Intraoperative crystalloid utilization variability and association with postoperative outcomes: A post hoc analysis of two multicenter prospective cohort studies

BACKGROUND

The optimal regimen for intravenous administration of intraoperative fluids remains unclear. Our goal was to analyze intraoperative crystalloid volume administration practices and their association with postoperative outcomes.

METHODS

We extracted clinical data from two multicenter observational studies including adult patients undergoing colorectal surgery and total hip (THA) and knee arthroplasty (TKA). We analyzed the distribution of intraoperative fluid administration. Regression was performed using a general linear model to determine factors predictive of fluid administration. Patient outcomes and intraoperative crystalloid utilization were summarized for each surgical cohort. Regression models were developed to evaluate associations of high or low intraoperative crystalloid with the likelihood of increased postoperative complications, mainly acute kidney injury (AKI) and hospital length of stay (LOS).

RESULTS

7,580 patients were included. The average adjusted intraoperative crystalloid infusion rate across all surgeries was to 7.9 (SD 4) mL/kg/h. The regression model strongly favored the type of surgery over other patient predictors. We found that high fluid volume was associated with 40% greater odds ratio (OR 1.40; 95% confidence interval1.01-1.95, p = 0.044) of postoperative complications in patients undergoing THA, while we found no associations for the other types of surgeries, AKI and LOS CONCLUSIONS: A wide variability was observed in intraoperative crystalloid volume administration; however, this did not affect postoperative outcomes.

Anaesthesia evaluation and perioperative strategies in liver disease patients with cardiohepatic syndrome

Cardiohepatic syndrome (CHS) presents a significant challenge in perioperative management due to the complex interaction between liver and heart dysfunction. CHS, analogous to cardiorenal syndrome, encompasses various conditions where hepatic and cardiovascular pathologies exacerbate one another. Patients with chronic liver disease, cirrhosis, or heart failure often exhibit increased perioperative morbidity and mortality, necessitating tailored anesthetic strategies. A comprehensive understanding of CHS pathophysiology is crucial, as it informs risk assessment and guides perioperative management. Risk stratification tools such as the Child-Pugh and MELD scores are commonly used, but they have limitations in fully capturing perioperative risks. The updated STS 2024 model includes liver-specific parameters, improving risk prediction in cardiac surgeries. Additionally, the VOCAL-Penn score addresses gaps in traditional risk models, providing a more accurate assessment for patients with advanced liver disease. Perioperative management focuses on minimizing hemodynamic stress and avoiding drugs metabolized by the liver. Agents like Remifentanil, Atracurium, and Esmolol are preferred for their minimal hepatic metabolism. Vasopressors such as terlipressin and vasopressin, which target the splanchnic circulation, improve hemodynamics in these patients. Within the Enhanced Recovery After Surgery (ERAS) framework, optimizing nutrition and fluid management is essential for reducing perioperative complications. Effective management of patients with CHS requires a multidisciplinary approach that integrates comprehensive risk assessment and individualized anesthetic strategies. This approach improves outcomes by reducing perioperative complications and mortality in this high-risk population.

Intraoperative goal-directed hemodynamic therapy targeting both arterial pressure and flow parameters using uncalibrated pulse contour techniques: A meta-analysis of randomized controlled trials

BACKGROUND

Goal-directed haemodynamic therapy (GDHT) aims to optimize haemodynamic variables. However, its effectiveness in reducing postoperative complications in major abdominal surgery, particularly when targeting both arterial pressure and flow variables, remains unclear. This meta-analysis addresses this by evaluating GDHT using uncalibrated pulse contour (uPC) methods.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCT) in adult patients undergoing major abdominal surgery who received GDHT using uncalibrated pulse contour (uPC) methods for cardiac output monitoring, with predefined targets for both blood flow and blood pressure. The primary outcome was postoperative complications; secondary outcomes included postoperative acute kidney injury (AKI), hospital length of stay (EH), intraoperative fluid administration and mortality.

RESULTS

Initial search retrieved 860 reports, with 12 RCTs (1367 patients) meeting the inclusion criteria. Our meta-analysis showed a significant reduction in postoperative complications (RR 0.78, 95% CI 0.68-0.90), AKI (RR 0.7, 95% CI 0.51-0.97), and hospital LOS (SMD -0.30, 95% CI -0.54 to -0.06) with uPC-guided GDHT. No significant differences were observed in intraoperative fluid volume and mortality.

CONCLUSIONS

Implementing GDHT in major abdominal surgery with predefined arterial pressure and blood flow targets significantly reduces postoperative morbidity and hospital EH without increasing intraoperative fluid administration.

Intraoperative crystalloid utilization variability and association with postoperative outcomes: A post hoc analysis of two multicenter prospective cohort studies

BACKGROUND

The optimal regimen for intravenous administration of intraoperative fluids remains unclear. Our goal was to analyze intraoperative crystalloid volume administration practices and their association with postoperative outcomes.

METHODS

We extracted clinical data from two multicenter observational studies including adult patients undergoing colorectal surgery and total hip (THA) and knee arthroplasty (TKA). We analyzed the distribution of intraoperative fluid administration. Regression was performed using a general linear model to determine factors predictive of fluid administration. Patient outcomes and intraoperative crystalloid utilization were summarized for each surgical cohort. Regression models were developed to evaluate associations of high or low intraoperative crystalloid with the likelihood of increased postoperative complications, mainly acute kidney injury (AKI) and hospital length of stay (LOS).

RESULTS

7580 patients were included. The average adjusted intraoperative crystalloid infusion rate across all surgeries was to 7.9 (SD 4) mL/kg/h. The regression model strongly favored the type of surgery over other patient predictors. We found that high fluid volume was associated with 40% greater odds ratio (OR 1.40; 95% confidence interval 1.01-1.95, p = 0.044) of postoperative complications in patients undergoing THA, while we found no associations for the other types of surgeries, AKI and LOS CONCLUSIONS: A wide variability was observed in intraoperative crystalloid volume administration; however, this did not affect postoperative outcomes.

Colloids versus crystalloids in the prevention of hypotension induced by spinal anesthesia in elective cesarean section. A systematic review and meta-analysis

The incidence of hypotension associated to spinal anesthesia in elective cesarean section is high. To determine the effects of colloids and crystalloids in the incidence of hypotension induced by spinal anesthesia in elective cesarean section, an attempt was made to define which type of fluid and what total volume should be administered. Following the PRISMA methodology a systematic review and meta-analysis were carried out. A systematic Medline/PubMed, EMBASE and Cochrane Library search was made to identify trials where women were scheduled for elective cesarean section with spinal anesthesia and volume loading (preload or co-load). The primary outcome was the incidence of hypotension. Stratification into subgroups was made for the primary outcome according to the type of colloid administered, differentiating those studies employing new generation colloids (HES 6% 130/0.4) from those not using such colloids, based on the volume of colloid administered and the combination of a vasopressor. The secondary outcome was the incidence of intraoperative nausea and vomiting. Two-hundred and twenty-seven controlled clinical trials were analyzed; eleven randomized clinical trials including 990 patients were included. A significative decrease of incidence of hypotension associated to spinal anesthesia was observed with the use of colloids compared to crystalloids (RR [95% CI] 0.70 [0.53-0.92], P=0.01). However, there was no difference between crystalloid and colloid in the risk of intraoperative nausea and vomiting (RR [95% CI] 0.75 [0.41-1.38]; P=0.33). This meta-analysis shows colloid administration to significantly reduce the incidence of hypotension associated to spinal anesthesia in elective cesarean section compared with of crystalloid use.

Intraoperative goal-directed hemodynamic therapy through fluid administration to optimize the stroke volume: A meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the clinical impact of optimizing stroke volume (SV) through fluid administration as part of goal-directed hemodynamic therapy (GDHT) in adult patients undergoing elective major abdominal surgery.

METHODS

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered in the PROSPERO database in January 2024. The intervention was defined as intraoperative GDHT based on the optimization or maximization of SV through fluid challenges, or by using dynamic indices of fluid responsiveness, including stroke volume variation, pulse pressure variation, and plethysmography variation index compared to usual fluid management. The primary outcome was postoperative complications. Secondary outcome variables included postoperative acute kidney injury (AKI), length of stay (LOS), intraoperative fluid administration, and 30-day mortality.

RESULTS

A total of 29 randomized controlled trials (RCTs) met the inclusion criteria. There were no significant differences in the incidence of postoperative complications (RR 0.89; 95% CI, 0.78-1.00), postoperative AKI (OR 0.97; (95% IC, 0.55-1.70), and mortality (OR 0.80; 95% CI, 0.50-1.29). GDHT was associated with a reduced LOS compared to usual care (SMD: -0.17 [-0.32; -0.03]). The subgroup in which hydroxyethyl starch was used for hemodynamic optimization was associated with fewer complications (RR 0.79; 95% CI, 0.65-0.94), whereas the subgroup of patients in whom crystalloids were used was associated with an increased risk of postoperative complications (RR 1.08; 95% CI, 1.04-1.12).

CONCLUSIONS

In adults undergoing major surgery, goal-directed hemodynamic therapy focused on fluid-based stroke volume optimization did not reduce postoperative morbidity and mortality.