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Ronkainen HPO, Ylikauma LA, Pohjola MJ, Ohtonen PP, Erkinaro TM, Vakkala MA, Liisanantti JH, Juvonen TS, Kaakinen TI. Reliability of Bioreactance and Pulse-Power Analysis in Measuring Cardiac Index During Open Abdominal Aortic Surgery. J Cardiothorac Vasc Anesth 2024; 38:1484-1491. [PMID: 38631929 DOI: 10.1053/j.jvca.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To investigate the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and the mini invasive pulse-power device LiDCOrapid as compared to thermodilution cardiac output (TDCO) as measured by pulmonary artery catheter when assessing cardiac index (CIx) in the setting of elective open abdominal aortic (AA) surgery. DESIGN A prospective method-comparison study. SETTING Oulu University Hospital, Finland. PARTICIPANTS Forty patients undergoing elective open abdominal aortic surgery. INTERVENTIONS Intraoperative CI measurements were obtained simultaneously with TDCO and the study monitors, resulting in 627 measurement pairs with Starling SV and 497 with LiDCOrapid. MEASUREMENTS AND MAIN RESULTS The Bland-Altman method was used to investigate the agreement among the devices, and four-quadrant plots with error grids were used to assess trending ability. The agreement between TDCO and Starling SV was associated with a bias of 0.18 L/min/m2 (95% confidence interval [CI] = 0.13 to 0.23), wide limits of agreement (LOA = -1.12 to 1.47 L/min/m2), and a percentage error (PE) of 63.7 (95% CI = 52.4-71.0). The agreement between TDCO and LiDCOrapid was associated with a bias of -0.15 L/min/m2 (95% CI = -0.21 to -0.09), wide LOA (-1.56 to 1.37), and a PE of 68.7 (95% CI = 54.9-79.6). The trending ability of neither device was sufficient. CONCLUSION The CI measurements achieved with Starling SV and LiDCOrapid were not interchangeable with TDCO, and the ability to track changes in CI was poor. These results do not support the use of either study device in monitoring CI during open AA surgery.
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Affiliation(s)
- Heikki Pekka Oskari Ronkainen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Laura Anneli Ylikauma
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Mari Johanna Pohjola
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Pasi Petteri Ohtonen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Division of Operative Care, Oulu University Hospital, Oulu,Finland
| | - Tiina Maria Erkinaro
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Merja Annika Vakkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Janne Henrik Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tatu Sakari Juvonen
- Department of Cardiac Surgery, Heart, and Lung Center, Helsinki University Central Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Timo Ilari Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Kouz K, Thiele R, Michard F, Saugel B. Haemodynamic monitoring during noncardiac surgery: past, present, and future. J Clin Monit Comput 2024; 38:565-580. [PMID: 38687416 PMCID: PMC11164815 DOI: 10.1007/s10877-024-01161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
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Berger C, Greiner A, Brandhorst P, Reimers SC, Kniesel O, Omran S, Treskatsch S. How Would I Treat My Own Thoracoabdominal Aortic Aneurysm: Perioperative Considerations From the Anesthesiologist Perspective. J Cardiothorac Vasc Anesth 2024; 38:1092-1102. [PMID: 38310068 DOI: 10.1053/j.jvca.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 02/05/2024]
Abstract
A thoracoabdominal aortic aneurysm (TAAA) can be potentially life-threatening due to its associated risk of rupture. Thoracoabdominal aortic aneurysm repair, performed as endovascular repair and/or open surgery, is the recommended therapy of choice. Hemodynamic instability, severe blood loss, and spinal cord or cerebral ischemia are some potential hazards the perioperative team has to face during these procedures. Therefore, preoperative risk assessment and intraoperative anesthesia management addressing these potential hazards are essential to improving patients' outcomes. Based on a presented index case, an overview focusing on anesthetic measures to identify perioperatively and manage these risks in TAAA repair is provided.
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Affiliation(s)
- Christian Berger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Berlin, Germany
| | - Philipp Brandhorst
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Sophie Claire Reimers
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Olaf Kniesel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany.
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4
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Zhang Y, Wang X, Sang X, Zhou Z, Dai G, Zhang X. Effect of Fluid Therapy in Early Morning on the Incidence of Post-Induction Hypotension During Non-Cardiac Surgery After Noon: A Single-Center Retrospective Study. Drug Des Devel Ther 2024; 18:1339-1347. [PMID: 38681205 PMCID: PMC11048210 DOI: 10.2147/dddt.s453068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/15/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Post-induction hypotension (PIH) is a common clinical phenomenon linked to increased morbidity and mortality in various non-cardiac surgeries. Patients with surgery in the afternoon may have preoperative hypovolemia caused by prolonged fasting and dehydration, which increases the risk of hypotension during the induction period. However, studies on the fluid therapy in early morning combating PIH remain inadequate. Therefore, we aimed to investigate the influence of prophylactic high-volume fluid in the early morning of the operation day on the incidence of PIH during non-cardiac surgery after noon. Patients and Methods We reviewed the medical records of patients who underwent non-cardiac surgery after noon between October 2021 and October 2022. The patients were divided into two groups based on whether they received a substantial volume of intravenous fluid (high-volume group) or not (low-volume group) in the early morning of the surgery day. We investigated the incidence of PIH and intraoperative hypotension (IOH) as well as the accumulated duration of PIH in the first 15 minutes. In total, 550 patients were included in the analysis. Results After propensity score matching, the incidence of PIH was 39.7% in the high-volume group and 54.1% in the low-volume group. Multivariate logistic regression analysis showed that patients in the high-volume group had lower incidence of hypotension after induction compared with the low-volume group (odds ratio, 0.55; 95% CI, 0.34-0.89; p = 0.016). The high-volume fluid infusion in the preoperative morning was significantly correlated with the decreased duration of PIH (p = 0.013), but no statistical difference was observed for the occurrence of IOH between the two groups (p = 0.075). Conclusion The fluid therapy of more than or equal to 1000 mL in the early morning of the surgery day was associated with a decreased incidence of PIH compared with the low-volume group in patients undergoing non-cardiac surgery after noon.
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Affiliation(s)
- Ying Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu, People’s Republic of China
| | - Xinxin Wang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu, People’s Republic of China
| | - Xiaoqiao Sang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu, People’s Republic of China
| | - Zhou Zhou
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu, People’s Republic of China
| | - Guangrong Dai
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu, People’s Republic of China
| | - Xiaobao Zhang
- Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu, People’s Republic of China
- The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, Jiangsu, People’s Republic of China
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5
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Arslan-Carlon V, Qadan M, Puttanniah V, Seier K, Gönen M, Yang G, Fischer M, DeMatteo RP, Kingham TP, Jarnagin WR, D’Angelica MI. Randomized Prospective Trial of Epidural Analgesia after Open Hepatectomy. Ann Surg 2024; 279:598-604. [PMID: 38214168 PMCID: PMC10939918 DOI: 10.1097/sla.0000000000006205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To evaluate whether patient-controlled epidural analgesia (PCEA) improves postoperative pain during ambulation following elective open hepatectomy. BACKGROUND Strategies to alleviate postoperative pain are a critical element of recovery after surgery. However, the optimal postoperative pain management strategy following open hepatectomy remains unclear. METHODS We conducted a prospective, nonblinded, randomized comparison of PCEA (intervention) versus intravenous patient-controlled analgesia (IV PCA; control) for postoperative pain following elective open hepatectomy. The primary end point was pain during ambulation on postoperative day (POD) 2. The study was powered to detect a clinically significant 2-point difference on the pain numeric rating scale (NRS). Secondary end points included pain at rest, morbidity, time to return of bowel function, and length of stay. RESULTS From 2015 to 2020, 231 patients were randomized (116 patients in the PCEA arm and 115 in the IV PCA arm). The incidence of epidural failure was 3% (n=4/116), with no epidural-related complications. Patients in the PCEA arm had a <2-point difference in NRS pain scores during ambulation on POD 2 vs. IV PCA (median 4.0 vs. 5.0, P <0.001). There was no difference in overall complications between the PCEA and IV PCA arms (33% vs. 40%, P =0.276). Secondary outcomes, including pain scores at rest, were similar between the study arms. CONCLUSIONS PCEA was safe following open hepatectomy and was associated with a small difference in pain with activity on POD 2 that did not reach our pre-specified definition of clinical significance.
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Affiliation(s)
- Vittoria Arslan-Carlon
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Vinay Puttanniah
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth Seier
- Department of Biostatistics & Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gönen
- Department of Biostatistics & Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gloria Yang
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mary Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ronald P. DeMatteo
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Trauzeddel RF, Nordine M, Fucini GB, Sander M, Dreger H, Stangl K, Treskatsch S, Habicher M. Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis. Braz J Cardiovasc Surg 2024; 39:e20220470. [PMID: 38426709 PMCID: PMC10903543 DOI: 10.21470/1678-9741-2022-0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/19/2023] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes. METHODS Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch. RESULTS Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ. CONCLUSION GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.
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Affiliation(s)
- Ralf Felix Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine,
Charité - Universitätsmedizin Berlin, Corporate Member of Freie
Universität Berlin and Humboldt-Universität zu Berlin, Campus Benjamin
Franklin, Berlin, Germany
| | - Michael Nordine
- Department of Anesthesiology, Intensive Care Medicine, and Pain
Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt,
Hessen, Germany
| | - Giovanni B. Fucini
- Institute of Hygiene and Environmental Medicine and National
Reference Center for the Surveillance of Nosocomial Infections, Charité -
Universitätsmedizin Berlin, Corporate Member of Freie Universität
Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine,
and Pain Therapy, Justus Liebig University of Giessen, Hessen, Germany
| | - Henryk Dreger
- Department of Cardiology, Angiology, and Intensive Care Medicine,
Deutsches Herzzentrum der Charité - Medical Heart Center of Charité
and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Karl Stangl
- Department of Cardiology and Angiology, Deutsches Herzzentrum der
Charité - Medical Heart Center of Charité and German Heart Institute
Berlin, Campus Charité Mitte, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine,
Charité - Universitätsmedizin Berlin, Corporate Member of Freie
Universität Berlin and Humboldt-Universität zu Berlin, Campus Benjamin
Franklin, Berlin, Germany
| | - Marit Habicher
- Department of Anesthesiology, Operative Intensive Care Medicine,
and Pain Therapy, Justus Liebig University of Giessen, Hessen, Germany
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Dodwad SJM, Mueck KM, Kregel HR, Guy-Frank CJ, Isbell KD, Klugh JM, Wade CE, Harvin JA, Kao LS, Wandling MW. Impact of Intra-Operative Shock and Resuscitation on Surgical Site Infections After Trauma Laparotomy. Surg Infect (Larchmt) 2024; 25:19-25. [PMID: 38170174 PMCID: PMC10825266 DOI: 10.1089/sur.2023.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
Background: Patients undergoing trauma laparotomy experience high rates of surgical site infection (SSI). Although intra-operative shock is a likely contributor to SSI risk, little is known about the relation between shock, intra-operative restoration of physiologic normalcy, and SSI development. Patients and Methods: A retrospective review of trauma patients who underwent emergent definitive laparotomy was performed. Using shock index and base excess at the beginning and end of laparotomy, patients were classified as normal, persistent shock, resuscitated, or new shock. Univariable and multivariable analyses were performed to identify predictors of organ/space SSI, superficial/deep SSI, and any SSI. Results: Of 1,191 included patients, 600 (50%) were categorized as no shock, 248 (21%) as resuscitated, 109 (9%) as new shock, and 236 (20%) as persistent shock, with incidence of any SSI as 51 (9%), 28 (11%), 26 (24%), and 32 (14%), respectively. These rates were similar in organ/space and superficial/deep SSIs. On multivariable analysis, resuscitated, new shock, and persistent shock were associated with increased odds of organ/space SSI (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.3-3.5; p < 0.001) and any SSI (OR, 2.0; 95% CI, 1.4-3.2; p < 0.001), but no increased risk of superficial/deep SSI (OR, 1.4; 95% CI, 0.8-2.6; p = 0.331). Conclusions: Although the trajectory of physiologic status influenced SSI, the presence of shock at any time during trauma laparotomy, regardless of restoration of physiologic normalcy, was associated with increased odds of SSI. Further investigation is warranted to determine the relation between peri-operative shock and SSI in trauma patients.
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Affiliation(s)
- Shah-Jahan M. Dodwad
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Krislynn M. Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Heather R. Kregel
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Chelsea J. Guy-Frank
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Kayla D. Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - James M. Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - John A. Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Michael W. Wandling
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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Pisarska-Adamczyk M, Torbicz G, Gajewska N, Małczak P, Major P, Pędziwiatr M, Wysocki M. The impact of perioperative fluid therapy on the short-term outcomes after laparoscopic colorectal cancer surgery with ERAS protocol: a prospective observational study. Sci Rep 2023; 13:22282. [PMID: 38097695 PMCID: PMC10721599 DOI: 10.1038/s41598-023-49704-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023] Open
Abstract
The main goals of the Enhanced recovery after surgery (ERAS) protocol are focused on shortening the length of hospital stay (LOS), expediting convalescence, and reducing morbidity. A balanced perioperative fluid therapy is among the significant interventions incorporated by the ERAS protocol. The article contains extensive discussion surrounding the impact of this individual intervention on short-term outcomes. The aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes in patients after laparoscopic colorectal cancer surgery. The analysis included consecutive patients, who had undergone laparoscopic colorectal cancer operations between 2013 and 2020. Patients were divided into two groups: restricted (≤ 2500 ml) or excessive (> 2500 ml) perioperative fluid therapy. A standardized ERAS protocol was implemented in all patients. The study outcomes included recovery parameters and the morbidity rate, LOS and 30 days readmission rate. There were 361 and 80 patients in groups 1 and 2, respectively. There were no statistically significant differences between the groups in terms of demographic parameters and factors related to the surgical procedure. Logistic regression showed that restricted fluid therapy as a single intervention was associated with improvement in tolerance of diet on 1st postoperative day (OR 2.18, 95% CI 1.31-3.62, p = 0.003), accelerated mobilization on 1st postoperative day (OR 2.43, 95% CI 1.29-4.61, p = 0.006), lower risk of postoperative morbidity (OR 0.58, 95%CI 0.36-0.98, p = 0.046), shorter LOS (OR 0.49, 95% CI 0.29-0.81, p = 0.005) and reduced readmission rate (OR 0.48, 95% CI 0.23-0.98, p = 0.045). A balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter LOS and lower 30 days readmission rate.
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Affiliation(s)
| | - Grzegorz Torbicz
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Kraków, Poland
| | - Natalia Gajewska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Kraków, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Kraków, Poland.
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Kraków, Poland
| | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Kraków, Poland
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Marklin GF, Stephens M, Gansner E, Ewald G, Klinkenberg WD, Ahrens T. Clinical outcomes of a prospective randomized comparison of bioreactance monitoring versus pulse-contour analysis in a stroke-volume based goal-directed fluid resuscitation protocol in brain-dead organ donors. Clin Transplant 2023; 37:e15110. [PMID: 37615632 DOI: 10.1111/ctr.15110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/27/2023] [Accepted: 08/16/2023] [Indexed: 08/25/2023]
Abstract
Eighty percent of brain-dead (BD) organ donors develop hypotension and are frequently hypovolemic. Fluid resuscitation in a BD donor is controversial. We have previously published our 4-h goal-directed stroke volume (SV)-based fluid resuscitation protocol which significantly decreased time on vasopressors and increased transplanting four or more organs. The SV was measured by pulse-contour analysis (PCA) or an esophageal doppler monitor, both of which are invasive. Thoracic bioreactance (BR) is a non-invasive portable technology that measures SV but has not been studied in BD donors. We performed a randomized prospective comparative study of BR versus PCA technology in our fluid resuscitation protocol in BD donors. Eighty-four donors (53.1%) were randomized to BR and 74 donors to PCA (46.8%). The two groups were well matched based on 24 demographic, social, and initial laboratory factors, without any significant differences between them. There was no difference in the intravenous fluid infused over the 4-h study period [BR 2271 ± 823 vs. PCA 2230 ± 962 mL; p = .77]. There was no difference in the time to wean off vasopressors [BR 108.8 ± 61.8 vs. PCA 150.0 ± 68 min p = .07], nor in the number of donors off vasopressors at the end of the protocol [BR 16 (28.6%) vs. PCA 15 (29.4%); p = .92]. There was no difference in the total number of organs transplanted per donor [BR 3.25 ± 1.77 vs. PCA 3.22 ± 1.75; p = .90], nor in any individual organ transplanted. BR was equivalent to PCA in clinical outcomes and provides a simple, non-invasive, portable technology to monitor fluid resuscitation in organ donors.
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Affiliation(s)
| | | | | | - Gregory Ewald
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
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10
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Sae-Phua V, Tanasittiboon S, Sangtongjaraskul S. The Effect of Goal-directed Fluid Management based on Stroke Volume Variation on ICU Length of Stay in Elderly Patients Undergoing Elective Craniotomy: A Randomized Controlled Trial. Indian J Crit Care Med 2023; 27:709-716. [PMID: 37908429 PMCID: PMC10613877 DOI: 10.5005/jp-journals-10071-24551] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/13/2023] [Indexed: 11/02/2023] Open
Abstract
Background Inappropriate fluid management during neurosurgery can increase postoperative complications. In this study, we aimed to investigate the effect of goal-directed fluid therapy using stroke volume variation (SVV) in elderly patients undergoing elective craniotomy. Materials and methods We randomized 100 elderly patients scheduled for elective craniotomy into two groups: goal-directed therapy (GDT, n = 50) group and conventional group (n = 50). Fluid management protocol using SVV was applied in the GDT group. Decisions about fluid and hemodynamic management in the conventional group were made by the anesthesiologist. Perioperative variables including fluid balance, lactate level, and intensive care unit (ICU) length of stay were assessed. Results There was no significant difference in ICU length of stay between the two groups: 14 (12, 16.75) hours in GDT group vs 15 (13, 18) hours in control group (p = 0.116). Patients in the GDT group received a significantly less amount of crystalloid compared with the control group: 1311.5 (823, 2018) mL vs 2080 (1420, 2690) mL (p < 0.001). Our study demonstrated a better fluid balance in the GDT group as 342.5 (23, 607) mL compared with the conventional group 771 (462, 1269) mL (p < 0.001). Conclusion Intraoperative goal-directed fluid management based on SVV in elderly patients undergoing elective craniotomy did not reduce the ICU length of stay or postoperative complications. It did result in an improved fluid balance with no evidence of inadequate organ perfusion. Clinical trial registration number TCTR20190812003. How to cite this article Sae-Phua V, Tanasittiboon S, Sangtongjaraskul S. The Effect of Goal-directed Fluid Management based on Stroke Volume Variation on ICU Length of Stay in Elderly Patients Undergoing Elective Craniotomy: A Randomized Controlled Trial. Indian J Crit Care Med 2023;27(10):709-716.
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Affiliation(s)
- Vorrachai Sae-Phua
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sophitnapa Tanasittiboon
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sunisa Sangtongjaraskul
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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11
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Mladinov D, Isaza E, Gosling AF, Clark AL, Kukreja J, Brzezinski M. Perioperative Fluid Management. Anesthesiol Clin 2023; 41:613-629. [PMID: 37516498 DOI: 10.1016/j.anclin.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the elderly are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the elderly. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, CWN-L1, Boston, MA 02115, USA
| | - Erin Isaza
- University of California, San Francisco, School of Medicine, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Andre F Gosling
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845D, Birmingham, AL 35249, USA
| | - Adrienne L Clark
- Department of Anesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, 500 Parnassus Avenue, MU 405 W San Francisco, CA 94143, USA
| | - Marek Brzezinski
- Department of Anesthesia and Perioperative Care, University of California, VA Medical Center-San Francisco, 4150 Clement Street, San Francisco CA 94121, USA.
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12
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Zhang Y, Ding Y, Zhang J, Huang T, Gao J. Tidal volume challenge-induced hemodynamic changes can predict fluid responsiveness during one-lung ventilation: an observational study. Front Med (Lausanne) 2023; 10:1169912. [PMID: 37636561 PMCID: PMC10447224 DOI: 10.3389/fmed.2023.1169912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Background To evaluate the ability of tidal volume challenge (VTC)-induced hemodynamic changes to predict fluid responsiveness in patients during one-lung ventilation (OLV). Methods 80 patients scheduled for elective thoracoscopic surgery with OLV were enrolled. The inclusion criteria were: age ≥ 18 years, American Society of Anesthesiologists physical status I-III, normal right ventricular function, normal left ventricular systolic function (ejection fraction ≥55%), and normal or slightly impaired diastolic function. The study protocol was implemented 15 min after starting OLV. Simultaneous recordings were performed for hemodynamic variables of diameter of left ventricular outflow tract, velocity time integral (VTI) of aortic valve, and stroke volume (SV), and ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC were calculated at four time points: with VT 5 mL/kg (T1); after VT increased from 5 mL/kg to 8 mL/kg and maintained at this level for 2 min (T2); after VT was adjusted back to 5 mL/kg for 2 min (T3); and after volume expansion (250 mL of 0.9% saline infused over 10-15 min) (T4). Patients were considered as responders to fluid administration if SV increased by ≥10%. Receiver operating characteristic (ROC) curves for percent decrease in SV, VTI, and MAP by VTC were generated to evaluate their ability to discriminate fluid responders from nonresponders. Results Of the 58 patients analyzed, there were 32 responders (55%) and 26 nonresponders (45%). The basic characteristics were comparable between the two groups (p > 0.05). The area under the curve (AUC) for ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC to discriminate responders from nonresponders were 0.81 (95% CI: 0.68-0.90), 0.79 (95% CI: 0.66-0.89), and 0.56 (95% CI: 0.42-0.69). The best threshold for ΔSV-VTC was -16.1% (sensitivity, 78.1%; specificity, 84.6%); the best threshold for ΔVTI-VTC was -14.5% (sensitivity, 78.1%; specificity, 80.8%). Conclusion Tidal volume challenge-induced relative change of stroke volume and velocity time integral can predict fluid responsiveness in patients during one-lung ventilation.Clinical Trial Registration: Chinese Clinical Trial Registry, No: chictr210051310.
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Affiliation(s)
| | | | | | | | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou, China
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13
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Mestrom EHJ, Bakkes THGF, Ourahou N, Korsten HHM, Serra PDA, Montenij LJ, Mischi M, Turco S, Bouwman RA. Prediction of postoperative patient deterioration and unanticipated intensive care unit admission using perioperative factors. PLoS One 2023; 18:e0286818. [PMID: 37535542 PMCID: PMC10399824 DOI: 10.1371/journal.pone.0286818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Currently, no evidence-based criteria exist for decision making in the post anesthesia care unit (PACU). This could be valuable for the allocation of postoperative patients to the appropriate level of care and beneficial for patient outcomes such as unanticipated intensive care unit (ICU) admissions. The aim is to assess whether the inclusion of intra- and postoperative factors improves the prediction of postoperative patient deterioration and unanticipated ICU admissions. METHODS A retrospective observational cohort study was performed between January 2013 and December 2017 in a tertiary Dutch hospital. All patients undergoing surgery in the study period were selected. Cardiothoracic surgeries, obstetric surgeries, catheterization lab procedures, electroconvulsive therapy, day care procedures, intravenous line interventions and patients under the age of 18 years were excluded. The primary outcome was unanticipated ICU admission. RESULTS An unanticipated ICU admission complicated the recovery of 223 (0.9%) patients. These patients had higher hospital mortality rates (13.9% versus 0.2%, p<0.001). Multivariable analysis resulted in predictors of unanticipated ICU admissions consisting of age, body mass index, general anesthesia in combination with epidural anesthesia, preoperative score, diabetes, administration of vasopressors, erythrocytes, duration of surgery and post anesthesia care unit stay, and vital parameters such as heart rate and oxygen saturation. The receiver operating characteristic curve of this model resulted in an area under the curve of 0.86 (95% CI 0.83-0.88). CONCLUSIONS The prediction of unanticipated ICU admissions from electronic medical record data improved when the intra- and early postoperative factors were combined with preoperative patient factors. This emphasizes the need for clinical decision support tools in post anesthesia care units with regard to postoperative patient allocation.
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Affiliation(s)
- Eveline H J Mestrom
- Anesthesiology Department, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Tom H G F Bakkes
- Signal Processing Department, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Nassim Ourahou
- Anesthesiology Department, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Hendrikus H M Korsten
- Anesthesiology Department, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
- Signal Processing Department, Eindhoven University of Technology, Eindhoven, The Netherlands
| | | | - Leon J Montenij
- Anesthesiology Department, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Massimo Mischi
- Signal Processing Department, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Simona Turco
- Signal Processing Department, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Anesthesiology Department, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
- Signal Processing Department, Eindhoven University of Technology, Eindhoven, The Netherlands
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Paranjape VV, Garcia-Pereira FL, Menciotti G, Saksena S, Henao-Guerrero N, Ricco-Pereira CH. Evaluation of Electrical Cardiometry for Measuring Cardiac Output and Derived Hemodynamic Variables in Comparison with Lithium Dilution in Anesthetized Dogs. Animals (Basel) 2023; 13:2362. [PMID: 37508139 PMCID: PMC10376001 DOI: 10.3390/ani13142362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Numerous cardiac output (CO) technologies were developed to replace the 'gold standard' pulmonary artery thermodilution due to its invasiveness and the risks associated with it. Minimally invasive lithium dilution (LiD) shows excellent agreement with thermodilution and can be used as a reference standard in animals. This study evaluated CO via noninvasive electrical cardiometry (EC) and acquired hemodynamic variables against CO measured using LiD in six healthy, anesthetized dogs administered different treatments (dobutamine, esmolol, phenylephrine, and high-dose isoflurane) impacting CO values. These treatments were chosen to cause drastic variations in CO, so that fair comparisons between EC and LiD across a wide range of CO values (low, intermediate, and high) could be made. Statistical analysis included linear regression, Bland-Altman plots, Lin's concordance correlation coefficient (ρc), and polar plots. Values of p < 0.05 represented significance. Good agreement was observed between EC and LiD, but consistent underestimation was noted when the CO values were high. The good trending ability, ρc of 0.88, and low percentage error of ±31% signified EC's favorable performance. Other EC-acquired variables successfully tracked changes in CO measured using LiD. EC may be a pivotal hemodynamic tool for continuously monitoring circulatory changes, as well as guiding and treating cardiovascular anesthetic complications in clinical settings.
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Affiliation(s)
- Vaidehi V Paranjape
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA 24061, USA
| | | | - Giulio Menciotti
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA 24061, USA
| | - Siddharth Saksena
- Department of Civil and Environmental Engineering, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
| | - Natalia Henao-Guerrero
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA 24061, USA
| | - Carolina H Ricco-Pereira
- Department of Veterinary Clinical Sciences, The Ohio State University-College of Veterinary Medicine, Columbus, OH 43210, USA
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15
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Hrdy O, Duba M, Dolezelova A, Roskova I, Hlavaty M, Traj R, Bönisch V, Smrcka M, Gal R. 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. Perioper Med (Lond) 2023; 12:32. [PMID: 37408018 DOI: 10.1186/s13741-023-00321-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/28/2023] [Indexed: 07/07/2023] Open
Abstract
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.
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Affiliation(s)
- Ondrej Hrdy
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milos Duba
- Department of Neurosurgery, University Hospital Brno, Brno, Czech Republic.
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Andrea Dolezelova
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivana Roskova
- Department of Neurosurgery, University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Hlavaty
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Rudolf Traj
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vit Bönisch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Smrcka
- Department of Neurosurgery, University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Gal
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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16
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Wang Y, Zhang Y, Zheng J, Dong X, Wu C, Guo Z, Wu X. Intraoperative pleth variability index-based fluid management therapy and gastrointestinal surgical outcomes in elderly patients: a randomised controlled trial. Perioper Med (Lond) 2023; 12:16. [PMID: 37173788 PMCID: PMC10182655 DOI: 10.1186/s13741-023-00308-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/08/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Intraoperative goal-directed fluid therapy (GDFT) has been reported to reduce postoperative complications of patients undergoing major abdominal surgery. The clinical benefits of pleth variability index (PVI)-directed fluid management for gastrointestinal (GI) surgical patients remain unclear. Therefore, this study aimed to evaluate the impact of PVI-directed GDFT on GI surgical outcomes in elderly patients. METHODS This randomised controlled trial was conducted in two university teaching hospitals from November 2017 to December 2020. In total, 220 older adults undergoing GI surgery were randomised to the GDFT or conventional fluid therapy (CFT) group (n = 110 each). The primary outcome was a composite of complications within 30 postoperative days. The secondary outcomes were cardiopulmonary complications, time to first flatus, postoperative nausea and vomiting, and postoperative length of stay. RESULTS The total volumes of fluid administered were less in the GDFT group than in the CFT group (2.075 L versus [vs.] 2.5 L, P = 0.008). In intention-to-treat analysis, there was no difference in overall complications between the CFT group (41.3%) and GDFT group (43.0%) (odds ratio [OR] = 0.935; 95% confidence interval [CI], 0.541-1.615; P = 0.809). The proportion of cardiopulmonary complications was higher in the CFT group than in the GDFT group (19.2% vs. 8.4%; OR = 2.593, 95% CI, 1.120-5.999; P = 0.022). No other differences were identified between the two groups. CONCLUSIONS Among elderly patients undergoing GI surgery, intraoperative GDFT based on the simple and non-invasive PVI did not reduce the occurrence of composite postoperative complications but was associated with a lower cardiopulmonary complication rate than usual fluid management. TRIAL REGISTRATION This trial was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-17012220) on 1 August 2017.
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Affiliation(s)
- Yu Wang
- Department of Anaesthesiology, Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Yue Zhang
- Clinical Research Institute, Shenzhen-Peking University, The Hong Kong University of Science & Technology Medical Center, Shenzhen, China
| | - Jin Zheng
- Department of Anaesthesiology, Yuebei People's Hospital, Shaoguan, China
| | - Xue Dong
- Department of Anaesthesiology, Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Caineng Wu
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhijia Guo
- Department of Anaesthesiology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xinhai Wu
- Department of Anaesthesiology, Peking University Shenzhen Hospital, Shenzhen, 518036, China.
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17
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Trauzeddel RF, Leitner M, Dehé L, Nordine M, Piper SK, Habicher M, Sander M, Perka C, Treskatsch S. Goal-directed fluid therapy using uncalibrated pulse contour analysis and balanced crystalloid solutions during hip revision arthroplasty: a quality implementation project. J Orthop Surg Res 2023; 18:281. [PMID: 37024966 PMCID: PMC10078091 DOI: 10.1186/s13018-023-03738-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND To implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study. METHODS Adult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction. RESULTS Sixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54-74 ml; colloids: 67.5 (60-75.25 ml) and total volume infused (crystalloids: 2575 (2000-4210) ml; colloids: 2435 (1760-3480) ml; and controls: 2210 (1658-3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3-55.2%) for crystalloids and 49.2% (95%CI 40.4-58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1-74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6-42.9); colloids: 43% (95%CI 34.4-52.0); and controls: 62% (95%CI 52.6-69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay. CONCLUSIONS Perioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01753050.
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Affiliation(s)
- R F Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Leitner
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - L Dehé
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - M Nordine
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - S K Piper
- Institute of Medical Informatics, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - M Habicher
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - M Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte and Virchow-Klinikum, Charitéplatz 1, 10117, Berlin, Germany
| | - S Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Khanna AK, Nosow L, Sands L, Saha AK, Agashe H, Harris L, Martin RS, Marchant B. Agreement between cardiac output estimation by multi-beat analysis of arterial blood pressure waveforms and continuous thermodilution in post cardiac surgery intensive care unit patients. J Clin Monit Comput 2023; 37:559-565. [PMID: 36269451 PMCID: PMC10068656 DOI: 10.1007/s10877-022-00924-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
Abstract
We sought to assess agreement of cardiac output estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CTD) and a novel pulse wave analysis (PWA) method that performs an analysis of multiple beats of the arterial blood pressure waveform (CO-MBA) in post-operative cardiac surgery patients. PAC obtained CO-CTD measurements were compared with CO-MBA measurements from the Argos monitor (Retia Medical; Valhalla, NY, USA), in prospectively enrolled adult cardiac surgical intensive care unit patients. Agreement was assessed via Bland-Altman analysis. Subgroup analysis was performed on data segments identified as arrhythmia, or with low CO (less than 5 L/min). 927 hours of monitoring data from 79 patients was analyzed, of which 26 had arrhythmia. Mean CO-CTD was 5.29 ± 1.14 L/min (bias ± precision), whereas mean CO-MBA was 5.36 ± 1.33 L/min, (4.95 ± 0.80 L/min and 5.04 ± 1.07 L/min in the arrhythmia subgroup). Mean of differences was 0.04 ± 1.04 L/min with an error of 38.2%. In the arrhythmia subgroup, mean of differences was 0.14 ± 0.90 L/min with an error of 35.4%. In the low CO subgroup, mean of differences was 0.26 ± 0.89 L/min with an error of 40.4%. In adult patients after cardiac surgery, including those with low cardiac output and arrhythmia CO-MBA is not interchangeable with the continuous thermodilution method via a PAC, when using a 30% error threshold.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Lillian Nosow
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lauren Sands
- University of Maryland School of Medicine, Baltimore, USA
| | - Amit K Saha
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | | | - Lynnette Harris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - R Shayn Martin
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Bryan Marchant
- Section on Critical Care Medicine, Section on Cardiac Anesthesiology, Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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19
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Saugel B, Thomsen KK, Maheshwari K. Goal-directed haemodynamic therapy: an imprecise umbrella term to avoid. Br J Anaesth 2023; 130:390-393. [PMID: 36732140 DOI: 10.1016/j.bja.2022.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/30/2022] [Accepted: 12/31/2022] [Indexed: 02/04/2023] Open
Abstract
'Goal-directed haemodynamic therapy' describes various haemodynamic treatment strategies that have in common that interventions are titrated to achieve predefined haemodynamic targets. However, the treatment strategies differ substantially regarding the underlying haemodynamic target variables and target values, and thus presumably have different effects on outcome. It is an over-simplifying approach to lump complex and substantially differing haemodynamic treatment strategies together under the term 'goal-directed haemodynamic therapy', an imprecise umbrella term that we should thus stop using.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamal Maheshwari
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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20
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Fischer A, Menger J, Mouhieddine M, Seidel M, Edlinger-Stanger M, Bevilacqua M, Brugger J, Hiesmayr M, Dworschak M. Stroke Volume and Arterial Pressure Fluid Responsiveness in Patients With Elevated Stroke Volume Variation Undergoing Major Vascular Surgery: A Prospective Intervention Study. J Cardiothorac Vasc Anesth 2023; 37:407-414. [PMID: 36529634 DOI: 10.1053/j.jvca.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/05/2022] [Accepted: 11/21/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The identification of potential hemodynamic indicators to increase the predictive power of stroke-volume variation (SVV) for mean arterial pressure (MAP) and stroke volume (SV) fluid responsiveness. DESIGN A prospective intervention study. SETTING At a single-center university hospital. PARTICIPANTS Nineteen patients during major vascular surgery with 125 fluid interventions. INTERVENTIONS When SVV ≥13% occurred for >30 seconds, 250 mL of Ringer's lactate were given within 2 minutes. MEASUREMENTS AND MAIN RESULTS Hemodynamic variables, such as pulse-pressure variation (PPV) and dynamic arterial elastance (Edyn), were measured by pulse power-wave analysis. The outcomes were MAP and SV responsiveness, defined as an increase of at least 10% of MAP and SV within 5 minutes of the fluid intervention. Of the fluid interventions, 48% were MAP-responsive, and 66% were SV-responsive. The addition of PPV and Edyn cut-off values to the SVV cut-off decreased sensitivity from 1-to-0.66 to-0.82, and concomitantly increased specificity from 0-to- 0.65-to-0.93 for the prediction of MAP and SV responsiveness in the authors' study setting. The areas under the receiver operating characteristic curves of PPV and Edyn for the prediction of MAP responsiveness were 0.79 and 0.75, respectively. The areas under the receiver operating characteristic curves for PPV and Edyn to predict SV responsiveness were 0.85 and 0.77, respectively. CONCLUSIONS The PPV and Edyn showed good accuracy for the prediction of MAP and SV responsiveness in patients with elevated SVV during vascular surgery. Either PPV or Edyn may be used in conjunction with SVV to better predict MAP and SV fluid responsiveness in patients undergoing vascular surgery.
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Affiliation(s)
- Arabella Fischer
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria
| | - Johannes Menger
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria; Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Mohamed Mouhieddine
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria
| | - Mathias Seidel
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria
| | - Maximilian Edlinger-Stanger
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria
| | - Michele Bevilacqua
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria
| | - Jonas Brugger
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Michael Hiesmayr
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Martin Dworschak
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria.
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21
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Ronen O, Robbins KT, Shaha AR, Kowalski LP, Mäkitie AA, Florek E, Ferlito A. Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity. Oncol Ther 2023; 11:1-13. [PMID: 36565427 PMCID: PMC9935772 DOI: 10.1007/s40487-022-00217-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/01/2022] [Indexed: 12/25/2022] Open
Abstract
All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.
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Affiliation(s)
- Ohad Ronen
- Head and Neck Surgery Unit, Department of Otolaryngology-Head and Neck Surgery, Affiliated With Azrieli Faculty of Medicine, Galilee Medical Center, Bar-Ilan University, POB 21, Nahariya, Safed, 2210001, Israel.
| | - K Thomas Robbins
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Ashok R Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Luiz P Kowalski
- Department of Otorhinolaryngology-Head and Neck Surgery, A.C. Camargo Cancer Center, São Paulo, Brazil
- Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ewa Florek
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, Poznan, Poland
| | - Alfio Ferlito
- Coordinator of International Head and Neck Scientific Group, Padua, Italy
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22
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Fukui K, Wirkus JM, Hartmann EK, Schmidtmann I, Pestel GJ, Griemert EV. Non-invasive assessment of Pulse Wave Transit Time (PWTT) is a poor predictor for intraoperative fluid responsiveness: a prospective observational trial (best-PWTT study). BMC Anesthesiol 2023; 23:60. [PMID: 36849887 PMCID: PMC9969649 DOI: 10.1186/s12871-023-02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Aim of this study is to test the predictive value of Pulse Wave Transit Time (PWTT) for fluid responsiveness in comparison to the established fluid responsiveness parameters pulse pressure (ΔPP) and corrected flow time (FTc) during major abdominal surgery. METHODS Forty patients undergoing major abdominal surgery were enrolled with continuous monitoring of PWTT (LifeScope® Modell J BSM-9101 Nihon Kohden Europe GmbH, Rosbach, Germany) and stroke volume (Esophageal Doppler Monitoring CardioQ-ODM®, Deltex Medical Ltd, Chichester, UK). In case of hypovolemia (difference in pulse pressure [∆PP] ≥ 9%, corrected flow time [FTc] ≤ 350 ms) a fluid bolus of 7 ml/kg ideal body weight was administered. Receiver operating characteristics (ROC) curves and corresponding areas under the curve (AUCs) were used to compare different methods of determining PWTT. A Wilcoxon test was used to discriminate fluid responders (increase in stroke volume of ≥ 10%) from non-responders. The predictive value of PWTT for fluid responsiveness was compared by testing for differences between ROC curves of PWTT, ΔPP and FTc using the methods by DeLong. RESULTS AUCs (area under the ROC-curve) to predict fluid responsiveness for PWTT-parameters were 0.61 (raw c finger Q), 0.61 (raw c finger R), 0.57 (raw c ear Q), 0.53 (raw c ear R), 0.54 (raw non-c finger Q), 0.52 (raw non-c finger R), 0.50 (raw non-c ear Q), 0.55 (raw non-c ear R), 0.63 (∆ c finger Q), 0.61 (∆ c finger R), 0.64 (∆ c ear Q), 0.66 (∆ c ear R), 0.59 (∆ non-c finger Q), 0.57 (∆ non-c finger R), 0.57 (∆ non-c ear Q), 0.61 (∆ non-c ear R) [raw measurements vs. ∆ = respiratory variation; c = corrected measurements according to Bazett's formula vs. non-c = uncorrected measurements; Q vs. R = start of PWTT-measurements with Q- or R-wave in ECG; finger vs. ear = pulse oximetry probe location]. Hence, the highest AUC to predict fluid responsiveness by PWTT was achieved by calculating its respiratory variation (∆PWTT), with a pulse oximeter attached to the earlobe, using the R-wave in ECG, and correction by Bazett's formula (AUC best-PWTT 0.66, 95% CI 0.54-0.79). ∆PWTT was sufficient to discriminate fluid responders from non-responders (p = 0.029). No difference in predicting fluid responsiveness was found between best-PWTT and ∆PP (AUC 0.65, 95% CI 0.51-0.79; p = 0.88), or best-PWTT and FTc (AUC 0.62, 95% CI 0.49-0.75; p = 0.68). CONCLUSION ΔPWTT shows poor ability to predict fluid responsiveness intraoperatively. Moreover, established alternatives ΔPP and FTc did not perform better. TRIAL REGISTRATION Prior to enrolement on clinicaltrials.gov (NC T03280953; date of registration 13/09/2017).
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Affiliation(s)
- Kimiko Fukui
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Johannes M Wirkus
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Erik K Hartmann
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics Medical (IMBEI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Gunther J Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany.
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23
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Lanning KM, Ylikauma LA, Erkinaro TM, Ohtonen PP, Vakkala MA, Kaakinen TI. Changes in transcranial near-infrared spectroscopy values reflect changes in cardiac index during cardiac surgery. Acta Anaesthesiol Scand 2023; 67:599-605. [PMID: 36740457 DOI: 10.1111/aas.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/27/2022] [Accepted: 01/26/2023] [Indexed: 02/07/2023]
Abstract
To determine whether changes in transcranial near-infrared spectroscopy (NIRS) values reflect changes in cardiac index (CI) in adult cardiac surgical patients. Single-center prospective post hoc analysis. University hospital. One hundred and twenty-four adult patients undergoing cardiac surgery. In each patient, several CI measurements were taken, and NIRS values were collected simultaneously. We used a hierarchical linear regression model to assess the association between NIRS values and CI. We calculated a crude model with NIRS as the only factor included, and an adjusted model, where mean arterial pressure, end-tidal CO2 , and oxygen saturation were used as confounding factors. A total of 1301 pairs of NIRS and CI values were collected. The analysis of separate NIRS and CI pairs revealed a poor association, which was not statistically significant when adjusted with the chosen confounders. However, when the changes in NIRS from baseline or from the previous measurement were compared to those of CI, a clinically and statistically significant association between NIRS and CI was observed also in the adjusted model. Compared to the baseline and to the previous measurement, respectively, the regression coefficients with 95% confidence intervals were 0.048 (0.041-0.056) and 0.064 (0.055-0.073) in off-pump coronary artery bypass patients and 0.022 (0.016-0.029) and 0.026 (0.020-0.033) in patients who underwent cardiopulmonary bypass. In an unselected cardiac surgical population, the changes in NIRS values reflect those in CI, especially in off-pump coronary artery bypass patients. In this single-center post hoc analysis of data from a prospectively collected database of cardiac surgery patients, paired measurements of cardiac output and NIRS revealed that while there was a no correlation between individual paired measurements, a small correlation was found in changes in the two measurements from baseline values. This highlights a potential to utilize changes in NIRS from baseline to suggest changes in cardiac output in cardiac surgical populations.
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Affiliation(s)
- Katriina M Lanning
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Laura A Ylikauma
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tiina M Erkinaro
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Pasi P Ohtonen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland.,Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Merja A Vakkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Timo I Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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24
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Fumagalli Romario U, de Pascale S, Colombo S, Attanasio A, Sabbatini A, Sandrin F. Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage. Updates Surg 2023; 75:343-355. [PMID: 35851675 DOI: 10.1007/s13304-022-01332-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/06/2022] [Indexed: 01/24/2023]
Abstract
Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.
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25
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Ylikauma LA, Tuovila MJ, Ohtonen PP, Erkinaro TM, Vakkala MA, Takala HT, Liisanantti JH, Kaakinen TI. Reliability of bioreactance and pulse power analysis in measuring cardiac index during cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). BMC Anesthesiol 2023; 23:38. [PMID: 36721097 PMCID: PMC9887811 DOI: 10.1186/s12871-023-01988-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/16/2023] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Various malignancies with peritoneal carcinomatosis are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). The hemodynamic instability resulting from fluid balance alterations during the procedure necessitates reliable hemodynamic monitoring. The aim of the study was to compare the accuracy, precision and trending ability of two less invasive hemodynamic monitors, bioreactance-based Starling SV and pulse power device LiDCOrapid with bolus thermodilution technique with pulmonary artery catheter in the setting of cytoreductive surgery with HIPEC. METHODS Thirty-one patients scheduled for cytoreductive surgery were recruited. Twenty-three of them proceeded to HIPEC and were included to the study. Altogether 439 and 430 intraoperative bolus thermodilution injections were compared to simultaneous cardiac index readings obtained with Starling SV and LiDCOrapid, respectively. Bland-Altman method, four-quadrant plots and error grids were used to assess the agreement of the devices. RESULTS Comparing Starling SV with bolus thermodilution, the bias was acceptable (0.13 l min- 1 m- 2, 95% CI 0.05 to 0.20), but the limits of agreement were wide (- 1.55 to 1.71 l min- 1 m- 2) and the percentage error was high (60.0%). Comparing LiDCOrapid with bolus thermodilution, the bias was acceptable (- 0.26 l min- 1 m- 2, 95% CI - 0.34 to - 0.18), but the limits of agreement were wide (- 1.99 to 1.39 l min- 1 m- 2) and the percentage error was high (57.1%). Trending ability was inadequate with both devices. CONCLUSION Starling SV and LiDCOrapid were not interchangeable with bolus thermodilution technique limiting their usefulness in the setting of cytoreductive surgery with HIPEC.
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Affiliation(s)
- Laura Anneli Ylikauma
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Mari Johanna Tuovila
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Pasi Petteri Ohtonen
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland ,grid.412326.00000 0004 4685 4917Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Tiina Maria Erkinaro
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Merja Annika Vakkala
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Heikki Timo Takala
- grid.412326.00000 0004 4685 4917Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Janne Henrik Liisanantti
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Timo Ilari Kaakinen
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
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26
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Bhavya G, Gupta A, Nagesh KS, Murthy PR, Nagaraja PS, Ragavendran S, Mishra SK, Veera G. Functional Evaluation of Microcirculation in Response to Fluid Resuscitation in Hypovolemic Adult Post-cardiac Surgical Patients. JOURNAL OF CARDIAC CRITICAL CARE TSS 2023. [DOI: 10.25259/mm_jccc_308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objectives:
Microcirculation is bound to be altered during cardiac surgery due to multiple factors, mainly the intense systemic inflammatory response syndrome which peaks in the first 24-h postoperatively. Decreased microvascular flow associated with increased postoperative morbidity has been reported. The literature suggests a potential independence of macrocirculation and microcirculation during fluid loading. The present study was conducted to assess thenar muscle tissue oxygen saturation (StO2) changes during vascular occlusion test (VOT) in response to hypovolemia and to assess the dynamic responses of the StO2 variables post-volume expansion (VE).
Material and Methods:
Thirty-five adult post-cardiac surgical patients, with stroke volume (SV) variation >12% were included in the study. Fifty-two fluid challenges were studied. Functional evaluation of microcirculation using VOT and near infrared spectroscopy (NIRS) variables along with monitoring of macrocirculatory indices was performed before and after VE. Statistical analysis was done using Student t-test.
Results:
Post-VE, 34 were responders with increase in SV ≥15% and 18 were non-responders (SV <15%). Rate of resaturation was significantly faster in responders compared to non-responders after VE (P = 0.0293 vs. P = 0.1480). However, macrocirculatory indices including cardiac output, SV, and delivery of oxygen showed significant improvement in both responders and non-responders.
Conclusion:
Preload dependence is associated with significant change in the StO2 recovery slope measured at the thenar eminence in volume responders. Functional evaluation of microcirculation using VOT and StO2 can be a useful complimentary tool along with the macrocirculatory indices for optimal fluid rescuscitaion in adult post-cardiac surgical patients.
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Affiliation(s)
- G. Bhavya
- Department of Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India,
| | - Apoorva Gupta
- Department of Anesthesiology, The Oxford Medical College Hospital and Research Centre, Bengaluru, Karnataka, India,
| | - K. S. Nagesh
- Department of Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India,
| | - P. Raghavendra Murthy
- Department of Cardiovascular and Thoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India,
| | - P. S. Nagaraja
- Department of Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India,
| | - S. Ragavendran
- Department of Cardiac Anesthesia, Cleveland Clinic, Abu Dhabi, United Arab Emirates,
| | - Satish Kumar Mishra
- Department of Anesthesiology, Command Hospital Airforce, Bengaluru, Karnataka, India,
| | - Gowthami Veera
- Department of Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India,
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27
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Chen YW, Xu LQ, Yi B. Early recognition of risk of critical adverse events based on deep neural decision gradient boosting. Front Public Health 2023; 10:1065707. [PMID: 36777782 PMCID: PMC9909024 DOI: 10.3389/fpubh.2022.1065707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023] Open
Abstract
Introduction Perioperative critical events will affect the quality of medical services and threaten the safety of patients. Using scientific methods to evaluate the perioperative risk of critical illness is of great significance for improving the quality of medical services and ensuring the safety of patients. Method At present, the traditional scoring system is mainly used to predict the score of critical illness, which is mainly dependent on the judgment of doctors. The result is affected by doctors' knowledge and experience, and the accuracy is difficult to guarantee and has a serious lag. Besides, the statistical prediction method based on pure data type do not make use of the patient's diagnostic text information and cannot identify comprehensive risk factor. Therefore, this paper combines the text features extracted by deep neural network with the pure numerical type features extracted by XGBOOST to propose a deep neural decision gradient boosting model. Supervised learning was used to train the risk prediction model to analyze the occurrence of critical illness during the perioperative period for early warning. Results We evaluated the proposed methods based on the real data of critical illness patients in one hospital from 2014 to 2018. The results showed that the critical disease risk prediction model based on multiple modes had faster convergence rate and better performance than the risk prediction model based on text data and pure data type. Discussion Based on the machine learning method and multi-modal data of patients, this paper built a prediction model for critical adverse events in patients, so that the risk of critical events can be predicted for any patient directly based on the preoperative and intraoperative characteristic data. At present, this work only classifies and predicts the occurrence of critical illness during or after operation based on the preoperative examination data of patients, but does not discuss the specific time when the patient was critical illness, which is also the direction of our future work.
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Affiliation(s)
- Yu-wen Chen
- Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Lin-quan Xu
- Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Science, Chongqing, China
| | - Bin Yi
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China,*Correspondence: Bin Yi ✉
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Le Guen M, Le Gall-Salaun A, Josserand J, Gaudin de Vilaine A, Viquesnel S, Muller D, Rozec B, Billet KB, Cinotti R. Goal-Directed Fluid Therapy and major postoperative complications in elective craniotomy. A retrospective analysis of a before-after multicentric study. BMC Anesthesiol 2023; 23:11. [PMID: 36624375 PMCID: PMC9827012 DOI: 10.1186/s12871-022-01962-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Goal-Directed Fluid Therapy (GDFT) is recommended to decrease major postoperative complications. However, data are lacking in intra-cranial neurosurgery. METHODS We evaluated the efficacy of a GDFT protocol in a before/after multi-centre study in patients undergoing elective intra-cranial surgery for brain tumour. Data were collected during 6 months in each period (before/after). GDFT was performed in high-risk patients: ASA score III/IV and/or preoperative Glasgow Coma Score (GCS) < 15 and/or history of brain tumour surgery and/or tumour greater size ≥ 35 mm and/or mid-line shift ≥ 3 mm and/or significant haemorrhagic risk. Major postoperative complication was a composite endpoint: re-intubation after surgery, a new onset of GCS < 15 after surgery, focal motor deficit, agitation, seizures, intra-cranial haemorrhage, stroke, intra-cranial hypertension, hospital-acquired related pneumonia, surgical site infection, cardiac arrythmia, invasive mechanical ventilation ≥ 48 h and in-hospital mortality. RESULTS From July 2018 to January 2021, 344 patients were included in 3 centers: 171 in the before and 173 in the after (GDFT) period. Thirty-six (21.1%) patients displayed a major postoperative complication in the Before period, and 50 (28.9%) in the After period (p = 0.1). In the propensity score analysis, we matched 48 patients in each period: 9 (18.8%) patients in the After period and 14 (29.2%) patients in the Before period displayed a major perioperative complication (p = 0.2). Sixty-two (35.8%) patients received GDFT in the After period, with great heterogeneity among centers (p < 0.05). CONCLUSIONS In our before-after study, GDFT was not associated with a decrease in postoperative major complications in elective intra-cranial neurosurgery.
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Affiliation(s)
- Morgan Le Guen
- grid.414106.60000 0000 8642 9959Department of Anesthesia, Hôpital Foch, 40 Rue Worth, 92150 Suresne, France
| | - Amandine Le Gall-Salaun
- grid.414271.5Department of Anaesthesia and Critical Care, CHU Rennes, Hôpital Pontchaillou, 35000 Rennes, France
| | - Julien Josserand
- grid.414106.60000 0000 8642 9959Department of Anesthesia, Hôpital Foch, 40 Rue Worth, 92150 Suresne, France
| | - Augustin Gaudin de Vilaine
- Department of Anaesthesia, Hospital of Saint-Nazaire, 11 Boulevard George Charpak, 44600 Saint-Nazaire, France
| | - Simon Viquesnel
- grid.414271.5Department of Anaesthesia and Critical Care, CHU Rennes, Hôpital Pontchaillou, 35000 Rennes, France
| | - Damien Muller
- grid.277151.70000 0004 0472 0371Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôpital Laennec, 44000 Nantes, France
| | - Bertrand Rozec
- grid.277151.70000 0004 0472 0371Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôpital Laennec, 44000 Nantes, France ,grid.4817.a0000 0001 2189 0784University of Nantes, CNRS INSERM, Institut du Thorax, 44000 Nantes, France
| | - Kévin Buffenoir Billet
- grid.277151.70000 0004 0472 0371Department of Neuro-Traumatology, CHU Nantes, Nantes Université, Hôtel Dieu, 44000 Nantes, France
| | - Raphaël Cinotti
- grid.277151.70000 0004 0472 0371Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000 Nantes, France ,grid.4817.a0000 0001 2189 0784UMR 1246 SPHERE “MethodS in Patients-Centered Outcomes and HEalth Research”, University of Nantes, University of Tours, INSERM, IRS2 22 Boulevard Benoni Goulin, 44200 Nantes, France
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Peltoniemi P, Pere P, Mustonen H, Seppänen H. Optimal Perioperative Fluid Therapy Associates with Fewer Complications After Pancreaticoduodenectomy. J Gastrointest Surg 2023; 27:67-77. [PMID: 36131201 PMCID: PMC9876870 DOI: 10.1007/s11605-022-05453-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal fluid management in pancreaticoduodenectomy patients remains contested. We aimed to examine the association between perioperative fluid administration and postoperative complications. METHODS We studied 168 pancreaticoduodenectomy patients operated in 2015 (n = 93) or 2017 (n = 75) at Helsinki University Hospital. In 2015, patients received intraoperative fluids following a goal-directed approach and, in 2017, according to anesthesiologist's clinical practice (conventional fluid management). We analyzed the differences in perioperative fluid administration between the groups, specifically examining the occurrence of severe complications (Clavien-Dindo ≥ III), pancreatic fistulas, cardiovascular complications, and the length of hospital stay. RESULTS The goal-directed group received more intraoperative fluids than the conventional fluid management group (12.0 ml/kg/h vs. 8.3 ml/kg/h, p < 0.001). Urine output (770 ml vs. 575 ml, p = 0.004) and intraoperative fluid balance (9.4 ml/kg/h vs. 6.3 ml/kg/h, p < 0.001) were higher in the goal-directed group than in the conventional fluid management group. Severe surgical complications (19.4% vs. 38.7%, p = 0.009) as well as clinically relevant pancreatic fistulas (1.1% vs. 10.7%, p = 0.011) occurred more frequently in patients receiving conventional fluid management. Moreover, the conventional fluid management group experienced longer hospital stays (9.0 vs. 11.5 days, p = 0.02). Lower intraoperative fluid volume accompanying conventional fluid management was associated with a higher risk of severe postoperative complications compared with higher volume in the goal-directed group (odds ratio 2.58 (95% confidence interval 1.04-6.42), p = 0.041). CONCLUSIONS The goal-directed group experienced severe complications less frequently. Our findings indicate that optimizing the intraoperative fluid administration benefits patients, while adopting a too-restrictive approach represents an inferior choice.
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Affiliation(s)
- Piia Peltoniemi
- grid.7737.40000 0004 0410 2071Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pertti Pere
- grid.7737.40000 0004 0410 2071Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Mustonen
- grid.7737.40000 0004 0410 2071Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Seppänen
- grid.7737.40000 0004 0410 2071Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 244] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Zhang Y, Jin L, Liu H, Meng X, Ji F. Ephedrine vs. phenylephrine effect on sublingual microcirculation in elderly patients undergoing laparoscopic rectal cancer surgery. Front Med (Lausanne) 2022; 9:969654. [PMID: 36275828 PMCID: PMC9581143 DOI: 10.3389/fmed.2022.969654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The effects of anesthesia administration on sublingual microcirculation are unknown. It is unclear how sublingual microcirculation responds to ephedrine or phenylephrine administration. We hypothesized that microvascular perfusion is impaired under anesthesia. Materials and methods We randomly divided 100 elderly patients undergoing laparoscopic rectal cancer surgery into phenylephrine and ephedrine groups in a 1:1 ratio. Ephedrine or phenylephrine was administered when MAP was < 80% for > 1 min. The heart rate (HR) and mean arterial pressure (MAP) were recorded every 5 min. Lactic acid was tested both pre- and postoperatively. The sublingual microcirculation characteristics of the microvascular flow index, the percentage of perfused vessels, the density of perfused vessels, and the heterogeneity index were monitored using a sidestream dark field imaging device. Results Their MAP showed an evident decrease of > 20%. At this point, the HR, microvascular flow index, perfused vessel density, and proportion of perfused vessels decreased similarly in ephedrine and phenylephrine groups. Conversely, the heterogeneity index increased in both groups. After phenylephrine and ephedrine administration, ephedrine treatment significantly increased the proportion of perfused vessels, microvascular flow index, and HR compared with phenylephrine treatment. Conclusion General anesthesia was associated with reduced MAP, HR, and sublingual microcirculation in elderly patients undergoing laparoscopic rectal cancer surgery. The results of ephedrine treatment were better than those of phenylephrine treatment in terms of HR, increased the proportion of perfused vessels, and microvascular flow index of sublingual microcirculation. Clinical trial registration [www.ClinicalTrials.gov], identifier [ChiCTR-2000035959].
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Dmytriiev D, Nazarchuk O, Melnychenko M, Levchenko B. Optimization of the target strategy of perioperative infusion therapy based on monitoring data of central hemodynamics in order to prevent complications. Front Med (Lausanne) 2022; 9:935331. [PMID: 36262276 PMCID: PMC9573976 DOI: 10.3389/fmed.2022.935331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are increasingly used in the perioperative period around the world. The concept of goal-directed fluid therapy (GDT) is a key element of the ERAS protocols. Inadequate perioperative infusion therapy can lead to a number of complications, including the development of an infectious process, namely surgical site infections, pneumonia, urinary tract infections. Optimal infusion therapy is difficult to achieve with standard parameters (e.g., heart rate, blood pressure, central venous pressure), so there are various methods of monitoring central hemodynamics - from invasive, minimally invasive to non-invasive. The latter are increasingly used in clinical practice. The current evidence base shows that perioperative management, specifically the use of GDT guided by real-time, continuous hemodynamic monitoring, helps clinicians maintain a patient's optimal fluid balance. The manuscript presents the analytical data, which describe the benefits and basic principles of perioperative targeted infusion therapy based on central hemodynamic parameters to reduce the risk of complications.
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Affiliation(s)
- Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Oleksandr Nazarchuk
- Department of Microbiology, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Mykola Melnychenko
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Bohdan Levchenko
- Department of Anesthesiology and Intensive Care, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
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Comparison of Goal-Directed Fluid Therapy using LiDCOrapid System with Regular Fluid Therapy in Patients Undergoing Spine Surgery as a Randomised Clinical Trial. Rom J Anaesth Intensive Care 2022; 28:1-9. [PMID: 36846537 PMCID: PMC9949010 DOI: 10.2478/rjaic-2021-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background Goal-directed fluid therapy (GDFT) is a new concept to describe the cardiac output (CO) and stroke volume variation to guide intravenous fluid administration during surgery. LiDCOrapid (LiDCO, Cardiac Sensor System, UK Company Regd 2736561, VAT Regd 672475708) is a minimally invasive monitor that estimates the responsiveness of CO versus fluid infusion. We intend to find whether GDFT using the LiDCOrapid system can decrease the volume of intraoperative fluid therapy and facilitate recovery in patients undergoing posterior fusion spine surgeries in comparison to regular fluid therapy. Methods This study is a randomised clinical trial, and the design was parallel. Inclusion criteria for participants in this study were patients with comorbidities such as diabetes mellitus, hypertension, and ischemic heart disease undergoing spine surgery; exclusion criteria were patients with irregular heart rhythm or severe valvular heart disease. Forty patients with a previous history of medical comorbidities undergoing spine surgery were randomly and evenly assigned to receive either LiDCOrapid guided fluid therapy or regular fluid therapy. The volume of infused fluid was the primary outcome. The amount of bleeding, number of patients who needed packed red blood cell transfusion, base deficit, urine output, days of hospital length of stay and intensive care unit (ICU) admission, and time needed to start eating solids were monitored as secondary outcomes. Results The volume of infused crystalloid and urinary output in the LiDCO group was significantly lower than that of the control group (p = .001). Base deficit at the end of surgery was significantly better in the LiDCO group (p < .001). The duration of hospital length of stay in the LiDCO group was significantly shorter (p = .027), but the duration of ICU admission was not significantly different between the two groups. Conclusion Goal-directed fluid therapy using the LiDCOrapid system reduced the volume of intraoperative fluid therapy.
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Isidoro Duarte T, Amaral M, Pires C, Casimiro J, Germano N. Hemodynamic monitoring for liver transplantation: Agreement between invasive and non-invasive devices? Med Intensiva 2022; 46:527-529. [PMID: 36057442 DOI: 10.1016/j.medine.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/15/2021] [Indexed: 06/15/2023]
Affiliation(s)
- T Isidoro Duarte
- Department of Intensive Care Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal.
| | - M Amaral
- Department of Internal Medicine, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - C Pires
- Department of Intensive Care Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - J Casimiro
- Department of Intensive Care Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - N Germano
- Department of Intensive Care Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
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Hamilton DB, Jooma Z. Haemodynamic monitoring in patients undergoing high-risk surgery: a survey of current practice among anaesthesiologists at the University of the Witwatersrand. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2022. [DOI: 10.36303/sajaa.2022.28.4.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- DB Hamilton
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand,
South Africa
| | - Z Jooma
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand,
South Africa
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Gricourt Y, Prin Derre C, Demattei C, Bertran S, Louart B, Muller L, Simon N, Lefrant JY, Cuvillon P, Jaber S, Roger C. A Pilot Study Assessing a Closed-Loop System for Goal-Directed Fluid Therapy in Abdominal Surgery Patients. J Pers Med 2022; 12:jpm12091409. [PMID: 36143194 PMCID: PMC9505637 DOI: 10.3390/jpm12091409] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This prospective multicentre pilot study of patients scheduled for elective major abdominal surgery aimed to validate the fluid challenge (FC) proposed by the closed-loop (CL) system via anaesthesiologist assessment. Methods: This was a phase II trial consisting of two inclusion stages (SIMON method). Each FC (250 mL saline solution for 10 min) proposed by the CL was systematically validated by the anaesthesiologist who could either confirm or refuse the FC or give FC without the CL system. A ≥ 95% agreement between the CL and the anaesthesiologist was considered acceptable. Results: The study was interrupted after interim analysis of the first 19 patients (10 men, median age = 61 years, median body mass index = 26 kg/m2). The anaesthesiologists accepted 165/205 (80%) of fluid boluses proposed by the CL. Median cardiac index (CI) was 2.9 (interquartile: IQ (2.7; 3.4) L/min/m2) and the median coefficient of variation (CV) for CI was 13% (10; 17). Fifteen out of nineteen patients (79%) had a mean CI > 2.5 L/min/m2 or spent > 85% surgery time with pulse pressure variation < 13%. No adverse events related to the CL were reported. Conclusion: In this study of patients scheduled for elective major abdominal surgery, the agreement between CL and anaesthesiologist for giving fluid challenge was 80%, suggesting that CL cannot replace the physician but could help in decision making.
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Affiliation(s)
- Yann Gricourt
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Camille Prin Derre
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Christophe Demattei
- Laboratoire de Biostatistique, Epidémiologie Clinique, Santé Publique Innovation et Méthodologie (BESPIM), Pôle Pharmacie, Santé Publique, Nîmes University Hospital, 30900 Nîmes, France
| | - Sébastien Bertran
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
- Polyclinique Grand Sud, 350 Avenue Saint-André de Codols, 30000 Nîmes, France
| | - Benjamin Louart
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Laurent Muller
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Natacha Simon
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Jean-Yves Lefrant
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
- Correspondence: ; Tel.: +33-4-66-68-30-50; Fax: +33-4-66-68-38-41
| | - Philippe Cuvillon
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Samir Jaber
- Département d’Anesthésie Réanimation B St Eloi Hospital, 80 Avenue Augustin Fliche, 34295 Montpellier, France
| | - Claire Roger
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
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Liu B, Liu S, Zheng T, Lu D, Chen L, Ma T, Wang Y, Gao G, He S. Neurosurgical enhanced recovery after surgery ERAS for geriatric patients undergoing elective craniotomy: A review. Medicine (Baltimore) 2022; 101:e30043. [PMID: 35984154 PMCID: PMC9388027 DOI: 10.1097/md.0000000000030043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Population aging is an unprecedented, multifactorial, and global process that poses significant challenges to healthcare systems. Enhanced recovery after surgery (ERAS) protocols aim to optimize perioperative care. The first neurosurgical ERAS protocol for elective craniotomy has contributed to a shortened postoperative hospital stay, accelerated functional recovery, improved patient satisfaction, and reduced medical care cost in adult patients aged 18 to 65 years compared with conventional perioperative care. However, ERAS protocols for geriatric patients over 65 years of age undergoing cranial surgery are lacking. In this paper, we propose a novel ERAS protocol for such patients by reviewing and summarizing the key elements of successful ERAS protocols/guidelines and optimal perioperative care for geriatric patients described in the literature, as well as our experience in applying the first neurosurgical ERAS protocol for a quality improvement initiative. This proposal aimed to establish an applicable protocol for geriatric patients undergoing elective craniotomy, with evidence addressing its feasibility, safety, and potential efficacy. This multimodal, multidisciplinary, and evidence-based ERAS protocol includes preoperative, intraoperative, and postoperative assessment and management as well as outcome measures. The implementation of the current protocol may hold promise in reducing perioperative morbidity, enhancing functional recovery, improving postoperative outcomes in geriatric patients scheduled for elective craniotomy, and serving as a stepping stone to promote further research into the advancement of geriatric patient care.
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Affiliation(s)
- Bolin Liu
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Shujuan Liu
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Tao Zheng
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Dan Lu
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Lei Chen
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Tao Ma
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
| | - Yuan Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Guodong Gao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Shiming He
- Department of Neurosurgery, Xi’an International Medical Center, Xi’an, China
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Shiming He, Department of Neurosurgery, Xi’an International Medical Center, No. 777 Xitai Road, Xi’an 710100, China (e-mail: ; )
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Moon JS, Cannesson M. A Century of Technology in Anesthesia & Analgesia. Anesth Analg 2022; 135:S48-S61. [PMID: 35839833 PMCID: PMC9298489 DOI: 10.1213/ane.0000000000006027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Technological innovation has been closely intertwined with the growth of modern anesthesiology as a medical and scientific discipline. Anesthesia & Analgesia, the longest-running physician anesthesiology journal in the world, has documented key technological developments in the specialty over the past 100 years. What began as a focus on the fundamental tools needed for effective anesthetic delivery has evolved over the century into an increasing emphasis on automation, portability, and machine intelligence to improve the quality, safety, and efficiency of patient care.
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Affiliation(s)
- Jane S Moon
- From the Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
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Ward based goal directed fluid therapy (GDFT) in acute pancreatitis (GAP) trial: A feasibility randomised controlled trial. Int J Surg 2022; 104:106737. [PMID: 35835346 DOI: 10.1016/j.ijsu.2022.106737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Goal-directed fluid therapy (GDFT) reduces complications in patients undergoing major general surgery. There are no reports of cardiac output evaluation being used to optimise the fluid administration for patients with acute pancreatitis (AP) in a general surgery ward. METHOD 50 patients with AP were randomised to either ward-based GDFT (n = 25) with intravenous (IV) fluids administered based on stroke volume optimisation protocol or standard care (SC) (n = 25), but with blinded cardiac output evaluation, for 48-h following hospital admission. Primary outcome was feasibility. RESULTS 50 of 116 eligible patients (43.1%) were recruited over 20 months demonstrating feasibility. 36 (72%) completed the 48-h of GDFT; 10 (20%) discharged within 48-h and 4 withdrawals (3 GDFT, 1 SC). Baseline characteristics were similar with only 3 participants having severe disease (6%, 1 GDFT, 2 SC). Similar volumes of IV fluids were administered in both groups (GDFT 5465 (1839) ml, SC 5211 (1745) ml). GDFT group had a lower heart rate, blood pressure and respiratory rate and improved oxygen saturations. GDFT was not associated with any harms. There was no evidence of difference in complications of AP (GDFT 24%, SC 32%) or in the duration of stay in intensive care (GDFT 0 (0), SC 0.7 [(Van DIjk et al., 2017) 33 days). Length of hospital stay was 5 (2.9) days in GDFT and 6.3 (7.6) in SC groups. CONCLUSION Ward-based GDFT is feasible and shows a signal of possible efficacy in AP in this early-stage study. A larger multi-site RCT is required to confirm clinical and cost effectiveness.
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Starke H, von Dossow V, Karsten J. Intraoperative Circulatory Support in Lung Transplantation: Current Trend and Its Evidence. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071005. [PMID: 35888094 PMCID: PMC9322250 DOI: 10.3390/life12071005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.
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Affiliation(s)
- Henning Starke
- Institute of Anaesthesiology, Heart and Diabetes Centre NRW, Bad Oeynhausen, Ruhr University Bochum, 44801 Bochum, Germany;
| | - Vera von Dossow
- Institute of Anaesthesiology, Heart and Diabetes Centre NRW, Bad Oeynhausen, Ruhr University Bochum, 44801 Bochum, Germany;
- Correspondence: ; Tel.: +49-(0)-5731-97-1128; Fax: +49-(0)-5731-97-2196
| | - Jan Karsten
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany;
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Enhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled. Transplant Direct 2022; 8:e1333. [PMID: 35747520 PMCID: PMC9208883 DOI: 10.1097/txd.0000000000001333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/03/2022] [Accepted: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) pathway is a multimodal perioperative care pathway designed to achieve early recovery after surgery. ERAS protocols have not yet been well recognized in kidney transplantation. The aim of this study was to investigate the impact of ERAS pathway on early recovery and short-term clinical outcomes of kidney transplant.
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Palma CD, Mamba M, Geldenhuys J, Fadahun O, Rossaint R, Zacharowski K, Brand M, Díaz-Cambronero Ó, Belda J, Westphal M, Brauer U, Dormann D, Dehnhardt T, Hernandez-Gonzalez M, Schmier S, de Korte D, Plani F, Buhre W. PragmaTic, prospEctive, randomized, controlled, double-blind, mulTi-centre, multinational study on the safety and efficacy of a 6% HydroxYethyl Starch (HES) solution versus an electrolyte solution in trauma patients: study protocol for the TETHYS study. Trials 2022; 23:456. [PMID: 35655234 PMCID: PMC9164328 DOI: 10.1186/s13063-022-06390-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Trauma may be associated with significant to life-threatening blood loss, which in turn may increase the risk of complications and death, particularly in the absence of adequate treatment. Hydroxyethyl starch (HES) solutions are used for volume therapy to treat hypovolemia due to acute blood loss to maintain or re-establish hemodynamic stability with the ultimate goal to avoid organ hypoperfusion and cardiovascular collapse. The current study compares a 6% HES 130 solution (Volulyte 6%) versus an electrolyte solution (Ionolyte) for volume replacement therapy in adult patients with traumatic injuries, as requested by the European Medicines Agency to gain more insights into the safety and efficacy of HES in the setting of trauma care. Methods TETHYS is a pragmatic, prospective, randomized, controlled, double-blind, multicenter, multinational trial performed in two parallel groups. Eligible consenting adults ≥ 18 years, with an estimated blood loss of ≥ 500 ml, and in whom initial surgery is deemed necessary within 24 h after blunt or penetrating trauma, will be randomized to receive intravenous treatment at an individualized dose with either a 6% HES 130, or an electrolyte solution, for a maximum of 24 h or until reaching the maximum daily dose of 30 ml/kg body weight, whatever occurs first. Sample size is estimated as 175 patients per group, 350 patients total (α = 0.025 one-tailed, power 1–β = 0.8). Composite primary endpoint evaluated in an exploratory manner will be 90-day mortality and 90-day renal failure, defined as AKIN stage ≥ 2, RIFLE injury/failure stage, or use of renal replacement therapy (RRT) during the first 3 months. Secondary efficacy and safety endpoints are fluid administration and balance, changes in vital signs and hemodynamic status, changes in laboratory parameters including renal function, coagulation, and inflammation biomarkers, incidence of adverse events during treatment period, hospital, and intensive care unit (ICU) length of stay, fitness for ICU or hospital discharge, and duration of mechanical ventilation and/or RRT. Discussion This pragmatic study will increase the evidence on safety and efficacy of 6% HES 130 for treatment of hypovolemia secondary to acute blood loss in trauma patients. Trial registration Registered in EudraCT, No.: 2016-002176-27 (21 April 2017) and ClinicalTrials.gov, ID: NCT03338218 (09 November 2017).
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Affiliation(s)
| | | | | | | | - Rolf Rossaint
- RWTH University Hospital, Rhineland-Westfalen Technical University, Aachen, Germany
| | - Kai Zacharowski
- Frankfurt University Hospital, Johannes Goethe University, Frankfurt, Germany
| | - Martin Brand
- Steve Biko Academic Hospital, Pretoria, South Africa
| | | | - Javier Belda
- Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | | | - Ute Brauer
- B. Braun Melsungen AG, Melsungen, Germany
| | - Dirk Dormann
- Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany
| | | | | | | | - Dianne de Korte
- Division of Acute and Critical Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Frank Plani
- Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Wolfgang Buhre
- Division of Acute and Critical Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands. .,Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
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Jacob M, Chappell D. It actually does matter what and how much you give! Minerva Anestesiol 2022; 88:323-325. [PMID: 35510445 DOI: 10.23736/s0375-9393.22.16576-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Matthias Jacob
- Department of Anesthesiology and Intensive Care Medicine, Klinikum St. Elisabeth Straubing GmbH, Straubing, Germany
| | - Daniel Chappell
- Department of Anesthesiology and Intensive Care Medicine, Varisano Klinikum Frankfurt Höchst, Frankfurt, Germany -
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Virág M, Rottler M, Gede N, Ocskay K, Leiner T, Tuba M, Ábrahám S, Farkas N, Hegyi P, Molnár Z. Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis. J Pers Med 2022; 12:jpm12050734. [PMID: 35629156 PMCID: PMC9143059 DOI: 10.3390/jpm12050734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: Whether goal-directed fluid therapy (GDFT) provides any outcome benefit as compared to non-goal-directed fluid therapy (N-GDFT) in elective abdominal laparoscopic surgery has not been determined yet. (2) Methods: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, Web of Science, and Scopus. The main outcomes were length of hospital stay (LOHS), time to first flatus and stool, intraoperative fluid and vasopressor requirements, serum lactate levels, and urinary output. Pooled risks ratios (RRs) with 95% confidence intervals (CI) were calculated for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. (3) Results: Eleven studies were included in the quantitative, and fifteen in the qualitative synthesis. LOHS (WMD: −1.18 days, 95% CI: −1.84 to −0.53) and time to first stool (WMD: −9.8 h; CI −12.7 to −7.0) were significantly shorter in the GDFT group. GDFT resulted in significantly less intraoperative fluid administration (WMD: −441 mL, 95% CI: −790 to −92) and lower lactate levels at the end of the operation: WMD: −0.25 mmol L−1; 95% CI: −0.36 to −0.14. (4) Conclusions: GDFT resulted in enhanced recovery of the gastrointestinal function and shorter LOHS as compared to N-GDFT.
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Affiliation(s)
- Marcell Virág
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
- Department of Anesthesiology and Intensive Therapy, Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Máté Rottler
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
- Department of Anesthesiology and Intensive Therapy, Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Noémi Gede
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
| | - Klementina Ocskay
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Tamás Leiner
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
- Anaesthetic Department, Hinchingbrooke Hospital, North West Anglia NHS Foundation Trust, Huntingdon PE29 6NT, UK
| | - Máté Tuba
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
| | - Szabolcs Ábrahám
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
| | - Nelli Farkas
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
| | - Péter Hegyi
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Division for Pancreatic Disorders, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Zsolt Molnár
- Szentágothai Research Centre, Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (M.R.); (N.G.); (K.O.); (T.L.); (M.T.); (S.Á.); (N.F.); (P.H.)
- Doctoral School of Clinical Medicine, University of Szeged, 6720 Szeged, Hungary
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, 1082 Budapest, Hungary
- Correspondence: ; Tel.: +36-30-302-6668
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Froghi F, Gopalan V, Anastasiou Z, Koti R, Gurusamy K, Eastgate C, McNeil M, Filipe H, Pinto M, Singh J, Longworth L, Mallett S, Schofield N, Thorburn D, Martin D, Davidson BR. Effect of post-operative goal-directed fluid therapy (GDFT) on organ function after orthotopic liver transplantation: Secondary outcome analysis of the COLT randomised control trial. Int J Surg 2022; 99:106265. [PMID: 35181556 DOI: 10.1016/j.ijsu.2022.106265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/28/2021] [Accepted: 02/09/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Goal-directed fluid therapy (GDFT) has been shown to reduce the complications following a variety of major surgical procedures, possibly mediated by improved organ perfusion and function. We have shown that it is feasible to randomise patients to GDFT or standard fluid management following liver transplant in the cardiac-output optimisation following liver transplantation (COLT) trial. The current study compares end organ function in patients from the COLT trial who received GDFT in comparison to those receiving standard care (SC) following liver transplant. METHODS Adult patients with liver cirrhosis undergoing liver transplantation were randomised to GDFT or SC for the first 12 h following surgery as detailed in a published trial protocol. GDFT protocol was based on stroke volume (SV) optimisation using 250 ml crystalloid boluses. Total fluid administration and time to extubation were recorded. Hourly SV and cardiac output (CO) readings were recorded from the non-invasive cardiac output monitoring (NICOM) device in both groups. Pulmonary function was assessed by arterial blood gas (ABG) and ventilatory parameters. Lung injury was assessed using PaO2:FiO2 ratios and calculated pulmonary compliance. The KDIGO score was used for determining acute kidney injury. Renal and liver graft function were assessed during the post-operative period and at 3 months and 1-year. RESULTS 60 patients were randomised to GDFT (n = 30) or SC (n = 30). All patients completed the 12 h intervention period. GDFT group received a significantly higher total volume of fluid during the 12 h trial intervention period (GDFT 5317 (2335) vs. SC 3807 (1345) ml, p = 0.003); in particular crystalloids (GDFT 3968 (2073) vs. SC 2510 (1027) ml, p = 0.002). There was no evidence of significant difference between the groups in SV or CO during the assessment periods. Time to extubation, PaO2: FIO2 ratios, pulmonary compliance, ventilatory or blood gas measurements were similar in both groups. There was a significant rise in serum creatinine from baseline (77 μmol/L) compared to first (87 μmol/L, p = 0.039) and second (107 μmol/L, p = 0.001) post-operative days. There was no difference between GDFT and SC in the highest KDIGO scores for the first 7 days post-LT. At 1-year follow-up, there was no difference in need for renal replacement therapy or graft function. CONCLUSIONS In this randomised trial of fluid therapy post liver transplant, GDFT was associated with an increased volume of crystalloids administered but did not alter early post-operative pulmonary or renal function when compared with standard care.
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Affiliation(s)
- Farid Froghi
- UCL Division of Surgery & Interventional Sciences, HPB and Liver Transplantation, London, United Kingdom UCL Joint Research Office, Biostatistics Group, London, United Kingdom Royal Free Hospital, Critical Care Unit, London, United Kingdom PHMR Limited, London, United Kingdom UCL Institute for Liver and Digestive Health, London, United Kingdom UCL Division of Surgery & Interventional Sciences, London, United Kingdom Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
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Jessen MK, Vallentin MF, Holmberg MJ, Bolther M, Hansen FB, Holst JM, Magnussen A, Hansen NS, Johannsen CM, Enevoldsen J, Jensen TH, Roessler LL, Lind PC, Klitholm MP, Eggertsen MA, Caap P, Boye C, Dabrowski KM, Vormfenne L, Høybye M, Henriksen J, Karlsson CM, Balleby IR, Rasmussen MS, Pælestik K, Granfeldt A, Andersen LW. Goal-directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis. Br J Anaesth 2022; 128:416-433. [PMID: 34916049 PMCID: PMC8900265 DOI: 10.1016/j.bja.2021.10.046] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/28/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND During general anaesthesia for noncardiac surgery, there remain knowledge gaps regarding the effect of goal-directed haemodynamic therapy on patient-centred outcomes. METHODS Included clinical trials investigated goal-directed haemodynamic therapy during general anaesthesia in adults undergoing noncardiac surgery and reported at least one patient-centred postoperative outcome. PubMed and Embase were searched for relevant articles on March 8, 2021. Two investigators performed abstract screening, full-text review, data extraction, and bias assessment. The primary outcomes were mortality and hospital length of stay, whereas 15 postoperative complications were included based on availability. From a main pool of comparable trials, meta-analyses were performed on trials with homogenous outcome definitions. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). RESULTS The main pool consisted of 76 trials with intermediate risk of bias for most outcomes. Overall, goal-directed haemodynamic therapy might reduce mortality (odds ratio=0.84; 95% confidence interval [CI], 0.64 to 1.09) and shorten length of stay (mean difference=-0.72 days; 95% CI, -1.10 to -0.35) but with low certainty in the evidence. For both outcomes, larger effects favouring goal-directed haemodynamic therapy were seen in abdominal surgery, very high-risk surgery, and using targets based on preload variation by the respiratory cycle. However, formal tests for subgroup differences were not statistically significant. Goal-directed haemodynamic therapy decreased risk of several postoperative outcomes, but only infectious outcomes and anastomotic leakage reached moderate certainty of evidence. CONCLUSIONS Goal-directed haemodynamic therapy during general anaesthesia might decrease mortality, hospital length of stay, and several postoperative complications. Only infectious postoperative complications and anastomotic leakage reached moderate certainty in the evidence.
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Affiliation(s)
- Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Maria Bolther
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Johanne M Holst
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niklas S Hansen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Thomas H Jensen
- Department of Internal Medicine, University Hospital of North Norway, Narvik, Norway
| | - Lara L Roessler
- Department of Emergency Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peter C Lind
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Maibritt P Klitholm
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mark A Eggertsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Philip Caap
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Caroline Boye
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karol M Dabrowski
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lasse Vormfenne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeppe Henriksen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Carl M Karlsson
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Ida R Balleby
- National Hospital of the Faroe Islands, Torshavn, Faroe Islands, Denmark
| | - Marie S Rasmussen
- Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Kim Pælestik
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lars W Andersen
- Research Center for Emergency Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.
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Buhre W, de Korte-de Boer D, de Abreu MG, Scheeren T, Gruenewald M, Hoeft A, Spahn DR, Zarbock A, Daamen S, Westphal M, Brauer U, Dehnhardt T, Schmier S, Baron JF, De Hert S, Gavranović Ž, Cholley B, Vymazal T, Szczeklik W, Bornemann-Cimenti H, Soro Domingo MB, Grintescu I, Jankovic R, Belda J. Prospective, randomized, controlled, double-blind, multi-center, multinational study on the safety and efficacy of 6% Hydroxyethyl starch (HES) sOlution versus an Electrolyte solutioN In patients undergoing eleCtive abdominal Surgery: study protocol for the PHOENICS study. Trials 2022; 23:168. [PMID: 35193648 PMCID: PMC8862305 DOI: 10.1186/s13063-022-06058-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Hydroxyethyl starch (HES) solutions are used for volume therapy to treat hypovolemia due to acute blood loss and to maintain hemodynamic stability. This study was requested by the European Medicines Agency (EMA) to provide more evidence on the long-term safety and efficacy of HES solutions in the perioperative setting. Methods PHOENICS is a randomized, controlled, double-blind, multi-center, multinational phase IV (IIIb) study with two parallel groups to investigate non-inferiority regarding the safety of a 6% HES 130 solution (Volulyte 6%, Fresenius Kabi, Germany) compared with a crystalloid solution (Ionolyte, Fresenius Kabi, Germany) for infusion in patients with acute blood loss during elective abdominal surgery. A total of 2280 eligible patients (male and female patients willing to participate, with expected blood loss ≥ 500 ml, aged > 40 and ≤ 85 years, and ASA Physical status II–III) are randomly assigned to receive either HES or crystalloid solution for the treatment of hypovolemia due to surgery-induced acute blood loss in hospitals in up to 11 European countries. The dosing of investigational products (IP) is individualized to patients’ volume needs and guided by a volume algorithm. Patients are treated with IP for maximally 24 h or until the maximum daily dose of 30 ml/kg body weight is reached. The primary endpoint is the treatment group mean difference in the change from the pre-operative baseline value in cystatin-C-based estimated glomerular filtration rate (eGFR), to the eGFR value calculated from the highest cystatin-C level measured during post-operative days 1-3. Further safety and efficacy parameters include, e.g., combined mortality/major post-operative complications until day 90, renal function, coagulation, inflammation, hemodynamic variables, hospital length of stay, major post-operative complications, and 28-day, 90-day, and 1-year mortality. Discussion The study will provide important information on the long-term safety and efficacy of HES 130/0.4 when administered according to the approved European product information. The results will be relevant for volume therapy of surgical patients. Trial registration EudraCT 2016-002162-30. ClinicalTrials.govNCT03278548
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Affiliation(s)
- Wolfgang Buhre
- Division of Acute and Critical Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Dianne de Korte-de Boer
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthias Gruenewald
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Andreas Hoeft
- Department of Anesthesiology and Operative Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital of Zürich, Zürich, Switzerland.,Anesthesiology, Intensive Care Medicine and OR Facilities, University and University Hospital of Zürich, Zürich, Switzerland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Sylvia Daamen
- European Society of Anaesthesiology and Intensive Care, Brussels, Belgium
| | | | - Ute Brauer
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | - Tamara Dehnhardt
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | - Sonja Schmier
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | | | - Stefan De Hert
- Department of Anesthesioloy and Perioperative Medicine, Gent University Hospital - Gent University, Ghent, Belgium
| | - Željka Gavranović
- Department of Anesthesiology and Intensive Care, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Bernard Cholley
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Paris, France
| | - Tomas Vymazal
- Department of Anesthesiology and Intensive Medicine, University Hospital Motol, Prague, Czech Republic
| | - Wojciech Szczeklik
- Department of Anaesthesiology and Intensive Therapy, 5th Military Clinical Hosptial, Krakow, Poland
| | - Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Marina Blanca Soro Domingo
- Department of Surgery, Clinic University Hospital, Valencia, Spain.,Department of Anesthesia, Reanimation and Pain Therapy, Clinic University Hospital, Valencia, Spain
| | - Ioana Grintescu
- Clinic of Anaesthesia and Intensive Care Medicine, Clinical Emergency Hospital of Bucharest, Bucharest, Romania.,Department of Anaesthesia and Intensive Care Medicine, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania
| | - Radmilo Jankovic
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia
| | - Javier Belda
- Department of Surgery, Clinic University Hospital, Valencia, Spain
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50
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Increased risk of hip fracture mortality associated with intraoperative hypotension in elderly hip fracture patients is related to under resuscitation. J Clin Orthop Trauma 2022; 26:101783. [PMID: 35242530 PMCID: PMC8857490 DOI: 10.1016/j.jcot.2022.101783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND As the US and world population ages, hip fractures are increasingly more common. The mortality associated with these fractures remains high both in the immediate postoperative period and at one year. Perioperative resuscitation in this population is of key interest to prevent organ injury and mortality. Our objectives were to evaluate the effect of fluid resuscitation and hemodynamic status in the form of mean arterial pressure (MAP) on inpatient mortality of hip fracture patients. METHODS An institutional database was queried to compare elderly hip fracture patients that sustained in-hospital mortality to a matched control cohort. Pre-, intra-, and post-operative intravenous fluid (IVF) administration and MAP were extracted from the electronic medical record. Time from hospital presentation to the OR was also recorded. RESULTS 1,114 total hip fractures were identified during the two-year study period, 16 of which suffered inpatient mortalities. The mortality cohort was then matched with a control of 394 hip fracture patients for the same period based on age, sex, and Charlson Comorbidity Index (CCI). Conditional logistical regression analysis found odds ratios (OR) indicating that longer time between presentation and surgery (OR per additional hour: 1.05; 95% CI: 1.01-1.08) and lower intraoperative minimum MAP (OR per 5 mmHg decrease: 0.77; 95% CI: 0.61-0.97) were associated with significantly increased odds of mortality. There was also a marginal relationship between greater intraoperative IVF administration and reduced odds of mortality (OR per 500 cc additional fluid: 0.61; 95% CI: 0.37-1.00). CONCLUSION Extended time from presentation to surgery and intraoperative hypotension were associated with increased likelihood of inpatient mortality in an elderly hip fracture cohort, with a possible additional effect of under-resuscitation. Further investigation into a safe intraoperative minimum MAP should be pursued. LEVEL OF EVIDENCE Level III.
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