Unstable Mechanically Ventilated Critically Ill Patients. Indian J Crit Care Med 2021;25(1):48–53.

An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation

On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.

Classification and differential effectiveness of goal-directed hemodynamic therapies in surgical patients: A network meta-analysis of randomized controlled trials

PURPOSE

To investigate the most effective goal-directed hemodynamic therapy (GDHT) in surgical patients.

METHODS

GDHTs were classified as methods for intravascular volume, preload, stroke volume, cardiac output, oxygen delivery, systemic oxygenation, or tissue oxygenation optimization, alone or in combination. Their relative effectiveness and ranking were assessed using network meta-analysis and the surface under the cumulative ranking curve (SUCRA), respectively.

RESULTS

101 randomized controlled trials investigating GDHT effectiveness in surgical patients were eligible. The most commonly reported outcomes were 30-day mortality, acute kidney injury (AKI), and arrhythmia. Mortality was significantly reduced by GDHTs aimed at intravascular volume and cardiac output optimization (OR 0.40; 95% CrI 0.14-0.997; low quality). AKI was significantly reduced by GDHT aimed at intravascular volume optimization (OR 0.26; 95% CrI 0.08-0.71; moderate quality). No GDHT significantly reduced arrhythmia. GDHT aimed at intravascular volume and stroke volume optimization was likely most effective for mortality reduction (SUCRA = 78.8%) while that aimed at intravascular volume, stroke volume, and cardiac output optimization was likely most effective for AKI reduction (SUCRA = 85.4%).

CONCLUSIONS

Different GDHTs likely have different and outcome-dependent effectiveness in surgical patients. GDHTs aimed at intravascular volume, stroke volume, and cardiac output optimization are likely most effective as per the overall evidence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42020159978.

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

Postoperative outcomes based on crystalloid administration in pediatric patients with necrotizing enterocolitis undergoing laparotomy

Intravenous fluid prescription is an essential part of postoperative care and may play a causal role in postoperative complications. The objective of the present study was to evaluate the relationship between intraoperative fluid administration and postoperative outcomes in a large cohort of pediatric patients.This analysis included a retrospective review of 172 patients who underwent gastroenterological surgery from January 2012 to September 2018 at an academic tertiary care hospital. Patients were evaluated based on the median amount of corrected crystalloids and subsequently dichotomized as low (<25.89 mL/kg h) versus high (>25.89 mL/kg h). The primary outcome measure was the postoperative length of hospital stay (pLOS). Secondary outcome measures included the postoperative time to restore gastroenterological functions and postoperative complications.Patients who received larger amounts of crystalloids were more likely to have a lower intraoperative level of hemoglobin (P = .78) and an intraoperative blood transfusion (P = .27). There were trends toward lower incidence rates of hyperchloremic acidosis (P = .375) and metabolic acidosis (P = .54) in the high crystalloid administration cohort. The incidence of postoperative complications increased as the amount of administered fluid decreased (P = .046). The total length of hospital stay was shorter in patients who received high volumes of crystalloid fluid (19.5 [15.75-32.25] days) than in patients who received low volumes (22 [16-29.5] days, P = .283).Significant and multifaceted variability in crystalloid administration was noted among pediatric patients undergoing major surgery. High fluid administration was associated with favorable postoperative outcomes; these findings could be applied to improve patient safety and facilitate better quality of care.

Comparison of the ability of two continuous cardiac output monitors to detect stroke volume index: Estimated continuous cardiac output estimated by modified pulse wave transit time and measured by an arterial pulse contour-based cardiac output device

BACKGROUND

Estimated continuous cardiac output (esCCO), a non-invasive technique for continuously measuring cardiac output (CO), is based on modified pulse wave transit time, which is determined by pulse oximetry and electrocardiography.

OBJECTIVE

We examined the ability of esCCO to detect stroke volume index (SVI) and changes in SVI compared with currently available arterial waveform analysis methods.

METHODS

We retrospectively reanalysed 15 of the cases from our previous study on esCCO measurement. SVI was calculated using an esCCO system, measured using the arterial pressure-based CO (APCO) method, and compared with a corresponding intermittent bolus thermodilution CO (ICO) method. Percentage error measurement and statistical methods, including concordance analysis and polar plot analysis, were performed.

RESULTS

The difference in the SVI values between esCCO and ICO was -3.0 ± 8.8 ml (percentage error, 33.5%). The mean angular bias was 0.8 and the radial limits of agreement were ± 27.3. The difference in the SVI values between APCO and ICO was 0.9 ± 11.2 ml (percentage error, 42.6%). The mean angular bias was -6.8 and the radial limits of agreement were ± 44.1.

CONCLUSION

This study demonstrated that the accuracy, precision, and dynamic trend of esCCO are better than those of APCO.

Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury

BACKGROUND

Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk.

METHODS

Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline).

RESULTS

Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort.

CONCLUSIONS

Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.

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.

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

OBJECTIVE

To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017.

ELIGIBILITY CRITERIA

Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded.

DATA EXTRACTION AND SYNTHESIS

Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared.

RESULTS

117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions.

CONCLUSIONS

Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions.

STUDY REGISTRATION

Prospero CRD42016035662.

[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.

Perioperative Fluid Administration in Pancreatic Surgery: a Comparison of Three Regimens

BACKGROUND

Optimization of perioperative fluid management is a controversial issue. Weight-adjusted, fixed fluid strategies do not take into account patient hemodynamic status, so that individualized strategies guided by relevant variables may be preferable. We studied this issue in patients undergoing pancreatic surgery within our institution.

METHODS

All patients who underwent a laparotomy for pancreatic cancer during a 5-month period at our hospital (AOUI of Verona, Italy) were eligible to be included in this prospective, observational study. According to the responsible anesthesiologist's free choice, patients received, during surgery, either liberal (12 ml/kg/h) or restricted (4 ml/kg/h) fixed-volume weight-guided replacement fluids or goal-directed (GD) fluid replacement using stroke volume variation (SVV) determined by the FloTrac Vigileo device.

RESULTS

Eighty-six patients were included: 29 in the liberal group, 23 in the restricted group, and 34 in the GD group. The mean duration of surgery was 6 [4-7] h. Patients in the liberal group received more perioperative fluid than those in the GD and restricted groups. Nearly one third of all patients had a major complication, including delayed enteral feeding, and presented a longer duration of hospital stay. Despite the biases related to our limited cohort, there were significantly fewer postoperative complications (such as postoperative fistula, abdominal collection, and hemorrhage) in the restricted and GD groups of patients than in the liberal one.

CONCLUSION

In patients undergoing pancreatic surgery, a restricted or individually guided GD strategy for management of perioperative fluids can result in fewer complications than a liberal fluid strategy. Larger and randomized investigations are warranted to confirm these data on this domain.

Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Introduction

Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.

Aim

To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.

Methods

Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.

Results

Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.

Conclusions

There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

Goal-Directed vs Traditional Approach to Intraoperative Fluid Therapy during Open Major Bowel Surgery: Is There a Difference?

Introduction

Optimum perioperative fluid therapy is important to improve the outcome of the surgical patient. This study prospectively compared goal-directed intraoperative fluid therapy with traditional fluid therapy in general surgical patients undergoing open major bowel surgery.

Methodology

Patients between 20 and 70 years of age, either gender, ASA I and II, and scheduled for elective open major bowel surgery were included in the study. Patients who underwent laparoscopic and other surgeries were excluded. After routine induction of general anaesthesia, the patients were randomised to either the control group (traditional fluid therapy), the FloTrac group (based on stroke volume variation), or the PVI group (based on pleth variability index). Fluid input and output, recovery characteristics, and complications were noted.

Results

306 patients, with 102 in each group, were enrolled. Five patients (control (1), FloTrac (2), and PVI (2)) were inoperable and were excluded. Demographic data, ASA PS, anaesthetic technique, duration of surgery, and surgical procedures were comparable. The control group received significantly more crystalloids (3200 ml) than the FloTrac (2000 ml) and PVI groups (1875 ml), whereas infusion of colloids was higher in the FloTrac (400–700 ml) and PVI (200–500 ml) groups than in the control group (0–500 ml). The control group had significantly positive net fluid balance intraoperatively (2500 ml, 9 ml/kg/h) compared to the FloTrac (1515 ml, 5.4 ml/kg/h) and PVI (1420 ml, 6 ml/kg/h) groups. Days to ICU stay, HDU stay, return of bowel movement, oral intake, morbidity, duration of hospital stay, and survival rate were comparable. The total number of complications was not different between the three groups. Anastomotic leaks occurred more often in the Control group than in the others, but the numbers were small.

Conclusions

Use of goal-directed fluid management, either with FloTrac or pleth variability index results in a lower volume infusion and lower net fluid balance. However, the complication rate is similar to that of traditional fluid therapy. This trial is registered with CTRI/2018/04/013016.

Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis

BACKGROUND

Much uncertainty exists as to whether peri-operative goal-directed therapy is of benefit.

OBJECTIVES

To discover if peri-operative goal-directed therapy decreases mortality and morbidity in adult surgical patients.

DESIGN

An updated systematic review and random effects meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase and the Cochrane Library were searched up to 31 December 2016.

ELIGIBILITY CRITERIA

Randomised controlled trials enrolling adult surgical patients allocated to receive goal-directed therapy or standard care were eligible for inclusion. Trauma patients and parturients were excluded. Goal-directed therapy was defined as fluid and/or vasopressor therapy titrated to haemodynamic goals [e.g. cardiac output (CO)]. Outcomes included mortality, morbidity and hospital length of stay. Risk of bias was assessed using Cochrane methodology.

RESULTS

Ninety-five randomised trials (11 659 patients) were included. Only four studies were at low risk of bias. Modern goal-directed therapy reduced mortality compared with standard care [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.50 to 0.87; number needed to treat = 59; N = 52; I = 0.0%]. In subgroup analysis, there was no mortality benefit for fluid-only goal-directed therapy, cardiac surgery patients or nonelective surgery. Contemporary goal-directed therapy also reduced pneumonia (OR 0.69; 95% CI, 0.51 to 0. 92; number needed to treat = 38), acute kidney injury (OR 0. 73; 95% CI, 0.58 to 0.92; number needed to treat = 29), wound infection (OR 0.48; 95% CI, 0.37 to 0.63; number needed to treat = 19) and hospital length of stay (days) (-0.90; 95% CI, -1.32 to -0.48; I = 81. 2%). No important differences in outcomes were found for the pulmonary artery catheter studies, after accounting for advances in the standard of care.

CONCLUSION

Peri-operative modern goal-directed therapy reduces morbidity and mortality. Importantly, the quality of evidence was low to very low (e.g. Grading of Recommendations, Assessment, Development and Evaluation scoring), and there was much clinical heterogeneity among the goal-directed therapy devices and protocols. Additional well designed and adequately powered trials on peri-operative goal-directed therapy are necessary.