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Punzo G, Beccia G, Cambise C, Iacobucci T, Sessa F, Sgreccia M, Sacco T, Leone A, Congedo MT, Meacci E, Margaritora S, Sollazzi L, Aceto P. Goal-Directed Fluid Therapy Using Pulse Pressure Variation in Thoracic Surgery Requiring One-Lung Ventilation: A Randomized Controlled Trial. J Clin Med 2024; 13:5589. [PMID: 39337076 PMCID: PMC11432644 DOI: 10.3390/jcm13185589] [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: 08/16/2024] [Revised: 09/15/2024] [Accepted: 09/18/2024] [Indexed: 09/30/2024] Open
Abstract
Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO2/FiO2 ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO2/FiO2 ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters.
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Affiliation(s)
- Giovanni Punzo
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Giovanna Beccia
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Chiara Cambise
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Tiziana Iacobucci
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Flaminio Sessa
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Mauro Sgreccia
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Teresa Sacco
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Angela Leone
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
| | - Maria Teresa Congedo
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.T.C.); (E.M.); (S.M.)
| | - Elisa Meacci
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.T.C.); (E.M.); (S.M.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Stefano Margaritora
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.T.C.); (E.M.); (S.M.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Liliana Sollazzi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
- Department of Basic Biotechnological Science, Intensive Care and Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Paola Aceto
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (G.B.); (C.C.); (T.I.); (F.S.); (M.S.); (T.S.); (A.L.); (L.S.)
- Department of Basic Biotechnological Science, Intensive Care and Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Al-Qudsi O, Ellis AR, Krishnamoorthy V, Ohnuma T, Patoli D, Taicher B, Mamoun N, Pant P, Wongsripuemtet P, Cobert J, Raghunathan K. Perioperative Albumin Among Adults Undergoing Thoracic Surgery in the United States: Utilization, Associations With Clinical Outcomes, and Contribution to Hospital Costs. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00433-6. [PMID: 39069383 DOI: 10.1053/j.jvca.2024.06.041] [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: 04/01/2024] [Revised: 06/05/2024] [Accepted: 06/27/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES To estimate the use of albumin among adults undergoing thoracic surgery in the United States, compare baseline characteristics, clinical and cost outcomes of recipients versus nonrecipients, and determine albumin's contribution to total hospital costs. DESIGN Retrospective cohort study. SETTING Nationwide sample of US hospitals. PARTICIPANTS Adults undergoing open and minimally invasive thoracic surgery between 2011 and 2017. INTERVENTIONS Albumin on the day of surgery (identified using itemized hospital billing logs). MEASUREMENTS AND MAIN RESULTS Albumin was used in 170 of 342 US hospitals, among 13% and 7% of 14,672 and 22,532 patients who, respectively, underwent open and minimally invasive thoracic surgery (median volume 500 mL). Baseline comorbidities and organ-supportive treatments were several-fold more prevalent among recipients (particularly vasopressors, mechanical ventilation, and red cell transfusions). In standardized mortality ratio propensity score weighted analysis, albumin use was not associated with in-hospital mortality (adjusted relative risk 1.17 [0.72, 1.92] and 1.51 [0.97, 2.34], with open and minimally invasive procedures), but was associated with morbidity and higher costs, more so with minimally invasive procedures than with open surgery. Total costs among recipients were higher by $4,744 ($3,591, $5,897) and $5,088 ($4,075, $6,100) for open and minimally invasive procedures, respectively. Albumin accounted for 2.6% of this difference (median $124 [$83-$189] per patient). CONCLUSIONS Albumin use varies widely across hospitals, and 9% of patients receive it (median 500 mL). Use was not associated with in-hospital mortality and was associated with more morbidity and cost. The cost of albumin accounted for a trivial portion of hospital costs. Clinical trials must examine the effects of albumin on complications and costs after thoracic surgery.
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Affiliation(s)
- Omar Al-Qudsi
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Alan R Ellis
- School of Social Work, North Carolina State University, Raleigh, NC
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine. Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Daneel Patoli
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brad Taicher
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Negmeldeen Mamoun
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Praruj Pant
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Pattrapun Wongsripuemtet
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Julien Cobert
- Department of Anesthesiology, University of California San Francisco. San Francisco, CA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine. Durham, NC; Anesthesia Service, Durham VA Healthcare System. Durham, NC
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Chen Q, Wu B, Deng M, Wei K. Effect of different targets of goal-directed fluid therapy on intraoperative hypotension and fluid infusion in robot-assisted laparoscopic gynecological surgery: a randomized non-inferiority trial. J Robot Surg 2024; 18:127. [PMID: 38492125 DOI: 10.1007/s11701-024-01875-0] [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: 12/23/2023] [Accepted: 02/17/2024] [Indexed: 03/18/2024]
Abstract
Carotid corrected flow time (FTc) and tidal volume challenge pulse pressure variation (VtPPV) are useful clinical parameters for assessing volume status and fluid responsiveness in robot-assisted surgery, but their usefulness as goal-directed fluid therapy (GDFT) targets is unclear. We investigated whether FTc or VtPPV as targets are inferior to PPV in GDFT. This single-center, prospective, randomized, non-inferiority study included 133 women undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. Patients were equally divided into three groups, and the GDFT protocol was guided by FTc, VtPPV, or PPV during surgery. Primary outcomes were non-inferiority of the time-weighted average of hypotension, intraoperative fluid volume, and urine output. Secondary outcomes were optic nerve sheath diameter (ONSD) pre- and post-operatively and creatinine and blood urea nitrogen preoperatively and on day 1 post-operatively. No significant differences were observed in intraoperative hypotension index, infusion and urine volumes, and ONSD post-operatively between the FTc and VtPPV groups and the PPV group. No differences in serum creatinine and urea nitrogen levels were identified between the FTc and VtPPV groups preoperatively, but on day 1 post-operatively, the urea nitrogen level in the FTc group was higher than that in the PPV group (4.09 ± 1.28 vs. 3.0 ± 1.1 mmol/L, 1.08 [0.59, 1.58], p < 0.0001), and the difference from the preoperative value was smaller than that in the PPV group (- 2 [- 2.97, 1.43] vs. - 1.34 [- 1.9, - 0.67], p = 0.004). FTc- or VtPPV-guided protocols are not inferior to that of PPV in GDFT during robot-assisted laparoscopic surgery in the modified head-down lithotomy position.Trial registration: Chinese Clinical Trial Registry (ChiCTR2200064419).
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Affiliation(s)
- Qi Chen
- Department of Anesthesiology, The First Affiliated of Chongqing Medical University, Chongqing, China
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Bin Wu
- Department of Anesthesiology, The First Affiliated of Chongqing Medical University, Chongqing, China
| | - Meiling Deng
- Department of Anesthesiology, The First Affiliated of Chongqing Medical University, Chongqing, China
| | - Ke Wei
- Department of Anesthesiology, The First Affiliated of Chongqing Medical University, Chongqing, China.
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Batchelor TJP. Modern fluid management in thoracic surgery. Curr Opin Anaesthesiol 2024; 37:69-74. [PMID: 38085874 DOI: 10.1097/aco.0000000000001333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW To provide an approach to perioperative fluid management for lung resection patients that incorporates the entire patient pathway in the context of international guidelines on enhanced recovery after surgery (ERAS). RECENT FINDINGS The concern with intraoperative fluid management is that giving too little or too much fluid is associated with worse outcomes after lung resection. However, it has not emerged as a key care element in thoracic ERAS programs probably due to the influence of other ERAS elements. Carbohydrate loading 2 h before surgery and the allowance of water until just prior to induction ensures the patient is both well hydrated and metabolically normal when they enter the operating room. Consequently, maintaining a euvolemic state during anesthesia can be achieved without goal-directed fluid therapy despite the recommendations of some guidelines. Intravenous fluids can be safely stopped in the immediate postoperative period. SUMMARY The goal of perioperative euvolemia can be achieved with the ongoing evolution and application of ERAS principles. A focus on the pre and postoperative phases of fluid management and a pragmatic approach to intraoperative fluid management negates the need for goal-directed fluid therapy in most cases.
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Affiliation(s)
- Timothy J P Batchelor
- Department of Thoracic Surgery, Barts Thorax Centre, St. Bartholomew's Hospital, West Smithfield, London, UK
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