The Impact of Goal-Directed Fluid Therapy in Prolonged Major Abdominal Surgery on Extravascular Lung Water and Oxygenation: A Randomized Controlled Trial

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

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.

A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

Effect of goal-directed fluid therapy based on plasma colloid osmotic pressure on the postoperative pulmonary complications of older patients undergoing major abdominal surgery

BACKGROUND

As an important component of accelerated rehabilitation surgery, goal-directed fluid therapy (GDT) is one of the optimized fluid therapy strategies and is closely related to perioperative complications and mortality. This article aimed to study the effect of combining plasma colloid osmotic pressure (COP) with stroke volume variation (SVV) as a target for intraoperative GDT for postoperative pulmonary complications in older patients undergoing major abdominal surgery.

METHODS

In this study, older patients (n = 100) undergoing radical resection of gastroenteric tumors were randomized to three groups: Group C (n1 = 31) received a conventional infusion regimen, Group S1 (n2 = 34) received GDT based on SVV, and Group S2 (n3 = 35) received GDT based on SVV and COP. The results were recorded, including the lung injury score (LIS); PaO₂/FiO₂ ratio; lactic acid value at the times of beginning (T0) and 1 h (T1), 2 h (T2), and 3 h (T3) after liquid infusion in the operation room; the total liquid infusion volume; infusion volumes of crystalline and colloidal liquids; urine production rate; pulmonary complications 7 days after surgery; and the severity grading of postoperative pulmonary complications.

RESULTS

The patients in the S2 group had fewer postoperative pulmonary complications than those in the C group (P < 0.05) and the proportion of pulmonary complications of grade 1 and higher than grade 2 in S2 group was significantly lower than that in C group (P <0.05); the patients in the S2 group had a higher PaO₂/FiO₂ ratio than those in the C group (P < 0.05), lower LIS than those in the S1 and C groups (P < 0.05), less total liquid infusion than those in the C group (P < 0.05), and more colloidal fluid infusion than those in the S1 and C groups (P < 0.05).

CONCLUSION

The findings of our study show that intraoperative GDT based on COP and SVV can reduce the incidence of pulmonary complications and conducive to shortening the hospital stay in older patients after gastrointestinal surgery.

TRIAL REGISTRATION

Chinese Clinical Trial. no. ChiCTR2100045671. Registry at www.chictr.org.cn on April 20, 2021.

The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position

Objective  Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay.

Materials and Methods  Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18–60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients ( n  = 15) served as control group and received SFT intraoperatively, while patients in group G ( n  = 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLV _AI ) and before extubation (CLV _BE ).

Statistical Analysis and Results  CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL; p -value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G ( p -value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower ( p -value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable.

Conclusion  GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.

Utility of lung ultrasound for extravascular lung water volume estimation during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Background and Aims:

Rising extravascular lung-water index (ELWI) following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC), if not timely intervened, can progress to pulmonary oedema. Transpulmonary thermodilution (TPTDL) is a standard technique to estimate ELWI (T-ELWI score), and track ongoing changes. Lung ultrasound (LUS) is another technique for ELWI (L-ELWI score) estimation. However, reproducibility and reliability of LUS for tracking serial L-ELWI changes during CRS + HIPEC remains to be validated.

Methods:

This prospective observational study included 360 L-ELWI and T-ELWI measurements at 12 peri-operative time-points. Cohen's Kappa test was used to assess reproducibility, Inter-rater agreement (between the anaesthetist and radiologist), and agreement between LUS and TPTDL for classifying the severity of pulmonary oedema. Reliability of LUS for 'tracking serial changes' in ELWI over time in individual patients was assessed by determining the repeated measures correlation (z-rrm) between weighted L-ELWI and T-ELWI scores. The ability of both techniques to discriminate pulmonary oedema was compared by analysing the area under ROC curves.

Results:

Excellent inter-rater agreement for assigned L-ELWI scores was observed (linear weighted κ = 0.95 for both). Both techniques had a good agreement in classifying the severity of pulmonary oedema (linear weighted κ = 0.63, 95% CI 0.51–0.79). T-ELWI and weighted L-ELWI scores correlated strongly (z-rrm = 0.88, 95% CI 0.80–0.92, P < 0.0001). Both techniques had comparable ability to discriminate pulmonary oedema (difference in area under ROC curve = 0.0014, 95%CI –0.0027 to 0.0055, P = 0.5043).

Conclusion:

We found the utility of LUS as a reliable and reproducible technique for ELWI estimation and tracking its changes over time in CRS + HIPEC.

Pulse Pressure Variation-Guided Fluid Therapy during Supratentorial Brain Tumour Excision: A Randomized Controlled Trial

BACKGROUND:

Goal-directed fluid therapy (GDFT) improved patient outcomes in various surgical procedures; however, its role during mass brain resection was not well investigated.

AIM:

In this study, we evaluated a simple protocol based on intermittent evaluation of pulse pressure variation for guiding fluid therapy during brain tumour resection.

METHODS:

Sixty-one adult patients scheduled for supratentorial brain mass excision were randomized into either GDFT group (received intraoperative fluids guided by pulse pressure variation) and control group (received standard care). Both groups were compared according to the following: brain relaxation scale (BRS), mean arterial pressure, heart rate, urine output, intraoperative fluid intake, postoperative serum lactate, and length of hospital stay.

RESULTS:

Demographic data, cardiovascular data (mean arterial pressure and heart rate), and BRS were comparable between both groups. GDFT group received more intraoperative fluids {3155 (452) mL vs 2790 (443) mL, P = 0.002}, had higher urine output {2019 (449) mL vs 1410 (382) mL, P < 0.001}, and had lower serum lactate {0.9 (1) mmol versus 2.5 (1.1) mmol, P = 0.03} compared to control group.

CONCLUSION:

In conclusion, PPV-guided fluid therapy during supratentorial mass excision, increased intraoperative fluids, and improved peripheral perfusion without increasing brain swelling.