Chloride-guided bolus vs conventional fluid therapy for preoperative optimisation in infantile hypertrophic pyloric stenosis.

Diagnostic aids in the differentiation of pyloric stenosis from severe gastroesophageal reflux during early infancy: The utility of serum bicarbonate and serum chloride

BackgroundThis study evaluated impact of intraoperative goal-directed therapy (GDT) judged by changes of stroke volume variation (SVV) and cardiac index (CI) using the Vigileo/FloTrac system on postoperative (PO) morbidities and mortality rates in high risk patients scheduled for major abdominal surgeries in comparison to conventional fluid therapy (CT).Methods86 patients were randomly allocated into one of two equal groups: CT group = 43 patients received crystalloid solution and on demand bolus of 250 ml colloids with possible addition of vasopressor or inotrope to target MAP at 60–90 mmHg, CVP at 8–12 mmHg and urine output at >0.5 ml/kg/hr and GDT group = 43 patients received crystalloid fluid therapy (FT) and colloids (3 ml/kg) with possible addition of vasopressor or inotrope according to predefined protocol with a target CI 2.5 L/min/m2, SVV < 12% with MAP > 65 mmHg. Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) was used to predict morbidity and mortality rates. Study outcomes included ICU and total hospital morbidity and mortality rates and length of stay (LOS).ResultsIntraoperative GDT reduced ICU morbidity rate (16.3%) than the POSSUM predicted rate (39.78%) and significantly (p = 0.039) than CT group (37.2%), while in CT group ICU morbidity rate coincided with POSSUM predicted rate (42.86%). ICU and total hospital LOS were significantly shorter with GDT group than with CT group. However, mortality rates weren’t significantly lower with GDT group than CT group (7% vs. 11.6%). The applied protocol for intraoperative GDT reduced significantly crystalloid infusion and despite of significantly higher amount of received colloids, the total amount of FT was significantly less than CT group.ConclusionThe applied protocol for intraoperative GDT provided significant reduction of PO morbidities, ICU and hospital LOS but couldn‘t significantly reduce mortality rates in high risk patients scheduled for major abdominal surgeries.

Infantile hypertrophic pyloric stenosis (IHPS) is a common gastrointestinal disease in neonates and hypochloremia metabolic alkalosis is a typical laboratory finding in affected patients. This study aimed to analyze the clinical characteristics of infants with IHPS and evaluate the association of clinical and laboratory parameters with ultrasonographic findings. Infants diagnosed with IHPS between January 2017 and July 2022 were retrospectively evaluated. A total of 67 patients were included in the study. The mean age at diagnosis was 40.5±19.59 days, and the mean symptom duration was 11.97±9.91 days. The mean pyloric muscle thickness and pyloric canal length were 4.87±1.05 mm and 19.6±3.46 mm, respectively. Hyponatremia and metabolic alkalosis were observed in five (7.5%) and 36 (53.7%) patients, respectively. Serum sodium (p=0.011), potassium (p=0.023), and chloride levels (p=0.015) were significantly lower in patients with high bicarbonate levels (≥30 mmol/L). Furthermore, pyloric canal length was significantly higher in patients with high bicarbonate levels (p=0.015). To assess metabolic alkalosis in IHPS patients, the area under the receiver operating characteristic curve of pyloric canal length was 0.910 and the optimal cutoff value of the pyloric canal length was 23.5 mm. We found a close association between laboratory and ultrasonographic findings of IHPS. Clinicians should give special consideration to patients with pyloric lengths exceeding 23.5 mm and appropriate fluid rehydration should be given to these patients.

Background Intraoperative goal-directed fluid therapy (GDFT) is recommended in most perioperative guidelines for intraoperative fluid management in patients undergoing elective colorectal surgery. However, the evidence in elective colorectal surgery alone is not well established. The aim of this meta-analysis was to compare the effects of GDFT with those of conventional fluid therapy on outcomes after elective colorectal surgery. Methods A meta-analysis of RCTs examining the role of transoesophageal Doppler-guided GDFT with conventional fluid therapy in adult patients undergoing elective colorectal surgery was performed in accordance with PRISMA methodology. The primary outcome measure was overall morbidity, and secondary outcome measures were length of hospital stay, time to return of gastrointestinal function, 30-day mortality, acute kidney injury, and surgical-site infection and anastomotic leak rates. Results A total of 11 studies were included with a total of 1113 patients (556 GDFT, 557 conventional fluid therapy). There was no significant difference in any clinical outcome measure studied between GDFT and conventional fluid therapy, including overall morbidity (risk ratio (RR) 0·90, 95 per cent c.i. 0·75 to 1·08, P = 0·27; I 2 = 47 per cent; 991 patients), 30-day mortality (RR 0·67, 0·23 to 1·92, P = 0·45; I 2 = 0 per cent; 1039 patients) and length of hospital stay (mean difference 0·01 (95 per cent c.i. -0·92 to 0·94) days, P = 0·98; I 2 = 34 per cent; 1049 patients). Conclusion This meta-analysis does not support the perceived benefits of GDFT guided by transoesophageal Doppler monitoring in the setting of elective colorectal surgery.

BackgroundIntraoperative goal‐directed fluid therapy (GDFT) is recommended in most perioperative guidelines for intraoperative fluid management in patients undergoing elective colorectal surgery. However, the evidence in elective colorectal surgery alone is not well established. The aim of this meta‐analysis was to compare the effects of GDFT with those of conventional fluid therapy on outcomes after elective colorectal surgery.MethodsA meta‐analysis of RCTs examining the role of transoesophageal Doppler‐guided GDFT with conventional fluid therapy in adult patients undergoing elective colorectal surgery was performed in accordance with PRISMA methodology. The primary outcome measure was overall morbidity, and secondary outcome measures were length of hospital stay, time to return of gastrointestinal function, 30‐day mortality, acute kidney injury, and surgical‐site infection and anastomotic leak rates.ResultsA total of 11 studies were included with a total of 1113 patients (556 GDFT, 557 conventional fluid therapy). There was no significant difference in any clinical outcome measure studied between GDFT and conventional fluid therapy, including overall morbidity (risk ratio (RR) 0·90, 95 per cent c.i. 0·75 to 1·08, P = 0·27; I2 = 47 per cent; 991 patients), 30‐day mortality (RR 0·67, 0·23 to 1·92, P = 0·45; I2 = 0 per cent; 1039 patients) and length of hospital stay (mean difference 0·01 (95 per cent c.i. −0·92 to 0·94) days, P = 0·98; I2 = 34 per cent; 1049 patients).ConclusionThis meta‐analysis does not support the perceived benefits of GDFT guided by transoesophageal Doppler monitoring in the setting of elective colorectal surgery.

Background: This study aimed to compare the effects of intraoperative conventional fluid therapy using central venous pressure guidance and goal-directed fluid therapy using stroke volume variation guidance on the incidence of delayed graft function in renal transplant surgery. Materials and Methods: We retrospectively analyzed 179 patients who underwent renal transplant surgery at a single tertiary hospital. Patients were categorized into conventional fluid therapy and goal-directed fluid therapy groups. Patients in the conventional fluid therapy group were managed based on a target central venous pressure of 8–12 mm Hg, while patients in the goal-directed fluid therapy group were managed by targeting a stroke volume variation of 10% within the preoperative baseline, apart from the target mean arterial pressure &gt;80 mm Hg in both groups. Preoperative characteristics and intraoperative parameters were evaluated to determine their association with postoperative outcomes. Results: The goal-directed fluid therapy group demonstrated a significant reduction in the incidence of postoperative delayed graft function ( P = 0.007), metabolic acidosis ( P &lt; 0.001), cardiorespiratory complications ( P = 0.011), ventilator dependency ( P = 0.013), and length of intensive care unit ( P &lt; 0.001) and hospital stays ( P &lt; 0.001). Multiple logistic regression analysis revealed that receiving a graft from a deceased donor increased the odds of developing delayed graft function by 4.07 times compared with a living donor. In contrast, patients managed with goal-directed fluid therapy had a 72% lower risk of developing delayed graft function and were 9.17 times more likely to achieve 28-day graft function compared with those in the conventional fluid therapy group. Conclusions: Goal-directed fluid therapy reduced the incidence of delayed graft function, metabolic acidosis, cardiorespiratory complications, and ventilator dependency and shortened intensive care unit and hospital stays in renal transplant surgery.

Health disparities in infants with hypertrophic pyloric stenosis

Interdisciplinary Collaboration: Volunteers in Health Care: Helping Patients in Need

Goal-directed fluid therapy versus conventional fluid therapy in colorectal surgery: A meta analysis of randomized controlled trials

Goal-directed fluid therapy (GDFT) has conflicting evidence regarding outcomes in neurosurgical patients. This meta-analysis aimed to compare the effect of GDFT and conventional fluid therapy on various perioperative outcomes in patients undergoing neurosurgical procedures. A comprehensive literature search was conducted using PubMed, EMBASE, Scopus, ProQuest, Web of Science, EBSCOhost, Cochrane and preprint servers. The search was conducted up until 16 October 2023, following PROSPERO registration. The search strategy included terms related to GDFT, neurosurgery and perioperative outcomes. Only randomised controlled trials involving adult humans and comparing GDFT with standard/liberal/traditional/restricted fluid therapy were included. The studies were evaluated for risk of bias (RoB), and pooled estimates of the outcomes were measured in terms of risk ratio (RR) and mean difference (MD). No statistically significant difference was observed in neurological outcomes between GDFT and conventional fluid therapy [RR with 95% confidence interval (CI) was 1.10 (0.69, 1.75), two studies, 90 patients, low certainty of evidence using GRADEpro]. GDFT reduced postoperative complications [RR = 0.67 (0.54, 0.82), six studies, 392 participants] and intensive care unit (ICU) and hospital stay [MD (95% CI) were -1.65 (-3.02, -0.28) and -0.94 (-1.47, -0.42), respectively] with high certainty of evidence. The pulmonary complications were significantly lower in the GDFT group [RR (95% CI) = 0.55 (0.38, 0.79), seven studies, 442 patients, high certainty of evidence]. Other outcomes, including total intraoperative fluids administered and blood loss, were comparable in GDFT and conventional therapy groups [MD (95% CI) were -303.87 (-912.56, 304.82) and -14.79 (-49.05, 19.46), respectively]. The perioperative GDFT did not influence the neurological outcome. The postoperative complications and hospital and ICU stay were significantly reduced in the GDFT group.

The aim of this study is to evaluate the intra/perioperative fluid management and early postoperative outcomes of patients who underwent radical cystectomy with Enhanced Recovery After Surgery protocol, using goal-directed fluid therapy compared to conventional fluid therapy. This cohort study included patients who underwent open RC for urothelial bladder carcinoma with intent to cure and Enhanced Recovery After Surgery protocol between May 2012 and August 2019. Patients who had palliative or salvage cystectomy and/or adjunct procedures, as well as those with missing detailed perioperative data were excluded. Data were compared between patients who received goal-directed fluid therapy using stroke volume variation by FloTrac™/Vigileo system (n = 119) and conventional fluid therapy based on the anesthesiologist discretion (n = 192). Primary outcome variable was 90-day complications and secondary outcome measures included in-hospital GFR trend, length of stay, and 90-day readmission. The goal-directed fluid therapy group received less total and net intra/perioperative fluid, yet early postoperative glomerular filtration rate trends were similar between both groups (p = 0.7). Estimated blood loss, blood transfusion, index hospital stay, 90-day complication and readmission rates were also comparable between the two groups. Multivariable logistic regression showed no significant association between perioperative fluid management method and 90-day complication rate (OR 1.4, 95% CI 0.8-2.4, p = 0.2). Stroke volume variation guided goal-directed fluid therapy is safe in radical cystectomy without compromising the renal function. It is associated with less intra- and perioperative fluid infusion; however, no association with hospital stay, 90-day complication or readmission rates were noted.

Objective To evaluate the effect of goal-directed fluid therapy on postoperative rehabili-tation in elderly patients undergoing surgery in the prone position. Methods Sixty patients of both sexes, aged 60-75 yr, of American Society of Anesthesiologists physical status Ⅱ or Ⅲ, scheduled for elective lumbar surgery in the prone position under general anesthesia, were divided into 2 groups(n=30 each)using a random number table: conventional fluid therapy group(group C)and goal-directed fluid therapy group(group G). The CNAP system was used to monitor stroke volume variation and cardiac index continuously in group G. Mean arterial pressure was maintained at 60-110 mmHg, central venous pressure at 6-12 cmH2O and urine volume more than 0.5 ml·kg-1·h-1 using conventional fluid therapy in group C. In group G, goal-directed fluid therapy was performed under the guidance of stroke volume variation, and cardiac index was maintained at 2.5-4.0 L·min-1·m-2.The requirement for crystalloid and colloid solution, total volume of fluid infused, blood loss, urine volume and requirement for vasoactive agents were recorded during operation.After anesthesia induction, at 1 h after turning to the prone position and at the end of operation, blood samples were collected from the left radial artery for blood gas analysis, and the blood lactate concentration was recorded.The volume of drainage within 3 days after operation, perioperative blood transfusion, early postoperative cardiovascular and pulmonary complications, development of oliguria and anuria, emergence time and length of hospital stay were recorded. Results Compared with group C, the requirement for crystalloid solution, total volume of fluid infused, urine volume and requirement for vasoactive agents were significantly decreased during operation, the requirement for colloid solution was increased during operation, the blood lactate concentration was decreased at 1 h after turning to the prone position and at the end of operation, the length of hospital stay was shortened, and the incidence of postoperative cardiovascular and pulmonary complications was decreased in group G(P<0.05). Conclusion Goal-directed fluid therapy can promote postoperative rehabilitation and shows a certain clinical value in elderly patients undergoing surgery in the prone position. Key words: Fluid therapy; Aged; Prone position; Rehabilitation

Background and Aim:Head and neck cancer surgeries with free tissue transfer are complex procedures, and fluid management can grossly affect the microvascular anastomosis. We hypothesise that intra-operative goal-directed fluid therapy (GDFT) is the key to administer fluid individualised to a patient's requirement. The aim of this study was to observe the role of GDFT in perioperative flap outcome and length of hospital stay.Methods:A randomised prospective controlled study was performed in 106 patients undergoing composite resection of head and neck cancer with free tissue transfer. Patients in Group A received GDFT based on stroke volume variation whereas Group B received conventional fluid therapy intra-operatively. The endpoints of this study were total perioperative fluid, fluid boluses, vasopressor requirement, flap outcome and length of intensive care unit and hospital stay. Statistical analysis was done using Chi-square test. Results:The total intra-operative fluid given to both the groups was comparable but patients in Group A received more boluses and vasopressors compared to Group B during intra-operative period. The amount of fluid given in the first 24 hours post-operatively was significantly less in Group A (1807 + 476 ml) compared to Group B (2205 + 382 ml). Incidence of hypotension with tachycardia was observed in three patients in Group B and none in Group A. Poor flap outcome was observed in one patient in Group A versus four in Group B due to thrombosis.Conclusion:GDFT helps in early detection of fluid deficit and may avoid complications arising due to inadequate microvascular perfusion during the peri-operative period.

Objectives:To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols.Methods:Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality.Results:A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66–0.89, P = 0.0007), hospital length of stay (LOS; mean difference −1.55 days, 95% CI −2.73 to −0.36, P = 0.01), intensive care LOS (mean difference −0.63 days, 95% CI −1.18 to −0.09, P = 0.02), and time to passage of feces (mean difference −0.90 days, 95% CI −1.48 to −0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference −0.63 days, 95% CI −0.94 to −0.32, P < 0.0001) and time to passage of feces (mean difference −1.09 days, 95% CI −2.03 to −0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to −0.84, P = 0.0002) and total hospital LOS (mean difference −2.14, 95% CI −4.15 to −0.13, P = 0.04).Conclusions:GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting.

BackgroundPostoperative complications have become the main cause of prolonged hospitalization and reduced postoperative survival rate among surgical patients. Goal-directed fluid therapy (GDFT) has been reported to reduce the incidence of postoperative complications and mortality, shorten the hospital stay, and improve the outcome in major abdominal surgery patients. However, the benefit of GDFT in patients undergoing head and neck cancer surgery remains controversial. The purpose of this study is to evaluate whether GDFT can reduce the occurrence of serious postoperative complications and shorten the postoperative hospital stay, compared with standard conventional fluid therapy in patients undergoing head and neck cancer surgery.MethodsA total of 340 adult patients who scheduled for head and neck cancer surgery will be enrolled in this prospective, single-center, partly blinded, randomized controlled trial. Both groups will receive standard general anesthesia. Participants will be randomly assigned to GDFT group (group G) or conventional fluid therapy group (group C). Patients in group G will receive GDFT protocol associated with the stroke volume variation (SVV) ≤ 12% and the cardiac index (CI) was controlled at a minimum of 2.5 L/min/m2, whereas patients in group C underwent conventional fluid therapy based on mean arterial pressure (MAP) and urine output. The primary outcome is serious postoperative complications occurred within 30 days after surgery.DiscussionThis study will better demonstrate whether GDFT has a positive effect on postoperative outcomes in head and neck cancer patients. Results of the study will provide evidence for selecting appropriate intraoperative fluid management methods in such patients.Trial registrationClinicalTrials.gov NCT06468852. Registered on June 21, 2024Supplementary InformationThe online version contains supplementary material available at 10.1186/s13063-025-09152-7.