Intraoperative Fluid Balance Research Articles

Response to Assessing Association Between Intraoperative Fluid Balance and the Risk of Acute Kidney Injury After Liver Transplantation: Methodological Issues.

Response to Assessing Association Between Intraoperative Fluid Balance and the Risk of Acute Kidney Injury After Liver Transplantation: Methodological Issues.

Assessing Association Between Intraoperative Fluid Balance and the Risk of Acute Kidney Injury After Liver Transplantation: Methodological Issues.

Assessing Association Between Intraoperative Fluid Balance and the Risk of Acute Kidney Injury After Liver Transplantation: Methodological Issues.

Effects of intraoperative hemodynamic management on postoperative acute kidney injury in liver transplantation: An observational cohort study.

Intraoperative restrictive fluid management strategies might improve postoperative outcomes in liver transplantation. Effects of vasopressors within any hemodynamic management strategy are unclear. We conducted an observational cohort study on adult liver transplant recipients between July 2008 and December 2017. We measured the effect of vasopressors infused at admission in the intensive care unit (ICU) and total intraoperative fluid balance. Our primary outcome was 48-hour acute kidney injury (AKI) and our secondary outcomes were 7-day AKI, need for postoperative renal replacement therapy (RRT), time to extubation in the ICU, time to ICU discharge and survival up to 1 year. We fitted models adjusted for confounders using generalized estimating equations or survival models using robust standard errors. We reported results with 95% confidence intervals. We included 532 patients. Vasopressors use was not associated with 48-hour or 7-day AKI but modified the effects of fluid balance on RRT and mortality. A higher fluid balance was associated with a higher need for RRT (OR = 1.52 [1.15, 2.01], p<0.001 for interaction) and lower survival (HR = 1.71 [1.26, 2.34], p<0.01 for interaction) only among patients without vasopressors. In patients with vasopressors, higher doses of vasopressors were associated with a higher mortality (HR = 1.29 [1.13, 1.49] per 10 μg/min of norepinephrine). The presence of any vasopressor at the end of surgery was not associated with AKI or RRT. The use of vasopressors might modify the harmful association between fluid balance and other postoperative outcomes. The liberal use of vasopressors to implement a restrictive fluid management strategy deserves further investigation.

Impact of intraoperative zero-balance fluid therapy on the occurrence of acute kidney injury in patients who had undergone colorectal cancer resection within an enhanced recovery after surgery protocol: a propensity score matching analysis.

An enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection encourages perioperative euvolemic status, and zero-balance fluid therapy is recommended for low-risk patients. Recently, several studies have reported concerns of increased acute kidney injury (AKI) in patients within an ERAS protocol. In the present study, we investigated the impact of intraoperative zero-balance fluid therapy within an ERAS protocol on postoperative AKI. Patients who underwent elective surgery for primary colorectal cancer were divided into zero-balance and non-zero-balance fluid therapy groups according to intraoperative fluid amount and balance. After propensity score (PS) matching, 210 patients from each group were selected. Incidences of AKI were compared between the two groups according to the Kidney Disease Improving Global Outcomes criteria. Postoperative kidney functions and surgical outcomes were also compared. AKI was significantly higher in the zero-balance fluid therapy group compared to the non-zero-balance fluid therapy group (21.4% vs. 13.8%, p = 0.040) in PS-matched patients. The decrease in the estimated glomerular filtration rate on the day of surgery was significantly higher in the zero-balance fluid therapy group (- 5.9mL/min/1.73m2 vs. - 1.4mL/min/1.73m2, p = 0.005). There were no differences in general morbidity or mortality rate, although surgery-related complications were more common in the zero-balance group. Despite the proven benefits of zero-balance fluid therapy in colorectal ERAS protocols, care should be taken to monitor for postoperative AKI. Further studies regarding the clinical significance of postoperative AKI occurrence and optimised intraoperative fluid therapy are needed in a colorectal ERAS setting.

Intraoperative fluid therapy and postoperative complications during minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study.

Compared with open thoracotomy, minimally invasive esophagectomy (MIE) methods, such as transhiatal or thoracoscopic esophagectomy, likely have lower morbidity. However, the relationship between intraoperative fluid management and postoperative complications after MIE remains unclear. Thus, we investigated the association of cumulative intraoperative fluid balance and postoperative complications in patients undergoing MIE. This single-center retrospective cohort study examined patients undergoing thoracoscopic esophagectomy for esophageal cancer in the prone position. Postoperative complications included pneumonia, arrhythmia, thrombotic events and acute kidney injury (AKI). We compared patients with higher and lower intraoperative fluid balance (higher and lower than the median). Multivariable logistic regression analyses were performed to estimate the odds ratio of intraoperative fluid balance status on the incidence of postoperative complications. In total, 135 patients were included in the study. Postoperative complications occurred in 43 (32%), including cardiac arrhythmia (n = 12, 9%), thrombosis (n = 20, 15%), pneumonia (n = 13, 10%), and AKI required hemodialysis (n = 1, 1%). Patients with a higher fluid balance had higher incidence of complications than those with a lower fluid balance (46% vs. 18%, p < 0.001). After adjusting for age, ASA-PS ≥ III, blood loss, and the use of radical surgery, the higher intraoperative fluid balance group was significantly and independently associated with postoperative complications (adjusted OR 5.31, 95% CI 2.26-13.6, p < 0.0001). In patients undergoing thoracoscopic esophagectomy in the prone position, a greater intraoperative positive fluid balance was independently associated with a higher incidence of complications.

Intraoperative Fluid Balance and Perioperative Outcomes After Aortic Valve Surgery

The effect of intraoperative fluid balance on postoperative acute kidney injury (AKI) in cardiac surgical patients is poorly defined. In this retrospective study of patients undergoing aortic valve replacement for aortic stenosis, the primary outcome of interest was postoperative AKI. Secondary outcomes were postoperative fluid balance, cardiac index, vasopressor use, hospital-free days, stroke, myocardial infarction, hospital readmission, and 30- and 90-day mortality. A total of 2327 patients were analyzed. Positive intraoperative fluid balance was associated with lower odds of AKI; the lowest odds were in the 20- to 39-mL/kg group (odds ratio, 0.56; 95% confidence interval, 0.38-0.81; P= .002). Positive intraoperative fluid balance was associated with a lower postoperative fluid balance. Increased ultrafiltration volume was associated with increased postoperative fluid resuscitation and vasopressor use. AKI was associated with increased 30- and 90-day mortality. Increased fluid balance was associated with increased odds of myocardial infarction and 30-day mortality. Increased ultrafiltration volume was associated with increased odds of 30- and 90-day mortality. In patients who underwent aortic valve replacement for aortic stenosis, positive intraoperative fluid balance was associated with decreased odds of AKI. Patients developing AKI had increased 30- and 90-day mortality. Although the overall incidence was low, increased intraoperative fluid balance was associated with myocardial infarction and 30-day mortality, whereas increased ultrafiltration volume was associated with 30- and 90-day morality. Prospective studies are needed to better define proper intraoperative fluid management in patients undergoing cardiac surgery.

Effect of remifentanil on intraoperative fluid balance: a retrospective statistical examination of factors contributing to fluid balance

BackgroundPostoperative fluid retention is a factor that causes delay in recovery and unexpected adverse events. It is important to prevent intraoperative fluid retention, which is putatively caused by intraoperative release of stress hormones, such as ADH (anti-diuretic hormone) or others. We hypothesized that intraoperative analgesia may prevent pathological fluid retention. We retrospectively explored the relationship between analgesics and in-out balance in surgical patients from anesthesia records.MethodsAnesthetic records of 80 patients who had undergone orthognathic surgery were checked in this study. Patients were anesthetized with either TIVA (propofol and remifentanil) or inhalational anesthesia (sevoflurane and remifentanil). During surgery, acetated Ringer's solution was infused for maintenance at a rate of 3–5 ml/kg/h at the discretion of the anesthetist. The perioperative parameters, including the amount of crystalloid and colloid infused, and the amount of urine and bleeding were checked. Furthermore, we checked the amount and administration rate of remifentanil during the surgical procedure. The correlation coefficient between the remifentanil dose and the in-out balance or the urinary output was analyzed using the Pearson correlation coefficient. The contributing factor to fluid retention, including urinary output, was statistically examined by means of multivariate logistic regression analysis.ResultsA significant positive correlation was found between remifentanil dose and urinary output. Urinary output less than 0.04 ml/kg/min was suggested to cause positive fluid balance. Although in-out balance approaches zero balance with increase in remifentanil administration rate, no contributing factor for near-zero fluid balance was statistically picked up. The remifentanil administration rate was statistically picked up as the significant factor for higher urinary output (> 0.04 ml/kg/min) (OR, 2,644; 95% CI, 3.2–2.2 × 106) among perioperative parameters.ConclusionsIn conclusion, remifentanil contributes in maintaining the urinary output during general anesthesia. Although further prospective study is needed to confirm this hypothesis, it was suggested that fluid retention could be avoided through suppressing intraoperative stress response by means of appropriate maintenance of remifentanil infusion rate.

Novel Urinary Biomarkers for Acute Kidney Injury and Prediction of Clinical Outcomes After Pediatric Cardiac Surgery.

Acute kidney injury (AKI) is a serious complication of pediatric cardiac surgery, with high morbidity and mortality. We aimed to evaluate the perioperative risk factors for AKI, and the validity of novel diagnostic urinary biomarkers after pediatric cardiac surgery. We analyzed 103 consecutive pediatric patients (≤ 18years old), who underwent cardiac surgery. AKI was defined by ≥ 50% increase in serum creatinine levels from baseline. Urinary liver-type fatty acid binding protein (L-FABP) and neutrophil gelatinase-associated lipocalin (NGAL) were measured postoperatively at the intensive care unit (ICU) admission, subsequently at 4, 12, and 24h. Areas under the receiver-operating characteristic curves (AUC) were calculated at each assessment time. AKI had developed in 47 patients (45.6%) by the second postoperative day. Univentricular status, aortic cross-clamping time, and intraoperative fluid balance were independently associated with AKI (p = 0.02, 0.01 and 0.01, respectively). Urinary L-FABP and NGAL were significantly higher in the AKI group at each point (p < 0.05). The predictive abilities of both biomarkers (AUC = 0.78-0.90) at ICU admission and 4h after were especially high. The patients with L-FABP greater than the cutoff value at ICU admission and 4h after ICU admission had significantly longer intubation and hospitalization periods (p < 0.05). Those with elevated NGAL levels at admission, and 4h and 24h after ICU admission, had significantly longer intubation, ICU stay, and hospitalization (p < 0.05). L-FABP and NGAL can be useful biomarkers for detecting early AKI after pediatric cardiac surgery and predicting adverse clinical outcomes.

Positive association between intra-operative fluid balance and post-operative acute kidney injury in non-cardiac surgery: the NARA-AKI cohort study.

Little is known about the association between intra-operative fluid balance (IFB) and post-operative acute kidney injury (AKI) in non-cardiac surgery. This is a retrospective cohort study. Adults who underwent non-cardiac surgery under general anesthesia from 2007 to 2011 at Nara Medical University Hospital were included. Those with obstetric or urological surgery, missing data, or pre-operative dialysis were excluded. Exposure of interest was IFB, defined as (amount of fluid administration - urine output - amount of bleeding)/body weight. Outcome variable was post-operative AKI within 1week after surgery. Data were analyzed using logistic regression models and restricted cubic spline (RCS) analysis. Among 5168 subjects, AKI was observed in 309 (6.0%). Higher IFB (per 1 standard deviation) was independently associated with post-operative AKI after adjustment for potential confounders (odds ratio [95% confidence interval] of 1.18 [1.06-1.31]). The RCS curve showed an increase in expected probability of AKI associated with increase in IFB above 40mL/kg. Subgroup analyses indicated higher IFB was especially associated with AKI among those with lower serum albumin, higher C-reactive protein, or positive proteinuria. The association was similar across intra-operative urine output or amount of bleeding (p for interaction 0.34 and 0.47, respectively), suggesting the association was not due to intra-operative oliguria or large amount of bleeding necessitating volume resuscitation. Higher IFB was independently associated with increase in post-operative AKI. Excessive fluid administration might have caused renal congestion and subsequent AKI. Avoiding fluid overload might be important in prevention of AKI.

The effects of hemodynamic management using the trend of the perfusion index and pulse pressure variation on tissue perfusion: a randomized pilot study

BackgroundIntraoperative hemodynamic management is challenging because precise assessment of the adequacy of the intravascular volume is difficult during surgery. Perfusion index (PI) has been shown to reflect changes in peripheral circulation perfusion. Pulse pressure variation (PPV) reflects the preload responsiveness. The hypothesis of this study was that hemodynamic management using the trend of the PI and PPV would improve tissue perfusion.MethodsThis was a prospective, randomized, parallel design, single-blind, single-center pilot study. Patients undergoing elective open gynecological surgery requiring a direct arterial line were included. The patients were randomly allocated to two groups. The intervention group received hemodynamic management using the trend of the PI and PPV in an effort to improve tissue perfusion. The control group received hemodynamic management at the discretion of the anesthesia care provider. The primary outcome was the peak lactate level during surgery. The secondary outcomes were the duration of hypotension, intraoperative fluid balance, intraoperative urine output, and postoperative complication rate. Statistical analysis was performed using Student’s t test and Fisher’s exact test. A P value of < 0.05 was considered statistically significant.ResultsAlthough the intervention significantly decreased the duration of hypotension and intraoperative fluid balance, the peak lactate level was not different between the intervention group and the control group. Intraoperative urine output and postoperative complication rate were not different between the groups.ConclusionHemodynamic management using the trend of the PI and PPV does not improve tissue perfusion in patients undergoing open gynecological surgery.Trial registrationThis trial was prospectively registered on a publicly accessible database (UMIN Clinical Trials Registry ID: UMIN 000026957. Registered 12 April 2017, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000030916).

Effects of Intraoperative Fluid Balance During Liver Transplantation on Postoperative Acute Kidney Injury: An Observational Cohort Study.

Liver transplant recipients suffer many postoperative complications. Few studies evaluated the effects of fluid management on these complications. We conducted an observational cohort study to evaluate the association between intraoperative fluid balance and postoperative acute kidney injury (AKI) and other postoperative complications. We included consecutive adult liver transplant recipients who had their surgery between July 2008 and December 2017. Our exposure was intraoperative fluid balance, and our primary outcome was the grade of AKI at 48 hours after surgery. Our secondary outcomes were the grade of AKI at 7 days, the need for postoperative renal replacement therapy, postoperative red blood cell transfusions, time to first extubation, time to discharge from the intensive care unit (ICU), and 1-year survival. Every analysis was adjusted for potential confounders. We included 532 transplantations in 492 patients. We observed no effect of fluid balance on either 48-hour AKI, 7-day AKI, or on the need for postoperative renal replacement therapy after adjustments for confounders. A higher fluid balance increased the time to ICU discharge, and increased the risk of dying (hazard ratio = 1.21 [1.04,1.40]). We observed no association between intraoperative fluid balance and postoperative AKI. Fluid balance was associated with longer time to ICU discharge and lower survival. This study provides insight that might inform the design of a clinical trial on fluid management strategies in this population.

Elevated artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids

To study the influential factor of hyperlactatemia after the brain tumor craniotomy. Patients who underwent selective brain tumor (including glioma, meningioma and acoustic schwannoma) craniotomyin the neurosurgery intensive care unit (NSICU) of the First Affiliated Hospital, Sun Yat-sen University from December 1st 2018 to May 20th 2019 were enrolled. The incidence of hyperlactatemia after the brain tumor craniotomy was investigated. Univariate and multivariate linear regression analysis were performed to identify the association of initial artery lactate with the operation duration, the intraoperative blood loss, the total intraoperative fluid infusion, intraoperative ringer lactate fluid infusion, intraoperative urine volume, intraoperative fluid balance, the total intraoperative corticosteroids dosage and the tumor type. Pearson method was used to analyze the correlation between lactate in arterial blood and independent related factors. A total of 148 patients were enrolled including 45 patients (30.41%) with glioma, 64 patients (43.24%) with meningioma, and 39 patients (26.35%) with acoustic schwannoma. The initial lactate level in arterial blood increased significantly in 148 patients, with a median of 4.80 (3.68, 5.90) mmol/L. Among them, 78 patients (52.70%) had mild elevation of lactate in arterial blood (2 mmol/L < lactate ≤ 5 mmol/L), 61 patients (41.22%) had significant elevation of lactate in arterial blood (5 mmol/L < lactate ≤ 10 mmol/L), and 2 patients (1.35%) had serious elevation of artery lactate (> 10 mmol/L). And only 7 patients (4.73%) had normal level of lactate in arterial blood (≤ 2 mmol/L). Univariate analysis showed that initial postoperative artery lactate was positively correlated with the operation duration [β = 0.556, 95% confidence interval (95%CI) was 0.257-0.855, P < 0.001] and the total intraoperative corticosteroids dosage (β = 0.477, 95%CI was 0.174-0.779, P = 0.002). There was no significant correlation between the initial postoperative artery lactate and tumor types, the intraoperative blood loss, the total fluid infusion, the ringer lactate fluid infusion, urine volume, and the fluid balance. Further multivariate linear regression analysis showed that the operation duration (β = 0.499, 95%CI was 0.204-0.795, P = 0.001) and the total intraoperative corticosteroids dosage (β = 0.407, 95%CI was 0.111-0.703, P = 0.008) were independent risk factors affecting the initial postoperative artery lactate. The correlation analysis showed that there was a significant positive correlation between lactate in arterial blood and operation time and total hormone dosage during operation (r1 = 0.289, r2 = 0.248, both P < 0.01). Initial artery lactate after brain tumor craniotomy is associated with surgery duration and exogenous administration of corticosteroids.

Bio-electrical impedance analysis for perioperative fluid evaluation in open major abdominal surgery

Water retention and intercompartmental redistribution occur frequently in association with adverse postoperative outcomes, yet the available strategies for non-invasive assessment are limited. One such approach for evaluating body water composition in various circumstances is bio-electrical impedance analysis (BIA). This study aims to appraise the usefulness of the Body Composition Monitor (BCM, Fresenius Medical Care, Germany) in assessing body fluid composition and intercompartmental shifts before and after open major abdominal surgery. This prospective, clinician blinded observational study enrolled all the patients scheduled consecutively for elective major open abdominal surgery during a 1-year period starting from January 1st, 2016. BIA parameters—total body water (TBW), extracellular water (ECW), intracellular water (ICW), absolute fluid overload (AFO), and relative fluid overload (RFO) were measured before and after surgery. The results were compared with fluid balance and outcome parameters such as organ dysfunction, ICU-and hospital length of stay (-LOS). The study population included 71 patients aged 60.2 ± 12 of whom 60.6% men and with a BMI of 26.3 ± 5.1 kg/m2. Postoperative acute kidney injury, respiratory dysfunction, and infections occurred in 14.0%, 19.7% and 28.1% of cases, respectively. The median LOS in ICU was 20 h and the hospital-LOS was 10 days. Positive intraoperative fluid balance (2.4 ± 1.0 L) resulted in a significant increase of TBW (1.4 ± 2.4 L) and of ECW (1.4 ± 1.2 L). Intraoperative fluid balance significantly correlated with TBW change (r = 0.23, p = 0.04) and with AFO change (r = 0.31, p < 0.01). A significant correlation was found between pre- and postoperative AFO and RFO on one hand, and ICU-LOS on the other. BIA may be a useful tool for the perioperative assessment of volume status.

Post-Extubation Inhaled Nitric Oxide Therapy via High-Flow Nasal Cannula After Fontan Procedure.

In 2014, our hospital introduced inhaled nitric oxide (iNO) therapy combined with high-flow nasal cannula (HFNC) oxygen therapy after extubation following the Fontan procedure in patients with unstable hemodynamics. We report the benefits of HFNC-iNO therapy in these patients. This was a single-center, retrospective review of 38 patients who underwent the Fontan procedure between January 2010 and June 2016, and required iNO therapy before extubation. The patients were divided into two groups: patients in Epoch 1 (n = 24) were treated between January 2010 and December 2013, receiving only iNO therapy; patients in Epoch 2 (n = 14) were treated between January 2014 and June 2016, receiving iNO therapy and additional HFNC-iNO therapy after extubation. There were no significant differences between Epoch 1 and 2 regarding preoperative cardiac function, age at surgery, body weight, initial diagnosis (hypoplastic left heart syndrome, 4 vs. 2; total anomalous pulmonary venous return, 5 vs. 4; heterotaxy, 7 vs. 8), intraoperative fluid balance, or central venous pressure upon admission to the intensive care unit. Epoch 2 had a significantly shorter duration of postoperative intubation [7.2 (3.7-49) vs. 3.5 (3.0-4.6) hours, p = 0.033], pleural drainage [23 (13-34) vs. 9.5 (8.3-18) days, p = 0.007], and postoperative hospitalization [36 (29-49) vs. 27 (22-36) days, p = 0.017]. Two patients in Epoch 1 (8.3%), but none in Epoch 2, required re-intubation. Our results suggest that HFNC-iNO therapy reduces the duration of postoperative intubation, pleural drainage, and hospitalization.

Early Postoperative Serum Creatinine Adjusted for Fluid Balance Precisely Predicts Subsequent Acute Kidney Injury After Cardiac Surgery

Cumulative fluid overload may influence acute kidney injury (AKI) diagnosis due to the dilution effect. The authors hypothesized a small increase of early postoperative serum creatinine (SCr) adjusted for fluid balance might have superior discrimination ability in subsequent AKI prediction. Retrospective analyses. A single-center study in a university hospital. The study comprised 1,016 adult patients who underwent elective isolated or combined valve surgery in 2015. None. Baseline characteristics, intraoperative parameters, and intraoperative and postoperative fluid balance were collected through a retrospective chart review. Early postoperative SCr level was drawn within 12 hours of surgical completion and then measured daily. Early relative changes of SCr were categorized as a cutoff value of 10% with or without adjustment for cumulative fluid balance. Kidney Disease: Improving Global Outcomes criteria were used to detect AKI. Logistic analyses were performed to determine risk factors for subsequent AKI with the inclusion of measured or fluid-adjusted early relative changes of SCr, respectively. In this study, 355 patients (34.9%) developed AKI. Multivariate logistic analyses showed age, weight, European System for Cardiac Operative Risk Evaluation II, and cardiopulmonary bypass duration were associated independently with the development of AKI. Model discrimination for AKI prediction was improved significantly when the addition of measured (area under the receiver operating characteristic curve [AUROC] 0.830) and fluid-adjusted early changes of SCr to the basic model (AUROC 0.850). Early fluid-adjusted relative changes of SCr could improve the predictive ability for subsequent development of AKI in valve surgery patients.

Intraoperative reduction of vasopressors using processed electroencephalographic monitoring in patients undergoing elective cardiac surgery: a randomized clinical trial.

Intraoperative vasopressor and fluid application are common strategies against hypotension. Use of processed electroencephalographic monitoring (pEEG) may reduce vasopressor application, a known risk factor for organ dysfunction, in elective cardiac surgery patients. Randomized single-centre clinical trial at Jena University Hospital. Adult patients operated on cardiopulmonary bypass or off-pump coronary artery bypass grafting were randomised to receive anesthesia with visible or blinded pEEG using Narcotrend™. In blinded-Narcotrend (NT) depth of anesthesia was extrapolated from clinical signs, hemodynamic response and anesthetic concentration, supplemented by target indices between 37 and 64 in the visible-NT group. Intraoperative norepinephrine requirement (primary endpoint), fluid balance, extubation time, delirium occurrence and adverse events were evaluated. Patients of the intent-to-treat population (visible-NT: n = 123, blinded-NT: n = 122) had similar patient and procedural characteristics. Adjusted for type of surgery intraoperative Norepinephrine application was significantly reduced in visible-NT (n = 120, robust mean of cumulative dose 4.71µg/kg bodyweight) compared to blinded-NT patients (n = 119, 6.14µg/kg bodyweight) (adjusted robust mean difference 1.71 (95% CI 0.33-3.10) µg/kg bodyweight). Although reduction in patients operated on cardiopulmonary bypass was higher the interaction was not significant in post-hoc subgroup analysis. Intraoperative fluid balance was similar among both groups and strata. Extubation time was non-significantly lower in visible than in blinded-NT group. Overall postoperative delirium risk was 16.4% without differences among the groups. Adverse events-sudden movement/coughing, perspiration or hypertension-occurred more often with visible-NT, while one blinded-NT patient experienced intraoperative awareness. Titration of depth of anesthesia in elective cardiac surgery patients using pEEG allows to reduce application of norepinephrine.

Risk factors of postoperative complications after laparoscopic surgery for pheochromocytoma

Objective: To investigate the effects of intraoperative hemodynamic instability on postoperative complications of laparoscopic surgery for pheochromocytoma. Methods: It was a retrospective cohort study. According to inclusion/exclusion criteria, adult patients underwent laparoscopic surgery for pheochromocytoma from January 2005 to December 2017 in Peking University First Hospital were enrolled in this study. Eligible patients were divided into two groups by evidence of postoperative complications to find out the effects of intraoperative hemodynamic instability and its' effects on other prognostic indices. The normally distributed continuous variables were compared between two groups by Student's t test, Mann-Whitney U test were used for the comparison for non-normally distributed continuous variables and χ(2) test for categorical variables. Results: A total of 198 patients were finally enrolled in this study, including 87 males and 111 females with an average age of (47±15) years. Postoperative complications occurred in 17 patients with an incidence of 8.6%, and intraoperative hemodynamic instability occurred in 45 patients (22.7%). It was found that history of stroke[odds ratio (OR)=13.387, 95% confidence interval (CI): 2.284-78.460, P=0.004], intraoperative hemodynamic instability (OR=3.351, 95%CI: 1.119-10.039, P=0.031) and intraoperative positive fluid balance (for each additional 100 ml) (OR=1.087, 95%CI: 1.031-1.146, P=0.002)were the independent risk factors of postoperative complications of laparoscopic surgery for pheochromocytoma. Furthermore, more postoperative complications, higher rate of admitting to ICU and longer hospital stay was found in patients with hemodynamic instability. Conclusion: Intraoperative hemodynamic instability is an independent risk factor for postoperative complications of laparoscopic surgery in patients with pheochromocytoma, and it associates with more postoperative complications and higher rate of admitting to ICU.

Risk Factors for Postoperative Chylothorax After Radical Subtotal Esophagectomy

Chylothorax is one of the complications of esophagectomy for esophageal cancer. The treatment of this condition has been well discussed, but the risk factors for postoperative chylothorax remain unclear. A retrospective review of 294 patients who underwent esophagectomy for esophageal cancer was conducted. These were patients with squamous cell carcinoma or adenocarcinoma of the esophagus including Siewert type I tumor of the esophagogastric junction who underwent subtotal esophagectomy with two-field or three-field lymphadenectomy. Of these, 24 patients who were diagnosed with chylothorax as a postoperative complication were allocated to the chylothorax group and the other 270 patients were allocated to the nonchylothorax group. Univariate analysis showed a significant difference in three factors: resection of thoracic duct, post-chemoradiotherapy, and high intraoperative fluid balance. Multivariate analysis revealed that post-chemoradiotherapy [hazard ratio (HR) = 3.430; 95% confidence interval (CI) 1.364-8.625] and high intraoperative fluid balance (HR = 1.569; 95% CI 1.2.7-2.039) were independent factors predicting chylothorax. In addition, resection of the thoracic duct may be a predictor of chylothorax after esophagectomy (HR = 3.389; 95% CI 0.941-12.201, p = 0.062). Receiver operating characteristic curve analysis of intraoperative fluid revealed that the sensitivity was 62.5%, specificity was 74.1%, and the cutoff value was 6.55mL/kg/h. This study revealed that post-chemoradiotherapy and high intraoperative fluid balance are predictors of chylothorax after esophagectomy. The elucidation of clinicopathological factors that can predict the incidence of chylothorax will help to establish more effective perioperative management for esophageal cancer patients.

The Correlation between the Change in Thoracic Fluid Content and the Change in Patient Body Weight in Fontan Procedure.

Background The thoracic fluid content (TFC) and its percent change compared to the baseline (TFCd0%) derived from a bioreactance technique using a noninvasive cardiac output monitoring (NICOM) device correlate well with the amount of fluid removal in patients undergoing hemodialysis and with intraoperative fluid balance in pediatric patients undergoing cardiac surgery. We hypothesized that TFC or TFCd0% would also be a useful indicator allowing fluid management in pediatric patients undergoing a Fontan procedure. Methods The medical records of patients who underwent an elective Fontan procedure were reviewed retrospectively. The intraoperative variables recorded at two time points were used in the analysis: when the NICOM data obtained just after anesthesia induction (T0) and just before transfer of the patient from the operating room to the ICU (T1). The analyzed variables were hemodynamic parameters, TFC, TFCd0%, stroke volume variation, body weight gain, change in the central venous pressure, and difference in the TFC (ΔTFC). Results The correlation coefficient between TFCd0% and body weight gain was 0.546 (p = 0.01); between TFCd0% and body weight gain% 0.572 (p = 0.007); and between TFCd0% and intraoperative fluid balance 0.554 (p = 0.009). The coefficient of determination derived from a linear regression analysis of TFCd0% versus body weight gain was 0.30 (p = 0.01); between TFCd0% and body weight gain% 0.33 (p = 0.007); and between TFCd0% and intraoperative fluid balance 0.31 (p = 0.009). Conclusions TFCd0% correlated well with body weight gain, body weight gain%, and intraoperative fluid balance. It is a useful indicator in the intraoperative fluid management of pediatric patients undergoing a Fontan procedure. Trial Registration This trial is registered with Clinical Research Information Service KCT0002062.

Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial.

We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. “precision” fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.