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

Application feasibility of virtual models and computational fluid dynamics for the planning and evaluation of aortic repair surgery for Williams syndrome

BACKGROUND

Accurate diagnosis and evaluation of Williams Syndrome (WS) are essential yet challenging for effective surgical management. This study aimed to quantify the hemodynamic changes of surgical repair for WS through virtual surgery and computational fluid dynamics (CFD) for surgical guidance and postoperative evaluation.

METHODS

A patient preliminarily diagnosed with WS was included in this study. 3D model alongside hemodynamic analysis was used to guide and evaluate the surgical procedure. Preoperative, predictive and postoperative models were created and analyzed using CFD. Key parameters, including blood flow velocity, pressure differences, wall shear stress, and other critical factors, were assessed to evaluate the surgery's effectiveness.

RESULTS

In the hemodynamics analysis, the CFD results of predictive model and postoperative model demonstrated a high level of consistency, and showed significant differences compared to the preoperative model. The velocity at the stenosis on the aorta decreased from 5.6 m/s before the operation to 1.6 m/s in the virtual model and 1.5 m/s in the postoperative model. Surgical repair increased the proportion of outlet flow of the descending aorta (dAo) from 28.7% to 35.5%.

CONCLUSIONS

Virtual surgery and CFD can predict surgical outcomes, enabling doctors to optimize and rehearse the procedure before the actual surgery. The method of predicting surgery through virtual surgery and CFD is accurate and feasible.

TRIAL REGISTRATION

Registered by the Ethics Committee of Peking University International Hospital (No. IRB2019-062).

Intraoperative goal-directed hemodynamic therapy through fluid administration to optimize the stroke volume: A meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the clinical impact of optimizing stroke volume (SV) through fluid administration as part of goal-directed hemodynamic therapy (GDHT) in adult patients undergoing elective major abdominal surgery.

METHODS

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered in the PROSPERO database in January 2024. The intervention was defined as intraoperative GDHT based on the optimization or maximization of SV through fluid challenges, or by using dynamic indices of fluid responsiveness, including stroke volume variation, pulse pressure variation, and plethysmography variation index compared to usual fluid management. The primary outcome was postoperative complications. Secondary outcome variables included postoperative acute kidney injury (AKI), length of stay (LOS), intraoperative fluid administration, and 30-day mortality.

RESULTS

A total of 29 randomized controlled trials (RCTs) met the inclusion criteria. There were no significant differences in the incidence of postoperative complications (RR 0.89; 95% CI, 0.78-1.00), postoperative AKI (OR 0.97; (95% IC, 0.55-1.70), and mortality (OR 0.80; 95% CI, 0.50-1.29). GDHT was associated with a reduced LOS compared to usual care (SMD: -0.17 [-0.32; -0.03]). The subgroup in which hydroxyethyl starch was used for hemodynamic optimization was associated with fewer complications (RR 0.79; 95% CI, 0.65-0.94), whereas the subgroup of patients in whom crystalloids were used was associated with an increased risk of postoperative complications (RR 1.08; 95% CI, 1.04-1.12).

CONCLUSIONS

In adults undergoing major surgery, goal-directed hemodynamic therapy focused on fluid-based stroke volume optimization did not reduce postoperative morbidity and mortality.

Improving perioperative care in low-resource settings with goal-directed therapy: a narrative review

Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

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.