Intraoperative Fluid Requirements Research Articles

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

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

Intraoperative goal-directed fluid therapy in neurosurgical patients: A systematic review.

Perioperative fluid management is critical in neurosurgery as over perfusion can lead to brain edema whereas under perfusion may lead to brain hypoperfusion or ischemia. We aimed to determine the effectiveness of intraoperative goal-directed fluid therapy (GDFT) in patients undergoing intracranial surgeries. We searched MEDLINE, Cochrane, and PubMed databases and forward-backward citations for studies published between database inception and February 22, 2024. Randomized controlled trials where intraoperative GDFT was performed in neurosurgery and compared to the conventional regime were included in the study. GDFT was compared with the conventional regime as per primary outcomes - total intraoperative fluid requirement, serum lactate, hemodynamics, brain relaxation, urine output, serum biochemistry, and secondary outcomes - intensive care unit and hospital length of stay. The quality of evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO (CRD42024518816). Of 75 records identified, eight were eligible, the majority of which had a low to moderate risk of overall bias. In four studies, more fluid was given in the control group. No difference in postoperative lactate values was noted in 50% of studies. In the remaining 50%, lactate was more in the control group. Three out of four studies did not find any significant difference in the incidence of intraoperative hypotension, and four out of six studies did not find a significant difference in vasopressor requirement. The majority of studies did not show significant differences in urine output, brain relaxation, and length of stay between both groups. None found any difference in acid base status or electrolyte levels. GDFT, when compared to the conventional regime in neurosurgery, showed that the total volume of fluids administered was lesser in the GDFT group with no increase in serum lactate. There was no difference in the hemodynamics, urine output, brain relaxation, urine output, length of stay, and biochemical parameters.

Team-Based Surgical Approach to Head and Neck Microvascular Free Flap Reconstruction

Because microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care. To assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction. This retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included. Patient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision. Among 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach. Findings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.

Pulse Pressure Variance (PPV)-Guided Fluid Management in Adult Patients Undergoing Supratentorial Tumor Surgeries: A Randomized Controlled Trial.

Objective Appropriate fluid management in neurosurgery is critical due to the risk of secondary brain injury. Determination of volume status is challenging with static variables being unreliable. Goal-directed fluid therapy with dynamic variables allows reliable determination of fluid responsiveness and promises better outcomes. We aimed to compare the intraoperative fluid requirement between conventional central venous pressure (CVP)-guided and pulse pressure variance (PPV)-guided fluid management in supratentorial tumor surgeries. Materials and Methods This prospective, randomized, double-blind, single-center trial was conducted with 72 adults undergoing supratentorial tumor surgery in a supine position. Patients were divided into two groups of 36 patients each receiving CVP- and PPV-guided fluid therapy. The CVP-guided group received boluses to target CVP greater than 8 mm Hg along with hourly replacement of intraoperative losses and maintenance fluids. The PPV-guided group received boluses to target PPV less than 13% in addition to maintenance fluids. Total intraoperative fluids administered and the incidence of hypotension was recorded along with the brain relaxation score. Postoperatively, serum lactate levels, periorbital and conjunctival edema, as well as postoperative nausea and vomiting were assessed. Statistical Analyses All statistical analyses were performed with Statistical Package for Social Sciences, version-20 (SPSS-20, IBM, Chicago, Illinois, United States). To compare the means between the two groups (CVP vs. PPV), independent samples t -test was used for normal distribution data and Mann-Whitney U test for nonnormal distribution data. The chi-square test or Fischer's exact test was used for categorical variables. Results The CVP group received significantly more intraoperative fluids than the PPV group (4,340 ± 1,010 vs. 3,540 ± 740 mL, p < 0.01). Incidence of hypotension was lower in the PPV group (4 [11.1%] vs. 0 [0%], p = 0.04). Brain relaxation scores, serum lactate levels, periorbital and conjunctival edema, and incidence of postoperative nausea and vomiting were comparable between the groups. Conclusion The requirement for intraoperative fluids was less in PPV-guided fluid management with better hemodynamic stability, adequate brain conditions, and no compromise of perfusion.

Effect of Total Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Microvascular Reconstruction for Head and Neck Cancer

Free flap surgery is a lengthy procedure with massive tissue destruction and reconstruction, which makes postoperative pulmonary complications (PPCs) a noticeable issue among patients with head and neck cancer. Propofol-based total intravenous anesthesia (TIVA) has better survival outcomes than inhalational anesthesia (INH) in several types of cancer surgery. A previous retrospective study found that patients in the TIVA group had a lower PPC rate, which may be correlated with a lower intraoperative fluid requirement. We hypothesize that the protective effect remains among patients undergoing free flap surgery for head and neck cancer in a prospective and goal-directed fluid therapy setting. To assess the effect of TIVA vs INH on PPCs in patients undergoing microvascular reconstruction for head and neck cancer. This prospective, 2-arm, randomized clinical trial was conducted at a tertiary hospital in Taiwan; a total of 78 patients 18 years and older with American Society of Anesthesiologists physical status classification 1 to 3 who were scheduled for elective free flap surgery under general anesthesia were included. The trial started in October 2017, completed in October 2019, and finished analysis in January 2022. Patients were enrolled and randomized to the TIVA or INH group. All patients received goal-directed fluid therapy and hemodynamic management if they had a mean arterial pressure (MAP) below 75 mm Hg or a reduction of 10% from baseline MAP. The primary outcome was a composite of PPCs. The secondary outcomes were the differences in intraoperative hemodynamic values (mean arterial pressure, MAP; cardiac index, CI; systemic vascular resistance index, SVRI; and stroke volume variation, SVV). A total of 70 patients (65 men [93%]; 5 women [7%]) completed the trial; median (IQR) age was 52.0 (48-59) years in the TIVA group and 57.0 (46-64) years in the INH group. The demographic characteristics were similar between the 2 groups, except that patients in the TIVA group had a slightly lower body mass index. Patients in the TIVA group had a lower risk of developing PPCs (unadjusted odds ratio, 0.25; 95% CI, 0.08-0.80). The TIVA group had significantly higher MAP, lower CI, and higher SVRI than the INH group after the third hour of monitoring. The TIVA group showed a relatively stable hourly MAP, CI, SVRI, and SVV across time points, while the INH group showed a more varying pattern. The generalized estimating equation showed no clinical differences in the trend of hemodynamic parameters across time between groups. In this randomized clinical trial, using propofol-based TIVA reduced the incidence of PPCs in free flap surgery. This finding may be related to more stable hemodynamic manifestations and a lower total balance of fluid throughout the surgery. ClinicalTrials.gov Identifier: NCT03263078.

Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis.

(1) Background: Whether goal-directed fluid therapy (GDFT) provides any outcome benefit as compared to non-goal-directed fluid therapy (N-GDFT) in elective abdominal laparoscopic surgery has not been determined yet. (2) Methods: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, Web of Science, and Scopus. The main outcomes were length of hospital stay (LOHS), time to first flatus and stool, intraoperative fluid and vasopressor requirements, serum lactate levels, and urinary output. Pooled risks ratios (RRs) with 95% confidence intervals (CI) were calculated for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. (3) Results: Eleven studies were included in the quantitative, and fifteen in the qualitative synthesis. LOHS (WMD: −1.18 days, 95% CI: −1.84 to −0.53) and time to first stool (WMD: −9.8 h; CI −12.7 to −7.0) were significantly shorter in the GDFT group. GDFT resulted in significantly less intraoperative fluid administration (WMD: −441 mL, 95% CI: −790 to −92) and lower lactate levels at the end of the operation: WMD: −0.25 mmol L−1; 95% CI: −0.36 to −0.14. (4) Conclusions: GDFT resulted in enhanced recovery of the gastrointestinal function and shorter LOHS as compared to N-GDFT.

Influence of 3% Hypertonic Saline Versus 0.9% Saline on Intraoperative Maintenance Fluid Requirements in Adult Patients Undergoing Major Open Abdominal Surgeries: Randomized Controlled Study.

Three percent hypertonic saline (3% HTS) acts like an osmotic buffer and draws fluid from the extracellular space into the intravascular compartment. Primary objective was to evaluate whether use of 3% HTS resulted in a difference in intraoperative maintenance fluid requirement versus 0.9% saline (NS). Secondary objectives were to evaluate differences in 24h fluid requirements and safety of 3% HTS. Adult patients of either sex, 18-65years, undergoing elective major open abdominal surgeries were randomized to receive infusions of 3% HTS or NS at 1ml/kg/hr through large bore peripheral i.v cannulas, or central venous catheters after anesthesia induction. Intraoperative maintenance fluids were administered to maintain mean arterial pressure (≥70mmHg), urine output (≥0.5ml/kg/hr) and central venous pressure of 8-10cm H2O. Ninety-three patients completed the study (46 in 3% HTS and 47 in NS group). No difference was seen in the volume of intraoperative maintenance fluids (3% HTS vs NS; 2243.9 ± 896.7ml vs 2093.6 ± 868.7ml; P = 0.34). Similarly, the 24h postoperative fluid requirement was not different (3% HTS vs NS; 2006.6 ± 398.6ml vs 2018.3 ± 389.3ml; P = 0.94). Patients in 3% HTS group had statistically but not clinically significant higher serum sodium values at postoperative 12th and 24h. No complication like thrombophlebitis or tissue ischemia was reported due to administration of 3% HTS through peripheral lines. Administration of 3% HTS did not reduce intraoperative maintenance fluid requirements in patients undergoing major open abdominal surgeries. CTRI/2019/09/021032.

Euvolemic off pump coronary surgery further improves early postoperative outcomes.

Background:Fluid resuscitation during Off-Pump Coronary Surgery (OPCABG) is still not protocolized and depends on multiple variables. We are exploring in this study whether a restrictive or euvolemic approach has any impact on short term surgical outcomes following OPCABG.Methods:It is a retrospective study of 300 patients analyzed based on the intraoperative fluid requirement with 150 patients in each group (Group I: Fluid <2 Litres, Group II: Fluid >2 Litres).Results:Multivariable analysis showed echocardiography variables such as E/e ratio, LA volume index, and atrial fibrillation (AF). LA volume index is related to the higher fluid requirement. Group II had significantly higher ventilation time (P < 0.05), drain output (P = 0.05), drain removal time (<0.05), inotropic requirement, and diuretic use.Conclusion:The requirement of the intraoperative fluid was associated with various factors including diastolic dysfunction (left atrial volume index, left ventricle mass index, E/e ratio) and preoperative dual antiplatelet use. Group II patients had longer ventilation time, diuretics use, high drain output, and required drains for a longer period of time. Although there was no statistical difference among two groups as far as postoperative AF concerned, a reversal of AF to sinus rhythm was delayed in group II patients.

Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds — A double blind randomised controlled trial

IntroductionThis study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns. MethodsThis was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15−55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH). ResultsThirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm2; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups. ConclusionTXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.

Peri-operative Variables Associated With Prolonged Intensive Care Stay Following Cytoreductive Surgery for Ovarian Cancer.

Peri-operative variables associated with prolonged Intensive Care Unit (ICU) admission following cytoreductive surgery for ovarian cancer were investigated. A retrospective review was carried out of patients admitted to the ICU following cytoreductive surgery for ovarian cancer in a single tertiary referral centre from 2015-2019. Patients were categorized according to length of ICU stay (<48 h and ≥48 h), and peri-operative variables were compared across the two groups. A total of 56 patients were admitted to the ICU post-operatively, 37 for <48 h and 19 for ≥48 h (range=3-11 days). Greater duration of procedure and estimated blood loss, bowel resection, higher post-operative lactate level, lower post-operative albumin level and requirement for post-operative blood products were associated with prolonged ICU stay. Increased intraoperative fluid requirement was an independent predictor of extended ICU stay. Utilizing identified intra-operative risk factors to perform individualized risk assessments might improve planning of ICU resources. Optimizing intraoperative fluid management may improve short-term patient outcomes.

The efficacy of enhanced recovery protocol from anesthesia in diabetic patients undergoing radical cystectomy

ABSTRACT Background: Prevalence of diabetes in surgical patients is 10–40%. They have higher incidence of complications, and longer stay in hospital compared to non-diabetic. Radical cystectomy with urinary diversion is considered one of the high-risk surgeries associated with morbidity and mortality. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care protocol that improves post-operative outcomes and length of stay (LOS) in patients without diabetes. This study evaluates the evidence on whether diabetic patientswould benefit from ERAS pathway. The aim of the study: was to evaluate the efficacy of ERAS protocol from anesthesia in diabetic patients undergoing radical cystectomy. Patients and methods: This study was carried out in Alexandria main University Hospital on fifty-four adult ASA physical status I, II and III participants of either sex. Participants were scheduled for radical cystectomy surgeries under the effect of general anesthesia, following ERAS protocol, divided into two group diabetic and non-diabetic27 participants each. The ICON device was used to measure the stroke volume variation (SVV) to apply goal-directed fluid therapy (GDFT) for all patients. Measurements: Demographic data, hemodynamic parameters (stoke volume, cardiac index), intra-operative fluid requirement, blood loss, postoperative pain intensity, time of first bowel movement, PH, Bicarbonate level, serum lactate level, heamatocrit and LOS were measured and recorded. Main results: No statistical significant difference was detected between both groups as regard age, sex, weight, vital signs, serum lactate, first bowel movement and VAS. There was statistical significant difference between both groups as regard fluid requirement, and the days of hospital stay. Conclusion: ERAS is a beneficial protocol to improve postoperative outcome in radical cystectomy surgeries, it can be used in diabetic patients to decrease postoperative morbidity and mortality.

Effect of Intraoperative Goal-Directed Fluid Management on Tissue Oxygen Tension in Obese Patients: a Randomized Controlled Trial

BackgroundPerioperative subcutaneous tissue oxygen tension (PsqO2) is substantially reduced in obese surgical patients. Goal-directed fluid therapy optimizes cardiac performance and thus tissue perfusion and oxygen delivery. We therefore tested the hypothesis that intra- and postoperative PsqO2 is significantly reduced in obese patients undergoing standard fluid management compared to goal-directed fluid administration.MethodsWe randomly assigned 60 obese patients (BMI ≥ 30 kg/m2) undergoing laparoscopic bariatric surgery to receive either esophageal Doppler-guided goal-directed fluid management or conventional fluid treatment. Our primary outcome parameter was intra- and postoperative PsqO2 measured with a polarographic electrode in the subcutaneous tissue of the upper arm. A random effects linear regression model was used to analyze the effect of intervention.ResultsOverall, mean (± SD) PsqO2 was significantly higher in obese patients receiving goal-directed therapy compared to conventional fluid therapy (65.8 ± 28.0 mmHg vs. 53.7 ± 21.7, respectively; repeated measures design adjusted difference: 13.0 mmHg [95% CI 2.3 to 23.7; p = 0.017]). No effect was seen intraoperatively (69.6 ± 27.9 mmHg vs. 61.4 ± 28.8, difference: 9.7 mmHg [95% CI -3.8 to 23.2; p = 0.160]); however, goal-directed fluid management improved PsqO2 in the early postoperative phase (63.1 ± 27.9 mmHg vs. 48.4 ± 12.5, difference: 14.5 mmHg [95% CI 4.1 to 24.9; p = 0.006]). Intraoperative fluid requirements did not differ between the two groups.ConclusionsGoal-directed fluid therapy improved subcutaneous tissue oxygenation in obese patients. This effect was more pronounced in the early postoperative period.Clinical Trial Number and RegistryThe study was registered at ClinicalTrials.gov (NCT 01052519).

A Comparison of Surgical Outcomes Between Minimally Invasive and Open Thoracolumbar Corpectomy.

Minimally invasive (MIS) techniques have gained considerable attention for the management of degenerative spinal pathologies. However, few studies have compared the outcomes between MIS and open thoracolumbar corpectomies. The purpose of this study was to compare perioperative variables between MIS and open thoracolumbar corpectomy. Retrospective review of 33 patients who underwent either an MIS or open thoracolumbar corpectomy by a single surgeon between 2005 and 2012 was performed. Patients were separated into anterior-posterior MIS (MIS AP), anterior-posterior open (AP), and posterior open (P) cohorts. Postoperative narcotic use was converted to oral morphine equivalents (OMEs). Demographics, comorbidity, perioperative variables, complications, and computed tomographic analyses were assessed. Fisher exact test was performed for categorical variables and Student t test for continuous variables. A P value of ≤ .05 denoted statistical significance. Thirty-three patients underwent an MIS AP, AP, or P thoracolumbar corpectomy (39.4% vs 15.2% vs 45.5%, respectively). MIS AP patients were younger with a lower comorbidity burden than either open cohorts. In addition, MIS AP patients demonstrated a decreased procedural time, lower blood loss, and shorter hospitalization than either open cohorts. MIS AP patients required less units of transfusion than P and AP patients while demonstrating lower postoperative narcotics consumption and reoperations rates than open AP patients. Surgical site infection rates, body mass index, intraoperative fluid requirements, and complication rates were similar between cohorts. All patients demonstrated successful arthrodesis at 1 year based upon computed tomography. MIS AP thoracolumbar corpectomy patients incurred decreased procedural times, shorter hospitalization, and lower blood loss compared with open patients. MIS AP patients demonstrated decreased postoperative narcotics consumption and reoperation rates compared with traditional AP patients. All patients demonstrated successful arthrodesis. The MIS approach to thoracolumbar corpectomies appears to be a safe and efficacious alternative when compared with traditional methods.

Considering healthcare value and associated risk factors with postoperative urinary retention after elective laminectomy

BACKGROUNDMitigating common complications such as postoperative urinary retention (POUR) following elective spine surgery is prudent. Identifying patients at risk for POUR and recognizing associated factors, to avoid a more complicated postoperative episode should be a priority and easily achievable. Understanding the financial burden of complications, such as POUR, is also important for value-based healthcare, not only for providers, but for employers and payors as well. PURPOSEThe purpose of this study is to examine patient and surgical factors that may lead to increased risk for POUR and its associated cost following elective lumbar laminectomies. STUDY DESIGN/SETTINGThis is a retrospective study of the incidence of postoperative urinary retention after elective one- and two-level primary lumbar laminectomies. PATIENT SAMPLEWe followed patients undergoing one- and two-level primary elective lumbar laminectomies performed between April 2014 and December 2016. OUTCOME MEASURESPatient factors included age, gender, body-mass index, and comorbidities. Surgical factors included surgical time, intraoperative fluid volume requirements, anesthesia type, and surgical levels involved. Other outcome variables included length of stay, discharge disposition, 30-day all-cause readmissions and emergency department visits, 90-day complications, and variable direct costs. METHODSThe incidence of POUR was evaluated and compared with patient and surgical factors and cost-specific variables to identify correlations and potential risk for POUR after one- and two-level primary lumbar laminectomies. RESULTSAnalysis included 333 patients – 203 one-level laminectomies and 130 two-level laminectomies. The overall incidence of POUR was 17.4%. Age, male gender, and history of urinary retention were significantly associated with POUR. There was a significantly increased risk of POUR with increased surgical time, but not with anesthesia type. There were also no significant differences in body-mass index, other study comorbidities, intraoperative fluid requirements, readmission, emergency department visit, and complication rates between groups. On average, patients with POUR had a significantly longer length of stay than patients without POUR. In addition, more POUR patients were discharged to acute rehabilitation facilities and had higher average variable direct cost compared tonon-POUR patients. CONCLUSIONSPOUR is a significant risk after elective laminectomy. This study supports several widely accepted beliefs regarding POUR risk, while challenging others. It also highlights the burden of POUR development after surgery. At our institution, we developed a protocol supported by these findings.

A comparative study of spinal anaesthesia versus epidural anaesthesia for inguinal hernioplasty

Introduction: Inguinal hernia repair is normally implemented under spinal anaesthesia. However, epidural anaesthesia procedure offers constant hemodynamic with early ambulation and less urinary retention, less frequency of nausea and vomiting. We compared efficacy, feasibility and safety of ilioinguinal nerve block for inguinal hernia repair with spinal anaesthesia versus epidural anaesthesia. Material and methods: Hundred adult male patients scheduled for elective inguinal hernia repair were randomized into two groups to receive either spinal anaesthesia or epidural anaesthesia. The total time to perform anaesthetic procedures, time of onset, hemodynamic variations, supplemental sedation, intraoperative fluid requirement, duration of postoperative analgesia and ambulation were compared in both groups. Continuous data are presented as mean±S.D. Unpaired t-test and paired t-test were applied for intergroup and intragroup comparisons respectively. P< 0.05 was taken as significant. Results: Duration to perform the procedure was significantly longer with epidural than spinal block (7.95±0.41 Vs 3.73±0.67 minutes). Intraoperative fluid requirement was statistically higher in Spinal than Epidural (1580±190.1 ml vs 1021.33±77.16 ml) (p< 0.0001). Duration of Surgery was significantly shorter in Spinal as compared to Epidural (85.17±7.82 vs 101.00±10.20 mins.) (p=0.019). Systolic and mean blood pressure showed statistically significant reduction in Spinal as compared to Epidural (19(40%) vs 3(6%)) (p< 0.001). Duration of ambulation was significantly shorter in Epidural as compared to Spinal (3.95±2.57 vs 9.58±0.82 hours) (p< 0.001). Conclusion: Epidural anaesthesia can be a safe alternative to spinal anaesthesia for elective inguinal hernia repair.

Implementation Of continuous wound infiltration In pancreatoduodenectomy reduced hospital stay as well as fluid resuscitation

Background: There is no consensus regarding the optimal analgesic modality in pancreatoduodenectomy (PD). Continuous wound infiltration (CWI) with local anesthetics through pre-peritoneal catheters seems equally effective as epidural analgesia. We hypothesized CWI might reduce hospital stay since less fluid resuscitation is required. Methods: A total of 257 consecutive patients undergoing PD in the University Hospital Southampton NHS between January 2009 and February 2015 were analyzed. Patients received perioperative analgesia with epidural analgesia (n=70), and after implementation patients received CWI (n=187). Results: After implementation of continuous wound infiltration a shorter length of hospital stay was observed (15 days [12–22] vs 11 [8–14], p<0.001). Postoperative IV-fluid requirement [day 1–5] was lower (15 liter [14-16] vs 13 [12–14, p<0.001), whereas intraoperative fluid requirement was similar. No difference in the incidence of anastomotic leakage or delayed gastric emptying was observed. In a multivariable logistic regression model, CWI remained a significant predictor of reduced hospital stay and fluid resuscitation. Conclusion: Implementation of CWI after PD was associated with reduced hospital stay and less postoperative fluid resuscitation.

Implementation of continuous wound infiltration in pancreatoduodenectomy reduced hospital stay as well as fluid resuscitation

Background: There is no consensus regarding the optimal analgesic modality in pancreatoduodenectomy (PD). Continuous wound infiltration (CWI) with local anesthetics through pre-peritoneal catheters seems equally effective as epidural analgesia. We hypothesized CWI might reduce hospital stay since less fluid resuscitation is required. Methods: A total of 257 consecutive patients undergoing PD in the University Hospital Southampton NHS between January 2009 and February 2015 were analyzed. Patients received perioperative analgesia with epidural analgesia (n=70), and after implementation patients received CWI (n=187). Results: After implementation of continuous wound infiltration a shorter length of hospital stay was observed (15 days [12-22] vs 11 [8-14], p<0.001). Postoperative IV-fluid requirement [day 1-5] was lower (15 liter [14-16] vs 13 [12-14, p<0.001), whereas intraoperative fluid requirement was similar. No difference in the incidence of anastomotic leakage or delayed gastric emptying was observed. In a multivariable logistic regression model, CWI remained a significant predictor of reduced hospital stay and fluid resuscitation. Conclusion: Implementation of CWI after PD was associated with reduced hospital stay and less postoperative fluid resuscitation.

Preoperative inferior vena cava collapsibility is a poor marker of intraoperative fluid requirements and hypotension: A pilot study.

Preoperative inferior vena cava collapsibility is a poor marker of intraoperative fluid requirements and hypotension: A pilot study.

Anaesthetic management and perioperative outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: A retrospective analysis.

Background and Aims:Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is becoming the standard treatment option for peritoneal carcinomatosis but is associated with high rates of morbidity and mortality. Our aim was to retrospectively analyse and evaluate intra-operative factors associated with morbidity and mortality of CRS and HIPEC.Methods:Intra-operative data were collected for cases done over 1 year (24 cases) and analysed for the primary outcome of post-operative ventilation >24 h, and secondary outcome of length of the Intensive Care Unit (ICU) stay >5 days. Statistical analysis was carried out in STATA 11 software.Results:Higher peritoneal carcinoma index (PCI), (P = 0.0047), longer duration of surgery (P = 0.0016), higher delta temperatures (P = 0.0119), increased estimated blood loss (EBL) (P = 0.0054), high intraoperative fluid requirement (P = 0.0038), lower mean arterial pressure (MAP) (P = 0.0021) and higher blood products requirement were associated with >24 h ventilation. These factors were also associated with longer ICU stay. All these factors associated with >24 h ventilation and prolonged ICU stay are related to the PCI which is an indicator of the extent of surgery.Conclusion:Higher PCI, longer duration of surgery, higher delta temperatures, increased EBL, high intraoperative fluid requirement, lower mean arterial pressure and higher blood products requirement were associated with >24 h postoperative ventilation as well as ICU stay >5 days. All these factors are related to the PCI, which is a major predictor of post-operative morbidity.

Double-blind randomized controlled trial of the routine perioperative use of terlipressin in adult living donor liver transplantation.

Perioperative terlipressin (Tp) during living donor liver transplantation (LDLT) has been shown to reduce intraoperative portal pressures and improve renal function. Its role and safety profile have never been evaluated in a double-blind randomized controlled trial (RCT). The aim was to evaluate the hemodynamic effects, clinical benefits, and safety of perioperative Tp infusion in adult LDLT. This was a single-center double-blind RCT. Consenting adults with chronic liver disease and low risk of posttransplant renal dysfunction undergoing their first LDLT were randomized. The study group (terlipressin group [TpG]) received an initial bolus of Tp during surgery followed by a Tp infusion for 72 hours in the postoperative period. The placebo group (PbG) received a saline infusion. The primary endpoint was portal pressure after arterial reperfusion. Multiple intraoperative and postoperative variables served as secondary endpoints. A total of 41 patients were enrolled in the trial (TpG, 21; PbG, 20). There were no significant differences in intraoperative portal pressures, blood loss, fluid requirement, vasopressor requirement, or urine output. Peak intraoperative and end of surgery lactate levels were significantly higher in the Tp group. There was no difference in postoperative liver function tests. Incidence of acute kidney injury as assessed by Risk, Injury, Failure, Loss, and End-Stage Kidney Disease criteria was lower in the Tp group (27% versus 60%; P = 0.04). The TpG had less postoperative ascites, a lower need for percutaneous interventions, and a shorter hospital stay. Incidence of bradycardia requiring pharmacological intervention and withdrawal from study was significantly higher in the TpG. In conclusion, this study has not demonstrated a reduction in postreperfusion portal pressure with Tp. However, Tp infusion reduced postoperative ascitic drain output resulting in less frequent percutaneous interventions and reduced hospital stay. Intraoperative hyperlactatemia and symptomatic bradycardia are major concerns. Its use should be restricted to patients with high-volume ascites, and it needs close monitoring during drug infusion. Liver Transplantation 23 1007-1014 2017 AASLD.