Postoperative fluid management

Postoperative Intravenous Fluids and Electrolytes Management After Gastrointestinal Surgery in a Sudanese Teaching Hospital: A Prospective Audit

BACKGROUND

Postoperative fluid and electrolyte management is crucial for adequate patients' recovery and healing. This audit aimed to assess the current practice of postoperative intravenous fluids (IV) and electrolyte administration and investigate postoperative electrolyte disturbances.

METHOD

This study was conducted at Soba Teaching Hospital and comprised two cycles, it examined adult patients who underwent abdominal surgery and were exclusively on postoperative intravenous fluid therapy for at least one day. Exclusions were made for certain conditions (Heart or renal failure, ICU admissions, day surgeries). Data collected from medical records including intravenous fluid types and amounts, electrolytes, and daily serum sodium and potassium levels, were compared to British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). Following cycle one, regular educational sessions were conducted for medical staff, emphasizing the need for improved practices in postoperative care.

RESULTS

A total of 14 patients in cycle one and 15 patients in cycle two were included. The data analysis unit was the patient-day. Patient-days refers to the total number of days patients were on IV fluids after surgery, starting from the day after the operation and excluding the day of surgery. It is calculated by adding up the number of days each patient remained exclusively on IV fluids. A total of 33 and 30 patient-days were analyzed in cycle one and cycle two respectively. The recommended daily amount of IV fluids for maintenance was given in 0.00% of patient-days in cycle one as compared to 76.7% in cycle two. Sodium and potassium doses were given within the recommended range of 0.00% and 24% patient-days respectively in cycle one. In cycle two, sodium and potassium were given according to the guidelines in 46.7% and 60% of patient-days respectively. Electrolyte disturbances occurred in 69.7% of patient-days in cycle one, decreasing to 46.7% in cycle two, primarily in the form of hyponatremia and hypokalemia.

CONCLUSION

This study highlighted the need for continued monitoring and emphasized the importance of adequate medical staff training about postoperative IV fluids and electrolytes.

Effect of rigorous fluid management using monitoring of ECW ratio by bioelectrical impedance analysis in critically ill postoperative patients: A prospective, single-blind, randomized controlled study

BACKGROUND & AIMS

Precise assessment of postoperative volume status is important to administrate optimal fluid management. Bioelectrical impedance analysis (BIA) which measures the body composition using electric character. Extracellular water (ECW) ratio by BIA represented as the ratio of ECW to total body water (TBW) and is known to reflect the hydration status. Based on this, we aimed to determine whether aggressive fluid control using ECW ratio could improve clinical outcomes through a single blind, randomized controlled trial.

METHODS

From November 2021 to December 2022, intensive care unit (ICU) patients admitted after surgery were randomly assigned to an intervention group or a control group whether postoperative fluid management was controlled via BIA. Among patients in the intervention group, dehydrated patients received a bolus infusion with crystalloid fluid whereas diuretics were administrated to overhydrated patients until the value of ECW ratio fell within its normal setting range (0.390-0.406). Contrarily, BIA was performed once a day for the control group. Patients in the control group received traditional fluid treatment regardless of BIA results. Primary outcome was in-hospital mortality in two groups. The secondary outcomes were postoperative morbidities, 28-day mortality.

RESULTS

77 patients of the intervention group and 90 patients of the control group were finally analyzed. The in-hospital mortality (0 in intervention, 4.4% in control, p = 0.125) and 28-day mortality (1.3% in intervention, 14.4% in control, p = 0.002) showed lower incidence in the intervention group than in the control group. In multivariate analysis, the overhydrated status whose ECW ratio exceeding 0.406 [odds ratio (OR): 2.731, 95% confidence interval (CI): 1.001-7.663, p = 0.049] and high capillary leak index (CLI) value at ICU admission (OR: 1.024, 95% CI: 1.008-1.039, p = 0.002) were risk factors of postoperative morbidities. Regarding the 28-day mortality, high CLI value (OR: 1.025, 95% CI: 1.002-1.050, p = 0.037) and traditional strategy without BIA monitoring (OR: 9.903, 95% CI: 1.095-89.566, p = 0.041) were the significant predisposing factors.

CONCLUSION

Our results revealed the rigorous fluid treatment with volume control based on ECW ratio by BIA failed to achieve significant improvement in in-hospital mortality, but it could reduce 28-day mortality of ICU patients. Monitoring of ECW ratio may help establish optimal fluid treatment strategies for postoperative ICU patients who are susceptible to fluid imbalances with fluid overload.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT06097923, retrospectively registered on October 16, 2023, https://clinicaltrials.gov/study/NCT06097923?term=NCT06097923&rank=1.

Beyond the Valve: Incidence, Outcomes, and Modifiable Factors of Acute Kidney Injury in Patients with Infective Endocarditis Undergoing Valve Surgery-A Retrospective, Single-Center Study

Background/Objectives: Infective endocarditis (IE) often requires surgical intervention, with postoperative acute kidney injury (AKI), posing a significant concern. This retrospective study aimed to investigate AKI incidence, its impact on short-term mortality, and identify modifiable factors in patients with IE scheduled for valve surgery. Methods: This single-center study enrolled 130 consecutive IE patients from 2013 to 2021 undergoing valve surgery. The creatinine levels were monitored pre- and postoperatively, and AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patient demographics, comorbidities, procedural details, and complications were recorded. Primary outcomes included AKI incidence; the relevance of creatinine levels for AKI detection; and the association of AKI with 30-, 60-, and 180-day mortality. Modifiable factors contributing to AKI were explored as secondary outcomes. Results: Postoperatively, 35.4% developed AKI. The highest creatinine elevation occurred on the second postoperative day. Best predictive value for AKI was a creatinine level of 1.35 mg/dL on the second day (AUC: 0.901; sensitivity: 0.89, specificity: 0.79). Elevated creatinine levels on the second day were robust predictors for short-term mortality at 30, 60, and 180 days postoperatively (AUC ranging from 0.708 to 0.789). CK-MB levels at 24 h postoperatively and minimum hemoglobin during surgery were identified as independent predictors for AKI in logistic regression. Conclusions: This study highlights the crucial role of creatinine levels in predicting short-term mortality in surgical IE patients. A specific threshold (1.35 mg/dL) provides a practical marker for risk stratification, offering insights for refining perioperative strategies and optimizing outcomes in this challenging patient population.

Prediction of hematocrit decline and the impact of peri-operative fluid use in lumbar spinal fusion surgery

PURPOSE

Peri-operative blood loss unaccounted for and post-operative hematocrit decline could have a significant impact on the outcome of elective spinal surgery patients. The study assesses the accuracy of predictive models of hematocrit decline and blood loss in spinal surgery and determines the impact of peri-operative fluid administration on hematocrit levels of patients undergoing first-time single level lumbar fusion surgery for degenerative spine disease and the trend thereof in the first 24 h post-operatively.

METHODS

Clinical and biochemical parameters were prospectively collected in patients undergoing single level lumbar spinal surgery. Predictive models were applied to assess their accuracy in intra-operative blood loss and post-operative hematocrit decline.

RESULTS

High correlation (0.98 Pearson correlation coefficient) occurred between calculated (predicted) and recorded hematocrit from hours 2 to 6 post-operatively. Predictive accuracy declined thereafter yet remained moderate. Patients received an average intra-operative fluid volume of 545.45 ml per hour (47% of estimated total blood volume). A significant hematocrit decline occurred post-induction (43.47-39.78%, p < 0.001) with total fluid volume received being the significant contributing variable (p < 0.001). Hypertensive patients were the only subgroup to drop below the safe hematocrit threshold of 30%.

CONCLUSION

Iatrogenic hemodilution can accurately be predicted for the first six hours post-operatively, with high risk patients identifiable. Fluid therapy should be goal directed rather than generic, and good communication between the surgeon and anesthesiologist remains the cornerstone to manage physiological changes secondary to blood loss. Although helpful, predictive formulas are not universally applicable to all phenotypes.

Bilateral Urinary Stones in a Transgender Woman: A Case Report in Lebanon

This case report presents a 38-year-old transgender woman, assigned male at birth, who presented with severe right flank pain associated with nausea and hematuria. After previously undergoing gender-affirming surgeries, including abdominoplasty, liposuction, breast augmentation, and reconstructive vaginal surgery, the patient developed bilateral ureteral and kidney stones leading to significant hydronephrosis. Bilateral double J insertion was performed following a computed tomography (CT) Uroscan. This was followed by flexible ureteroscopy and laser fragmentation of the stone bilaterally. The patient's anatomy was remarkable for the presence of neovagina and prostate. This case highlights the unique challenges and considerations in managing genitourinary complications in transgender individuals. The literature is limited in the Middle East concerning transgender individuals, hence the need to conduct further research and compile comprehensive case reports on transgender individuals in the Middle East in order to establish a robust database and draw meaningful epidemiological conclusions.

Comparison of superior and inferior vena cava diameter variation measured with transthoracic echocardiography to predict fluid responsiveness in mechanically ventilated patients after abdominal surgery

Background

The volume status of patients after major abdominal surgery constantly varies owing to postoperative diverse issues comprising fluid loss or capillary leakage secondary to systemic inflammatory reaction syndrome, et.al, the precise fluid responsiveness assessment is crucial for those patients. The purpose of this study is to validate the transthoracic ultrasonographic measurement of superior and inferior vena cava variation in predicting fluid responsiveness of mechanically ventilated patients after surgery.

Methods

A total of 70 patients undergoing the scheduled major abdominal surgeries in the anesthesia ICU ward were included. The superior vena cava (SVC) collapsibility index (SVCCI), the inferior vena cava distensibility index (dIVC), SVC variation over the cardiac cycle (SVCV), and cardiac output (CO) were measured by transthoracic ultrasonography were recorded before and after fluid challenge test of 5 ml/kg crystalloid within 15 min. The responders were defined as a 15% or more increment in CO.

Results

Thirty patients (42.9%) responded to fluid challenge, while the remnant forty patients (57.1%) did not. The areas under the ROC curve (AUC) of SVCCI, dIVC and SVCV were 0.885 (95% CI, 0.786–0.949; P < 0.0001) and 0.727 (95% CI, 0.608–0.827; P < 0.001) and 0.751 (95% CI, 0.633–0.847; P < 0.0001), respectively. AUC_dIVC and AUC_SVCV were significantly lower when compared with AUC_SVCCI (P < 0.05). The optimal cutoff values were 19% for SVCCI, 14% for dIVC, and 15% for SVCV. The gray zone for SVCCI was 20%-25% and included 15.7% of patients, while 7%-27% for dIVC including 62.9% of patients and 9%-21% for SVCV including 50% of patients.

Conclusion

Superior vena cava-related parameters measured by transthoracic ultrasound are reliable indices to predict fluid responsiveness. The accuracy of SVCCI in mechanically ventilated patients after abdominal surgery is better than that of dIVC and SVCV.

Trial registration

ChiCTR-INR-17013093. The initial registration date was 24/10/2017.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Factors Predicting Pressure Injury Incidence in Older Adults Following Elective Total Hip Arthroplasty: A Longitudinal Study

OBJECTIVE

To identify the factors associated with pressure injury (PI) development in older adult patients who underwent elective total hip arthroplasty (THA).

METHODS

A nonexperimental longitudinal prospective study was conducted with a sample of 40 patients undergoing elective THA. Patients were evaluated for PI at hospital admission, 24 hours postsurgery, at discharge, and 1 month after surgery.

RESULTS

The incidence of PIs (category 1 or category 2) in this study was 7.9% 24 hours after surgery and 24.3% at discharge. The most common PI location was the sacrum/coccyx or the ischial tuberosity. This study found significant relationships between PIs and female sex (odds ratio [OR], 8.75), body fat mass percentage (OR, 1.15), and the motor score from a Functional Independence Measure scale (OR, 0.89). Finally, the following variables were also associated with PIs (P < .1): skeletal muscle mass (OR, 0.82), lower limb with osteoarthritis weight (OR, 0.61), lower limb without osteoarthritis weight (OR, 0.62), and geriatric depression scale (OR, 1.12).

CONCLUSIONS

This work identifies those patients at higher risk of PI, enabling targeted prevention and treatment in the population of patients undergoing elective THA. The findings of this study are in line with extant literature and suggest that women with a higher percentage of body fat and less mobility had a higher risk of PI.

Prediction of Postoperative Sepsis Based on Changes in Presepsin Levels of Critically Ill Patients with Acute Kidney Injury after Abdominal Surgery

Presepsin (PSP) is a viable biomarker for the detection of bacterial infection, but it lacks accuracy when acute kidney injury (AKI) develops. Herein, we evaluated the diagnostic and prognostic value of PSP in predicting postoperative sepsis after abdominal surgery respective to the degree of AKI. A total of 311 patients who underwent abdominal surgery and were admitted to a surgical intensive care unit were enrolled and classified into non-AKI, mild-AKI (stage 1, stage 2 and stage 3 without renal replacement therapy (RRT)) and severe-AKI (stage 3 with RRT) group, according to the Kidney Disease Improving Global Outcomes criteria. In each group, PSP and other biomarkers were statistically analyzed between non-sepsis and postoperative sepsis at the admission (T0), 24 h (T1), 48 h (T2) and 72 h (T3) after surgery. In non-AKI and mild-AKI group, PSP levels were significantly higher in postoperative sepsis than non-sepsis group, whereas no difference was detected in the severe-AKI group. Cutoff values of PSP in the mild-AKI group for the prediction of postoperative sepsis were 544 pg/mL (AUC: 0.757, p < 0.001) at T0 and 458.5 pg/mL (AUC: 0.743, p < 0.001) at T1, significantly higher than in non-AKI group. In multivariate analysis, predictors of postoperative sepsis in the mild-AKI group were PSP at T2 (odds ratio (OR): 1.002, p = 0.044) and PSP at T3 (OR: 1.001, p = 0.049). PSP can be useful for predicting newly developed sepsis in patients with transient AKI after abdominal surgery with modified cutoff values.

Perianesthesia Care of the Oncologic Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Retrospective Study

PURPOSE

This study was to understand the perianesthesia care for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS  + HIPEC).

METHOD

This is a retrospective study.

DESIGN

The perioperative electronic medical records of 189 CRS  + HIPEC surgical cases at a hospital of Western Pennsylvania from 2012 to 2018 were analyzed to study the characteristics of perianesthesia care for CRS  + HIPEC surgery.

FINDINGS

The patients' median age was 57 (range 21-83) years, and 60% were men. The mean anesthesia time was 10.47 ± 2.54 hours. Most tumors were appendix or colorectal in origin, and the mean peritoneal cancer index score was 16.19 ± 8.76. The mean estimated blood loss was 623 ± 582 mL. The mean total intravenous crystalloid administered was 8,377 ± 4,100 mL. Fifty-two patients received packed red blood cells during surgery. Postoperatively, 100% of the patients were transferred to the intensive care unit. A majority (52%) of patients were extubated in the operating room. Median lengths of hospital and intensive care unit stays were 13 and 2 days, respectively. A majority (73%) of patients had 1 or more postoperative complications and 29% of patients experienced major postoperative complications (Clavien-Dindo grade III or higher) during the hospital stay. Prolonged hospitalization was owing to gastrointestinal dysfunctions and respiratory failure related to atelectasis and pleural effusion.

CONCLUSIONS

CRS  + HIPEC is a major surgery with numerous challenges to the perianesthesia care team regarding hemodynamic adjustment, pain control, and postoperative complications, which demand training and future studies from the perianesthesia care team.

Usefulness of bioelectrical impedance analysis and ECW ratio as a guidance for fluid management in critically ill patients after operation

We determined the relationship between changes in bioelectrical impedance analysis (BIA) parameters and response of critically ill patients to fluid therapy during early postoperative period. Associations between BIA values indicating volume status of postoperative patient and clinical outcomes were also evaluated. From May 2019 to April 2020, patients who were admitted to the surgical intensive care unit (SICU) of our institution at more than 48 h after surgery were enrolled. Volume status was measured with a portable BIA device every morning for five days from SICU admission. Overhydration was defined as the case where extracellular water (ECW) ratio > 0.390 measured by BIA. Participants were daily classified into an overhydration or a normohydration group. The relationship between daily hydration status and postoperative outcome was evaluated. Most of the 190 participants showed the overhydration status in the first 48 h after surgery. The overhydration status on day 3 was significant predictor of postoperative morbidities (OR 1.182) and in-hospital mortality (OR 2.040). SOFA score was significant factor of postoperative morbidities (OR 1.163) and in-hospital mortality (OR 3.151) except for the overhydration status on day 3. Cut-off values of overhydration status by ECW ratio at day 3 for predicting postoperative morbidities and in-hospital mortality were > 0.3985 and > 0.4145, respectively. BIA would be a useful and convenient tool to assess the volume status of patients requiring intensive fluid resuscitation in early postoperative period. Overhydration status by ECW ratio on postoperative day 3 needs careful monitoring and appropriate interventions to improve clinical outcomes.

Postoperative Care of the Maxillofacial Surgery Patient

“Surgery” is defined as “treatment of injuries or disorders of the body by incision or manipulation, especially with instruments”. As such, it is nothing more than the mere performance of maneuvers at the operating room and certainly does not qualify to be called “treatment”. It is postoperative care that completes the process, ultimately benefitting the patient. In general, this includes the overall maintenance of wellbeing and early recovery of function before the patient can be discharged to be on his own. Additionally, the maxillofacial patient presents with issues exclusive to the anatomy and physiology of the head and neck region. One needs to have in-depth knowledge of these unique aspects, in addition to being a shrewd clinician at the postoperative ward. This chapter aims to equip the surgeon with such information as is necessary to provide the best of services following maxillofacial surgery.

Perioperative Pregabalin for Preventive Analgesia in Breast Cancer Surgery: A Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Pregabalin is a drug for neuropathic pain. Antipronociceptive properties of pregabalin have led to its recent use as an adjuvant to the multimodal postoperative pain regimen. This meta-analysis was conducted to evaluate the efficacy of perioperative pregabalin on acute and chronic postsurgical pain (CPSP) after breast cancer surgery.

METHODS

A meta-analysis including 8 randomized controlled trials searched from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted. Subgroup analysis was performed according to doses and timecourse of pregabalin administration. Review Manager 5.3 was selected to conduct the meta-analysis.

RESULTS

Preoperative pregabalin in breast cancer surgery alleviated acute postoperative pain at rest 24 hours after surgery by 0.31 points on an 0 to 10 Numerical Rating Scale (95% confidence interval [CI] -0.57 to -0.05). Morphine consumption showed a decrease in postoperative use by 1.09 mg (95% CI: -1.61 to -0.57). The incidence of CPSP 3 months after surgery was reduced to 46% (95% CI: 0.25-0.85). Postoperative nausea and vomiting, dizziness, and sedation showed no overall significant reductions. However, a decrease in the incidence of postoperative nausea and vomiting and an increase in the incidence of dizziness were noted when patients received 300 mg of pregabalin before surgery.

DISCUSSION

This study demonstrated that pregabalin showed more efficacy on chronic pain than acute pain after a breast cancer surgery. Further study based on doses and treatment course of pregabalin should be conducted to establish stronger evidence of treatment effects.

The Impact of Suprarenal Cross-Clamping on Kidney Function in Patients Undergoing Retroperitoneal Abdominal Aortic Aneurysm Repair following an Enhanced Recovery Protocol

BACKGROUND

The retroperitoneal approach (RP) is a well-established procedure for juxtarenal and infrarenal (IR) abdominal aortic aneurysm (AAA) repair when an endovascular option is not available. The aim of this study is to compare the effect of suprarenal (SR) and IR aortic clamping on postoperative renal function following an Enhanced Recovery Protocol (ERP). Since there are no defined guidelines within aortic surgery, we focused our attention on the role of fluid and vasopressor administration in the development of postoperative acute kidney injury (AKI).

METHODS

This is a single-center retrospective cohort study on 140 RP aortic aneurysm repair patients operated between 2009 and 2019. Patients were divided in 2 groups: 24 had SR clamping and 116 IR clamping. Since 2009, at our institution all patients have followed an Enchanced Recovery Program which has been implemented as standard care for patients undergoing open AAA repair.

RESULTS

The 2 groups were well matched for baseline characteristics, preoperative renal function, and comorbidity. There was an increased need for intraoperative fluids (P = 0.015), and vasopressors (P = 0.002) in the SR group compared to the IR group. Patients in the SR group showed a higher trend of postoperative AKI as opposed to the control group (37.5% vs. 19.8%), although this event was not statistically significant (P = 0.106). Acute Kidney Injury Network stage III requiring temporary dialysis occurred in only 3 patients who all belonged to the IR group. Conversely, stage I and II with a 2- or 3-fold increase in postoperative creatinine were more frequent in the SR group. However, these normalized before discharge in all cases. To the best of our knowledge, none of the above required permanent dialysis.

CONCLUSIONS

The results from this study show that SR clamping during RP juxtarenal aortic aneurysm repair does not have an adverse effect on postoperative renal function in the short term. However, patients undergoing SR clamping require greater fluid and vasopressor usage, in contrast with the restrictive fluid therapy established by traditional protocols. This could be an important benchmark for future implementation of ERPs in vascular surgery, especially in open procedures requiring visceral clamping.

Epidural anesthesia may be associated with increased postoperative complications in the elderly population undergoing radical cystectomy: an analysis from the National Surgical Quality Improvement Project (NSQIP) database

BACKGROUND

Epidural anesthesia has been associated with a decrease in cardiopulmonary complications and a decrease in blood loss in orthopedic procedures. Its influence on the outcomes of patients receiving radical cystectomies is unknown. We aim to use the large national database from the National Surgical Quality Improvement Project (NSQIP) to examine whether postoperative complications may be affected by the use of epidural anesthesia during radical cystectomy.

METHODS

Data were collected from the 2014-2016 participant user files of the NSQIP database. Patients receiving radical cystectomy were identified by CPT code and further stratified by anesthesia type. Demographics, length of stay, and 30-day complications including death were collected and analyzed using univariable and multivariable analysis.

RESULTS

A total of 6448 patients met the inclusion criteria for analysis. Between 2014 and 2016, 5064 patients received general anesthesia only (GA) and 1384 patients received general and epidural anesthesia (GEA). Statistical analysis showed an overall increase in major complications (17.8% vs 18.5%) in the GEA group (p = 0.0046). Subgroup analysis showed major complications to be more likely in patients older than 75 years receiving GEA instead of GA (p = 0.0301).

CONCLUSIONS

Elderly patients (age > 75) undergoing radical cystectomy may experience more major complications with the use of epidural anesthesia. This may be due to end-organ effects from the hemodynamic changes of epidural anesthesia which are poorly tolerated in the elderly population. Further single intervention epidural studies need to be performed to isolate the effects of epidural anesthesia on individual surgical procedures.

Contribution of intravenous medication to water and sodium intake in upper and lower gastrointestinal surgical patients

OBJECTIVES

The quantitative importance of prescribed intravenous (IV) medication to water and sodium intake in routine clinical practice is undocumented, with uncertain influence on clinical outcomes. The present study aimed to redress this issue in surgical patients with gastrointestinal problems.

METHODS

The prescription and administration of IV medication and fluids were retrospectively reviewed for water and sodium over 24-h periods in 86 patients in upper and lower gastrointestinal surgical wards in two teaching hospitals. Changes over 5 y were assessed in the same two wards using the same methodology.

RESULTS

Among 90.7% of patients prescribed IV medication, the median intake was 272 mL water/d (range, 40-2687 mL water/d) and 27 mmol sodium/d (range, 2-420 mmol sodium/d), with no significant difference between hospitals or ward type. In 28.2% of patients receiving any infusates, the only source of water and sodium was IV medication, and in 14.3% of patients, the medication provided more sodium than other infusates. Antibiotic agents and paracetamol accounted for 58.3% of water and 52.3% of sodium in IV medication. Historic data of IV medicine-related water and sodium intake did not differ significantly from current data. The literature suggests that clinical outcomes can be modulated by variations in water and sodium intake well within the range provided by IV medication.

CONCLUSION

IV medicine prescriptions, particularly antibiotic agents and paracetamol, can make substantial and clinically relevant contributions to daily water and sodium intake. These contributions have persisted over time and should be considered during routine assessments of fluid balance and interventions aiming to improve clinical outcomes.

The Effect of Fluid Loading and Hypertonic Saline Solution on Cortical Cerebral Microcirculation and Glycocalyx Integrity

BACKGROUND

Fluid loading and hyperosmolar solutions can modify the cortical brain microcirculation and the endothelial glycocalyx (EG). This study compared the short-term effects of liberal fluid loading with a restrictive fluid intake followed by osmotherapy with hypertonic saline (HTS) on cerebral cortical microcirculation and EG integrity in a rabbit craniotomy model.

METHODS

The experimental rabbits were allocated randomly to receive either <2 mL/kg/h (group R, n=14) or 30 mL/kg/h (group L, n=14) of balanced isotonic fluids for 1 hour. Then, the animals were randomized to receive 5 mL/kg intravenous infusion of either 3.2% saline (group HTS, n=14) or 0.9% saline (group normal saline, n=13) in a 20-minute infusion. Microcirculation in the cerebral cortex based on sidestream dark-field imaging, a morphologic index of glycocalyx damage to sublingual and cortical brain microcirculation (the perfused boundary region), and serum syndecan-1 levels were evaluated.

RESULTS

Lower cortical brain perfused small vessel density (P=0.0178), perfused vessel density (P=0.0286), and total vessel density (P=0.0447) were observed in group L, compared with group R. No differences were observed between the HTS and normal saline groups after osmotherapy. Cerebral perfused boundary region values (P=0.0692) and hematocrit-corrected serum syndecan-1 levels (P=0.0324) tended to be higher in group L than in group R animals.

CONCLUSIONS

Liberal fluid loading was associated with altered cortical cerebral microcirculation and EG integrity parameters. The 3.2% saline treatment did not affect cortical cerebral microcirculation or EG integrity markers.

The Impact of Preoperative Immunonutrition and Standard Polymeric Supplements on Patient Outcomes After Pelvic Exenteration Surgery, Taking Compliance Into Consideration: A Randomized Controlled Trial

BACKGROUND

The effect of immunonutrition vs standard polymeric nutrition in the preoperative phase on patient outcomes is still unclear, which could be due to contributing factors such as poorly reported compliance and unequal provision of protein, energy, and volume. The aim of this study was to examine the effects of preoperative immunonutrition compared with standard polymeric supplements matched for energy, protein, volume, length of stay, and postoperative complications in pelvic exenteration surgery, taking into consideration compliance.

METHODS

This was a single-blinded, randomized, controlled trial in patients undergoing pelvic exenteration surgery. Fifty-two participants were randomly assigned to consume 3 immunonutrition supplements/d for 5 days preoperatively, and 56 participants were randomly assigned to consume 3 standard polymeric supplements/d for 5 days preoperatively. Primary and secondary outcome measures were assessed. Compliance with each nutrition regime was recorded during the intervention, and subanalysis was conducted.

RESULTS

There was no significant difference between immunonutrition and standard polymeric supplements on length of stay (P = 0.988) or postoperative complications (P = 0.179) after pelvic exenteration surgery. Compliance with nutrition supplements was significantly less in malnourished (n = 33) compared with well-nourished participants (n = 74) (P = 0.016). Compliance varied between study groups, although not significant.

CONCLUSION

Preoperative immunonutrition did not significantly impact length of stay or postoperative complications compared with standard polymeric supplements after pelvic exenteration surgery, despite controlling for protein, energy, and volume. Compliance, protein, and energy may considerably impact the effect of immunonutrition, particularly in malnourished patients.

Postoperative Management in Patients with Pheochromocytoma and Paraganglioma

Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.

The bioimpedance spectroscopy as useful tool for measuring the fluid excess and fluid management in severe polytrauma patients

Although the fluid therapy plays a fundamental role in the management of polytrauma patients (PP), a tool which could determine it appropriately is still lacking. The aim of this study was to evaluate the application of a bioimpedance spectroscopy (BIS) for body fluids volume and distribution monitoring in these patients. This prospective, observational study was performed on 25 severe PP and 25 healthy subjects. The body fluids composition was repeatedly assessed using BIS between days 3 to 11 of intensive care unit stay while the impact of fluid intake and balance was evaluated. Fluid intake correlated significantly with fluid excess (FE) in edemas, and their values were significantly higher in comparison with the control group. FE was strongly associated with cumulative fluid balance (p<0.0001; r=0.719). Furthermore, this parameter was associated with the entire duration of mechanical ventilation (p=0.001, r=0.791) independently of injury severity score. In conclusion, BIS measured FE could be useful in PP who already achieved negative fluid balance in prevention the risk of repeated hypovolemia through inappropriate fluid restriction. What is more, measured FE has a certain prognostic value. Further studies are required to confirm BIS as a potential instrument for the improvement of PP outcome.

Sublingual microcirculation in pancreatico-biliary surgery: An observational study

BACKGROUND

An observational cohort study was conducted to identify potential sublingual microcirculation parameters as a target for goal-directed fluid therapy.

METHODS

Patients that were scheduled for an open elective pancreatico-biliary surgery in Erasmus Medical Center were included. All patients underwent sublingual microcirculatory measurement at three time points: one day before surgery (T0), within the first 24 hours after surgery (T1) and on the fourth day after surgery (T2). The following parameters were obtained: microvascular flow index (MFI (AU)), Total vessels density (TVD (mm/mm2/)), Perfused vessels density (PVD (mm/mm2)), and proportion of perfused vessels (PPV (%)).

RESULTS

Sixteen patients were included in the final analysis. The differences between the time points T1 and T0 in patients without clinical significant complication and in patients with these complications gave a significant difference for PVD small vessels (PVDs) (delta PVDs mean -0.1 vs -8.2, p=0.01) and PPV small vessels (PPVs) (delta PPVs median 7.0 % vs -15.5 %, p=0.01).

CONCLUSION

The most significant microcirculatory parameter for a perioperative complicated course is the change of PVD and PPV. In the first 24 hours after surgery, if these parameters decrease there is a high chance of a complicated perioperative course.

Postoperative complications of spine surgery

A variety of surgical approaches are available for the treatment of spine diseases. Complications can arise intraoperatively, in the immediate postoperative period, or in a delayed fashion. These complications may lead to severe or even permanent morbidity if left unrecognized and untreated [1-4]. Here we review a range of complications in the early postoperative period from more benign complications such as postoperative nausea and vomiting (PONV) to more feared complications leading to permanent loss of neurological function or death [5]. Perioperative pain management is covered in a separate review (Chapter 8).