Crystalloid Infusion Research Articles

The influence of enhanced recovery after cardiac surgery on 30-day readmission rate, hospital and ICU length of stay

Introduction Enhanced Recovery After Surgery (ERAS) pathways have been proven to increase patient satisfaction scores, decrease the complication rate, decrease the length of stay (LOS), and decrease cost for many surgical specialties. Recently, ERAS for cardiac surgery guidelines have been published and are being implemented in many centers. However, few data are reported on clinically important outcomes. We examined the effect of ERAS for cardiac patients on the duration of mechanical ventilation, ICU and hospital LOS.¹ Methods We retrospectively analyzed prospectively collected outcome data of patients undergoing cardiac surgery enrolled in the ERAS pathway (n = 115) compared to a historical standard care group (n = 188). The ERAS pathway included pre-operative patient education, multimodal pain management to minimize opioid usage, carbohydrate loading 2-4hrs before induction of anesthesia, minimizing crystalloid infusions, tight glucose control, early postoperative invasive access and chest tube removal, early extubation, and early mobilization. The standard care group was treated per preexisting institutional guidelines. Data were compared using univariate analysis: parametric and non-parametric data were analyzed with Student's t-test and Wilcoxon rank-sum test, respectively. A p-value of less than 0.05 was considered statistically significant. Results The median (25th, 75th) intensive care unit (ICU) length of stay (LOS) was 1 day (1, 2) in the ERAS group and 2 days (1, 3) in the standard care group (p Discussion The Enhanced Recovery Pathway after Surgery pathway uses a standardized approach to perioperative patient care. Implementation of ERAS for cardiac surgery results in shorter ICU and hospital LOS, comparable ICU and 30-day readmission rates, without a noticeable increase in 30-day mortality. Further studies focusing on other relevant outcome parameters are warranted.

The Impact of Different Intraoperative Fluid Administration Strategies on Postoperative Extubation Following Multilevel Thoracic and Lumbar Spine Surgery: A Propensity Score Matched Analysis.

Patients undergoing multilevel spine surgery are at risk for delayed extubation. To evaluate the impact of type and volume of intraoperative fluids administered during multilevel thoracic and/or lumbar spine surgery on postoperative extubation status. Retrospective evaluation of medical records of patients≥18 yr undergoing≥4 levels of thoracic and/or lumbar spine fusions was performed. Patients were organized according to postoperative extubation status: immediate (IMEX; in OR/PACU) or delayed (DEX; outside OR/PACU). Propensity score matched (PSM) analysis was performed to compare IMEX and DEX groups. Volume, proportion, and ratios of intraoperative fluids administered were evaluated for the associated impact on extubation status. A total of 246 patients (198 IMEX, 48 DEX) were included. PSM analysis demonstrated that increased administration of non-cell saver blood products (NCSB) and increased ratio of crystalloid: colloids infused were independently associated with delayed extubation. With increasing EBL, IMEX had a proportionate reduction in crystalloid infusion (R=-0.5, P<.001), while the proportion of crystalloids infused remained relatively unchanged for DEX (R=-0.27; P=.06). Twenty-six percent of patients receiving crystalloid: colloid ratio>3:1 had DEX compared to none of those receiving crystalloid: colloid ratio≤3:1 (P=.009). DEX had greater cardiac and pulmonary complications, surgical site infections and prolonged intensive care unit and hospital stay (P<.05). PSM analysis of patients undergoing multilevel thoracic and/or lumbar spine fusion demonstrated that increased administration of crystalloid to colloid ratio is independently associated with delayed extubation. With increasing EBL, a proportionate reduction of crystalloids facilitates early extubation.

Usefulness of Therapeutic Hypothermia to Improve Survival in Out-of-Hospital Cardiac Arrest.

In recent years, therapeutic hypothermia (TH) has been used to improve outcomes in patients with out-of-hospital cardiac arrest (OHCA). Despite these recommendations, many centers are still hesitant to implement such hypothermia protocols. In this study, we assessed the effects of TH for OHCA patients. A total of 58 OHCA patients who had return of spontaneous circulation after OHCA presumed to be due to cardiac causes were enrolled. Twenty-three patients underwent TH, which was performed using a large volume of ice crystalloid fluid infusions in the emergency room and conventional cooling blankets in the ICU to maintain a body temperature of 32-34 °C for 24 hours using a tympanic thermometer. Patients in the control group received standard supportive care without TH. Hospital survival and neurologic outcomes were compared. There were no significant differences between the groups in patient characteristics, underlying etiologies and disease severity. In the 23 patients who received TH, 17 were alive at hospital discharge. In the 35 patients who received supportive care, only 11 were alive at hospital discharge (73.91% vs. 31.43%, p = 0.0015). Approximately 52% of the patients in the TH group had good neurologic outcomes (12 of 23) compared with the 20% (7 of 35) of the patients in the supportive group (p = 0.01). TH can improve the outcomes of OHCA patients. Further large-scale studies are needed to verify our results.

Plasma expanders for people with cirrhosis and large ascites treated with abdominal paracentesis.

Plasma expanders for people with cirrhosis and large ascites treated with abdominal paracentesis.

LO73: The state of the evidence for emergency medical services care of adult patients with sepsis: an analysis of appraised research from the Prehospital Evidence-Based Practice (PEP) program

Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.

Retrospective Analysis of Eighty-Nine Caesarean Section Cases with Abnormal Placental Invasion.

Abnormal placental invasion (API) is defined as an abnormal adherence of the placenta to the underlying uterine wall. Undiagnosed API may result in catastrophic maternal haemorrhage during delivery. In the present retrospective analysis, anaesthetic and surgical records were evaluated in patients with API who had undergone caesarean delivery (CD). Clinical records of 89 patients with API who had undergone CD were retrospectively reviewed in our clinic between April 2010 and February 2017. Amongst the patients, 87 (97.8%) had a history of previous CD and 68 (76.4%) had placenta previa. In regression analysis, weak positive correlation was found between an increase in packed red blood cell (PRBC) (r=0.420, p=0.001) and fresh frozen plasma (FFP) (r=0.476, p=0.022) transfusions and time of hospital stay. PRBC and FFP consumptions were significantly greater in intensive care unit (ICU) patients than in non-ICU patients (p<0.001). ICU requirement were significantly greater in patients who had more than average crystalloid (p=0.004) and colloid (p<0.001) infusions. Elective CD was performed in 81 (91%) patients and emergency CD in 8 (9%). PRBC transfusions were 7±4.3 U in patients undergoing emergency CD and 3.85±3 U in patients undergoing elective CD (p=0.034). The number of patients requiring care in ICU was 4 (50%), who underwent emergency CD and 12 (14%) who underwent elective CD, (p=0.032). It is crucial that the anaesthesiologist should be familiar with the risk factors and diagnosis of API because of the potential risk of massive haemorrhage. Multidisciplinary approach with surgery and blood bank decreases the amount of bleeding, blood transfusion requirement, ICU and hospital stay in patients with API.

The haemodynamic effects of crystalloid and colloid volume resuscitation on primary, derived and efficiency variables in post-CABG patients

BackgroundRecent studies in haemodynamic management have focused on fluid management and assessed its effects in terms of increase in cardiac output based on fluid challenges or variations in pulse pressure caused by cyclical positive pressure ventilation. The theoretical scope may be characterised as Starling-oriented. This approach ignores the actual events of right-sided excitation and left-sided response which is consistently described in a Guyton-oriented model of the cardiovascular system.AimBased on data from a previous study, we aim to elucidate the primary response to crystalloid and colloid fluids in terms of cardiac output, mean blood pressure and right atrial pressure as well as derived and efficiency variables defined in terms of Guyton venous return physiology.MethodRe-analyses of previously published data.ResultsCardiac output invariably increased on infusion of crystalloid and colloid solutions, whereas static and dynamic efficiency measures declined in spite of increasing pressure gradient for venous return.DiscussionWe argue that primary as well as derived and efficiency measures should be reported and discussed when haemodynamic studies are reported involving fluid administrations.

Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the “one-size-fits-all” approach

ObjectiveThe Surviving Sepsis Campaign and Centers for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) recommend rapid crystalloid infusion (≥30 mL/kg) for patients with sepsis-induced hypoperfusion or septic shock. We aimed to assess compliance with this recommendation, factors associated with non-compliance, and how compliance relates to mortality. DesignRetrospective, observational study. Setting1136-bed academic and 235-bed community hospital (January 2015–June 2016). PatientsPatients with septic shock. InterventionsCrystalloid infusion (≥30 mL/kg) within 6 h of identification of septic shock as required by CMS. MeasurementsAssociations with compliance and how compliance associates with mortality; odds ratios (OR) and 95% confidence intervals (CI) reported. Main resultsOverall, 1027 septic shock patients were included. Of these, 486 (47.3%) met the 6-hour 30 ml/kg fluid requirement. Compliance was lower in patients with congestive heart failure (CHF) (40.9%), chronic kidney disease (CKD) (42.3%) or chronic liver disease (38.5%) and among those that were identified in the inpatient setting (35.4%) rather than in the emergency department (51.7%). When adjusting for relevant covariates, compliance (compared to non-compliance) was not associated with in-hospital mortality: OR 1.03 CI 0.76–1.41. ConclusionsThese findings question a “one-size-fits-all” approach to fluid administration and performance measures for patients with sepsis.

Is perioperative colloid infusion more effective than crystalloid in preventing postoperative nausea and vomiting?: A systematic review and meta-analysis.

Adequate intravenous fluid replacement is recommended as an effective nonpharmacologic strategy for reducing postoperative nausea and vomiting (PONV), one of the most common and stressful complications of general anesthesia. We aimed to evaluate the effect of hydration, according to the type of fluid, on PONV as previous studies have reported inconsistent results. We performed a systemic review and meta-analysis of randomized controlled trials (RCTs) comparing infusion of colloid with that of crystalloid in terms of PONV incidence and the need for rescue antiemetic therapies for 24 hours after surgery under general anesthesia. The effect of fluid infusion according to the duration of anesthesia was also examined. A literature search was performed, using MEDLINE, Excerpta Medica Database, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus, up to February 2018. We included 8 RCTs. Compared with the crystalloid infusion, perioperative colloid infusion did not reduce PONV incidence, with a relative risk of 0.87 (95% confidence interval [CI], 0.60-1.25). However, subgroup analysis by duration of anesthesia showed a statistically significant subgroup effect (P = .04, I = 77.4%), suggesting that the effect of colloid differed from that of crystalloid depending on the duration of anesthesia. In the subgroup that underwent anesthesia for more than 3 hours, in which the patients had mostly undergone abdominal surgeries, colloid infusion significantly reduced the incidence of PONV compared with crystalloid infusion (RR, 0.69; 95% CI, 0.53-0.89). In the subgroup that underwent anesthesia for <3 hours, colloid infusion did not reduce the incidence of PONV compared with crystalloid infusion (RR, 1.32; 95% CI, 0.76-2.27). The requirement for antiemetics was comparable between colloid and crystalloid infusions, with an RR of 0.93 (95% CI, 0.55-1.58). Colloid administration had a more preventive effect on PONV than crystalloid administration in patients undergoing abdominal surgery under general anesthesia for more than 3 hours but did not show a preventive effect in patients undergoing anesthesia for <3 hours.

Population Kinetics of 0.9% Saline Distribution in Hemorrhaged Awake and Isoflurane-anesthetized Volunteers.

Population-based, pharmacokinetic modeling can be used to describe variability in fluid distribution and dilution between individuals and across populations. The authors hypothesized that dilution produced by crystalloid infusion after hemorrhage would be larger in anesthetized than in awake subjects and that population kinetic modeling would identify differences in covariates. Twelve healthy volunteers, seven females and five males, mean age 28 ± 4.3 yr, underwent a randomized crossover study. Each subject participated in two separate sessions, separated by four weeks, in which they were assigned to an awake or an anesthetized arm. After a baseline period, hemorrhage (7 ml/kg during 20 min) was induced, immediately followed by a 25 ml/kg infusion during 20 min of 0.9% saline. Hemoglobin concentrations, sampled every 5 min for 60 min then every 10 min for an additional 120 min, were used for population kinetic modeling. Covariates, including body weight, sex, and study arm (awake or anesthetized), were tested in the model building. The change in dilution was studied by analyzing area under the curve and maximum plasma dilution. Anesthetized subjects had larger plasma dilution than awake subjects. The analysis showed that females increased area under the curve and maximum plasma dilution by 17% (with 95% CI, 1.08 to 1.38 and 1.07 to 1.39) compared with men, and study arm (anesthetized increased area under the curve by 99% [0.88 to 2.45] and maximum plasma dilution by 35% [0.71 to 1.63]) impacted the plasma dilution whereas a 10-kg increase of body weight resulted in a small change (less than1% [0.93 to 1.20]) in area under the curve and maximum plasma dilution. Mean arterial pressure was lower in subjects while anesthetized (P < 0.001). In awake and anesthetized subjects subjected to controlled hemorrhage, plasma dilution increased with anesthesia, female sex, and lower body weight. Neither study arm nor body weight impact on area under the curve or maximum plasma dilution were statistically significant and therefore no effect can be established.

SPINAL ANAESTHESIA-INDUCED HYPOTENSION IN OBSTETRICS: PREVENTION AND THERAPY.

SUMMARYRegional centro-axial anaesthesia, primarily spinal block, is the preferred method of anaesthesia for elective caesarean section because it entails fewer risks for the mother and the foetus compared to general anaesthesia. The most common side effect associated with spinal block is hypotension due to sympatholysis, occurring in up to 75% of cases. Spinal block-induced sympatholysis leads to vasodilatation and consequently causes maternal hypotension, which may compromise uterine blood flow and foetal circulation, and thus cause foetal hypoxia, bradycardia and acidosis. The selection of the most efficient treatment strategy to achieve haemodynamic stability during spinal anaesthesia for caesarean section continues to be one of the main challenges in obstetric anaesthesiology. A number of measures for the prevention and treatment of spinal block-induced hypotension are used in clinical practice, such as preloading and coloading with crystalloid and/or colloid infusion, wrapping of lower limbs with compression stockings or bandages, administering an optimal dose of local anaesthetic and achieving an optimal spinal block level, left tilt positioning, and administering inotropes and vasopressors. Instead of administering vasopressors after a drop in blood pressure has already occurred, the latest algorithms recommend a prophylactic administration of vasopressor infusion. The preferred vasoconstrictor in this case is phenylephrine, which is associated with a lower incidence of foetal acidosis, and maternal nausea and vomiting compared to other vasoconstrictors.

Modern aspects of the volemic management of patients with acute abdominal pathology.

In conditions of urgent surgical care, the age of patients, concomitant somatic chronic pathology are factors that significantly increase the risk of postoperative complications and lethality. The latter in this group of patients is 30-80% and is associated with the development of hypovolemia. Treatment of the latter is traditionally provided by the routine conduct of a liberal regimen of infusion therapy (IT) to achieve hypervolemic hemodilution by infusion of crystalloid and colloidal drugs. It was found that the consequences of the liberal regime of IT is the development of acute hypervolemia. The accumulation of excess fluid forms the development of interstitial edema of tissues, causing a decrease in tissue oxygenation, the development of coagulation disorders and multi-organ dysfunction ̸ inadequacy, inhibits the healing of wounds. Therefore, in recent years, a restrictive (restricted) IT regimen has become available for clinical use, the goal of which is to achieve normovolemia. At the same time, evidence-based clinical studies indicate the possibility of using perioperative optimization of hemodynamics in the clinic by individualizing IT in accordance with the indices of central hemodynamics.

Abstract 190: Hybrid Strategy of Damage Control IR (DCIR) and REBOA Would be Feasible for Traumatic Hemorrhagic Shock Patients Suffering From Severe Pelvic Injuries

Introduction: Massive hemorrhage with pelvic injury is sometimes lethal. So, success or failure of hemostatic intervention in the hyperacute phase leads to survival of patients directly. Recently, a hybrid strategy with Operative Management (OM) and Interventional Radiology (IR) and/or Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for torso or pelvic severe trauma has been recognized world-widely. But, awareness of Damage control IR (DCIR) which is conscious of time and coagulopathy as Damage control surgery (DCS) is still not enough. So, we studied the possibility of the hybrid strategy with DCIR and REBOA for traumatic hemorrhagic shock patients with pelvic fracture. Methods: This study included patients who underwent traditional IR or DCIR with REBOA, if it were needed, for a traumatic shock state mainly due to pelvic fracture, at our emergency and trauma center. They were sorted into traditional IR group (group IR) and DCIR group (group DCIR). The primary endpoint was a survival rate in the first 30 days after injured. Secondary endpoints were fluid factors such as total amount of crystalloid infusion and blood transfusion within the first 24 hours, and for the duration of the recovery from shock state. Results: 64 trauma shock patients were sorted into group IR (n=38) and group DCIR (n=26). All REBOA patients (n=18) were in group DCIR. Initial systolic BP (group IR vs DCIR; 75mmHg vs. 54), RTS (5.66 vs. 4.12) and Ps (0.61 vs. 0.39) were significantly lower in group DCIR. ISS (32.8 vs. 41.5) and initial Shock Index (1.9 vs. 2.4) were higher in group DCIR significantly. There were no significant differences in the amount of total crystalloid infusion (7353+/-3152ml vs. 7140+/-5342ml) and blood transfusion (4183+/-3485ml vs. 3972+/-3188ml), and the survival rate (30/38 (79%) vs. 16/28 (62%)). But the required time to recovery from shock state was significantly shorter in group DCIR (65min vs. 43min). Conclusion: The hybrid strategy with DCIR and REBOA did not increase any amount of blood transfusion or crystalloid infusion or the mortality rate. But it could shorten the duration of shock state compared with traditional IR treatment. Thus, this hybrid strategy would be feasible for hemorrhage shock patients suffering from pelvic severe trauma.

Recurrent Polyuria

Recurrent Polyuria

Evaluation of postoperative complications in elderly patients submitted to parotidectomy.

to evaluate the most incident histological subtypes and the main postoperative complications in elderly patients with parotid tumors submitted to parotidectomy. we conducted a retrospective study with 57 elderly patients submitted to parotidectomy from 2003 to 2017, at the São José County Hospital of Joinville, Santa Catarina, Brazil. thirty-three (57.9%) patients had benign tumors, the most frequent being Warthin's tumor, and 17 (29.8%), malignant tumors, squamous cell carcinoma being the most frequent. Seven patients (12.3%) presented clinical complications, arterial pressure instability and respiratory complications being the most frequent, in four (7%) and three (5.3%) cases, respectively. Thirteen (22.1%) patients presented complications related to the surgical wound, hematoma and wound infection being the most frequent, with six (10.5%) cases each. Twenty-four (42.1%) patients had some degree of facial nerve dysfunction in the postoperative period, Brackman-House grade III being the most frequent, in 11 cases (19.3%). Surgical time and lymphadenectomy were associated with clinical complications. The main variables that showed an association with surgical complications were tumor size, longer surgical time, reoperation, and perioperative crystalloid infusion volume. parotid neoplasms present a differentiated profile in the elderly population, especially Warthin's tumor and squamous cell carcinoma. Hematoma and infection of the operative wound and facial nerve lesions were the most prevalent complications in the postoperative period.

What's New in SHOCK, September 2018?

What's New in SHOCK, September 2018?

Effect of Glucose Containing Crystalloid Infusion on Maternal Hemodynamic Status After Spinal Anesthesia for Cesarean Section.

BackgroundDespite preventive strategies, hypotension is the most common complication of spinal anesthesia in cesarean section.ObjectivesThe aim of this study was to assess the effect of glucose-containing crystalloid infusion on maternal hemodynamic status after spinal anesthesia for cesarean section.MethodsIn this prospective, randomized, double-blind clinical trial, 80 parturients undergoing elective cesarean section with spinal anesthesia were studied. In group A (n = 40) ringer with 1% glucose solution (10 gr glucose in 1000 mL ringer) and in group B (n = 40) only ringer solution infused before and after spinal anesthesia. Demographic data, hemodynamic change, complications and their treatments, maternal blood sugar level and neonatal APGAR (appearance, pulse, grimace, activity and respiration) score, intraoperative fluid, duration of surgery, and anesthesia were recorded in the two groups.ResultsThe incidence of hypotension in group A was significantly lower than group B (27.5% vs 75%) (P = 0.002). Other complications (sustained hypotension, nausea, pallor, and shivering were significantly lower in parturients of the group A (P < 0.05). Maternal blood sugar (BS), before and after surgery, was not significantly different in the two groups (P = 0.207 and P = 0.239, respectively). There was no statistically significant difference in the APGAR score of neonates at the 1st and 5th minutes of the birth between the two groups (P = 0.076).ConclusionsIt seems that adding 1% glucose to crystalloid solution improves the hemodynamic status and decreases post-spinal anesthesia complications without significant changes in the maternal blood sugar level and APGAR score of neonates.

Enhanced Recovery After Surgery: Intraoperative Fluid Management Strategies.

Ideal fluid management is a critical component of enhanced recovery after surgery protocols and should be considered throughout the perioperative period. The goal of preoperative fluid management is for the patient to arrive to the operating room euvolemic. Intraoperative goals of fluid management are to preserve intravascular volume and minimize salt and water uptake through intravenous crystalloid infusions. Postoperatively, once patients are tolerant of oral fluid intake, intravenous fluids are not required and should be restarted only if clinically necessary. This article reviews evidence-based, best practices for intraoperative fluid management for patients undergoing surgery within an enhanced recovery after surgery pathway.

Massive Localized Lymphedema: Analysis of Intraoperative Care.

Massive localized lymphedema (MLL) is rare, but as the prevalence of obesity in adults rises, it can be foreseen that cases will increase in prevalence. These patients are unable to ambulate and have uncontrollable rash and skin breakdown. Operative management for MLL is offered when nonsurgical measures are ineffective. The surgery can be difficult with ambiguous tissue planes saturated with lymphatic fluid, ill-defined margins, large arteries and dilated veins, and extensive intraoperative fluid and blood loss. We performed a retrospective chart review and analysis with a focus on the intraoperative findings and management in order to provide improved awareness and recommendations for preoperative care. We reviewed the charts of 15 patients with MLL undergoing a total of 17 surgical resections at our institution. Patients were morbidly obese with an average body mass index of 63 kg/m and 5.5 other medical comorbidities. Average operative time was 4.5 hours. Operative time showed a moderate correlation with increased blood loss. Operative transfusion averaged approximately 1 U per case, with 12% (2/17) of cases needing additional transfusions following surgery. An increase in operative time correlated with an increase in crystalloid infusion. In conclusion, we recommend close communication between the surgery and anesthesia teams regarding the extent of the resection and potential for fluid resuscitation and transfusions. Preoperative laboratory tests are recommended, as well as type and cross-match prior to the operation to obtain a baseline for intraoperative and postoperative monitoring. Recommendations for intraoperative management include strict input and output monitoring and aggressive fluid resuscitation with appropriate arterial and venous access.

Quadratus lumborum block: are we aware of its side effects? A report of 2 cases

The quadratus lumborum block was initially described in 2007 and aims at blocking the same nerves as the ones involved on the Transverse Abdominis Plane block, while accomplishing some visceral enervation as well due to closer proximity with the neuroaxis and sympathetic trunk. Given its versatility, we have successfully used it in a wide range of procedures. We report two cases where we believe the dispersion of local anesthetic is likely to have led to a previously undescribed complication. We report two cases in which we performed a quadratus lumborum type II block and general anesthesia for total gastrectomy and right hemicolectomy. There were no noteworthy events while performing the block and inducing general anesthesia, but within 30-40min serious hypotension and tachycardia were noted. As other motives for hypotension were ruled out, the event was interpreted as block-induced sympatholysis due to cephalad dispersion of the local anesthetic to the paravertebral and epidural space, and successfully managed with ephedrine and increase of the crystalloid infusion rate. The quadratus Lumborum block is safe to execute and provides effective abdominal wall and visceral analgesia. However, the possibility of eliciting undesired episodes should prompt caution when performing this block and practitioners should thereafter remain vigilant. Questions regarding ideal dosing, volumes, timing of block and pertinence of catheters remain to be answered.