Intraoperative Fluid Balance Research Articles

Effect of use of cuffed endotracheal tubes on the occurrence of postoperative extubation-related respiratory adverse events in pediatric patients with airway hypersensitivity: a retrospective cohort study.

Whether endotracheal tube (ETT) configuration (cuffed or uncuffed) influences the occurrence of respiratory adverse events (RAEs) in patients at risk remains largely unknown. We investigated the effects of cuffed ETTs on RAE occurrence after extubation in pediatric patients with airway hypersensitivity. Children aged < 8years with increased airway hypersensitivity (defined as upper airway symptoms, recent upper respiratory infection within 2weeks, or a history of asthma) who underwent general endotracheal anesthesia with inhaled agents between January 2021 and December 2022 were included. We retrospectively examined the patients' background and intraoperative anesthesia conditions by comparing the cuffed and uncuffed ETT groups. Multiple logistic regression analysis was performed to estimate the association between ETT configuration (cuffed vs. uncuffed) and the occurrence of RAEs or respiratory interventions (laryngospasm, peripheral capillary oxygen saturation < 92%, oxygen supplementation, epinephrine inhalation, or reintubation) after extubation. Cuffed ETTs were used in 163 patients and uncuffed ETTs in 143 patients. Apart from the frequency of upper airway surgery and intraoperative fluid balance, no significant differences in background characteristics were observed between the groups. RAEs after extubation were observed in 36 (22.1%) and 28 (19.6%) patients in each cuffed and uncuffed ETT groups. After adjusting for known RAE risk factors, no difference was observed in RAEs or respiratory interventions after extubation between both groups (odds ratio, 1.14; 95% confidence interval: 0.64, 2.06). In pediatric patients with airway hypersensitivity, the use of cuffed ETTs did not increase the occurrence of RAEs or respiratory interventions after extubation.

Intraoperative Fluid Balance and Perioperative Complications in Ovarian Cancer Surgery.

Fluid overload and hypovolemia promote postoperative complications in patients undergoing cytoreductive surgery for ovarian cancer. In the present study, postoperative complications and anastomotic leakage were investigated before and after implementation of pulse pressure variation-guided fluid management (PPVGFM) during ovarian cancer surgery. A total of n = 243 patients with ovarian cancer undergoing cytoreductive surgery at the University Hospital Bonn were retrospectively evaluated. Cohort A (CA; n = 185 patients) was treated before and cohort B (CB; n = 58 patients) after implementation of PPVGFM. Both cohorts were compared regarding postoperative complications. Ultrasevere complications (G4/G5) were exclusively present in CA (p = 0.0025). No difference between cohorts was observed regarding severe complications (G3-G5) (p = 0.062). Median positive fluid excess was lower in CB (p = 0.001). This was independent of tumor load [peritoneal cancer index] (p = 0.001) and FIGO stage (p = 0.001). Time to first postoperative defecation was shorter in CB (CB: d2 median versus CA: d3 median; p = 0.001). CB had a shorter length of hospital stay (p = 0.003), less requirement of intensive medical care (p = 0.001) and postoperative ventilation (p = 0.001). CB received higher doses of noradrenalin (p = 0.001). In the combined study cohort, there were more severe complications (G3-G5) in the case of a PFE ≥ 3000ml (p = 0.034) and significantly more anastomotic leakage in the case of a PFE ≥ 4000ml (p = 0.006). Intraoperative fluid reduction in ovarian cancer surgery according to a PPVGFM is safe and significantly reduces ultrasevere postoperative complications. PFEs of ≥ 3000ml and ≥ 4000ml were identified as cutoffs for significantly more severe complications and anastomotic leakage, respectively.

Influence of Intraoperative Fluid Management on Postoperative Outcome and Mortality of Cytoreductive Surgery for Advanced Ovarian Cancer-A Retrospective Observational Study.

Background: The surgical treatment of advanced ovarian cancer is associated with extensive tissue trauma, prolonged operating times and a considerable volume shift. It, therefore, represents a challenge for anaesthesiological management. Aim: The aim of this single-centre, retrospective, observational study was to investigate whether intraoperative extensive volume supply influences postoperative outcomes and long-term survival. Methods: The study included 73 patients with a mean (SD) age of 63 (13) years who underwent extensive tumour-reducing surgery for ovarian cancer between 2012 and 2015. The effect of the intraoperative fluid balance on postoperative complications, such as anastomotic insufficiency or pleural effusions, was investigated using logistic regression. Further, the influence of fluid balance, lactate and creatinine levels on 5-year survival was analysed in a Cox regression model. Associations between anaesthesia time and the intraoperative fluid balance were examined using Spearman's rank correlation coefficients. Results: The mean (SD) postoperative fluid balance in the considered patient cohort was 9.1 (3.4) litres (l) at a mean (SD) anaesthesia time of 529 (106) minutes. Cox regression did not reveal a statistically significant effect of the fluid balance, but it did reveal a statistically significant association between the lactate level 24 h following surgery and the 5-year survival (HR [95%-CI] fluid balance: 0.97 [0.85, 1.11]; HR [95%-CI] lactate: 1.79 [1.24, 2.58]). According to logistic regression, the intraoperative fluid balance was associated with an increased chance of postoperative complications in the considered patient cohort (OR [95%-CI] 1.28 [1.1, 1.54]). Conclusions: We could not detect a negative impact of an increased fluid balance on 5-year survival, but a negative impact on postoperative complications was found in our patient cohort.

Perioperative Care for Children With Syndromic Craniofacial Synostosis Undergoing Le Fort III Surgery: A Retrospective Cohort Study.

To present characteristics, surgical variables, complications, and postoperative care in pediatric patients with craniofacial synostosis undergoing Le Fort III osteotomy. Craniofacial synostoses are a group of genetic syndromes that result in premature fusion of cranial and facial sutures, leading to craniofacial deformities and associated complications. Midface advancement through Le Fort III osteotomy is the most frequent surgical option for these conditions. Retrospective monocentric cohort study including patients with syndromic craniofacial synostosis who underwent Le Fort III osteotomy between 2009 and 2022 in a specialized referral center. Data collection encompassed surgical time, blood loss, intraoperative transfusions, fluid balance, and postoperative parameters such as duration of invasive mechanical ventilation and intensive care unit (ICU) length of stay. Twenty-six children were included in the analysis. The median surgical time was 345 minutes (300-360), with an estimated blood loss of 15 (9.9-24) mL/kg. Patients required a median transfusion of 12.63 (7.1-24.5) mL/kg of packed red blood cells and 19.82 (11.1-33) mL/kg of fresh frozen plasma. Intraoperative fluid balance was + 12.5 (0.8-22.8) mL/kg, with a median infusion of 30.4 (23.9-38.7) mL/kg of crystalloids. All patients were transferred to the ICU after surgery to ensure a safe environment for extubation. The median duration of mechanical ventilation in the ICU was 30 (20.25-45) hours, and postoperative ICU length of stay was 2 (2-4) days, and complications were infrequent, with only one extubation failure recorded. Le Fort III osteotomy in craniofacial synostosis patients may be characterized by a complex perioperative course. A multidisciplinary approach in the care of these patients allows for minimizing complications in the perioperative phase. Further research is needed to enhance perioperative management in this unique patient population.

Do Laparoscopic Colorectal Procedures Need Fluid Optimization?

BACKGROUND: Goal-directed fluid therapy (GDFT) with hemodynamic monitoring may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in enhanced recovery after surgery protocols (ERAS) setting. AIMS: We predicted different fluid and vasoactive drug consumption during the procedure and less complications in the group of patients, where invasive hemodynamic monitoring was used. METHODS: Two groups of patients undergoing elective laparoscopic colorectal surgery were compared: A control group (CG), with standard hemodynamic monitoring, and a study group, (SG) with invasive hemodynamic monitoring and appropriate intraoperative interventions. We compared differences in intraoperative fluid consumption, length of hospital stay (LOS) and post-operative morbidity. RESULTS: A group of 29 patients in SG had similar average intraoperative fluid balance (+438 mL) as 27 patients in CG (+345 mL) p = 0.432. Average LOS was 8 days (±4) in SG and 6 days (±1) in CG (p = 0.124). Acute renal failure, anastomotic dehiscence, and indication for antibiotic treatment were predictors of statistically significant prolongation of hospital stay 3rd day after surgery, but independent of SG. CONCLUSION: Since no differences between the groups were shown in overall fluid and vasoactive drug consumption, we conclude that GDFT is not needed in laparoscopic colorectal surgery, when ERAS is followed.

Influence of different intraoperative fluid management on postoperative outcome after abdominal tumours resection.

Intraoperative fluid management is a crucial aspect of cancer surgery, including colorectal surgery and pancreatoduodenectomy. The study tests if intraoperative multimodal monitoring reduces postoperative morbidity and duration of hospitalisation in patients undergoing major abdominal surgery treated by the same anaesthetic protocols with epidural analgesia. A prospective study was conducted in 2 parallel groups. High-risk surgical patients undergoing major abdominal surgery were randomly selected in the control group (CG), where standard monitoring was applied (44 patients), and the protocol group (PG), where cerebral oxygenation and extended hemodynamic monitoring were used with the protocol for intraoperative interventions (44 patients). There were no differences in the median length of hospital stay, CG 9 days (interquartile range [IQR] 8 days), PG 9 (5.5), p = 0.851. There was no difference in postoperative renal of cardiac impairment. Procalcitonin was significantly higher (highest postoperative value in the first 3 days) in CG, 0.75 mcg/L (IQR 3.19 mcg/L), than in PG, 0.3 mcg/L (0.88 mcg/L), p = 0.001. PG patients received a larger volume of intraoperative fluid; median intraoperative fluid balance +1300 ml (IQR 1063 ml) than CG; +375 ml (IQR 438 ml), p < 0.001. There were significant differences in intraoperative fluid management and vasopressor use. The median postoperative value of procalcitonin was significantly higher in CG, suggesting differences in immune response to tissue trauma in different intraoperative fluid status, but there was no difference in postoperative morbidity or hospital stay.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study

ObjectivesAnemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes. MethodsThis was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon’s experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia. ResultsThe incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon’s experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012). ConclusionsAtleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

Association between intraoperative fluid management and post-operative acute kidney injury: A single-center observational study

Background: Post-operative acute kidney injury (AKI) poses significant risks. Identifying intraoperative determinants is crucial for enhancing patient outcomes and tailoring surgical interventions. Aims and Objectives: This study aimed to investigate the onset of post-operative AKI in patients subjected to various surgical interventions and identify potential intra-operative determinants. Materials and Methods: In this observational investigation conducted at our institution, 100 patients who underwent diverse surgical procedures were included in the study. AKI diagnosis was based on the kidney disease: improving global outcomes guidelines. The parameters assessed encompassed patient demographics, intraoperative fluid management, surgical and anesthetic durations, and post-operative AKI incidence. Determinants of AKI were identified using multivariate logistic regression. Results: The cohort comprised 58% males, with a mean age of 65±12 years. Key comorbidities included hypertension (42%), diabetes mellitus (28%), chronic kidney disease (15%), and cardiovascular disease (20%). Intraoperatively, the average fluid volume administered was 2.5 ± 0.8 L. Fluid management primarily included balanced crystalloids (70%), followed by normal saline (20%), and colloids (10%). Anesthesia was maintained for an average of 3.5 ± 1.2 h. Post-surgery, 15% of the patients developed AKI. A detailed evaluation revealed a strong association between positive intraoperative fluid balance and AKI onset. The statistical analysis pinpointed elevated intraoperative fluid balance (odds ratio: 5.89; 95% confidence interval [CI]: 1.72–20.15; P=0.004) and extended anesthesia duration (odds ratio: 2.12; 95% CI: 1.01–4.47; P=0.046) as significant predictors. Conclusion: AKI onset post-surgery is closely tied to intraoperative factors, notably fluid balance, and anesthesia duration. This underscores the importance of personalized fluid management and vigilant post-operative renal function monitoring to mitigate AKI risks.

Risk factors for venous thrombosis after esophagectomy.

Venous thrombosis (VT) after esophagectomy for esophageal cancer is an important complication, potentially leading to pulmonary embolism. However, there are few available information about the risk for the postsurgical VT. This study included 271 patients who underwent esophagectomy for esophageal cancer between 2006 and 2019. Contrast-enhanced computed tomography (CT) was performed for all patients on the seventh postoperative day to survey complications, including VT. VT was radiologically visualized in 48 patients (17.7%), 8 of whom (16.7%) had pulmonary embolism. The thrombus disappeared in 42 patients, the thrombus size was unchanged in 5 patients, and 1 patient died. Multivariate analysis was performed on factors clinically considered to have a significant influence on thrombus formation. The analysis showed that CVC insertion via the femoral vein (odds ratio, 7.67; 95% CI, 2.64-22.27; P < 0.001), retrosternal reconstruction route (odds ratio, 3.94; 95% CI, 1.90-8.17; P < 0.001) and intraoperative fluid balance < 5ml/kg/hr (odds ratio, 0.38; 95% CI, 0.17-0.85; P = 0.019) were independently related to VT. Intraoperative fluid balance < 5ml/kg/hr, along with CVC insertion via the femoral vein and retrosternal reconstruction may be potential risk factors for VT after esophagectomy.

High versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: a study protocol for the HISTAP randomized clinical trial

BackgroundThe intraoperative period is often characterized by hemodynamic instability, and intraoperative hypotension is a common complication. The optimal mean arterial pressure (MAP) target in hypertensive patients is still not clear. We hereby describe the protocol and detailed statistical analysis plan for the high versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP randomized clinical trial. The HISTAP trial aims at addressing whether the use of a higher intraoperative MAP target in high-risk hypertensive surgical patients scheduled for elective abdominal surgery would improve postoperative outcomes, as compared to the standard and recommended perioperative MAP, by using a composite outcome including a 30-day mortality from surgical intervention and at least one major organ dysfunction or new onset of sepsis and septic shock occurring 7 days after surgery.MethodsThe HISTAP trial is an investigator-initiated, pragmatic, parallel-grouped, randomized, stratified, analyst-blinded trial with adequate allocation sequence generation, and allocation concealment. We will allocate 636 patients to a MAP target ≥ 80 mmHg (treatment group) or to a MAP target ≥65 mmHg (control group). The primary outcome is a composite outcome including a 30-day mortality from the operation and major organ complications. Secondary outcomes are mortality at 30 days, intensive care unit (ICU) length of stay, ICU readmission, Sequential Organ Failure Assessment (SOFA) scores recorded up to postoperative day 7, overall intraoperative fluid balance, vasopressors use, and the need for reoperation. An unadjusted χ2 test will be used for the primary outcome analysis. A Cox proportional hazards model will be used to adjust the association between the primary outcome and baseline covariates.ConclusionsThe HISTAP trial results will provide important evidence to guide clinicians’ choice regarding the intraoperative MAP target in high-risk hypertensive patients scheduled for elective abdominal surgery.

Development of new colloid osmotic pressure measurement method using ultrafiltration membrane during cardiopulmonary bypass

Background: Clinical practice of measuring colloid osmotic pressure (COP) was abandoned after correcting hypoosmolarity did not improve overall patient outcomes. However, the use of albumin and colloidal solutions has contributed to maintaining intraoperative and postoperative fluid balance at lower levels. Reduced perioperative fluid balance is consistently reported to have positive effects on clinical outcomes. Priming solutions for cardiopulmonary bypass typically include colloids; however, the optimal type of priming solution has not yet been determined. Stricter COP management may further improve postoperative courses. To achieve this, the widespread adoption of a measurement method suitable for COP monitoring during cardiopulmonary bypass is required. Methods: A test circuit was made which measured COP using an ultrafiltration membrane method based on the changes in hydrostatic pressure that occurs across a semipermeable membrane. We then compared the measurements obtained using this method with colloidal osmometer measurements. Results: COP measurements were obtained for a total of 100 tests (10 times each for 10 test solutions). The evaluation parameters included simultaneous reproducibility, correlation with the colloid osmometer, and measurement time. The results demonstrated high accuracy of the ultrafiltration membrane method, simultaneous reproducibility within 3%, a high positive correlation with the colloid osmometer (correlation coefficient: R2 = 0.99; p &lt; 0.01), and equal time required for measurement. Conclusion: Measuring COP using ultrafiltration membranes solves problems within existing measurement methods. Although further improvements in the method are necessary, it has implications for future research and clinical applications.

The impact of intraoperative and postoperative fluid balance on complications for transthoracic esophagectomy: a retrospective analysis

ObjectiveTransthoracic esophagectomy is associated with significant morbidity and mortality. Therefore, it is imperative to optimize perioperative management and minimize complications. In this retrospective analysis, we evaluated the association between fluid balance and esophagectomy complications at a tertiary hospital in Melbourne, Australia, with a particular focus on respiratory morbidity and anastomotic leaks. Cumulative fluid balance was calculated intraoperatively, postoperatively in recovery postoperative day (POD) 0, and on POD 1 and 2. High and low fluid balance was defined as greater than or less than the median fluid balance, respectively, and postoperative surgical complications were graded using the Clavien-Dindo classification.ResultsIn total, 109 patients, with an average age of 64 years, were included in this study. High fluid balance on POD 0, POD1 and POD 2 was associated with a higher incidence of anastomotic leak (OR 8.59; 95%CI: 2.64-39.0). High fluid balance on POD 2 was associated with more severe complications (of any type) (OR 3.33; 95%CI: 1.4–8.26) and severe pulmonary complications (OR 3.04; 95%CI: 1.27–7.67). For every 1 L extra cumulative fluid balance in POD 1, the odds of a major complication increase by 15%, while controlling for body mass index (BMI) and American Society of Anaesthesiologists (ASA) class. The results show that higher cumulative fluid balance is associated with worsening postoperative outcomes in patients undergoing transthoracic esophagectomy. Restricted fluid balance, especially postoperatively, may mitigate the risk of postoperative complications – however prospective trials are required to establish this definitively.

Perioperative continuous body weight measurements with load cells under the bed legs in patients undergoing abdominal surgery

BACKGROUND Both excessive positive fluid balance and body weight increase after surgery are risk factors for poor postoperative outcomes. The use in clinical practice and the value of perioperative body weight measurements are unclear at present, possibly due to difficulty in measuring body weight in patients lying on the bed and insufficient clinical research. OBJECTIVES To investigate the relationship between intraoperative fluid balance and body weight change and perioperative nightly body weight change pattern throughout the hospital stay with contact-free unconstraint load cells placed under the bed legs. DESIGN Observational and exploratory study. SETTING A single university hospital. PATIENTS Twenty adult patients were undergoing elective abdominal surgery under general anaesthesia. MAIN OUTCOME MEASURES Body weight. RESULTS Immediately after surgery, body weight increased significantly by 2.7 ± 1.3 kg, equivalent to a 5% increase from the preoperative body weight. This increase was not correlated with (P = 0.178) the intraoperative fluid balance and was significantly greater than the intraoperative fluid balance 1.5 ± 0.4 kg (P &lt; 0.001). The body weight returned to the preoperative level on postoperative day (POD)3 and further significantly decreased to 97% of the preoperative body weight at POD6 (P &lt; 0.001). This physiological nocturnal weight loss pattern was maintained throughout hospitalisation except when fluid was infused. Compared with their preoperative status, patients stayed in bed longer with smaller body movements and left the bed less frequently during the daytime until POD3. Conversely, the patients had greater body movements in bed during the night leading to smaller diurnal variation in the body movements in bed after POD4. CONCLUSION Both perioperative fluid balance calculation and body weight measurement may have different but mutually complementary roles in perioperative managements. Postoperative fluid and nutrition management strategies are potentially new directions for treatment through continuous weight monitoring during the perioperative period. Trial registration : UMIN Clinical Trials Registry (UMIN000040164).

The impact of intra- and postoperative fluid balance in pancreatic surgery - A retrospective cohort study

Background/objectivesThe aim of this study was to evaluate the impact of perioperative fluid administration in pancreatic surgery. MethodsPatients who underwent pancreatic resections were identified from our institution's prospectively maintained database. Fluid balances were recorded intraoperatively and at 24hr postoperatively. Patients were stratified into tertiles of fluid administration (low, medium, high). Adjusted multivariable analysis was performed and outcome measures were postoperative complications. ResultsA total of 211 patients were included from 2012 to 2017. Complication rates were POPF(B/C) 19.4%, DGE(B/C) 14.7%, PPH(C) 10.0% and CDC ≥ IIIb 26.1%. In multivariable analysis, high perioperative fluid balance was an independent risk factor associated with POPF (OR = 10.5, 95%CI 2.7–40.7, p = .001), CDC (OR = 2.5, 95%CI 1.2–5.3, p < .002), DGE (OR = 2.3, 95%CI 1.0–5.2, p = .017), PPH (OR = 6.7 95%CI 2.2–20.0, p = .038) and reoperation (OR = 3.1, 95%CI 1.6–6.2, p = .006). In multivariable analysis with intraoperative and postoperative fluid balances as separate predictors, intraoperative (OR = 2,5, 95%CI 1.2–5.5, p = .04) and postoperative fluid balance (OR = 2.5, 95%CI 1.2–5.5, p = .02) were predictors of POPF. Postoperative fluid balance was the only predictor for mortality (OR = 4.5, 95%CI 1.0–18.9, p = .041) and predictor for CDC (OR = 2.0, 95%CI 1.0–4.0, p = .043) and OHS days (OR = 6.9, 95%CI 0.03–13.7, p = .038). ConclusionsHigh postoperative fluid balance in particular is associated with postoperative morbidity. Maintaining a fluid-restrictive strategy postoperatively should be recommended for patients undergoing pancreatic surgery.

Impact of Intraoperative Fluid Balance and Norepinephrine on Postoperative Acute Kidney Injury after Cystectomy and Urinary Diversion over Two Decades: A Retrospective Observational Cohort Study

The use of norepinephrine and the restriction of intraoperative hydration have gained increasing acceptance over the last few decades. Recently, there have been concerns regarding the impact of this approach on renal function. The objective of this study was to examine the influence of norepinephrine, intraoperative fluid administration and their interaction on acute kidney injury (AKI) after cystectomy. In our cohort of 1488 consecutive patients scheduled for cystectomies and urinary diversions, the overall incidence of AKI was 21.6% (95%-CI: 19.6% to 23.8%) and increased by an average of 0.6% (95%—CI: 0.1% to 1.1%, p = 0.025) per year since 2000. The fluid and vasopressor regimes were characterized by an annual decrease in fluid balance (−0.24 mL·kg−1·h−1, 95%—CI: −0.26 to −0.22, p &lt; 0.001) and an annual increase in the amount of norepinephrine of 0.002 µg·kg−1·min−1 (95%—CI: 0.0016 to 0.0024, p &lt; 0.001). The interaction between the fluid balance and norepinephrine levels resulted in a U-shaped association with the risk of AKI; however, the magnitude and shape depended on the reference categories of confounders (age and BMI). We conclude that decreased intraoperative fluid balance combined with increased norepinephrine administration was associated with an increased risk of AKI. However, other potential drivers of the observed increase in AKI incidence need to be further investigated in the future.

Retrospective analysis on incidence and risk factors for early acute renal injury after lung transplantation

BackgroundAcute renal injury (AKI) is a common complication of lung transplantation. However, there has been no related research on whether the relationship between fluid balance and input and output influences the occurrence of early AKI. This study aimed to explore the relationship between early fluid balance and input and output on the incidence of early AKI after lung transplantation. MethodsData from 31 patients who underwent lung transplantation in the Department of Intensive Care Medicine of the Sichuan Academy of Medical Sciences, Sichuan People's Hospital, from August 2018 to July 2021 were collected. To summarize the occurrence of early AKI after lung transplantation, The main indicators of lung transplantation patients were collected. The risk factors for early AKI after lung transplantation were analyzed. ResultsAmong the 31 patients who underwent lung transplantation, 21 had early postoperative AKI, with an incidence rate of 67.7%. Compared with the non-AKI group, the hospitalization and ICU hospitalization times of the AKI group were longer (P < 0.05). Multivariate regression analysis showed that intraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI. ConclusionIntraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI.

Predictive value of postoperative serum procalcitonin concentration for moderate to severe acute respiratory distress syndrome in patients undergoing cardiopulmonary bypass surgery

To explore the changes of serum procalcitonin (PCT) level in patients with moderate and severe acute respiratory distress syndrome (ARDS) after cardiac surgery under cardiopulmonary bypass (CPB), and try to find out the best cut-off of PCT to predict the progression to moderate and severe ARDS. Medical records of patients undergoing cardiac surgery with CPB in Fujian Provincial Hospital from January 2017 to December 2019 were retrospectively analyzed. Adult patients who were admitted in intensive care unit (ICU) for more than 1 day and had PCT values on the first postoperative day were enrolled. Clinical data such as patient demographics, past history, diagnosis, and New York Heart Association (HYHA) classification, and the operation mode, procedure duration, CPB duration, aortic clamp duration, intraoperative fluid balance, calculation of 24 hours postoperative fluid balance and vasoactive-inotropic score (VIS); 24 hours postoperative C-reactive protein (CRP), N-terminal B-type natriuretic peptide precursor (NT-proBNP) and PCT levels were collected. Two clinicians independently made the diagnosis of ARDS according to the Berlin definition, and the diagnosis was established only in patients with a consistent diagnosis. The differences in each parameter were compared between patients with moderate to severe ARDS and those without or with mild ARDS. Analysis of the ability of PCT to predict moderate to severe ARDS was evaluated by receiver operator characteristic curve (ROC curve). Multivariate Logistic regression was conducted to determine the risk factors of the development of moderate to severe ARDS. 108 patients were finally enrolled, including 37 patients with mild ARDS (34.3%), 35 patients with moderate ARDS (32.4%), 2 patients with severe ARDS (1.9%), and 34 patients without ARDS. Compared with patients with no or mild ARDS, patients with moderate to severe ARDS were older (years old: 58.5±11.1 vs. 52.8±14.8, P < 0.05), with a higher proportion of combined hypertension [45.9% (17/37) vs. 25.4% (18/71), P < 0.05], longer operative time (minutes: 363.2±120.6 vs. 313.5±97.6, P < 0.05), and higher mortality (8.1% vs. 0, P < 0.05), but there were no differences in the VIS score, incidence of acute renal failure (ARF), CPB duration, aortic clamp duration, and intraoperative bleeding, transfusion volume, and fluid balance between the two groups. Serum PCT and NT-proBNP levels in patients with moderate to severe ARDS at postoperative day 1 were significantly higher than those in patients with no or mild ARDS [PCT (μg/L): 16.33 (6.96, 32.56) vs. 2.21 (0.80, 5.76), NT-proBNP (ng/L): 2 405.0 (1 543.0, 6 456.5) vs. 1 680.0 (1 388.0, 4 667.0), both P < 0.05]. ROC curve analysis showed that the area under the curve (AUC) for PCT to predict the occurrence of moderate to severe ARDS was 0.827 [95% confidence interval (95%CI) was 0.739-0.915, P < 0.05]. When PCT cut-off value was 7.165 μg/L, the sensitivity was 75.7% and the specificity was 84.5%, for differentiating patients who developed moderate to severe ARDS from who did not. Multivariate Logistic regression showed that age and the elevated PCT concentration were independent risk factors for the development of moderate to severe ARDS [age: odds ratio (OR) = 1.105, 95%CI was 1.037-1.177, P = 0.002; PCT: OR = 48.286, 95%CI was 10.282-226.753, P < 0.001]. Patients with moderate to severe ARDS undergoing CPB cardiac surgery have a higher serum concentration of PCT than patients with no or mild ARDS. Serum PCT level may be a promising biomarker to predict the development of moderate to severe ARDS, the cut-off value is 7.165 μg/L.

Effects of intraoperative fluid balance during pancreatoduodenectomy on postoperative pancreatic fistula: an observational cohort study

BackgroundPerioperative fluid management during major abdominal surgery has been controversial. Postoperative pancreatic fistula (POPF) is a critical complication of pancreaticoduodenectomy (PD). We conducted a retrospective cohort study to analyze the impact of intraoperative fluid balance on the development of POPF.MethodsThis retrospective cohort study enrolled 567 patients who underwent open pancreaticoduodenectomy, and the demographic, laboratory, and medical data were recorded. All patients were categorized into four groups according to quartiles of intraoperative fluid balance. Multivariate logistic regression and restricted cubic splines (RCSs) were used to analyze the relationship between intraoperative fluid balance and POPF.ResultsThe intraoperative fluid balance of all patients ranged from -8.47 to 13.56 mL/kg/h. A total of 108 patients reported POPF, and the incidence was 19.0%. After adjusting for potential confounders and using restricted cubic splines, the dose‒response relationship between intraoperative fluid balance and POPF was found to be statistically insignificant. The incidences of bile leakage, postpancreatectomy hemorrhage, and delayed gastric emptying were 4.4%, 20.8%, and 14.8%, respectively. Intraoperative fluid balance was not associated with these abdominal complications. BMI ≥ 25 kg/m2, preoperative blood glucose < 6 mmol/L, long surgery time, and lesions not located in the pancreas were independent risk factors for POPF.ConclusionThe study did not find a significant association between intraoperative fluid balance and POPF. Well-designed multicenter studies are necessary to explore the association between intraoperative fluid balance and POPF.

Incidence and Risk Factors of Feeding Intolerance in Adult Patients Given Enteral Nutrition Therapy After Liver Transplant

This study aimed to describe the occurrence of feeding intolerance (FI) in adult patients given enteral nutrition (EN) during the first week after liver transplant and investigate the risk factors of FI. A total of 320 adult patients were enrolled and the incidence of FI was 50.3%. There are 5 independent risk factors for FI in these patients: average EN infusion rate, length of time to initiate EN, use of mechanical ventilation, use of sedatives or analgesics, and intraoperative fluid balance. Appropriate EN regimens and clinical treatments should be taken into consideration to prevent FI for these patients.

Optimal Perioperative Fluid Therapy Associates with Fewer Complications After Pancreaticoduodenectomy

BackgroundOptimal fluid management in pancreaticoduodenectomy patients remains contested. We aimed to examine the association between perioperative fluid administration and postoperative complications. MethodsWe studied 168 pancreaticoduodenectomy patients operated in 2015 (n = 93) or 2017 (n = 75) at Helsinki University Hospital. In 2015, patients received intraoperative fluids following a goal-directed approach and, in 2017, according to anesthesiologist’s clinical practice (conventional fluid management). We analyzed the differences in perioperative fluid administration between the groups, specifically examining the occurrence of severe complications (Clavien–Dindo ≥ III), pancreatic fistulas, cardiovascular complications, and the length of hospital stay. ResultsThe goal-directed group received more intraoperative fluids than the conventional fluid management group (12.0 ml/kg/h vs. 8.3 ml/kg/h, p < 0.001). Urine output (770 ml vs. 575 ml, p = 0.004) and intraoperative fluid balance (9.4 ml/kg/h vs. 6.3 ml/kg/h, p < 0.001) were higher in the goal-directed group than in the conventional fluid management group. Severe surgical complications (19.4% vs. 38.7%, p = 0.009) as well as clinically relevant pancreatic fistulas (1.1% vs. 10.7%, p = 0.011) occurred more frequently in patients receiving conventional fluid management. Moreover, the conventional fluid management group experienced longer hospital stays (9.0 vs. 11.5 days, p = 0.02). Lower intraoperative fluid volume accompanying conventional fluid management was associated with a higher risk of severe postoperative complications compared with higher volume in the goal-directed group (odds ratio 2.58 (95% confidence interval 1.04–6.42), p = 0.041). ConclusionsThe goal-directed group experienced severe complications less frequently. Our findings indicate that optimizing the intraoperative fluid administration benefits patients, while adopting a too-restrictive approach represents an inferior choice.