Fluid optimization guided by oesophageal Doppler significantly improves bowel perfusion

Abstract

Editor—We report an emergency laparotomy in an elderly patient, where central venous pressure (CVP) did not provide a reliable guide to intraoperative fluid administration. However, oesophageal Doppler-guided fluid resuscitation sufficiently improved perfusion of the compromised gut to allow a definitive and curative operation to proceed, in circumstances where conservative management and a second operation would otherwise have been necessary. An 82-yr-old lady presented with symptoms and signs of acute bowel obstruction. Examination revealed severe abdominal distension and an irreducible right femoral hernia. She was moderately hypotensive and anuric. Urea and creatinine levels were elevated, and there was a mild metabolic alkalosis. The lactate level was 4.8 mmol litre−1. Acute small bowel obstruction secondary to an incarcerated femoral hernia was diagnosed. The patient was taken to theatre for an emergency laparotomy. Anaesthesia was induced with fentanyl 100 µg, propofol 100 mg, and succinylcholine 100 mg, followed by rocuronium. Anaesthesia was maintained with oxygen 50%, air 50%, and desflurane. I.V. morphine (20 mg) was used for analgesia. An arterial line and a right jugular central venous line were inserted. At operation, the diagnosis of a strangulated femoral hernia containing ischaemic small bowel was confirmed. Three attempts were made to resect non-viable small bowel, but on each occasion, the ends of the bowel became extremely ischaemic and anastomosis could not be attempted. As the initial CVP was 15 mm Hg, fluid resuscitation in this first hour of surgery was restricted to 1 litre of Hartmann’s solution and 500 ml of Volulyte®. An oesophageal Doppler probe (Cardio-Q™, Deltex Medical Ltd, Chichester, West Sussex) was inserted, and the stroke volume and cardiac output were found to be significantly reduced, although the CVP was apparently adequate (Table 1). It was determined that severe intravascular volume depletion was the cause of the poor gut perfusion and was preventing the formation of an anastomosis. Surgery was halted, so that intensive fluid resuscitation could be undertaken. The ends of the small bowel were stapled off and returned to the abdomen. Over 45 min, 1.5 litre of Hartmann’s solution and 1.5 litre of Volulyte were infused. Stroke volume and cardiac output improved dramatically (Table 1). Surgery was recommenced.Table 1Comparison of intraoperative CVP and oesophageal Doppler recordings during volume resuscitation. Total volume given 4500 mlTime after induction of anaesthesia (min)Fluid given cumulative total (ml)Central venous pressure (mm Hg)Oesophageal Doppler measurementsHartmann’s solutionVolulyte®Stroke volume (ml)Cardiac output (litre min−1)6010005001470.675150010008121.09020001500151009.0105250020002014011.0 Open table in a new tab The cut ends of the small bowel were now well perfused and bleeding freely at the edges. A side-to-side ileal anastomosis was carried out and a defunctioning loop ileostomy was formed. The abdomen was closed easily and the patient was transferred to the intensive care unit. The trachea was extubated after 12 h, and inotropic support was weaned off after 48 h. Urine output improved to 40–100 ml kg−1 h−1 within 24 h of surgery, and lactate levels decreased rapidly. The patient was discharged from the intensive care unit (ICU) after 5 days. The loop ileostomy was closed without laparotomy some months later. Clinical trials demonstrating the benefits of oesophageal Doppler-guided fluid management in colorectal surgery have focused almost exclusively on elective bowel resection.1Wakeling HG McFall MR Jenkins CS et al.Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery.Br J Anaesth. 2005; 95: 634-642Abstract Full Text Full Text PDF PubMed Scopus (484) Google Scholar, 2Noblett SE Snowden CP Shenton BK Horgan AF Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection.Br J Surg. 2006; 93: 1069-1076Crossref PubMed Scopus (398) Google Scholar, 3Mowatt G Houston G Hernández R et al.Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients.Health Technol Assess. 2009; 13: 1-95Crossref Scopus (10) Google Scholar Greater improvements should be seen in patients undergoing emergency bowel resection, but no studies addressing this question have been published. This case demonstrates that the use of oesophageal Doppler can optimize perioperative fluid therapy in the elderly sick laparotomy patient. More fluid was administered than would have been the case had the CVP been used to guide therapy. The patient did not develop pulmonary oedema and was extubated successfully 12 h after admission to ITU. If CVP measurements had been used, the patient would have remained underperfused and the bowel could have been permanently compromised. The surgical course of the operation, and hence the outlook for the patient, may be changed dramatically by oesophageal Doppler-guided fluid management. None declared.