Perioperative Fluid Management Research Articles

Perioperative Fluid Management as a Component of Early Recovery after Surgery (ERAS) Protocols for Pediatric Patients

Sentinel studies by Bartram and Kehlet challenged the acceptance of the inevitable consequences of the adverse physiologic effects of the stress response to surgery. This led to the evolution of Enhanced Recovery after Surgery (ERAS) protocols. ERAS is a multi-disciplinary approach aimed at improving care of the surgical patient? ERAS protocols/pathways were developed by the application of sound scientific knowledge to perioperative care. ERAS protocols have been shown to reduce postoperative complications, reduce hospital length of stay, and reduce costs. Although some ERAS protocols are highly specific to the type of surgery, issues common to most of the protocols are pain management, perioperative nutrition, control of nausea and emesis, antimicrobial therapy, thromboembolism prophylaxis, and precise perioperative fluid administration. Protocols often introduce multiple changes to clinical practice simultaneously and, if a positive effect is found, it is difficult to determine the contribution of each component.

To Study The Correlation Between Preoperative Inferior Vena Cava Diameter And Intraoperative Hypotension During Spinal Anaesthesia In Caesarean Section

BACKGROUND: Assessment of maternal intravascular volume status during and after gestation is most crucial in the setting of complications that affect hemodynamic stability. The goal of the perioperative fluid management is to avoid acute kidney injury due to hypovolemia and hypotension due to spinal anaesthesia. Ultrasound measurements of dynamic change in inferior vena cava diameter (IVC) and collapsibility index are used to predict and prevent the hypotension after spinal anaesthesia.OBJECTIVES: To correlate the IVC diameter in expiration and incidences of intraoperative hypotension after spinal anaesthesia in full term pregnant patients posted for elective caesarean section.MATERIALS AND METHOD: Total 50 young female patients having full term pregnancy scheduled for elective caesarean sections were included in the study after taking informed consent. Preoperative assessment of all patients was done. Preoperative inferior vena cave diameter in expiration was measured by ultrasound guidance by subcostal approach. Spinal anaesthesia was given with injection bupivacaine heavy 0.5% 2ml between L3-L4 subarachnoid space after taking all aseptic precaution. Pulse, blood pressure was measured at regular interval. Incidence of intraoperative hypotension, bradycardia was noted. Results were expressed as mean ±SD and analysed by paired’ test and correlation coefficient was calculated.RESULTS: The mean inferior vena cava diameter in expiration was 17.4 ± 0.04 and collapsibility index was less than 36 in 80% of patients, and only one patient had developed hypotension after spinal anaesthesia. Correlation coefficient was -0.9.CONCLUSION: Preoperative inferior vena cava measurement is a reliable predictor of hypotension after spinal anaesthesia.

Association between perioperative fluid management and patient outcomes: a multicentre retrospective study

BackgroundPostoperative complications increase hospital length of stay and patient mortality. Optimal perioperative fluid management should decrease patient complications. This study examined associations between fluid volume and noncardiac surgery patient outcomes within a large multicentre US surgical cohort. MethodsAdults undergoing noncardiac procedures from January 1, 2012 to December 31, 2017, with a postoperative length of stay ≥24 h, were extracted from a large US electronic health record database. Patients were segmented into quintiles based on recorded perioperative fluid volumes with Quintile 3 (Q3) serving as the reference. The primary outcome was defined as a composite of any complications during the surgical admission and a postoperative length of stay ≥7 days. Secondary outcomes included in-hospital mortality, respiratory complications, and acute kidney injury. ResultsA total of 35 736 patients met the study criteria. There was a U-shaped pattern with highest (Q5) and lowest (Q1) quintiles of fluid volumes having increased odds of complications and a postoperative length of stay ≥7 days (Q5: odds ratio [OR] 1.51 [95% confidence interval {CI}: 1.30–1.74], P<0.001; Q1: OR 1.20 [95% CI: 1.04–1.38], P=0.011) compared with Q3. Patients in Q5 had greater odds of more severe acute kidney injury compared with Q3 (OR 1.52 [95% CI: 1.22–1.90]; P<0.001) and respiratory complications (OR 1.44 [95% CI: 1.17–1.77]; P<0.001). ConclusionsBoth very high and very low perioperative fluid volumes were associated with an increase in complications after noncardiac surgery.

Enhanced recovery after surgery of patients undergoing radical cystectomy for bladder cancer.

Radical cystectomy (RC) is the standard treatment for patients diagnosed with muscle invasive bladder cancer, but is associated with significant morbidity and long hospital stays. Enhanced recovery after surgery (ERAS) is based on a variety of interventions during the peri-treatment stage. It is designed to improve morbidity, enhance recovery, and reduce hospital stays after RC. The study provides an overview of the key elements of the ERAS protocol recommended for patients undergoing RC and directions for further research. We have analyzed the rationale for 15 key elements related to the ERAS protocol: preoperative patient counseling and education, preoperative medical optimization and nutrition, mechanical bowel preparation, preoperative fasting and carbohydrate loading, pre-anesthetic medication, thromboembolic prophylaxis, minimally invasive surgical approach, resection-site drainage, preventing intraoperative hypothermia, perioperative fluid management, perioperative analgesia, urinary drainage, prevention of postoperative ileus, nausea and vomiting, early oral feeding, and early mobilization. Several studies have shown that ERAS improves the recovery of RC patients. Evidence suggests that ERAS facilitates the recovery of RC patients. However, additional randomized controlled studies or large prospective studies are needed to demonstrate the effectiveness of ERAS in RC patients.

Perioperative fluid management in esophagectomy for cancer and its relation to postoperative respiratory complications.

The optimal perioperative fluid management during esophagectomy is still not clear. Liberal regimens have been associated with higher morbidity and respiratory complications. Restrictive regimens might raise concerns for kidney function and increase the need to associate vasopressors. The aim of this study was to investigate retrospectively the perioperative fluid administration during esophagectomy and to correlate this with postoperative respiratory outcome. All patients who underwent esophagectomy between January and December 2016 were retrospectively analyzed. Patient characteristics, type of surgery and postoperative course were reviewed. Fluid administration and vasopressor use were calculated intraoperatively and during the postoperative stay at the recovery unit. Fluid overload was defined as a positive fluid balance of more than 125mL/m2/h during the first 24hours. Patients were divided in 3 groups: GRP0 (no fluid overload/no vasopressors); GRP1 (no fluid overload/need for vasopressors); GRP2 (fluid overload with/without vasopressors). Postoperative complications were prospectively recorded according to Esophagectomy Complications Consensus Group criteria. A total of 103 patients were analyzed: 35 (34%) GRP0, 50 (49%) GRP1 and 18 (17%) GRP2. No significant differences were found for age, treatment (neoadjuvant vs. primary), type of surgery (open/minimally invasive), histology nor comorbidities. There were significant (P ≤ 0.001) differences in fluid balance/m2/h (75 ± 21mL; 86 ± 22mL and 144 ± 20mL) across GRP0, GRP1 and GRP2, respectively. We found differences in respiratory complications (GRP0 (20%) versus GRP1 (42%; P = 0.034) and GRP0 (20%) versus GRP2 (61%; P = 0.002)) and "Comprehensive Complications Index" (GRP0 (20.5) versus GRP1 (34.6; P = 0.015) and GRP0 (20.5) versus GRP2 (35.1; P = 0.009)). Multivariable analysis (binary logistic regression) for "any respiratory complication" was performed. Patients who received fluid overload (GRP2) had a 10.24 times higher risk to develop postoperative respiratory complications. When patients received vasopressors alone (GRP1), the chances of developing these complications were 3.57 times higher compared to GRP0. Among patients undergoing esophagectomy, there is a wide variety in the administration of fluid during the first 24hours. There was a higher incidence of respiratory complications when patients received higher amounts of fluid or when vasopressors were used. We believe that a personalized and protocolized fluid administration algorithm should be implemented and that individual risk factors should be identified.

Non-Invasive Wearable Patch Utilizing Seismocardiography for Peri-Operative Use in Surgical Patients.

Optimizing peri-operative fluid management has been shown to improve patient outcomes and the use of stroke volume (SV) measurement has become an accepted tool to guide fluid therapy. The Transesophageal Doppler (TED) is a validated, minimally invasive device that allows clinical assessment of SV. Unfortunately, the use of the TED is restricted to the intra-operative setting in anesthetized patients and requires constant supervision and periodic adjustment for accurate signal quality. However, post-operative fluid management is also vital for improved outcomes. Currently, there is no device regularly used in clinics that can track patient's SV continuously and non-invasively both during and after surgery. In this paper, we propose the use of a wearable patch mounted on the mid-sternum, which captures the seismocardiogram (SCG) and electrocardiogram (ECG) signals continuously to predict SV in patients undergoing major surgery. In a study of 12 patients, hemodynamic data was recorded simultaneously using the TED and wearable patch. Signal processing and regression techniques were used to derive SV from the signals (SCG and ECG) captured by the wearable patch and compare it to values obtained by the TED. The results showed that the combination of SCG and ECG contains substantial information regarding SV, resulting in a correlation and median absolute error between the predicted and reference SV values of 0.81 and 7.56mL, respectively. This work shows promise for the proposed wearable-based methodology to be used as an alternative to TED for continuous patient monitoring and guiding peri-operative fluid management.

U-Shaped Association Between Intraoperative Net Fluid Balance and Risk of Postoperative Recurrent Atrial Tachyarrhythmia Among Patients Undergoing the Cryo-Maze Procedure: An Observational Study

The ability of perioperative fluid management to prevent postoperative recurrence of atrial tachyarrhythmia remains controversial. The aim of the present study was to assess if intraoperative net fluid balance was associated with atrial tachyarrhythmia recurrence after the Cryo-Maze procedure. An observational cohort study. A tertiary care hospital from April 2007 to May 2019. Four hundred forty-four patients undergoing the Cryo-Maze procedure in conjunction with other cardiac surgeries. The Cryo-Maze procedure in conjunction with other cardiac surgeries. The main outcome was early atrial tachyarrhythmia recurrence, consisting of atrial fibrillation, atrial flutter, or atrial tachycardia, within the first three months after surgery. Complete follow-up was achieved in 443 patients (99.8%), of them 127 (28.6%) developed early atrial tachyarrhythmia recurrence. The median intraoperative net fluid balance was 1,627 mL (interquartile range, -215 to 3,557 mL). Multivariate logistic regression showed that intraoperative net fluid balance (p = 0.001), preoperative AF duration (adjusted odds ratio, 1.40; 95% CI, 1.17-1.68; p < 0.001) and left atrial volume index (aOR, 1.61; 95% CI, 1.06-2.45; p = 0.025) were independent predictors of early atrial tachyarrhythmia recurrence. The adjusted log odds were lowest (-1.52) when net fluid balance was 1,557 mL. There is a significant U-shaped association between intraoperative net fluid balance and early atrial tachyarrhythmia recurrence among patients undergoing the Cryo-Maze procedure.

Perioperative fluid management in major abdominal surgery

Die Gabe intravasaler Flüssigkeiten gehört zu den Grundpfeilern der perioperativen Therapie und nimmt insbesondere bei großen viszeralchirurgischen Eingriffen maßgeblichen Einfluss auf das chirurgische Behandlungsergebnis. Ein adäquates perioperatives Flüssigkeitsmanagement kann durch Vermeidung von Hypo- und Hypervolämie dazu beitragen, das Risiko einer unzureichenden Gewebeperfusion als Treiber postoperativer Morbidität und Letalität signifikant zu reduzieren. Der effektive Umgang mit intravasal zugeführten Flüssigkeiten setzt dabei die Kenntnis der Substanzen sowie Maßnahmen zur Therapiesteuerung voraus. Das Flüssigkeitsmanagement beginnt bereits präoperativ und sollte – unter Nutzung einer an die Bedürfnisse des Patienten angepassten und dem Eingriff entsprechenden hämodynamischen Überwachung – auch postoperativ im Aufwachraum und auf Station fortgesetzt werden. Der Kommunikation aller an der perioperativen Versorgung Beteiligten kommt im Sinne eines optimalen Flüssigkeitsmanagements eine entscheidende Bedeutung zu.

519 PERIOPERATIVE FLUID MANAGEMENT IN ESOPHAGECTOMY FOR CANCER AND ITS RELATION TO POSTOPERATIVE RESPIRATORY COMPLICATIONS

Abstract The optimal perioperative fluid management during esophagectomy is still not clear. Liberal regimens have been associated with higher morbidity and respiratory complications. Restrictive regimens might raise concerns for kidney function and increase the need to associate vasopressors. Recently, perioperative care is changing towards goal-directed fluid regimens as part of early recovery programs. The aim of this study was to investigate retrospectively the perioperative fluid administration during esophagectomy and to correlate this with postoperative respiratory outcome. Methods All patients who underwent esophagectomy between January–December 2016 were retrospectively analyzed. Patient characteristics, type of surgery and postoperative course were reviewed. Fluid administration and vasopressor use were calculated intra-operatively and during the postoperative stay at the recovery room. Fluid overload was defined as a positive fluid balance of more than 125 mL/m2/h during the first 24 hours. Patients were divided in 3 groups: GRP0 (no fluid overload/no vasopressors); GRP1 (need for vasopressors); GRP2 (fluid overload with/without vasopressors). Postoperative complications were prospectively recorded according to Esophagectomy Complications Consensus Group criteria. Multivariable analysis (binary logistic regression) for “any respiratory complication” was performed. Results 103 patients were analyzed: 35 (34%) GRP0, 50 (49%) GRP1 and 18 (17%) GRP2. No significant differences were found for age, treatment (neoadjuvant vs. primary), type of surgery (Open/MIE), histology and comorbidities. There were significant (p ≤ 0.001) differences in fluid balance/m2/h (75 ± 21 mL; 86 ± 22 mL and 144 ± 20 mL) across GRP0, GRP1 and GRP2 respectively. We found differences in respiratory complications GRP0 (20%) versus GRP1 (42%;p = 0.034) and GRP0 (20%) versus GRP2 (61%;p = 0.002)) and “Comprehensive Complications Index” GRP0 (20.5) versus GRP1 (34.6;p = 0.015) and GRP0 (20.5) versus GRP2 (35.1;p = 0.009). Multivariable analysis for any respiratory complication is presented in FIGURE 1. Conclusion Among patients undergoing esophagectomy, there is a wide variety in the administration of fluid during the first 24 hours. There was a higher incidence of respiratory complications if patients received higher amounts of fluid or if vasopressors were used. Type of surgery (open versus MIE) did not impact respiratory outcome. We believe that a personalized and protocolized fluid administration algorithm should be implemented and that individual risk factors for patients at risk should be identified.

Estimation of pulse pressure variation and cardiac output in patients having major abdominal surgery: a comparison between a mobile application for snapshot pulse wave analysis and invasive pulse wave analysis

Pulse pressure variation (PPV) and cardiac output (CO) can guide perioperative fluid management. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a mobile application for snapshot pulse wave analysis (PWAsnap) and estimates PPV and CO using pulse wave analysis of a snapshot of the arterial blood pressure waveform displayed on any patient monitor. We evaluated the PPV and CO measurement performance of PWAsnap in adults having major abdominal surgery. In a prospective study, we simultaneously measured PPV and CO using PWAsnap installed on a tablet computer (PPVPWAsnap, COPWAsnap) and using invasive internally calibrated pulse wave analysis (ProAQT; Pulsion Medical Systems, Feldkirchen, Germany; PPVProAQT, COProAQT). We determined the diagnostic accuracy of PPVPWAsnap in comparison to PPVProAQT according to three predefined PPV categories and by computing Cohen’s kappa coefficient. We compared COProAQT and COPWAsnap using Bland-Altman analysis, the percentage error, and four quadrant plot/concordance rate analysis to determine trending ability. We analyzed 190 paired PPV and CO measurements from 38 patients. The overall diagnostic agreement between PPVPWAsnap and PPVProAQT across the three predefined PPV categories was 64.7% with a Cohen’s kappa coefficient of 0.45. The mean (± standard deviation) of the differences between COPWAsnap and COProAQT was 0.6 ± 1.3 L min− 1 (95% limits of agreement 3.1 to − 1.9 L min− 1) with a percentage error of 48.7% and a concordance rate of 45.1%. In adults having major abdominal surgery, PPVPWAsnap moderately agrees with PPVProAQT. The absolute and trending agreement between COPWAsnap with COProAQT is poor. Technical improvements are needed before PWAsnap can be recommended for hemodynamic monitoring.

Efficacy of goal-directed fluid therapy monitored by pulse-pressure variation using a continuous noninvasive arterial pressure monitoring system (the CNAPTM system) during parathyroidectomy in patients with end-stage renal failure – a randomised trial

IntroductionThere are no well-recognised guidelines for intraoperative fluid management in patients with end-stage renal failure (ESRF). Goal-directed fluid therapy (GDFT) is a concept of perioperative fluid management that improves patients’ prognosis. In this study, we assessed a GDFT protocol with monitoring of pulse pressure variation (PPV) in patients with ESRF undergoing parathyroidectomy.Material and methodsA total of 102 patients who underwent elective parathyroidectomy were randomised into a control group (restrictive group, n = 51), managed with a restricted fluid regimen, or a PPV group (GDFT group, n = 51), given a normal saline infusion, and they were monitored for changes in PPV. If PPV reached &gt; 13%, 250 ml of normal saline was administered over 15 min. Ephedrine was given to keep the mean arterial pressure &gt; 65 mm Hg. Haemodynamic variables in the perioperative period were recorded. The primary endpoint was the occurrence of postoperative hypotension.ResultsThe occurrence of postoperative hypotension (0 vs. 11.67%, p = 0.027) and complications (35.3% vs. 54.9%, p = 0.047) in the GDFT group was lower than in the restrictive group. The volume of saline infused during the operation was 364 (219–408) ml and 50 (50–50) ml, respectively (p = 0.001). Ephedrine was given to 16/51 (29.4%) patients of the GDFT group and 27/51 (52.9%) patients of the restrictive group (p = 0.027).ConclusionsThe use of GDFT with dynamic PPV monitoring in patients with ESRF undergoing parathyroidectomy could potentially be used to guide the administration of infused fluids, with the possibility of reducing the occurrence of postoperative hypotension.

Perioperative Infusion Therapy in Children

The composition and type of intravenous fluids during paediatric anaesthesia have been subjects of debates for decades. Errors in perioperative infusion therapy in children may lead to serious complications and a negative outcome. Therefore, in this review historical and recent developments and recommendations for perioperative fluid management in children are presented, based on physiology and focused on safety and efficacy. Recent studies showed that optimized preoperative fasting times and liberal clear fluid intake until 1 h improve patient comfort and metabolic and haemodynamic condition after induction of anaesthesia. Physiologically composed balanced isotonic electrolyte solutions are safer than hypotonic electrolyte solutions or saline 0.9% to protect young children against the risks of hyponatraemia and hyperchloremic acidosis. For intraoperative maintenance infusion, addition of 1 - 2% glucose is sufficient to avoid hypoglycaemia, lipolysis or hyperglycaemia. Modified fluid gelatine or hydroxyethyl starch in balanced electrolyte solution can safely be used to quickly normalize blood volume in case of perioperative circulatory instability and blood loss. In conclusion, physiologically composed infusion solutions are beneficial for maintaining homeostasis, shifting the status more towards the normal range in children with pre-existing imbalances and have a wide safety margin in case of accidental hyperinfusion.

The Effect of Intra-Operative Plethysmography Variability Index-guided Fluid Therapy on Serum Lactate Levels; A Randomized Double-blinded Clinical Trial

Background: Goal-directed fluid therapy may improve perioperative fluid management. This study aimed to evaluate the effects of Pleth variability index (PVI)-guided fluid therapy on changes in intraoperative serum lactate levels in comparison with liberal fluid therapy. Methods: This study was a randomized double-blinded clinical trial that was conducted in the operating room of a university hospital. Inclusion criteria comprised patients aged 18–60 years and classified as American Society of Anesthesiologists physical status class I and II, who were candidates for elective thyroidectomy. In total, 44 patients meeting the inclusion criteria were enrolled in the study and randomly assigned to two groups: the liberal and PVI groups. In both groups, 5 mL/kg bolus of normal saline was infused prior to the anesthesia induction. In the PVI group, 100 mL bolus of normal saline was administered every 5 min if the PVI remained &gt;13% during the operation. In the liberal group, continuous crystalloid infusion (5–6 mL/kg/h) was administered throughout the surgery. Arterial blood samples were taken, and serum lactate levels were measured following anesthesia induction and just before tracheal extubation. Results: In the PVI group, mean serum lactate decreased at the end of the surgery, with a difference of −0.6 ± 0.13 mmol/L, whereas it increased in the liberal group (0.070 ± 0.3, P&lt;0.05). Conclusion: In conclusion, we found that using intraoperative PVI-guided fluid therapy could decrease serum lactate levels and total fluid administration compared to the liberal method.

Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance

BackgroundOptimal fluid therapy in the perioperative and critical care settings depends on understanding the underlying cardiovascular physiology and individualizing assessment of the dynamic patient state.MethodsThe Perioperative Quality Initiative (POQI-5) consensus conference brought together an international team of multidisciplinary experts to survey and evaluate the literature on the physiology of volume responsiveness and perioperative fluid management. The group used a modified Delphi method to develop consensus statements applicable to the physiologically based management of intravenous fluid therapy in the perioperative setting.DiscussionWe discussed the clinical and physiological evidence underlying fluid responsiveness and venous capacitance as relevant factors in fluid management and developed consensus statements with clinical implications for a broad group of clinicians involved in intravenous fluid therapy. Two key concepts emerged as follows: (1) The ultimate goal of fluid therapy and hemodynamic management is to support the conditions that enable normal cellular metabolic function in order to produce optimal patient outcomes, and (2) optimal fluid and hemodynamic management is dependent on an understanding of the relationship between pressure, volume, and flow in a dynamic system which is distensible with variable elastance and capacitance properties.

Perioperative Fluid Management for Elective Major Surgery Patients at a Teaching Hospital in Rwanda

Background&#x0D; Every year, over 312 million surgical operations are performed globally. While perioperative goal-directed fluid strategy may reduce postoperative complications among patients undergoing major surgery, poor perioperative fluids management has been linked to adverse postoperative patients’ outcome.&#x0D; Methods&#x0D; This study used quantitative prospective design to assess the perioperative fluids management in 133 patients operated in the theatre of University Teaching Hospital of Butare (CHUB). The SPSS 21 was used to analyze the data, Chi-square test was performed to assess the association between fluid administered and patients’ hydration status with an acceptable cutoff at p&lt;0.05.&#x0D; Results&#x0D; The findings showed that 108 (81.2%) and 25 (18.8%) participants were in dehydration class A and B before surgery and strongly associated with age, surgeries, type and amount of intraoperative fluids. Participants received RL and NS (67.7%), 2091.73 ml, +803.6 ml and lost 218.42+131.9 ml fluid in average. Postoperatively, 53.4% and 46.6% participants were in dehydration class A and B respectively, strongly associated with type and duration of surgery (P&lt;0.05). All participants fasted more than 6 hours.&#x0D; Conclusion&#x0D; The dehydration rate increased intraoperatively in relation to type and duration of surgery and type and amount of fluid administered. Reduced fasting time and effective intraoperative fluid management would improve the patients’ hydration after surgery and postoperative patients’ outcome.&#x0D; Key words: Major Surgery, Elective Surgery, Perioperative care, Fluid management, patients

PD55-01 A PROSPECTIVE SINGLE-BLINDED RANDOMIZED CONTROLLED CLINICAL TRIAL OF PERIOPERATIVE GOAL-DIRECTED FLUID THERAPY VERSUS STANDARD FLUID THERAPY FOR PATIENTS UNDERGOING OPEN RADICAL CYSTECTOMY ON A STANDARDIZED POSTOPERATIVE ENHANCED RECOVERY PATHWAY

You have accessJournal of UrologyBladder Cancer: Invasive V (PD55)1 Apr 2020PD55-01 A PROSPECTIVE SINGLE-BLINDED RANDOMIZED CONTROLLED CLINICAL TRIAL OF PERIOPERATIVE GOAL-DIRECTED FLUID THERAPY VERSUS STANDARD FLUID THERAPY FOR PATIENTS UNDERGOING OPEN RADICAL CYSTECTOMY ON A STANDARDIZED POSTOPERATIVE ENHANCED RECOVERY PATHWAY Sherri M. Donat*, Kay See Tan, Guido Dalbagni, Alessia C. Pedoto, Harry W. Herr, Bernard H. Bochner, Eugene K. Cha, Timothy F. Donahue, Mary Fischer, and Vittoria Arslan-Carlon Sherri M. Donat*Sherri M. Donat* More articles by this author , Kay See TanKay See Tan More articles by this author , Guido DalbagniGuido Dalbagni More articles by this author , Alessia C. PedotoAlessia C. Pedoto More articles by this author , Harry W. HerrHarry W. Herr More articles by this author , Bernard H. BochnerBernard H. Bochner More articles by this author , Eugene K. ChaEugene K. Cha More articles by this author , Timothy F. DonahueTimothy F. Donahue More articles by this author , Mary FischerMary Fischer More articles by this author , and Vittoria Arslan-CarlonVittoria Arslan-Carlon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000965.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Postoperative ileus (POI) is a common complication of intra-abdominal surgeries, including radical cystectomy (RC) with reported POI rates as high as 32%. Targeted individualized perioperative fluid management has been shown to improve postoperative outcomes and POI for abdominal surgeries, compared to standard fluid therapy (SFT). We investigated whether goal-directed fluid therapy (GDFT) during open RC is associated with POI incidence (main outcome) and other perioperative/postoperative complications by 30 days post-surgery. METHODS: This prospective, single-blinded trial at a US cancer center randomized patients undergoing open RC to GDFT or SFT. Participants were ≥21 years old, had body mass index ≤45, and no active atrial fibrillation. The algorithm determining amount of fluid to administer combines preoperative and postoperative stroke volume optimization and intraoperative stroke volume variation minimalization, using the EV1000 clinical monitoring platform via a Flotrac sensor. All patients were treated on a standardized postoperative enhanced recovery pathway. Complications were collected prospectively up to 30 days postsurgery using the modified Clavien system and compared between groups using Fisher’s exact test. RESULTS: Between August 2014 and April 2018, 283 randomized RC patients received their assigned intervention, 142 GDFT and 141 SFT (ClinicalTrials.gov NCT02145871, no longer recruiting patients). Incidence of POI was similar between GDFT and SFT arms (25% vs 21%, p=0.5), as was incidence of grade 3-5 complications (15% vs 16%, p=0.7). Patients in the GDFT arm were more likely to experience at least one complication (96% vs 89%, p=0.028) and acute kidney injury (AKI) (56% vs 40%, p=0.006). All patients with AKI recovered to preoperative baseline by discharge, and no patient required dialysis. Median length of stay was 7 days in both arms (p=0.6), with similar urgent care visit and readmission rates between arms. CONCLUSIONS: In patients undergoing open RC, we found no significant benefit in rate reduction of POI or other high-grade perioperative/postoperative complications with individualized GDFT versus SFT. For future comparison, studies should standardize definitions of outcomes and better delineate their patient populations. Source of Funding: Supported by the Gary Gladstein Family, the Sidney Kimmel Center for Prostate and Urologic Cancers, Ruth L. Kirschstein National Research Service Award T32CA082088 (MG), and the P30-CA008748 National Institutes of Health cancer center support grant © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1182-e1182 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sherri M. Donat* More articles by this author Kay See Tan More articles by this author Guido Dalbagni More articles by this author Alessia C. Pedoto More articles by this author Harry W. Herr More articles by this author Bernard H. Bochner More articles by this author Eugene K. Cha More articles by this author Timothy F. Donahue More articles by this author Mary Fischer More articles by this author Vittoria Arslan-Carlon More articles by this author Expand All Advertisement PDF downloadLoading ...

Liberal Use of Hemofiltration to Optimize Volume Status in iPAH Patients Does Not Impair Long-Term Kidney Function

The post-operative phase after LTx for iPAH can be challenging. A restrictive fluid management facilitates unloading of the untrained left ventricle and reduces the risk for reperfusion edema. In our center, hemofiltration (HF) is pre-emptively started when a patient cannot be balanced negatively despite maximal medicamentous effort. It remains unclear whether such a strategy impairs long-term outcomes. iPAH patients transplanted between 2000 and 2018 were included in this retrospective analysis. Data collected included kidney function, immunosuppressive therapy, use of HF, PGD rates, length of mechanical ventilation and survival RESULTS: Within the study period 99 iPAH patients were transplanted in our institution. Preoperative kidney insufficiency was recorded in 21 patients (21%). Estimated glomerular filtration rate decreased from a median of 83 ml/min at arrival in ICU to a median of 62 ml/min two days after LTx. In thirty patients (30%) HF was started within the first 48 hours with a median length of 21 days (10-27). In these patients serum creatinine (1.1 vs 1.8 mg/dL, p<0.001) and blood urea nitrogen (28 vs 35 mg/dL, p<0.001) was significantly higher in the first three postoperative days. All patients could be successfully weaned from HF. No difference was found between the two groups in terms of serum creatinine at 1, 3 and 5 years: 1.12 vs 1.2 mg/dL, 1.12 vs 1.2 mg/dL and 1.14 vs 1.25 mg/dL, respectively. Patients requiring postoperative HF showed comparable long-term rates of higher CKD stages (18%) to the other patients (23%, p=0.99). Multivariable Cox regression revealed that HF was not a risk factor for long-term survival (p=0.127). Long-term survival was excellent with 5-year survival rates of 79% CONCLUSION: A liberal use of HF in the early postoperative period does not impact long-term kidney function. Our data suggest that an aggressive peri-operative fluid management including early implementation of HF leads to excellent long-term outcomes.

Abstract PD6-2: Enhanced recovery after surgery (ERAS) pathway reduces hospital stay and narcotic use in microsurgical breast reconstruction

Abstract Introduction: Enhanced recovery after surgery (ERAS) pathways strive to minimize surgical stress and restore normal physiological function through the implementation of standardized and streamlined protocols. ERAS pathways have shown benefits in many surgical populations including cardiac, colorectal, urology and general surgery by aiming to accelerate recovery and reduce post-operative morbidity. As microsurgical breast reconstruction continues to become more popular, study objectives aim to determine possible benefits of ERAS pathway implementation during abdominal-based free flap breast reconstruction related to post-operative narcotic use and health-care resource utilization. Methods: A retrospective analysis of consecutive patients undergoing abdominal-based free flap breast reconstruction from Nov 2015 to April 2018 was performed. Study populations were defined relative to uniform implementation of an ERAS pathway, which included preoperative counseling, optimization of nutrition, perioperative fluid management, early mobilization, and multimodal analgesia. Patient age, medical comorbidities, and BMI were recorded preoperatively. Procedural characteristics and immediate postoperative morbidity were recorded along with length of hospitalization. Utilization of narcotics was standardized for the entire hospitalization by determining morphine milligram equivalents. Results: During the study period, 409 patients met inclusion criteria. The pre-ERAS group was comprised of 205 patients, while 204 patients were managed via ERAS pathway. Mean age, laterality (unilateral vs. bilateral), timing (immediate vs. delayed) of reconstruction, and number of previous abdominal surgeries were similar (p &amp;gt; 0.05) between both groups. Mean BMI (30.4 ± 4.8 vs. 29 ± 5.1) and incidence of autoimmune disease (3.9% vs. 0%) were significantly higher (p &amp;lt; 0.05) in the pre-ERAS group. Mean operative time (minutes) between both groups (450.1 ± 92.7 vs. 440.7 ± 93.5) was similar (p &amp;gt; 0.05). Incidence of vascular thrombosis (6 (2.9%) vs. 5 (2.5%)), hematoma (4 (2%) vs.4 (2%)), flap loss (1 (0.5%) vs. 4 (2.%), or return to OR for any reason (10 (4.9%) vs. 8 (3.9%)) was similar (p &amp;gt; 0.05) between pre-ERAS and ERAS groups, respectively. Mean intra-operative (58.9 ± 32.5 vs. 31.7 ± 23.4) and post-operative (129.5 ± 80.1 vs. 90 ± 93.9) morphine milligram equivalents used were significantly (p &amp;lt; 0.001) higher in the pre-ERAS group. Mean length of stay (days) was significantly (p &amp;lt; 0.001) longer in the pre-ERAS group (4.5 ± 0.8 vs. 3.2 ± 0.6). Bivariate linear regression analysis demonstrates operative time is positively associated with total narcotic requirements [slope (95% CI)=0.217 (0.114, 0.320)], p &amp;lt; 0.001 and length of stay [slope (95% CI) =0.00177 (0.0008, 0.0028)], p &amp;lt; 0.001. Conclusion: Without detrimental effects on operative morbidity, ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In the current study, patients managed via ERAS pathways required 46% less intraoperative and 31% less postoperative narcotics with a 29% reduction in length of stay. Citation Format: Oscar Ochoa, Meenakshi Rajan, Minas Chrysopoulo, Steven Pisano, Peter Ledoux, Gary Arishita, Ramon Garza III, Chet Nastala. Enhanced recovery after surgery (ERAS) pathway reduces hospital stay and narcotic use in microsurgical breast reconstruction [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD6-2.

Perioperative fluid management

An appropriate perioperative infusion management is pivotal for the perioperative outcome of the patient. Optimization of the perioperative fluid treatment often results in enhanced postoperative outcome, reduced perioperative complications and shortened hospitalization. Hypovolemia as well as hypervolemia can lead to an increased rate of perioperative complications. The main goal is to maintain perioperative euvolemia by goal-directed therapy (GDT), acombination of fluid management and inotropic medication, to optimize perfusion conditions in the perioperative period; however, perioperative fluid management should also include the preoperative and postoperative periods. Thisencompasses the preoperative administration of carbohydrate-rich drinks up to 2 h before surgery. In the postoperative period, patients should be encouraged to start per os hydration early and excessive i.v. fluid administration should be avoided. Implementation of acomprehensive multimodal, goal-directed fluid management within an enhanced recovery after surgery (ERAS) protocol is efficient but the exact status of indovodual items remains unclear at present.

The James A. Rand Young Investigator's Award: Traditional Intravenous Fluid vs. Oral Fluid Administration in Primary Total Knee Arthroplasty: A Randomized Trial

BackgroundOptimal perioperative fluid management has not been established in patients undergoing orthopedic surgical procedures. Our purpose was to investigate the effects of perioperative fluid management (ie, preoperative, intraoperative, and postoperative) on patients undergoing total knee arthroplasty (TKA). MethodsOne hundred thirty patients who met inclusion criteria undergoing primary unilateral TKA were prospectively randomized into traditional (TFG) vs oral (OFG) perioperative fluid management groups. The primary outcome was change in body weight (BW). Secondary outcome measures included knee motion, leg girth, bioelectrical impendence, quadriceps activation, functional outcomes testing, Knee injury and Osteoarthritis Outcome Score JR, VR-12, laboratory values, vital signs, patient satisfaction, pain scores, and adverse events. ResultsThe TFG had increased BW the evening of surgery (7.0 ± 4.3 vs 3.0 ± 3.9, P < .0001), postoperative day (POD) #1 (9.1 ± 4.3 vs 4.7 ± 3.9, P < .0001), and POD #2 (6.2 ± 5.0 vs 4.4 ± 4.0, P = .032). Bioelectrical impedance showed less limb edema in the OFG (4.2 ± 29.7 vs 17.8 ± 30.3, P < .0001) on POD #1. Urine specific gravity differences were seen preoperatively between groups (OFG, more hydrated, P = .002). Systolic blood pressure decrease from the baseline was greater in the OFG on arrival to the floor (19.4 ± 13.5 vs 10.6 ± 12.8, P < .0001) and 8 (23.4 ± 13.3 vs 17.0 ± 12.9, P = .006) and 16 (25.8 ± 13.8 vs 25.8 ± 13.8, P = .046) hours after floor arrival. The TFG had more urine output on POD #1 (3369 mL ± 1343 mL vs 2435 mL ± 1151 mL, P < .0001). The OFG were more likely to go home on POD #1 than the TFG (63 vs 56, P = .02). ConclusionOral fluid intake with IVF restriction in the perioperative period after TKA may offer short-term benefits with swelling and BW fluctuations. The authors continue to limit perioperative IVFs and encourage patient initiated fluid intake.