Influence of stroke volume variation on fluid treatment and postoperative complications in thoracic surgery

The impact of goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing thoracic surgery: a systematic review and meta-analysis

BACKGROUND

Pulmonary complications after thoracic surgery are common and associated with significant morbidity and high cost of care. Goal-directed fluid therapy (GDFT) could reduce the incidence of postoperative pulmonary complications (PPCs) and facilitate recovery in patients undergoing major abdominal surgery. However, whether GDFT could reduce the incidence of PPCs in patients undergoing thoracic surgery was unclear. The present meta-analysis was designed to assess the impact of Goal-directed Fluid Therapy on PPCs in patients undergoing thoracic surgery.

METHODS

Randomized controlled trials (RCTs) comparing GDFT with other conventional fluid management strategies in adult patients undergoing thoracic surgery were identified. Databases searched included PubMed, Web of Science, Embase, and Cochrane Library databases. Review Manager 5.4 (The Cochrane Collaboration, Oxford, UK) software was used for statistical analysis. Heterogeneity was analyzed using I2 statistics, and a standardized mean difference with 95% CI and P value was used to calculate the treatment effect for outcome variables. The primary study outcomes were the incidence of PPCs. Secondary outcomes were the total volume infused, the length of hospitalization, the incidence of cardiac complications, and the incidence of renal dysfunction. Subgroup analysis was planned to verify the definite role of GDFT.

RESULTS

A total of 6 RCTs consisting of 680 patients were included in this meta-analysis, which revealed that GDFT did not reduce the incidence of PPCs in patients undergoing thoracic surgery (RR, 0.57; 95% CI 0.29-1.14). However, GDFT decreased the total intra-operative fluid input (MD, - 244.40 ml; 95% CI - 397.06 to - 91.74). There was no statistical difference in the duration of hospitalization (MD; - 1.31, 95% CI - 3.00 to 0.38), incidence of renal dysfunction (RR, 0.62; 95% CI 0.29-1.35), and incidence of cardiac complications (RR, 0.62; 95% CI 0.27-1.40).

CONCLUSIONS

The results of this meta-analysis indicate that GDFT did not reduce the postoperative incidence of pulmonary complications in individuals undergoing thoracic surgery. However, considering the small number of contributing studies, these results should be interpreted with caution.

Effect of perioperative goal-directed fluid therapy on postoperative complications after thoracic surgery with one-lung ventilation: a systematic review and meta-analysis

BACKGROUND

An understanding of the impact of goal-directed fluid therapy (GDFT) on the outcomes of patients undergoing one-lung ventilation (OLV) for thoracic surgery remains incomplete and controversial. This meta-analysis aimed to assess the effect of GDFT compared to other fluid therapy strategies on the incidence of postoperative complications in patients with OLV.

METHODS

The Embase, Cochrane Library, Web of Science, and MEDLINE via PubMed databases were searched from their inception to November 30, 2022. Forest plots were constructed to present the results of the meta-analysis. The quality of the included studies was evaluated using the Cochrane Collaboration tool and Risk Of Bias In Non-Randomized Study of Interventions (ROBINS-I). The primary outcome was the incidence of postoperative complications. Secondary outcomes were the length of hospital stay, PaO2/FiO2 ratio, total fluid infusion, inflammatory factors (TNF-α, IL-6), and postoperative bowel function recovery time.

RESULTS

A total of 1318 patients from 11 studies were included in this review. The GDFT group had a lower incidence of postoperative complications [odds ratio (OR), 0.47; 95% confidence interval (95% CI), 0.29-0.75; P = 0.002; I 2, 67%], postoperative pulmonary complications (OR 0.48, 95% CI 0.27-0.83; P = 0.009), and postoperative anastomotic leakage (OR 0.51, 95% CI 0.27-0.97; P = 0.04). The GDFT strategy reduces total fluid infusion.

CONCLUSIONS

GDFT is associated with lower postoperative complications and better survival outcomes after thoracic surgery for OLV.

Effects of intra-operative fluid management under the guidance of stroke volume variability on short-term prognosis after thoracoscopic lobectomy

AIM

We aimed to explore the influence of intra-operative fluid management under the guidance of stroke volume variability (SVV) on the short-term prognosis after thoracoscopic lobectomy.

METHODS

A total of 171 eligible patients from April 2017 to April 2019 were selected. All patients received intra-operative fluid management under the guidance of SVV, and were divided into low-, middle- and high-level groups (n = 57) using a random-numbers table. The general data, respiratory function indices at different time points, haemodynamic indices at different time points, use of vasoactive drugs, short-term prognosis indices and incidence of complications were compared.

RESULTS

There were no significant differences in age, gender, operation time, one-lung ventilation time, amount of bleeding, arterial partial pressure of oxygen, arterial partial pressure of carbon dioxide, lung compliance and peak airway pressure at different time points, usage amount of anisodamine and incidence rate of complications among the three groups. In the low-level group, the fluid infusion amount and urine volume were significantly larger, the forced expiratory volume in one second (FEV1), percentage of FEV1 in the predicted value (FEV1%pred) and FEV1/forced vital capacity (FEV1/FVC) seven days after operation were higher, and the six-minute walk test (6MWT) distance was longer than those in the other two groups. The usage amount of dopamine, norepinephrine and esmolol was smaller, and the postoperative exhaust time was shorter than those in the other two groups. The low-level group had a smaller usage amount of isosorbide dinitrate injection and shorter length of postoperative hospital stay than the high-level group. Stroke volume had a significant difference at T2 and T3 in the low-level group, central venous pressure (CVP) and stroke volume had significant differences at T2 and T3 in the middle-level group, and heart rate (HR), mean arterial pressure and CVP were significantly different at T2 and T3 in the high-level group.

CONCLUSIONS

Fluid management under the guidance of low-level SVV (8% ≤ SVV ≤ 9%) was conducive to the maintenance of stable haemodynamics in patients during thoracoscopic lobectomy, thereby improving short-term prognosis.

Correlation of carotid corrected flow time and respirophasic variation in blood flow peak velocity with stroke volume variation in elderly patients under general anaesthesia

BACKGROUND

Accurate assessment of volume responsiveness in elderly patients is important as it may reduce the risk of post-operative complications and enhance surgical recovery. This study evaluated the utility of two Doppler ultrasound-derived parameters, the carotid corrected flow time (FTc) and respirophasic variation in carotid artery blood flow peak velocity (ΔVpeak), to predict volume responsiveness in elderly patients under general anaesthesia.

METHODS

A total of 97 elderly patients undergoing elective abdominal surgery under general anaesthesia were enrolled in this prospective observational study. After entering the operating room, all patients underwent radial artery puncture connected with a LiDCO device to measure stroke volume variation (SVV), and fluid therapy was performed after anaesthesia induction. Patients were classified as responders if SVV ≥ 13% before fluid challenge and nonresponders if SVV < 13%. The FTc, ΔVpeak, SVV and haemodynamic data were measured by ultrasound at baseline (T0) and before (T1) and after (T2) fluid challenge. The correlations between the Doppler ultrasound-derived parameters and SVV were analysed, and the receiver operating characteristic (ROC) curves was computed to characterize both FTc and ΔVpeak as measures of volume responsiveness in elderly patients.

RESULTS

Forty-one (42.3%) patients were fluid responders. Carotid FTc before fluid challenge was negatively correlated with SVV before fluid challenge (r = -0.77; P < 0.01), and ΔVpeak was positively correlated with SVV (r = 0.72; P < 0.01). FTc and ΔVpeak predicted SVV ≥ 13% after general anaesthesia in elderly patients, with areas under the receiver operating characteristic curves (AUROCs) of 0.811 [95% confidence interval (CI), 0.721-0.900; P < 0.001] and 0.781 (95% CI, 0.686-0.875; P < 0.001), respectively. The optimal cut-off values of FTc and ΔVpeak to predict SVV ≥ 13% were 340.74 ms (sensitivity of 76.8%; specificity of 80.5%) and 11.69% (sensitivity of 78.0%; specificity of 67.9%), respectively.

CONCLUSIONS

There was a good correlation between carotid artery ultrasound parameters and SVV. FTc predicted fluid responsiveness better than ΔVpeak in elderly patients during general anaesthesia. Further study is needed before these parameters can be recommended for clinical application.

TRIAL REGISTRATION

www.chictr.org.cn (ChiCTR2000031193); registered 23 March 2020.

Stroke volume variation for predicting responsiveness to fluid therapy in patients undergoing cardiac and thoracic surgery: a systematic review and meta-analysis

OBJECTIVE

To evaluate the reliability of stroke volume variation (SVV) for predicting responsiveness to fluid therapy in patients undergoing cardiac and thoracic surgery.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, Cochrane Library, Web of Science up to 9 August 2020.

METHODS

Quality of included studies were assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We conducted subgroup analysis according to different anaesthesia and surgical methods with Stata V.14.0, Review Manager V.5.3 and R V.3.6.3. We used random-effects model to pool sensitivity, specificity and diagnostic odds ratio with 95% CI. The area under the curve (AUC) of receiver operating characteristic was calculated.

RESULTS

Among the 20 relevant studies, 7 were conducted during thoracic surgery, 8 were conducted during cardiac surgery and the remaining 5 were conducted in intensive critical unit (ICU) after cardiac surgery. Data from 854 patients accepting mechanical ventilation were included in our systematic review. The pooled sensitivity and specificity were 0.73 (95％ CI: 0.59 to 0.83) and 0.62 (95％ CI: 0.46 to 0.76) in the thoracic surgery group, 0.71 (95％ CI: 0.65 to 0.77) and 0.76 (95％ CI: 0.69 to 0.82) in the cardiac surgery group, 0.85 (95％ CI: 0.60 to 0.96) and 0.85 (95％ CI: 0.74 to 0.92) in cardiac ICU group. The AUC was 0.73 (95% CI: 0.69 to 0.77), 0.80 (95% CI: 0.77 to 0.83) and 0.88 (95% CI: 0.86 to 0.92), respectively. Results of subgroup of FloTrac/Vigileo system (AUC=0.80, Youden index=0.38) and large tidal volume (AUC=0.81, Youden index=0.48) in thoracic surgery, colloid (AUC=0.85, Youden index=0.55) and postoperation (AUC=0.85, Youden index=0.63) in cardiac surgery, passive leg raising (AUC=0.90, Youden index=0.72) in cardiac ICU were reliable.

CONCLUSION

SVV had good predictive performance in cardiac surgery or ICU after cardiac surgery and had moderate predictive performance in thoracic surgery. Nevertheless, technical and clinical variables may affect the predictive value potentially.

Utility of the FloTrac™ Sensor for Anesthetic Management of Laparoscopic Surgery in a Patient After Pneumonectomy: A Case Report and Literature Review

BACKGROUND Pneumonectomy is associated with various anatomical changes and potential complications involving the respiratory and cardiovascular systems. How laparoscopic surgery affects cardiorespiratory status in postpneumonectomy patients is yet to be ascertained. Here, we describe the use of the FloTrac™ sensor for the anesthetic management of laparoscopic adrenalectomy in a postpneumonectomy patient. CASE REPORT A 35-year-old woman underwent an extended hysterectomy and right pneumonectomy for retroperitoneal angiosarcoma and lung metastases, respectively. The metastasis was found in her left adrenal gland; therefore, laparoscopic adrenalectomy was scheduled. Spirometry demonstrated the following: forced vital capacity (FVC), 1.90 L (55.6% of predicted value); vital capacity, 53.6%; forced expiratory volume (FEV₁), 1.38 L (47.3% of predicted value); and FEV₁/FVC, 72.4%. The heart and mediastinal structures had shifted into the right hemithorax. Hugh-Jones classification was grade 2. The induction of general anesthesia was planned. The patient was orotracheally intubated and managed with the pressure control ventilation-volume guaranteed mode of ventilation, targeting an expired tidal volume of 6-7 ml/kg, without using PEEP. We evaluated cardiac output (CO), cardiac index (CI), stroke volume (SV), and stroke volume variation (SVV) using a FloTrac™ sensor. After the establishment of pneumoperitoneum, SVV increased. CO and SV decreased slightly; however, the patient's hemodynamic status was stable. After surgery, we extubated the patient in the operating room; she demonstrated good progress and was discharged home on postoperative day 5. CONCLUSIONS We found changes in the values of SVV after pneumoperitoneum in a postpneumonectomy patient. The FloTrac™ sensor may be a minimally invasive and promising monitor for detecting hemodynamic changes associated with laparoscopic surgery in postpneumonectomy patients.