Intraoperative Fluid Management Research Articles

The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 2

Study DesignStructured literature review. ObjectivesTo review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery. Summary of Background DataApplication of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery. MethodsCochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies. ResultsWe found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications. ConclusionGaps in the existing literature limit our ability to evaluate if all of the patient and surgical factors selected for this review are associated with increased or decreased complications and reoperations in ASD surgery. However, for both intraoperative TXA usage and optimized intraoperative fluid management that were supported by good evidence, developing Standard Work Protocols may optimize care. Level of EvidenceLevel II.

Complications after duodenopancreatectomy within eras protocols in a developing country

Background: Recent studies have suggested that intraoperative fluid overload is associated with the presence of postoperative pancreatic fistula after duodenopancreatectomy. Finding the ideal balance between hypoperfusion and tissue edema with fluids administration during major gastrointestinal surgery is challenging. The aim of this study was to evaluate whether intraoperative fluid management along with enhanced recovery protocols could affect the outcome after a major pancreatic resection. Methods: Data from 67 consecutive patients who underwent duodenopancreatectomy from January 2012 to January 2017 were analyzed. Patients were divided into two groups according to the use of enhanced recovery after surgery protocols. Patients in ERAS protocols had a fluid therapy algorithm which consists: Systolic Volume Variation (SVV) less than 13%, Cardiac Index (CI) higher than 2.5 L/Min/M2 and Delta CO2 less than 6 mmHg. Results: A total of 67 patients were analyzed from July 2012 to January 2017, of these 49.3 % correspond to the female gender. The most frequent diagnosis was Pancreatic Cancer n:48 (71.6%), followed by Intraductal Papillary Mucinous Neoplasm (IPMN) n:6 (9%). The majority of patients were in the ERAS Group with a total of 46 patients (68.7%). In the ERAS group, 80.4% and 95.7% did not develop POPF and Delayed Gastric Emptying (DGE) respectively. The incidence of POFP in all the patients was 11.94% (Grade A are considered biochemical leak and NOT a proper fistula). The incidence of DGE was 11.94%. The probability of intraoperative blood loss less than 300ml was higher in the ERAS group; however, the probability to need a transfusion was lower in the ERAS Group. The probability to use less than 5000ml of fluid therapy was higher in the ERAS group. The total length of stay was statistically significant shorter in the ERAS group. No differences in 30-days mortality were found. Conclusion: The implementation of ERAS protocols in PD did show a decrease in intraoperative blood loss, intravenous fluids therapy, need for transfusion, DGE, and total hospital stay; however, intraoperative fluid restriction in PD did not show to significantly affect POPF.

The validity of central venous to arterial carbon dioxide difference to predict adequate fluid management during living donor liver transplantation. A prospective observational study

BackgroundTo assess the validity of central and pulmonary veno-arterial CO2 gradients to predict fluid responsiveness and to guide fluid management during liver transplantation.MethodsIn adult recipients (ASA III to IV) scheduled for liver transplantation, intraoperative fluid management was guided by pulse pressure variations (PPV). PPV of ≥15% (Fluid Responding Status-FRS) indicated fluid resuscitation with 250 ml albumin 5% boluses repeated as required to restore PPV to < 15% (Fluid non-Responding Status-FnRS). Simultaneous blood samples from central venous and pulmonary artery catheters (PAC) were sent to calculate central venous to arterial CO2 gap [C(v-a) CO2 gap] and pulmonary venous to arterial CO2 gap [Pulm(p-a) CO2 gap]. CO and lactate were also measured.ResultsSixty seven data points were recorded (20 FRS and 47 FnRS). The discriminative ability of central and pulmonary CO2 gaps between the two states (FRS and FnRS) was poor with AUC of ROC of 0.698 and 0.570 respectively. Central CO2 gap was significantly higher in FRS than FnRS (P = 0.016), with no difference in the pulmonary CO2 gap between both states. The central and Pulmonary CO2 gaps are weakly correlated to PPV [r = 0.291, (P = 0.017) and r = 0.367, (P = 0.002) respectively]. There was no correlation between both CO2 gaps and both CO and lactate.ConclusionCentral and the Pulmonary CO2 gaps cannot be used as valid tools to predict fluid responsiveness or to guide fluid management during liver transplantation. CO2 gaps also do not correlate well with the changes in PPV or CO.Trial registrationClinicaltrials.gov Identifier: NCT03123172. Registered on 31-march-2017.

Reducing Surgical Site Infections in the Enhanced Recovery After Surgery Patient Population

BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based practice (EBP) inter-professional approach to improving care for the surgical patient. ERAS pathways include minimally invasive surgeries, pre-op nutritional support, intraoperative fluid management, and decreased opioid use with early mobilization, introduction of food, and gum chewing. Patient engagement is critical to achieving ERAS objectives. European countries have been implementing the concepts associated with ERAS for nearly 20?years. Benefits of ERAS innovative pathways are decreased length of stay, postop complications, infections, malnutrition, pain management and hospital readmission. METHODS Surgical site infections (SSIs) are associated with an increased length of stay, morbidity, costs of care, and readmissions. An ERAS program was started at a large acute care, level II trauma facility in January 2017 to utilize evidence-based interventions to improve patient outcomes in elective colorectal surgery patients. RESULTS From 1st to 4th Quarter 2017, there was a steady decrease in the surgical site infection rate in ERAS colon procedures from 6% to 2%. While a slight increase was noted in the first two quarters of 2018, the overall Colon SSI Standardized Infection Ration (SIR) dropped from 1.867 in the 1st Quarter of 2017 to 0.656 in the 2nd Quarter of 2018. CONCLUSIONS The ERAS program improved the outcomes of patients requiring a colon procedure by improving pain control and return of gastric motility and reducing SSI and length of hospital stay. Interventions that may have contributed to the reduced colon SSI SIR include changes in practice by colon surgeons (separate closure trays, oral antibiotics, separate staplers e.g.) and implementation of an evidenced-based ERAS program.

Risk Factors for Early Infection in Pediatric Spinal Deformity Surgery: A Multivariate Analysis

Study DesignRetrospective case-control study. ObjectivesTo identify risk factors for early deep surgical site infections (SSIs; within three months of index procedure) following pediatric spinal deformity surgery. BackgroundDeep surgical site infections (SSIs) following pediatric spinal deformity surgery are a source of significant morbidity. We sought to identify independent risk factors for early infection following primary, definitive single-stage pediatric posterior spinal fusion and instrumentation (PSFI). MethodsA total of 616 consecutive patients (2001–2016) from an institutional prospectively maintained Pediatric Orthopaedic Spine database were identified that met inclusion criteria of definitive single-stage PSFI. Early deep SSI was defined as infection within three months of index procedure requiring surgical intervention. A multivariate analysis of demographics, comorbidities, and perioperative factors was performed and independent risk factors were identified. ResultsEleven patients (1.6%) developed an early deep SSI. Independent risk factors for SSI identified were nonidiopathic (neuromuscular, syndromic, and congenital) etiologies of scoliosis (adjusted odds ratio [aOR]: 8.384, 95% confidence interval [CI]: 1.784-39.386, p = .007) and amount of intraoperative crystalloids (aOR: 1.547 per additional liter of fluid, 95% CI: 1.057-2.263, p = .025). Mean crystalloid administered in the SSI group was 3.3 ± 1.2 L versus 2.4 ± 1.0 L in the noninfected group (p = .019). On univariate analysis, there was no significant difference in weight of patients between cohorts (p = .869) or surgery time (p = .089). There was also no significant difference in infection rates from redosing of antibiotics intraoperatively after 3 hours of surgery (p = .231). ConclusionsNonidiopathic scoliosis and amount of intraoperative crystalloids were independently associated with early postoperative SSI. Further investigation into intraoperative fluid management may identify modifiable risk factors for early postoperative SSI in primary pediatric spinal deformity posterior spinal fusion patients. Level of EvidenceLevel III, case-control study.

The impact of intraoperative fluid management during laparoscopic donor nephrectomy on donor and recipient outcomes.

Intraoperative fluid management during laparoscopic donor nephrectomy (LDN) may have a significant effect on donor and recipient outcomes. We sought to quantify variability in fluid management and investigate its impact on donor and recipient outcomes. A retrospective review of patients who underwent LDN from July 2011 to January 2016 with paired kidney recipients at a single center was performed. Patients were divided into tertiles of intraoperative fluid management (standard, high, and aggressive). Donor and recipient demographics, intraoperative data, and postoperative outcomes were analyzed. Overall, 413 paired kidney donors and recipients were identified. Intraoperative fluid management (mL/h) was highly variable with no correlation to donor weight (kg) (R=0.017). The aggressive fluid management group had significantly lower recipient creatinine levels on postoperative day 1. However, no significant differences were noted in creatinine levels out to 6months between groups. No significant differences were noted in recipient postoperative complications, graft loss, and death. There was a significant increase (P<0.01) in the number of total donor complications in the aggressive fluid management group. Aggressive fluid management during LDN does not improve recipient outcomes and may worsen donor outcomes compared to standard fluid management.

Impact of intraoperative hypovolemic phlebotomy on blood loss and perioperative transfusion in patients undergoing hepatectomy for cancer

Background: Intraoperative blood loss (IOBL) and allogeneic blood transfusion are important determinants of outcome in patients undergoing elective hepatectomy for cancer. We assessed whether intraoperative hypovolemic phlebotomy (HP) used to perform hepatectomy under low central venous pressure (CVP) was associated with lower IOBL and perioperative transfusion rates, and whether these factors were linked to patient oncological outcomes. Methods: Restrospective analysis of a prospectively maintained database of consenting patients who underwent hepatectomy for primary and secondary liver malignancies between 01/2011 and 06/2017 in one academic center. Perioperative blood transfusion was defined as red blood cell unit transfused during hepatectomy until hospital discharge, and data were extracted from the hospital transfusion medicine database. We used the Fisher’s exact test to compare proportions, the Mann-Whitney or the Kruskal-Wallis tests to compare means, the Spearman r test for correlations, and Log Rank test and Cox regression for associations of variables with survival outcomes. Results: Intraoperative HP was used in 520 (76.0%) of the 684 patients included in this study. The median phlebotomy volume was 400 ml (range 50 to 900 ml), and median volume per patient weight was 5.3 ml/kg (range 0.5 to 30.1 ml/kg). Patients with large HP (>5.3 ml/kg) had lower IOBL than those with smaller HP (507 ml vs. 640.2 ml, p = 0.008). HP volume/weight was negatively correlated with IOBL (Spearman r = -0.11, p = 0.019). The perioperative transfusion rate was 14.6% in patients when HP was used, compared to 22.2% (p = 0.022) when HP was not used. The transfusion rate was lower in HP patients compared to non-HP patients even though more major hepatectomies (≥4 segments) (36.0% vs. 27.1%, p = 0.02) and less laparoscopic surgery (4.9% vs. 11.1%) were done in the HP group. Intraoperative HP reduced the perioperative transfusion risk by 8.9% (relative risk 0.91, 95% CI 0.82 to 0.99), and the number needed to treat to avoid one transfusion was 13 patients. The preoperative three-point transfusion risk score (hemoglobin 12.5 g/dl or less, primary liver malignancy, and resection of ≥ 4 liver segments) stratified patients by low vs. high transfusion requirements (13.3% if score 0 or 1 vs. 31% if score 2 or 3, p < 0.0001), irrespective of the use of HP. We did not find a significant association between IOBL or perioperative transfusions and recurrence-free or disease-specific survival. Conclusion: Intraoperative HP in patients undergoing hepatectomy was associated with lower IOBL and a perioperative transfusion rate of 14.6%, which was lower than non-HP patients and the 22% to 32% rate reported in contemporaneous series. Prospective studies with optimized preoperative hemoglobin level, standardized intraoperative hemostatic and fluid management methods, and defined perioperative transfusion criteria are needed to determine whether HP is superior to other anesthesiological techniques of low CVP for reducing IOBL and transfusion requirements.

Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway.

Fluid management is an essential component of the Enhanced Recovery after Surgery (ERAS) pathway. Optimal management begins in the preoperative period and continues through the intraoperative and postoperative phases. In this review, we outline current evidence-based practices for fluid management through each phase of the perioperative period. Preoperatively, patients should be encouraged to hydrate until 2 hours prior to the induction of anesthesia with a carbohydrate-containing clear liquid. When mechanical bowel preparation is necessary, with modern isoosmotic solutions, fluid repletion is not necessary. Intraoperatively, fluid therapy should aim to maintain euvolemia with an individualized approach. While some patients may benefit from goal-directed fluid therapy, a restrictive, zero-balance approach to intraoperative fluid management may be reasonable. Postoperatively, early initiation of oral intake and cessation of intravenous therapy are recommended.

Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice

BackgroundThere is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. MethodsA 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. ResultsA 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. ConclusionsThis questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

Effects of Intraoperative Fluid Management on Postoperative Outcomes After Lobectomy

The amount and type of intraoperative fluid in patients with pulmonary resection currently are controversial. This study evaluated the dose-response relationship between intraoperative fluid administration and postoperative outcomes in minimally invasive lobectomypatients. A retrospective analysis of adult patients undergoing minimally invasive lobectomy between May 2016 and April 2017 was performed. The primary exposure variables were intraoperative total fluid infusion rate and intraoperative colloid infusion rate. The observation outcomes were postoperative pulmonary complications (PPCs), acute kidney injury, in-hospital mortality, postoperative length of stay, and costs. Univariate analyses and multivariate analyses were performed. In 446 patients all resections were minimally invasive lobectomies. Two hundred one PPCs were observed in 172 patients. Binary logistics regression analysis demonstrated that compared with the moderate group of intraoperative total fluid infusion rate, the risk for PPCs was significantly increased at restrictive (odds ratio [OR], 2.202; 95% confidence interval [CI], 1.189-4.078; p= 0.012), moderately liberal (OR, 2.743; 95% CI, 1.451-5.184; p= 0.002), and liberal (OR, 2.609; 95% CI, 1.278-5.328; p= 0.008) groups. Compared with the moderate group of intraoperative colloid infusion rate, the risk for PPCs significantly increased at no colloid (OR, 2.095; 95% CI, 1.193-3.680; p= 0.010) and restrictive (OR, 2.911; 95% CI, 1.443-5.873; p= 0.003) groups. In patients undergoing minimally invasive lobectomy the infusion rates of intraoperative total fluid and intraoperative colloid were all significantly associated with PPCs. Both restrictive and liberal intraoperative fluid administration were related to adverse effects on postoperative outcomes.

Perioperative Mortality in Cancer Esophagus-a Case Control Study at a High-Volume Regional Cancer Center in South India.

Surgery for esophageal cancers carries high rates of morbidity and mortality despite improvements in perioperative care especially with increasingly safe anesthesia and postoperative ICU care. A case control study was conducted on 713 patients operated for esophageal cancer over a period of 8years (2009-2016). Multiple preoperative, intraoperative, and postoperative clinical and laboratory parameters were compared between patients who succumbed to the surgery, i.e., 30-day mortality, and those who did not. Of the preoperative parameters, age > 58.5years (p = 0.01), history of dysphagia with significant weight loss (p = 0.028), diabetes (p = 0.002), ischemic cardiac disease (p = 0.0001), low FEV1 < 69.5% (p = 0.036), preoperative length of hospital stay > 6.94days (p = 0.001), involvement of gastroesophageal junction (p = 0.04), and ASA score > 2 (p = 0.002) were significantly associated with perioperative mortality. Intraoperatively, blood loss (p = 0.003), intraoperative (p = 0.015) and postoperative (p = 0.0001) blood transfusion, splenectomy (p = 0.0001), and excessive intraoperative intravenous fluids (p = 0.003) were associated with mortality. Decreased postoperative day 1 serum albumin level < 2.38mg/dl (p = 0.0001), increased ICU stay > 7.32days (SD+/- = 6.28, p = 0.03), number of positive lymph nodes > 2.97 (SD+/- = 4.19, p = 0.013), conduit necrosis (p = 0.0001), recurrent laryngeal nerve palsy (p = 0.013), pulmonary venous thromboembolism (p = 0.0001), multiple organ dysfunction syndrome (p = 0.0001), LRTI (p = 0.0001), arrhythmia (p = 0.005), sepsis (p = 0.0001), and ARDS (p = 0.0001) were the postoperative complications that were significantly associated with mortality. Comprehensive patient care involving preoperative optimization, improved surgical skills, rigorous intraoperative fluid management, and dedicated intensive care units will continue to play a major role in further minimizing mortality and morbidity associated with esophageal cancer surgeries.

Surveying the Literature

Surveying the Literature

Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway.

Prolonged postoperative ileus (PPOI) is common after colorectal surgery but has not been widely studied in the context of enhanced recovery pathways (ERPs) that include interventions aimed to accelerate gastrointestinal recovery. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery. We analyzed data from an institutional colorectal surgery ERP registry. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and absence of flatus or bowel movement for ≥ 4days) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies, and their predictive ability was evaluated using Bayesian model averaging (BMA). Results are presented as posterior effect probability (PEP). Evidence of association was categorized as: no evidence (PEP < 50%), weak evidence (50-75%), positive evidence (75-95%), strong evidence (95-99%), and very strong evidence (> 99%). There were 323 patients analyzed (mean age 63.5years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11 and 59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48h (PEP 94%; strong evidence), postoperative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3ml/kg/h for laparoscopic and 5ml/kg/h for open; PEP 55%, weak evidence) were predictors of PPOI. The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably by diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated.

Clinical and economic impact of goal-directed fluid therapy during elective gastrointestinal surgery

BackgroundSeveral randomized controlled trials suggest that goal-directed fluid therapy (GDFT) may result in improved postoperative outcomes. The aim of this study was to assess the clinical and financial impact of the real-life implementation of intraoperative GDFT in patients undergoing elective gastrointestinal surgery in a Chinese tertiary medical center.MethodsThis Quality Improvement Program (QIP) study comprised three phases of 5, 1, and 5 months, respectively. During the first phase, we retrospectively collected perioperative data from patients who received standard intraoperative fluid management from January to May 2016. Then a 1-month training period allowed the clinical staff to become familiar with the GDFT protocol. After the training phase, GDFT was used from July to November 2016. In the GDFT group, stroke volume (SV) was continuously monitored and optimized towards the plateau of the Frank-Starling curve. The primary outcome measure was postoperative morbidity (the proportion of patients with one or more complications within 30 days after surgery). Secondary outcomes were total hospital cost, postoperative length of hospital stay, and 30-day mortality.ResultsData from 200 patients before (control group) and 201 patients after the implementation of GDFT (GDFT group) were collected and compared. There was no significant difference in demographics and surgical procedures between the two groups. Postoperative morbidity was significantly lower in the GDFT group than in the control group (30.8% vs. 44.0%, p = 0.006). No significant differences were observed for mean total hospital cost (76,793 RMB vs. 74,444 RMB; p = 0.430), median postoperative length of hospital stay (10 days vs. 10 days; p = 0.104), and 30-day mortality (1% vs. 0.5%; p = 0.565).ConclusionIn patients undergoing gastrointestinal surgery, the implementation of a GDFT protocol was associated with a reduction in postoperative morbidity without increasing costs.Trial registrationclinicaltrials.gov, NCT02507557. Registered 13 July 2015.

Intraoperative factors associated with free flap failure in the head and neck region: a four-year retrospective study of 216 patients and review of the literature

The aim of this study was to identify intraoperative factors associated with free flap failure. The outcomes of 216 patients (220 flaps) were analyzed retrospectively. A statistical analysis was performed to determine the association of flap failure with the intraoperative factors of prolonged operation time, flap type, vascular pedicle at the recipient site, and use of vasoactive medication. A review of the recent literature was also conducted to identify other intraoperative risk factors. Univariate regression analysis revealed that a prolonged operative time (P=0.013) and the vascular pedicle at the recipient site (P=0.027) were primary risk factors for flap failure. Furthermore, the intraoperative use of papaverine improved the success rate of free flap transfer (P=0.015). Multivariate regression analysis showed that only the application of papaverine remained statistically significant (P=0.011). The results confirmed that the choice of flap type had no influence on free flap survival (P=0.583). In addition, the literature review showed that excessive intraoperative fluid administration is a risk factor for free flap failure. These conclusions may provide microvascular surgeons with information to reduce the failure rate. Also, microvascular surgeons should always consider the details of intraoperative fluid management.

Clinical implications of intraoperative fluid therapy in pancreatic surgery: it is not “just water”

Background: Recent studies have suggested that intraoperative fluid overload is associated with a worse outcome after major abdominal surgery. However, evidence in the field of pancreatic surgery is still not consistent. The aim of this study was to evaluate whether intraoperative fluid management could affect the outcome of a major pancreatic resection. Methods: Prospective analysis of 350 major pancreatic resections performed in 2016 at The Pancreas Institute, University of Verona Hospital Trust. Patients were dichotomized according to intraoperative fluid volume administration into near-zero fluid balance (NZF - infusion rate 3 mL/kg/h) and liberal fluid balance groups (LF - >3 mL/kg/h). Intraoperative fluid administration was then correlated to the postoperative outcome. Results: Overall, a LF balance was associated with an increased rate of Clavien-Dindo IIIB (50.5% vs. 34.5%; p = 0.02) and delayed gastric emptying (DGE) (8.8% vs. 1.8%; p = 0.05). A NZF balance was associated with a reduced incidence of biliary fistula (0% vs. 7.9%; p = 0.05) and DGE (5% vs. 11.6%; p = 0,04) but an increased rate of post-operative acute pancreatitis (75% vs. 49.2%; p = 0.02) after pancreaticoduodenectomy. Considering patients with a soft pancreatic remnant, a NZF balance was associated with an increased rate of pancreatic fistula (60% vs. 45.2%, p = 0.02). Conclusion: Considering all pancreatic resections, a LF balance is associated with an increased rate of postoperative morbidity. However, in the case of PD with a soft pancreas, a NZF balance could lead to pancreatic stump ischemia and anastomotic failure. Intraoperative fluid management should be managed according to patient's pancreas-specific risk factors.

Enhanced Recovery After Surgery: Intraoperative Fluid Management Strategies.

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

Clinical Implications of Intraoperative Fluid Therapy in Pancreatic Surgery

BackgroundRecent studies have suggested that intraoperative fluid overload is associated with a worse outcome after major abdominal surgery. However, evidence in the field of pancreatic surgery is still not consistent. The aim of this study was to evaluate whether intraoperative fluid management could affect the outcome of a major pancreatic resection. MethodsProspective analysis of 350 major pancreatic resections performed in 2016 at the Department of General and Pancreatic Surgery—The Pancreas Institute, University of Verona Hospital Trust. Patients were dichotomized according to intraoperative fluid volume administration (near-zero vs. liberal fluid balance) and matched using propensity score. Intraoperative fluid administration was then correlated to the postoperative outcome. ResultsLiberal fluid balance was associated with an increased rate of Clavien-Dindo ≥ IIIB both after pancreaticoduodenectomy (60.3 vs. 30.2%, p < 0.01) and distal pancreatectomy (50 vs. 27.1%, p = 0.03). In case of pancreaticoduodenectomy, liberal fluid balance was also associated with an increased rate of pancreatic fistula (33.3 vs. 19.9%, p = 0.05), but when considering patients with soft remnants, an increase rate of pancreatic fistula (52.8 vs. 23%, p = 0.03) was indeed associated with the near-zero fluid balance. ConclusionConsidering all pancreatic resections, a liberal fluid balance is associated with an increased rate of postoperative morbidity. However, in the case of PD with a soft pancreas, an NZF balance could lead to pancreatic stump ischemia and anastomotic failure. Intraoperative fluid management should be managed according to patient’s pancreas-specific risk factors.

Comparison of conventional fluid management with PVI-based goal-directed fluid management in elective colorectal surgery

Intraoperative fluid management is quite important in terms of postoperative organ perfusion and complications. Different fluid management protocols are in use for this purpose. Our primary goal was to compare the effects of conventional fluid management (CFM) with the Pleth Variability Index (PVI) guided goal-directed fluid management (GDFM) protocols on the amount of crystalloids administered, blood lactate, and serum creatinine levels during the intraoperative period. The length of hospital stay was our secondary goal. Seventy ASA I–II elective colorectal surgery patients were randomly assigned to CFM or GDFM for fluid management. The hemodynamic data and the data obtained from ABG were recorded at the end of induction and during the follow-up period at 1 h intervals. In the preoperative period and at 24 h postoperatively, blood samples were taken for the measurement of hemoglobin, Na, K, Cl, serum creatinine, albumin and blood lactate. In the first 24 h after surgery, oliguria and the time of first bowel movement were recorded. Length of hospital stay was also recorded. Intraoperative crystalloid administration and urine output were statistically significantly higher in CFM group (p < 0.001, p: 0.018). The end-surgery fluid balance was significantly lower in Group GDFM. Preoperative and postoperative Na, K, Cl, serum albumin, serum creatinine, lactate and hemoglobin values were similar between the groups. The time to passage of stool was significantly short in Group-GDFM compared to Group-CFM (p = 0.016). The length of hospital stay was found to be similar in both group. PVI-guided GDFM might be an alternative to CFM in ASA I–II patients undergoing elective colorectal surgery. However, further studies need to be carried out to search the efficiency and safety of PVI.

Postoperative acute pancreatitis following pancreaticoduodenectomy: a determinant of fistula driven by the intraoperative fluid management

Postoperative acute pancreatitis following pancreaticoduodenectomy: a determinant of fistula driven by the intraoperative fluid management