Goal-directed Fluid Management Research Articles

The effect of goal-directed crystalloid versus colloid administration on postoperative spirometry parameters: a substudy of a randomized controlled clinical trial

BackgroundPulmonary function is impaired after major abdominal surgery and might be less impaired by restrictive fluid administration. Under the assumption of a fluid-sparing effect of colloids, we tested the hypothesis that an intraoperative colloid-based goal-directed fluid management strategy impairs postoperative pulmonary function parameters less compared to goal-directed crystalloid administration.MethodsWe performed a preplanned, single-center substudy within a recently published trial evaluating the effect of goal-directed crystalloids versus colloids on a composite of major complications. Sixty patients undergoing major open abdominal surgery were randomized to Doppler-guided intraoperative fluid replacement therapy with lactated Ringer’s solution (n = 31) or unbalanced 6% hydroxyethyl starch 130/0.4 (n = 29). A blinded investigator performed bedside spirometry (Spirobank-G, Medical International Research, Rome, Italy) preoperatively as well as 6, 24, and 48 h postoperatively.ResultsMedian total intraoperative fluid requirements were significantly higher during crystalloid administration compared to patients receiving colloids (4567 ml vs. 3044 ml, p = 0.01). Six hours after surgery, pulmonary function parameters did not differ significantly between the crystalloid — and the colloid group: forced vital capacity (FVC): 1.6 l (1.2–2 l) vs. 1.9 l (1.5–2.4 l), p = 0.15; forced expiratory volume in 1 second (FEV1): 1.1 l (0.9–1.6 l) vs. 1.4 l (1.2–1.7 l), p = 0.18; and peak expiratory flow (PEF): 2 l.sec−1 (1.5 – 3.6 l.sec −1) vs. 2.3 l.sec −1 (1.8 – 3.4 l.sec −1), p = 0.23. Moreover, postoperative longitudinal time × group interactions of FVC, FEV1, and PEF between 6 and 48 postoperative hours did not differ significantly.ConclusionPostoperative pulmonary function parameters were similarly impaired in patients receiving goal-directed crystalloid administration as compared to goal-directed colloid administration during open abdominal surgery.Trial registrationClinicalTrials.gov (NCT00517127, registered on August 16, 2007) and EudraCT (2005-004602-86).

Comparison of Dynamic Measures in Intraoperative Goal-Directed Fluid Therapy of Patients with Morbid Obesity Undergoing Laparoscopic Sleeve Gastrectomy

IntroductionObesity increases the risk of morbidity and mortality during surgical procedures. Goal-directed fluid therapy (GDFT) is a new concept for perioperative fluid management that has been shown to improve patient prognosis. This study aimed to investigate the role of the Pleth Variability Index (PVI), systolic pressure variation (SPV), and pulse pressure variation (PPV) in maintaining tissue perfusion and renal function during GDFT management in patients undergoing laparoscopic sleeve gastrectomy (LSG).Materials and MethodsTwo hundred ten patients were enrolled in our prospective randomized controlled clinical trial. Demographic data, hemodynamic parameters, biochemical parameters, the amount of crystalloid and colloid fluid administered intraoperatively, and the technique of goal-directed fluid management used were recorded. Patients were randomly divided into three groups: PVI (n = 70), PPV (n = 70), and SPV (n = 70), according to the technique of goal-directed fluid management. Postoperative nausea and vomiting, time of return of bowel movement, and hospital stay duration were recorded.ResultsThere was no statistically significant difference between the number of crystalloids administered in all three groups. However, the amount of colloid administered was statistically significantly lower in the SPV group than in the PVI group, and there was no significant difference in the other groups. Statistically, there was no significant difference between the groups in plasma lactate, blood urea, and creatinine levels.ConclusionIn LSG, dynamic measurement techniques such as PVI, SPV, and PPV can be used in patients with morbid obesity without causing intraoperative and postoperative complications. PVI may be preferred over other invasive methods because it is noninvasive.Graphical abstract

Anesthetic Aspects of Cytoreductive Surgery and Hyperthermic Intrathoracic Chemotherapy (HITHOC) in Treatment of Pleural Malignancies - Experiences from IORS

Background: Cytoreductive surgery (CRS) with hyperthermic intrathoracic chemotherapy (HITHOC) is a procedure that includes surgical removal of all visible tumor implants and intrathoracic application of gradually heated cytostatic solution. Numerous changes in hemodynamic, respiratory, core body temperature and metabolic parameters are possible during this complex procedure. The aim of this retrospective study was to analyze pathophysiological changes which occur during CRS + HITHOC procedure, and to suggest efficient strategies for perioperative patient care that might reduce complication rate. Methods: The study included 7 patients who underwent CRS + HITHOC in our cancer center. Enhanced Recovery After Surgery (ERAS) guideline for Thoracic Surgery was applied to all patients. Data on intraoperative hemodynamics (mean arterial pressure, stroke volume, heart rate, cardiac output) and temperature variations were collected from medical records and analyzed in three timelines: during the CRS phase, at the beginning, and the end of cytostatic perfusion. Occurrence of respiratory, renal, and cardiac complications was monitored. Results: All patients were respiratory stable during one-lung ventilation, with adequate gas exchange. Hemodynamic stability was compromised at the beginning of cytostatic perfusion, with significant decrease of mean arterial pressure and stroke volume. Two patients required vasopressor support. Average core body temperature was satisfactory in all patients. Coagulation disorders and acute renal failure were not recorded in postoperative period. One patient developed atrial fibrillation which was successfully pharmacologically restored. Conclusion: Our results indicate that goal directed fluid management following ERAS protocol, with maintaining hemodynamic stability and normothermia, could prevent perioperative complications during HITHOC procedure.

The Effect of Goal-directed Fluid Management based on Stroke Volume Variation on ICU Length of Stay in Elderly Patients Undergoing Elective Craniotomy: A Randomized Controlled Trial.

Inappropriate fluid management during neurosurgery can increase postoperative complications. In this study, we aimed to investigate the effect of goal-directed fluid therapy using stroke volume variation (SVV) in elderly patients undergoing elective craniotomy. We randomized 100 elderly patients scheduled for elective craniotomy into two groups: goal-directed therapy (GDT, n = 50) group and conventional group (n = 50). Fluid management protocol using SVV was applied in the GDT group. Decisions about fluid and hemodynamic management in the conventional group were made by the anesthesiologist. Perioperative variables including fluid balance, lactate level, and intensive care unit (ICU) length of stay were assessed. There was no significant difference in ICU length of stay between the two groups: 14 (12, 16.75) hours in GDT group vs 15 (13, 18) hours in control group (p = 0.116). Patients in the GDT group received a significantly less amount of crystalloid compared with the control group: 1311.5 (823, 2018) mL vs 2080 (1420, 2690) mL (p < 0.001). Our study demonstrated a better fluid balance in the GDT group as 342.5 (23, 607) mL compared with the conventional group 771 (462, 1269) mL (p < 0.001). Intraoperative goal-directed fluid management based on SVV in elderly patients undergoing elective craniotomy did not reduce the ICU length of stay or postoperative complications. It did result in an improved fluid balance with no evidence of inadequate organ perfusion. TCTR20190812003. Sae-Phua V, Tanasittiboon S, Sangtongjaraskul S. The Effect of Goal-directed Fluid Management based on Stroke Volume Variation on ICU Length of Stay in Elderly Patients Undergoing Elective Craniotomy: A Randomized Controlled Trial. Indian J Crit Care Med 2023;27(10):709-716.

Effects of goal-directed fluid management guided by a non-invasive device on the incidence of postoperative complications in neurosurgery: a pilot and feasibility randomized controlled trial

BackgroundThe positive effects of goal-directed hemodynamic therapy (GDHT) on patient-orientated outcomes have been demonstrated in various clinical scenarios; however, the effects of fluid management in neurosurgery remain unclear. Therefore, this study was aimed at assessing the safety and feasibility of GDHT using non-invasive hemodynamic monitoring in elective neurosurgery. The incidence of postoperative complications was compared between GDHT and control groups.MethodsWe conducted a single-center randomized pilot study with an enrollment target of 34 adult patients scheduled for elective neurosurgery. We randomly assigned the patients equally into control and GDHT groups. The control group received standard therapy during surgery and postoperatively, whereas the GDHT group received therapy guided by an algorithm based on non-invasive hemodynamic monitoring. In the GDHT group, we aimed to achieve and sustain an optimal cardiac index by using non-invasive hemodynamic monitoring and bolus administration of colloids and vasoactive drugs. The number of patients with adverse events, feasibility criteria, perioperative parameters, and incidence of postoperative complications was compared between groups.ResultsWe successfully achieved all feasibility criteria. The GDHT protocol was safe, because no patients in either group had unsatisfactory brain tissue relaxation after surgery or brain edema requiring therapy during surgery or 24 h after surgery. Major complications occurred in two (11.8%) patients in the GDHT group and six (35.3%) patients in the control group (p = 0.105).ConclusionsOur results suggested that a large randomized trial evaluating the effects of GDHT on the incidence of postoperative complications in elective neurosurgery should be safe and feasible. The rate of postoperative complications was comparable between groups.Trial registrationTrial registration: ClininalTrials.gov, registration number: NCT04754295, date of registration: February 15, 2021.

The influence of the Pringle maneuver in laparoscopic hepatectomy: continuous monitor of hemodynamic change can predict the perioperatively physiological reservation.

This is the first study to investigate the correlation between intra-operative hemodynamic changes and postoperative physiological status. Patients receiving laparoscopic hepatectomy were routinely monitored using FloTract for goal-directed fluid management. The Pringle maneuver was routinely performed during parenchymal dissection and the hemodynamic changes were prospectively recorded. We retrospectively analyzed the continuous hemodynamic data from FloTrac to compare with postoperative physiological outcomes. The Pringle maneuver during laparoscopic hepatectomy. Stroke volume variation that did not recover from the relief of the Pringle maneuver during the last application of Pringle maneuver predicted elevated postoperative MELD-Na scores. The complexity of the hemodynamic data recorded by the FloTrac system during the Pringle Maneuver in laparoscopic hepatectomy can be effectively analyzed using the growth mixture modeling (GMM) method. The results can potentially predict the risk of short-term liver function deterioration.

Goal-directed fluid management associates with fewer postoperative fluid collections in pancreatoduodenectomy patients

BackgroundThe association between perioperative fluid management and complications in pancreatoduodenectomy patients remains controversial. We explored the association between fluid management and radiological signs of complications. MethodsWe examined pancreatoduodenectomy patients operated between July 2014 and December 2015 (n = 125) and between January 2017 and June 2018 (n = 124). The first cohort received intraoperative fluid management according to a goal-directed strategy and the second cohort was treated conventionally. We analyzed fluid administration, edema visible in computed tomography (CT) scans seven days postoperatively, and radiological signs of complications occurring up to 30 days. We performed multivariable logistic regression analyses to identify risk factors for fluid collections. ResultsNo statistically significant difference in postoperative edema via CT scans emerged between the fluid management groups. However, the intraperitoneal space expanded in patients with severe Clavien–Dindo complications compared with patients experiencing mild or no complications (19.1% (IQR 10.4–40.5) vs 2.5% (IQR -7.9–16.6), p = 0.004). Fluid collections were less frequent in the goal-directed group than in the conventional fluid management group (16.8% vs 34.7%, p = 0.001). Risk factors for fluid collections included main pancreatic duct size ≤3 mm, less intraoperative fluid volume accompanying conventional fluid management, a lower postoperative urine output, and postoperative congestive heart failure. The goal-directed group received more intraoperative fluids than the conventional fluid management group and postoperative urine output was higher in the goal-directed group on postoperative days 1–3. ConclusionsOptimization of intraoperative fluid management through target-controlled strategies and early diuresis were associated with a lower frequency of fluid collections in postoperative CT.

Comparison of goal-directed and standard therapy for hemodynamic management in heart transplantation surgery

Background: Significant numbers of patients who undergo major surgery experience postoperative problems, the majority of which are preventable. It has been demonstrated that goal-directed therapy, a method for guiding clinicians in administering fluids, vasopressors, and inotropes, reduces mortality and postoperative complications. However, heart transplant patients were not exclusively investigated. This study focused on patients having heart transplant surgery, which compared the effects of goal-directed versus traditional fluid management. Methods: Goal-directed and standard therapy were examined on 74 patients who had received heart transplantation and were randomly divided into two groups.Using Lidco's CO, CI, SVV, and SVR to track progress toward treatment goals, two groups were compared in terms of fluid repositioning and the use of vasoactive medications.We also compared secondary outcomes like AKI, Cardiac dysrhythmia, CVA, ICU length of stay, and 30-day survival. Results: Both groups had similar baseline characteristics. The goal-directed therapy group had less fluid repositioning. AKI, Cardiac dysrhythmia, CVA, ICU stay, and 30-day survival rates did not differ significantly between the groups; however, Conventional patients spent more time in the ICU. Conclusion: Our data showed that the time spent in the intensive care unit after a heart transplant can be cut in half using GDT. Adverse events occurred in both groups with no statistically significant difference. Preoperative goal-directed therapy needs further well-designed and adequately powered studies.

Goal-Directed Hemodynamics in Rapid Response Teams

Rapid Response Teams became a hospital standard in 2004 after a campaign by the Institute of Healthcare Improvement. The intention was to reduce hospital morbidity and mortality by bringing the resources to the bedside that match the patient’s needs in a timely fashion. Rapid Response Teams, or RRTs, are now integral to most hospital operations. However, a wide variety of practices surround RRTs within a healthcare system, including team composition, the scope of interventions, team training, and administrative support. RRTs have not been shown to correlate strongly with reducing morbidity and mortality. Although RRTs may not reduce morbidity &amp;amp; mortality significantly, they do bring critical care expertise to the bedside of the deteriorating patient. One of the leading reasons for RRTs in a community hospital is hypotension. However, interventions to treat hypotension are limited. Evidence recommends goal-directed fluid management reduces renal and respiratory failure while improving patient outcomes in select patient populations (Douglas et al., 2020). Should RRTs utilize tools to treat patients by goal-directed fluid management?

Transesophageal Doppler corrected flow time versus plethysmography variability index for goal-directed fluid management in cirrhotic patients during liver resection: a randomized controlled trial

Abstract Background Central venous pressure (CVP) readings are affected by several factors. The need to test the technology of noninvasive or minimal invasive monitoring during liver surgery to guide fluids intake is the focus of this trial. Adult hepatic patients undergoing elective open liver resection were randomized into transesophageal Doppler (TED, n = 20) or plethysmography variability index (PVI, n = 20). PVI blinded to anesthetist in TED group (gp) and vice versa. During dissection, crystalloids were restricted to keep corrected flow time (FTc) parameter of TED &lt; 330 msec or PVI &gt; 14%, otherwise infused at 6 ml/kg/h. Following resection, colloids infused if FTc &lt; 330 msec or PVI &gt; 14% despite crystalloids infusion. Primary aim is to compare TED-corrected flow time (FTc, msec) parameter to PVI (%) for guiding intravenous fluids during liver resection. Secondary to study their correlations and each parameter effect on blood loss and consumption, morbidity and intensive care unit (ICU) stay. Results It is presented as median [IQ]. Volumes of crystalloids and colloids guided by FTc and PVI were not different (p = 0.3, p = 0.1, respectively) despite negligible correlations. Normovolemic existed during dissection despite 2 h of fluids restriction. FTc was 327 (320–341) msec, PVI was 11.50 (11.00–14.00) %, and CVP in TED gp 11.00 (10.00–12.00) vs. 9.00 (9.00–11.50) mmHg in PVI gp, p = 0.2. Blood loss was 1500 (475–2000) ml in TED vs. 950 (675–1925) in PVI, p = 0.5. Patients’ % in need for blood transfusion and volumes in TED vs. PVI gps were similar: red blood cells: 30%, 350 (350–350) vs. 40%, 525 (350–700) ml, and p = 0.2. Plasma is 20%, 200 (200–300) vs. 40%, and 400 (200–400) ml, p = 0.3. There was no difference in nausea, vomiting, or ICU stay, (p &gt; 0.05). Conclusions Volume of fluids guided by PVI was not different from that by TED, despite lack of correlation. Transfusion-free dissection was possible for a significant number of patients with normovolemia. Trial registration PACTR201808140151322 (www.pactr.org)

Conventional Fluid Management Versus Goal-Directed Fluid Management In Elective Colorectal Surgery

Conventional Fluid Management Versus Goal-Directed Fluid Management In Elective Colorectal Surgery

Incorporation of Blood and Fluid Management Within an Enhanced Recovery after Surgery Protocol in Complex Spine Surgery.

retrospective review. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery. A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay. Following implementation, the rate of blood transfusion decreased by 11.7%(P = .017) and average crystalloid infusion was reduced 680 mL per case(P < .001). Intraoperative blood loss decreased on average 342 mL per case(P = .001) and TXA use increased significantly by 25%(P < .001). Postoperative ICU admissions declined by 8.5%(P = .071); extubation within the OR increased by 13.3%(P = .005). This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions.

Enhanced recovery after surgery (ERAS®) in cardiac anesthesia

Enhanced Recovery After Cardiac Surgery (ERACS) is amultidisciplinary and multiprofessional treatment approach in cardiac surgery. Recently, atransfer and adaptation of enhanced recovery after surgery (ERAS) protocols from other disciplines, such as colorectal surgery, to cardiac surgery has been performed in different settings. First, prehabilitation programs have been established and investigated to improve patients' physical, psychological and nutritional status including treatment of preoperative anemia. Second, intraoperative therapeutic steps are described, such as infection reduction bundles, rigid sternal closure and guidance of perioperative anesthesia. For this, the use of short-acting agents, goal-directed fluid management and multimodal anesthesia are among the important measures. Third, early recovery and restoration of patient autonomy are achieved with early extubation and mobilization, efficient postoperative analgesia and diagnosis and treatment of delirium.The introduction of an ERACS protocol is ateam effort requiring aprotocol adapted to the institutional conditions and awillingness to perform ashift of culture in perioperative care. So far, the successful establishment of ERACS protocols in minimally invasive cardiac surgery has been reported and encourages the development of protocols of specific patient groups, such as pediatric cardiac surgery or left ventricular assist device implantation.

Pleth Variability Index Guided Volume Optimisation in Major Gynaecologic Surgery.

To compare conventional fluid management (CFM) with pleth variability index (PVI) guided goal-directed fluid management (GDFM) during elective total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO) operations. Randomised controlled trial. Department of Anaesthesiology and Reanimation, Faculty of Medicine, Health Sciences University, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey, from February to July 2021. This trial included 78 patients aged 18-65 years with ASA I-III who would undergo elective TAH-BSO under general anaesthesia. Following randomisation with the closed envelope method, standard monitoring, and 250 ml crystalloid infusion during anaesthesia induction, maintenance fluid therapy was administered at 8-10 ml/Kg/hour to the control group and 2-3 ml/Kg/hour to the PVI group. If the mean arterial pressure (MAP) was ≤65 mmHg and/or the MAP was decreased by more than 20%, and the PVI was >13%, a 250 ml colloid bolus was given. When there was no response, a vasoactive agent was administered. Vital signs, laboratory findings, and postoperative complications were evaluated. Age, weight, BMI, urine output, bleeding, hospital stay, comorbidities, intraoperative use of blood products, and complication rates were not significantly different between the PVI and CFM groups (p>0.05). The PVI group had shorter operational times and used less crystalloid than the control group (p=0.033 and p<0.001, respectively). The PVI group's postoperative base excess (BE) levels changed significantly less than the control group's (p<0.001). In both pre- and postoperative haemoglobin, haematocrit, urea, creatinine, electrolytes, and lactate measurements, there were no statistically significant differences between the groups (p>0.05). PVI-GDFM is equally safe as CFM for intraoperative fluid management during elective complete abdominal hysterectomy and bilateral salpingo-oophorectomy procedures. Pleth variability index, Fluid management, Base excess.

The Effect of Goal‐Directed Fluid Administration on Outcomes After Pancreatic Surgery

We evaluated the effect of an Enhanced Recovery After Surgery protocol on intraoperative fluid administration and postoperative outcomes in pancreatic surgery. Pancreatic cancer resections at our institution from 2012 to 2018 were grouped according to pre- or post-protocol initiation. Preoperative characteristics and postoperative outcomes were compared with Fisher's exact test and chi-square for categorical variables, and Mann-Whitney U test for continuous variables. Further analysis separated patients that had a Whipple from those who had distal pancreatectomy. A total of 263 patients underwent pancreatic cancer resection during the study period (169 Whipples, 84 DPs, 92 pre-ERAS and 171 post-ERAS). Intraoperative fluid administration significantly decreased after protocol implementation (mean 6,277ml vs. 3870ml, p &lt; 0.001). This held true when separating patients that had a Whipple procedure from those that had a DP (6,929ml vs. 4,513ml, p &lt; 0.001, 5,060ml vs. 2,833cc, p = 0.002, respectively). Intensive care unit (ICU) admission (41.3% vs. 20.5%, p &lt; 0.001) and length of stay (9.4 vs. 8.1days, p &lt; 0.01) were significantly reduced after ERAS implementation for all patients and in Whipple patients alone (47.5% vs. 23.6%, p = 0.002 and 10.7 vs. 6.6days, p = 0.004). DP patients also had significantly decreased ICU admissions (41.3% vs. 20.5%, p = 0.045). All other postoperative outcomes were not significantly different. For patients undergoing pancreatic cancer resection, goal-directed fluid management is associated with decreased intraoperative fluid administration, decreased ICU admission, and decreased length of stay without an increase in postoperative complications or readmission.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Perioperative goal-directed fluid management using noninvasive hemodynamic monitoring in gynecologic oncology

BackgroundIntraoperative fluid management is important for the prevention of perioperative morbidity and mortality. Our study aimed to investigate the perioperative feasibility and benefits of Goal-Directed Fluid Management (GDFM) using noninvasive hemodynamic monitoring in gynecologic oncology patients with acute blood loss and severe fluid loss. We assessed the effects of GDFM on hemodynamics, organ perfusion, complications, and mortality outcomes. MethodsThis randomized prospective study included 104 patients over the age of 18 years, including 56 patients with endometrial cancer and 48 patients with ovarian cancer who had open surgery. The anesthetic approach was standardized for all patients. We compared the perioperative results of the subjects who were randomized into GDFM (n = 51) and Liberal Fluid Management (LFM) (n = 53) groups using a computer program. ResultsThe median perioperative crystalloid replacement (2000 vs. 2700; p < 0.001) and total volume of fluid (2260 vs. 3200; p < 0.001) were lower in the GDFM group compared to the LFM group. The hemodynamic findings and the HCO3 and lactate levels of the GDFM group did not significantly change perioperatively. The heart rate, mean arterial pressure, and HCO3 levels of the LFM group decreased and serum lactate levels increased perioperatively. The hospitalization rate in ICU (7.8% vs. 28.3%; p = 0.010), rate of patients with comorbidity conditions indicated in ICU (2% vs. 17%; p = 0.024), and rate of complications (17.6% vs. 35.8%; p = 0.047) were lower in the GDFM group compared to the LFM group. ConclusionThe amount of intraoperatively administered crystalloid solution and complication rates were significantly lower in gynecologic oncologic surgery patients who received GDFM. Besides, hemodynamic findings, and lactate levels of the GDFM group did not change significantly during the perioperative period.

Goal-Directed Fluid Management Using Plethysmographic Variability Index in Patients Undergoing Laparoscopic Bariatric Surgery

Background: Optimal intraoperative fluid management is essential in surgical patients, including individuals with obesity undergoing bariatric surgery. The objective of this study was to assess the...

Rate of venous thromboembolism in gynecologic patients on an ERAS pathway.

214 Background: Venous thromboembolism (VTE) is a serious and potentially life-threatening complication of surgery. An Enhanced Recovery After Surgery (ERAS) program is a multimodal care pathway meant to facilitate faster recovery from surgery. ERAS protocols include mechanical and pharmacologic VTE prophylaxis and rapid return to ambulation. Our objective was to evaluate the rate of symptomatic VTE on an ERAS pathway among patients undergoing open and minimally invasive gynecologic surgery (MIS). Methods: Data was collected prospectively on patients undergoing gynecologic surgery on the ERAS pathway at a single academic institution between November 1, 2014 and March 31, 2021. For patients undergoing MIS data were collected from February 1, 2016 to March 31, 2021. Patients undergoing emergency surgery or requiring therapeutic anticoagulation prior to surgery were excluded. For planned open surgery, patients received heparin prophylaxis prior to surgery, sequential compression device (SCD) during surgery and goal directed fluid management. If also diagnosed with malignancy, patients received extended VTE prophylaxis with low molecular weight heparin for 28 days after surgery starting postoperative day 1. For planned MIS, patients received SCD and goal directed fluid management. Descriptive statistics, univariate and multivariate statistical analyses were performed. Results: Of the 3,932 patients, 2,016 (51%) underwent laparotomy, 1,541 (39%) laparoscopy and 375 (10%) robotic approach. The incidence of thromboembolism was 0.5% (N = 21) overall, 0.8% (N = 17) with open approach and 0.2% (N = 4) with MIS approach. Among laparotomy patients, there was 88% compliance with preoperative heparin prophylaxis. Characteristics associated with developing a VTE were black race, malignancy, open surgical approach, surgical time, surgical complexity, and receipt of intraoperative blood transfusion. On multivariate analysis, black race and transfusion remained associated with VTE. Among laparotomy patients, the rate of intraoperative blood transfusion was 5.9% (N = 120), reoperation for bleeding 0.3% (N = 5) and reoperation for hematoma 0.2% (N = 3). Conclusions: We found a low rate of VTE among patients undergoing laparotomy and MIS under an ERAS pathway. The rate of VTE following MIS surgery was low without use of extended pharmacologic VTE prophylaxis or receipt of preoperative prophylactic heparin. Receipt of preoperative heparin prophylaxis prior to open surgery is safe with a low complication rate. This establishes a benchmark for the expected rate of VTE following gynecologic surgery on an ERAS pathway.

Effect of goal-directed fluid management guided by non-invasive device on incidence of postoperative complications in neurosurgery

Abstract Introduction: Goal-directed hemodynamic therapy aims to reduce the incidence of postoperative complications in patients undergoing surgical procedures. Optimal preload is mandatory to achieve adequate cardiac output and oxygen supply to organs and tissues. Neurosurgical patients are at risk of inadequate preload, decreased blood flow and reduced oxygen delivery, all of which can lead to organ dysfunction. Current knowledge regarding the effect of fluid management on patient-orientated outcomes in neurosurgery is limited. Therefore, this study aims to compare the safety and feasibility of goal-directed therapy with standard management in patients undergoing neurosurgical procedures. Methods and analysis: Patients undergoing neurosurgical operation will be randomised into two groups. Therapy in the first group of patients will be guided by standard perioperative monitoring. In the second group, perioperative therapy will be guided using non-invasive hemodynamic monitoring in addition to standard monitoring. Administration of fluids and vasoactive drugs will depend on the assessment of stroke volume variation and cardiac index. The safety of goal-directed hemodynamic therapy protocol will be assessed by comparing incidences of adverse events between groups.