Intraoperative Fluid Management Research Articles

Intraoperative fluid management is not predictive of AKI in major pancreatic surgery: a retrospective cohort study

BackgroundPancreatic surgery is associated with a significant risk for acute kidney injury (AKI) and clinically relevant postoperative pancreatic fistula (CR-POPF). This investigation evaluated the impact of intraoperative volume administration, vasopressor therapy, and blood pressure management on the primary outcome of AKI and the secondary outcome of a CR-POPF after pancreatic surgery.MethodsThis retrospective single-center cohort investigated 200 consecutive pancreatic surgeries (January 2018–December 2021). Patients were categorized for the presence/absence of AKI (Kidney Disease Improving Global Outcomes) and CR-POPF. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes.ResultsAKI was identified in 20 patients (10%) with significant univariate differences in demographics (body mass index and gender), comorbidities, indices of chronic renal insufficiency, and an increased AKI Risk score. Surgical characteristics, intraoperative fluid, vasopressor, and blood pressure management were similar in patients with and without AKI. Patients with AKI had increased blood loss, lower urine output, and packed red blood cell administration. After multivariate analysis, male gender (OR = 7.9, 95% C.I. 1.8–35.1) and the AKI Risk score (OR = 6.3, 95% C.I. 2.4–16.4) were associated with the development of AKI (p < 0.001). Intraoperative and postoperative volume, vasopressor administration, and intraoperative hypotension had no significant impact in the multivariate analysis. CR-POPF occurred in 23 patients (11.9%) with no significant contributing factors in the multivariate analysis. Patients who developed AKI or a CR-POPF had an increase in surgical complications, length of stay, discharge to a skilled nursing facility, and mortality.ConclusionIn this analysis, intraoperative volume administration, vasopressor therapy, and a blood pressure < 55 mmHg for more than 10 min were not associated with an increased risk of AKI. After multivariate analysis, male gender and an elevated AKI Risk score were associated with an increased likelihood of AKI.

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

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

The predictive and prognostic value of risk factors in patients receiving hybrid coronary revascularization with postoperative pulmonary complications.

The mortality rate of coronary artery disease ranks first in developed countries, and coronary revascularization therapy is an important cornerstone of its treatment. The postoperative pulmonary complications (PPCs) in patients receiving one-stop hybrid coronary revascularization (HCR) aggravate the dysfunction of multiple organs such as the heart and lungs, therefore increasing mortality. However, the risk factors are still unclear. The objective of this study was to explore the risk factors of PPCs after HCR surgery. In this study, the perioperative data of 311 patients undergoing HCR surgery were reviewed. All patients were divided into two groups according to whether the PPCs occurred. The baseline information and surgery-related indicators in preoperative laboratory examination, intraoperative fluid management, and anesthesia management were compared between the two groups. Advanced age [odds ratio (OR): 1.065, 95% confidence interval (CI): 1.030-1.101, P<0.001], high body mass index (BMI; OR: 1.113, 95% CI: 1.011-1.225, P=0.02), history of percutaneous coronary intervention (PCI) surgery (OR: 2.831, 95% CI: 1.388-5.775, P=0.004), one-lung volume ventilation (OR: 3.804, 95% CI: 1.923-7.526, P<0.001), inhalation of high concentration oxygen (OR: 3.666, 95% CI: 1.719-7.815, P=0.001), the application of positive end-expiratory pressure (PEEP; OR: 2.567, 95% CI: 1.338-4.926, P=0.005), and long one-lung ventilation time (OR: 1.015, 95% CI: 1.006-1.023, P=0.001) may be risk factors for postoperative PPCs in patients undergoing one-stop coronary revascularization surgery. Using the above seven factors to jointly predict the risk of PPCs in patients undergoing one-stop coronary revascularization surgery, the receiver operating characteristic (ROC) curve showed an area under the curve (AUC) =0.873, 95% CI: 0.835-0.911, sensitivity: 84.81%, and specificity: 75.82%; the predictive model was shown to be effective. Patients undergoing HCR surgery with advanced age, high BMI, a history of PCI surgery, one-lung volume ventilation, inhalation of high concentration oxygen, use of PEEP, and prolonged single lung ventilation are more prone to PPCs.

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.

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.

Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study

BackgroundEsophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear.MethodsAfter the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications.ResultsAmong 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545–682] minutes; total intraoperative infusion volume was 3,747 [3,038–4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42–6.73] mL/kg/h; and fluid balance was + 2,648 [2,015–3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels.ConclusionsAmong patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.

Intraoperative Fluid Management Correlates with Intraoperative Complications in Cesarean Section: A Prospective Clinical Trial

Background: This study focused on perioperative fluid administration in pregnant women undergoing a caesarean section (CS) by comparing liberal and non-liberal fluid administration in a multicentre setting across various Hospitals in the Bali province and its surrounding areas.&#x0D; Methods: Sampling was conducted using a total sampling method. All patients meeting the inclusion criteria were included in this study. A total of 310 samples of pregnant patients undergoing CS surgery in various operating rooms across hospitals in the Bali province and surrounding areas were obtained during the period of January to December 2022. The fluid administration strategy was divided into two types: liberal and non-liberal. Data analysis was performed using the Chi-square test with the correlation test of the contingency coefficient.&#x0D; Results: The results showed that liberal fluid administration significantly increased complications in the operating room for pregnant patients undergoing cesarean section (p&lt;0.001; r=0.305; OR 6.22) but not in the recovery room or postoperative hospital ward.&#x0D; Conclusion: Liberal fluid administration could significantly increase complications in the operating room for pregnant patients undergoing cesarean section but not in the postoperative period.

Implementation and achievements of enhanced recovery after surgery program in perioperative management of gastric cancer patients†

Abstract Objective The enhanced recovery after surgery (ERAS) program is less implemented in gastric cancer patients. The purpose of this survey is to investigate the implementation status of ERAS in perioperative period in gastric cancer. Methods This clinical observational study enrolled 329 patients between January 2020 and August 2020 in a single gastric cancer center. The questionnaire consisted of 4 parts: basic information, preoperative status, intraoperative status, and postoperative status of ERAS implementation in gastric cancer surgery. Results In the preoperative period, patients’ education and counseling (100%) were well adopted. Smoking cessation (34.6%), drinking cessation (36.9%), avoidance of preoperative mechanical bowel preparation (24.3%), respiratory function training (11.2%), and administration of carbohydrate-rich drink before surgery (0.6%) were relatively not well adopted. During the operation, maintenance of intraoperative normothermia and fluid management (100%), as well as epidural analgesia (81.5%), were well adopted. Thromboprophylaxis was performed in 133 (40.4%) patients. In the postoperative period, early active mobilization was implemented about 9.5 h, and early ambulation was implemented about 39.5 h, after surgery. A total of 140 (42.5%) patients received prolonged prophylactic antibiotics; 268 (81.5%) patients were provided diet upon gas passage; and 320 (97.3%) patients received intravenous fluid administration more than 5 d after surgery. The practice rate of early removal of urinary catheter (0%) and nasogastric tube (15.5%) was relatively low. A total of 11 (3.3%) patients experienced postoperative complication, and 1 (0.3%) patient received unplanned reoperation. The average costs were ¥59,500, and the average hospital stay was 12 (5, 36) d. Conclusions Standard perioperative management of ERAS program in gastric cancer surgery in China still requires improvement.

Cardiac patient for lung surgery: Walking the tightrope

A patient with poor cardiac function undergoing any surgery under any form of anaesthesia is at high risk for perioperative morbidity and mortality. Both open thoracic surgery and emergency laparotomy in these patients are associated with high incidence of postoperative pulmonary and cardiac complications. Perioperative assessment and multidisciplinary approach are key to managing such cases. Having a clear plan for induction, invasive monitoring, intraoperative fluid management and post-operative analgesia is important for a positive outcome. We present a case of an elective open pulmonary lobectomy and emergency laparotomy conducted within an interval of 7 days in a patient with adenocarcinoma lung and ischemic heart disease with ejection fraction of 10-15%, highlighting the perioperative challenges and management.

Intraoperative fluid management of large volume liposuction surgery, cardiometry guided stroke volume variation versus Rohrich formula, a prospective randomized trial

Intraoperative fluid management of large volume liposuction surgery, cardiometry guided stroke volume variation versus Rohrich formula, a prospective randomized trial

Optimising Intraoperative Fluid Management in Patients Treated with Adolescent Idiopathic Scoliosis-A Novel Strategy for Improving Outcomes.

Scoliosis surgery is a challenge for the entire team in terms of safety, and its accomplishment requires the utilization of advanced monitoring technologies. A prospective, single centre, non-randomised controlled cohort study, was designed to assess the efficacy of protocolised intraoperative haemodynamic monitoring and goal-directed therapy in relation to patient outcomes following posterior fusion surgery for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure management during the surgical procedure, whereas the intervention group (n = 35, mean age: 14 years) underwent minimally invasive haemodynamic monitoring. Arterial pulse contour analysis (APCO) devices were employed, along with goal-directed therapy protocol centered on achieving target mean arterial pressure and stroke volume. This was facilitated through the application of crystalloid boluses, ephedrine, and noradrenaline. The intervention group was subjected to a comprehensive protocol following Enhanced Recovery After Surgery (ERAS) principles. Remarkably, the intervention group exhibited notable advantages (p < 0.05), including reduced hospital stay durations (median 7 days vs. 10), shorter episodes of hypotension (mean arterial pressure < 60 mmHg-median 8 vs. 40 min), lesser declines in postoperative haemoglobin levels (-2.36 g/dl vs. -3.83 g/dl), and quicker extubation times. These compelling findings strongly imply that the integration of targeted interventions during the intraoperative care of AIS patients undergoing posterior fusion enhance a set of treatment outcomes.

Pulse Pressure Variation-Based Intraoperative Fluid Management Versus Traditional Fluid Management for Colon Cancer Patients Undergoing Open Mass Resection and Anastomosis: A Randomized Controlled Trial.

Bowel edema leads to decreased perfusion and oxygenation of the intestine at the anastomotic site after colonic mass resection with failure of healing and leakage. Additionally, dehydration causes bowel hypoperfusion and difficulty healing with more complications. Fluid therapy guided by dynamic monitoring of fluid response can help avoid bowel dehydration and edema with fewer complications. The main goal of this study was to compare the effects of intraoperative fluid therapy based on pulse pressure variation (PPV) to traditional fluid therapy to maintain adequate hydration without intraoperative instability of hemodynamics and postoperative complications. This randomized controlled study was conducted on 90 adult patients (age range: 18-70 years) undergoing elective open colonic mass resection and anastomosis at Eldemerdash Hospital, Ain Shams University, Cairo, Egypt. There were two groups of patients, namely group A (n = 45; conventional fluid management [CFM] group) and group B (n = 45; goal-guided fluid management [GGFM] group based on PPV), using randomly generated data from a computer. Intraoperative fluids and vasopressors were given using GGFM or routine care. The key tool for directing hemodynamic management in the GGFM algorithm was the fluid protocol and PPV. As a result, the outcomes were measured to include the volume of intraoperative fluid, water fraction, and postoperative complications. In this study, 90 patients underwent analysis. Both groups' demographics were similar (P > 0.05). Baseline characteristics and surgical procedures did not differ significantly between the two groups (P > 0.05). Both the amount of urine output and the intraoperative administration of crystalloids were statistically significantly higher in group A (P < 0.05). The two groups' heart rate, mean arterial pressure and intraoperative usage of colloids and ephedrine were not statistically different (P > 0.05). Water fraction, bowel recovery, anastomotic leak, and length of hospital stay were significantly higher in the CFM group (P < 0.05). For patients with the American Society of Anesthesiologists physical status I - II undergoing elective open resection of colonic mass and anastomosis, PPV-based GGFM, a less invasive tool for intraoperative fluid management, might be a better option than CFM.

Perioperative considerations of pyruvate dehydrogenase complex deficiency: a case report of two consecutive anesthesia.

Pyruvate dehydrogenase complex (PDHC) deficiency is a rare mitochondrial disorder caused by a genetic mutation affecting the activity of the PDHC enzyme, which plays a major role in the tricarboxylic cycle. Few cases of surgery or anesthesia have been reported. Moreover, there is no recommended anesthetic method. A 24-month-old child with a PDHC deficiency presented to the emergency room with respiratory failure, mental decline, systemic cyanosis, and lactic acidosis. During hospitalization period, the patient presented with pneumothorax, pneumoperitoneum, and multiple air pockets in the heart. Two surgeries were performed under general anesthesia using an inhalational anesthetic agent. The patient was discharged with home ventilation. Anesthesiologists should be wary of multiple factors when administering anesthesia to patients with PDHC deficiency, including airway abnormalities, acid-base imbalance, intraoperative fluid management, selection of appropriate anesthetics, and monitoring of lactic acid levels.

Liberal intraoperative fluid management leads to increased complication rates in geriatric patients with hip fracture.

Fractures of the proximal femur in geriatric patients are life-changing and life-threatening events. Previous research has identified fluid volume as an independent factor contributing to trauma patients' complications. Therefore, we aimed to investigate the impact of intraoperative fluid volume on outcomes in geriatric patients undergoing hip fracture surgery. We conducted a retrospective single-center study with data from the hospital information systems. Our study included patients aged 70years or older who had sustained a proximal femur fracture. We excluded patients with pathologic, periprosthetic, or peri-implant fractures and those with missing data. Based on the fluids given, we divided patients into high-volume and low-volume groups. Patients with a higher American Society of Anesthesiologists (ASA) grade and more comorbidities were more likely to receive more than 1500ml of fluids. We observed significant differences in anesthesiologic management between the two groups, with a higher rate of invasive blood pressure management (IBP) and central venous catheter usage in the high-volume group. High-volume therapy was associated with a higher rate of complications (69.7% vs. 43.6%, p < 0.01), a higher transfusion rate (odds ratio 1.91 [1.26-2.91]), and an increased likelihood of patients being transferred to an intensive care unit (17.1% vs. 6.4%, p = 0.009). These findings were confirmed after adjusting for ASA grade, age, sex, type of fracture, Identification-of-Seniors-At-Risk (ISAR) score, and intraoperative blood loss. Our study suggests that intraoperative fluid volume is a significant factor that impacts the outcome of hip fracture surgery in geriatric patients. High-volume therapy was associated with increased complications.

The effect of intraoperative goal-directed fluid therapy combined with enhanced recovery after surgery program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection: a prospective randomized controlled study

BackgroundTo investigate the effect of intraoperative goal-directed fluid therapy (GDFT) combined with enhanced recovery after surgery (ERAS) program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection.MethodsPatients, more than 60 years old, undergoing thoracoscopic pulmonary resection for non-small cell lung cancer were randomly divided into GDFT group and restrictive fluid therapy (RFT) group. ERAS program was implemented in all patients. In GDFT group, the intraoperative fluid management was guided by stroke volume variation (SVV), cardiac index (CI), and mean arterial pressure (MAP) and maintained the SVV < 13%, CI > 2.5 L/min/m2, and MAP > 65 mmHg. In RFT group, fluid maintenance with 2 ml/kg/h of balanced crystalloid solution, norepinephrine was used to maintain MAP > 65 mmHg. The incidence of postoperative acute kidney injury (AKI) and pulmonary and cardiac complications was compared.ResultsTwo-hundred seventy-six patients were enrolled and randomly divided into two groups (138 in each group). Compared to RFT group, the total intraoperative infusion volume, colloids infusion volume, and urine output were more; the dosage of norepinephrine was lower in GDFT group. Although there were no significant differences of postoperative AKI (GDFT vs RFT; 4.3% vs 8%; P = 0.317) and composite postoperative complications (GDFT vs RFT; 66 vs 70) between groups, but the postoperative increase degree of serum creatinine was lower in GDFT group than that in RFT group (GDFT vs RFT; 91.9 ± 25.2 μmol/L vs 97.1 ± 17.6 μmol/L; P = 0.048).ConclusionsUnder ERAS program, there was no significant difference of AKI incidence between GDFT and RFT in elderly patients undergoing thoracoscopic pulmonary resection. But postoperative increase degree of serum creatinine was lower in GDFT group.Trial registrationRegistered at ClinicalTrials.gov, NCT04302467 on 26 February 2020.

The association between intraoperative fluid management and perioperative allogenic blood transfusion during adolescent idiopathic scoliosis surgery.

Bleeding and transfusion remain important concerns during surgical correction of scoliosis even when multiple conservative strategies, such as preoperative recombinant erythropoietin and/or antifibrinolytic agents, are used. The current work aimed to determine the impact of other potential risk factors, especially the volume of intraoperative fluid intake, on the perioperative risk of allogenic transfusion during surgical correction of adolescent idiopathic scoliosis. This prospective study included all cases of adolescent idiopathic scoliosis operated in a single center during 2 years (2018-2020). Predictors analyzed were as follows: body mass index, preoperative hemoglobin concentration, thoracoplasty, preoperative halo-gravity, volume of intraoperative crystalloid administration, use of esophageal Doppler (for goal-directed fluid therapy), and duration of surgery. Statistical analyses were performed using a multivariable logistic regression model. Two hundred patients were included in the analysis. Multivariable analysis found: an increased volume of intraoperative crystalloid administration as a significant predictor of allogenic blood transfusion. Receiving operator characteristics analysis found the model exhibiting an area under the curve of 0.85 (95% confidence interval: 0.75-0.95). Optimizing stroke volume using esophageal Doppler was associated with a decrease in intraoperative crystalloid intake. These results indicate a statistical association between the increase in crystalloid intake and the risk of allogenic blood transfusion during surgical correction of adolescent idiopathic scoliosis. Controlled studies are needed to address the causative relation between intraoperative fluid intake and the risk of allogenic transfusion.

Evaluating a unique enhanced recovery protocol in laparoscopic donor nephrectomy: A single center experience.

Enhanced recovery after surgery (ERAS) protocols have been associated with a reduction in opioid consumption and a hastening in recovery in abdominal surgery. However, their impact on laparoscopic donor nephrectomy (LDN) has not been fully elucidated. The aim of this study is to evaluate opioid consumption and other relevant outcome measures before and after implementation of a unique LDN ERAS protocol. 244 LDN patients were included in this retrospective cohort study. Forty-six underwent LDN prior to implementation of ERAS, whereas 198 patients received ERAS perioperative care. The primary outcome was daily oral morphine equivalent (OME) consumption averaged over the entire postoperative stay. Due to removal of preoperative oral morphine from the protocol partway through the study period, the ERAS group was further subdivided into morphine recipients and non-recipients for subgroup analysis. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), length of stay, pain scores, and other relevant measures. ERAS donors consumed significantly fewer average daily OMEs than Pre-ERAS donors (21.5vs. 37.6, respectively; p<.0001).There were no statistically significant differences in OME consumption between morphine recipients and non-recipients. The ERAS group experienced less PONV (44.4% requiring one or more rescue antiemetic postoperatively, vs. 60.9% of Pre-ERAS donors; p=.008). A protocol pairing lidocaine and ketamine with a comprehensive approach to preoperative PO intake, premedication, intraoperative fluid management and postoperative pain control is associated with reduced opioid consumption in LDN.

The Optimal Fluid Strategy Matters in Liver Surgery: A Retrospective Single Centre Analysis of 666 Consecutive Liver Resections.

As optimal intraoperative fluid management in liver surgery has not been established, we retrospectively analyzed our fluid strategy in a high-volume liver surgery center in 666 liver resections. Intraoperative fluid management was divided into very restrictive (<10 m kg-1 h-1) and normal (≥10 mL kg-1 h-1) groups for study group characterization. The primary endpoint was morbidity as assessed by the Clavien-Dindo (CD) score and the comprehensive complication index (CCI). Logistic regression models identified factors most predictive of postoperative morbidity. No association was found between postoperative morbidity and fluid management in the overall study population (p = 0.89). However, the normal fluid management group had shorter postoperative hospital stays (p = <0.001), shorter ICU stays (p = 0.035), and lower in-hospital mortality (p = 0.02). Elevated lactate levels (p < 0.001), duration (p < 0.001), and extent of surgery (p < 0.001) were the most predictive factors for postoperative morbidity. In the subgroup of major/extreme liver resection, very low total (p = 0.028) and normalized fluid balance (p = 0.025) (NFB) were associated with morbidity. Moreover, fluid management was not associated with morbidity in patients with normal lactate levels (<2.5 mmol/L). In conclusion, fluid management in liver surgery is multifaceted and must be applied judiciously as a therapeutic measure. While a restrictive strategy appears attractive, hypovolemia should be avoided.

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

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

Intraoperative pleth variability index-based fluid management therapy and gastrointestinal surgical outcomes in elderly patients: a randomised controlled trial

BackgroundIntraoperative goal-directed fluid therapy (GDFT) has been reported to reduce postoperative complications of patients undergoing major abdominal surgery. The clinical benefits of pleth variability index (PVI)-directed fluid management for gastrointestinal (GI) surgical patients remain unclear. Therefore, this study aimed to evaluate the impact of PVI-directed GDFT on GI surgical outcomes in elderly patients.MethodsThis randomised controlled trial was conducted in two university teaching hospitals from November 2017 to December 2020. In total, 220 older adults undergoing GI surgery were randomised to the GDFT or conventional fluid therapy (CFT) group (n = 110 each). The primary outcome was a composite of complications within 30 postoperative days. The secondary outcomes were cardiopulmonary complications, time to first flatus, postoperative nausea and vomiting, and postoperative length of stay.ResultsThe total volumes of fluid administered were less in the GDFT group than in the CFT group (2.075 L versus [vs.] 2.5 L, P = 0.008). In intention-to-treat analysis, there was no difference in overall complications between the CFT group (41.3%) and GDFT group (43.0%) (odds ratio [OR] = 0.935; 95% confidence interval [CI], 0.541–1.615; P = 0.809). The proportion of cardiopulmonary complications was higher in the CFT group than in the GDFT group (19.2% vs. 8.4%; OR = 2.593, 95% CI, 1.120–5.999; P = 0.022). No other differences were identified between the two groups.ConclusionsAmong elderly patients undergoing GI surgery, intraoperative GDFT based on the simple and non-invasive PVI did not reduce the occurrence of composite postoperative complications but was associated with a lower cardiopulmonary complication rate than usual fluid management.Trial registrationThis trial was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-17012220) on 1 August 2017.