Perioperative Fluid Resuscitation Research Articles

Endocrine emergencies in anesthesia.

An increasing number of patients with endocrine disorders will present to the operating rooms. In this review, we outline the common endocrine disorders that the anesthesiologist may face in the perioperative time span, review the controversies in optimal management, as well as summarize the recent literature for the management of these complex patients. Perioperative management of pheochromocytoma and paraganglioma has been facilitated by improved medical management and the adoption of minimally invasive surgical techniques. An improved understanding of the sequelae of carcinoid syndrome has resulted in safer perioperative management. Perioperative glycemic management requires a fundamental understanding of perioperative fluid resuscitation and adverse events associated with the new generation oral hyperglycemic agents to prevent avoidable complications. Endocrine disorders will commonly present in the perioperative time period and the anesthesiologist plays a critical role in achieving good operative outcomes.

Perioperative Fluid Resuscitation in Free Flap Breast Reconstruction: When Is Enough Enough?

Background:Perioperative liberal fluid resuscitation (LFR) can result in interstitial edema and venous congestion and may be associated with compromised perfusion of free flaps and higher incidence of wound complications. We hypothesized that restrictive intraoperative fluid resuscitation improves flap perfusion and lowers the wound complication rate in free flap breast reconstruction.Methods:Patients undergoing free flap reconstruction of the breast from 2010 to 2018 were retrospectively reviewed. The study population was divided into 2 groups, LFR (≥7 ml/kg/h) and restrictive fluid resuscitation (RFR) (<7 ml/kg/h). Mean percutaneous oximetry readings of the flap over the first 24 hours were recorded. Primary outcome was development of any wound complication. Secondary outcomes were mean percutaneous oximetry readings within the first 24 hours, length of stay, and development of acute kidney injury.Results:One hundred twenty-six patients were identified, with 41 patients undergoing LFR. The mean fluid received for the RFR group was 5.5 versus 10.2 ml/kg/h for the LFR group (P < 0.001). LFR resulted in a significantly higher incidence of wound complications (76% versus 15%, P < 0.001). The mean oximetry readings within 24 hours were significantly lower for the LFR group (41% versus 56%, P < 0.001). Urine output intraoperatively and within the first 24 hours was similar between the 2 groups. No patients developed acute kidney injury.Conclusion:RFR in free flap breast reconstruction is associated with increased flap perfusion and lower incidence of wound-related complications and should be considered whenever possible.

Impact of fluid resuscitation on major adverse events following pancreaticoduodenectomy

BackgroundPancreaticoduodenectomy remains a major undertaking with substantial perioperative morbidity and mortality. Previous studies in the colorectal population have noted a correlation between excessive postoperative fluid resuscitation and anastomotic complications. This study sought to assess the relationship between perioperative fluid management and clinical outcomes in patients undergoing pancreaticoduodenectomy. MethodsData from a single institution, prospective database over a 10-year period (2002 to 2012) were reviewed. Patients were compared for perioperative fluid balance and postoperative outcomes. Multivariable analysis was performed to assess the relationship between perioperative fluid administration and incidence of major adverse events. ResultsHigher positive fluid balance on postoperative day 0, postoperative day 1, and postoperative day 2 was associated with increased incidence of major adverse events, increased postoperative intensive care unit admission, and longer hospital stay. Higher positive fluid balance on postoperative day 0 was most strongly associated with postoperative morbidity (odds ratio 1.39, confidence interval 1.16 to 1.66, P = .0003). Fluid balance on postoperative day 3 was not associated with adverse events. ConclusionsIncreased early perioperative fluid resuscitation is associated with major adverse events in patients undergoing pancreaticoduodenectomy. More restrictive fluid administration may improve postoperative outcomes; further prospective clinical trials focused on fluid resuscitation and goal-directed therapy are needed.

Goal-Directed Fluid Therapy Using Stroke Volume Variation for Resuscitation after Low Central Venous Pressure-Assisted Liver Resection: A Randomized Clinical Trial

The optimal perioperative fluid resuscitation strategy for liver resections remains undefined. Goal-directed therapy (GDT) embodies a number of physiologic strategies to achieve an ideal fluid balance and avoid the consequences of over- or under-resuscitation. In a prospective randomized trial, patients undergoing liver resection were randomized to GDT using stroke volume variation as an end point or to standard perioperative resuscitation. Primary outcomes measure was 30-day morbidity. Between 2012 and 2014, one hundred and thirty-five patients were randomized (GDT: n = 69; standard perioperative resuscitation: n = 66). Median age was 57 years and 56% were male. Metastatic disease comprised 81% of patients. Overall (35% GDT vs 36% standard perioperative resuscitation; p = 0.86) and grade 3 morbidity (28% GDT vs 18% standard perioperative resuscitation; p = 0.22) were equivalent. Patients in the GDT arm received less intraoperative fluid (mean 2.0 L GDT vs 2.9 L standard perioperative resuscitation; p < 0.001). Perioperative transfusions were required in 4% (6% GDT vs 2% standard perioperative resuscitation; p = 0.37) and boluses in the postanesthesia care unit were administered to 24% (29% GDT vs 20% standard perioperative resuscitation; p = 0.23). Mortality rate was 1% (2 of 135 patients; both in GDT). On multivariable analysis, male sex, age, combined procedures, higher intraoperative fluid volume, and fluid boluses in the postanesthesia care unit were associated with higher 30-day morbidity. Stroke volume variation-guided GDT is safe in patients undergoing liver resection and led to less intraoperative fluid. Although the incidence of postoperative complications was similar in both arms, lower intraoperative resuscitation volume was independently associated with decreased postoperative morbidity in the entire cohort. Future studies should target extensive resections and identify patients receiving large resuscitation volumes, as this population is more likely to benefit from this technique.

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis

Objective To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications.Design Retrospective cohort study...

The development of pediatric fluid resuscitation: an interview with Dr. Frederic A. ‘Fritz’ Berry

Dr. Frederic A. 'Fritz' Berry (1935), Professor Emeritus of Anesthesiology and Pediatrics at the University of Virginia, has played a pioneering role in the development of pediatric anesthesiology through training generations of anesthesiologists. He identifies his early advocacy of balanced electrolyte solution for perioperative fluid resuscitation as his defining contribution. Based on his clinical experiences, he pushed to extend the advances in adult fluid resuscitation into pediatric practice. He imparted these and other insights to his colleagues although textbooks, book chapters, original journal publications, and decades of Refresher Course Lectures at the American Society of Anesthesiologists' annual meetings. A model educator, clinician, and researcher, he shaped the careers of hundreds of physicians-in-training while advancing the field of pediatric anesthesiology.

Perioperative incidence and management of hyponatremia in vWD patients undergoing adenotonsillectomy

To analyze the incidence and severity of hyponatremia in patients receiving synthetic desmopressin (DDAVP) in the perioperative setting of oropharyngeal surgery in the treatment of von Willebrand disease and to propose a standardized protocol for perioperative fluid resuscitation and postoperative sodium monitoring after DDAVP administration. Retrospective medical record review. A retrospective medical record review in an academic pediatric medical center was conducted. From October 1, 2002, to February 1, 2009, all patients undergoing adenotonsillectomy and receiving DDAVP preoperatively for the treatment of von Willebrand disease were identified. A total of 76 patients were identified by initial database review; 63 patients were included in the study, and 13 patients were excluded secondary to incomplete data. DDAVP dose and timing, perioperative fluid volume and composition, and postoperative sodium levels were collected. Extreme adverse events related to hyponatremia were recorded. Forty-seven of 63 (74.6%) patients developed some degree of hyponatremia after DDAVP administration, and six of 63 (9.5%) patients developed extreme hyponatremia, with the degree of hyponatremia related to the volume of perioperative fluid resuscitation. The sodium nadir occurred within 9 to 20 hours after DDAVP administration. No serious adverse events related to hyponatremia were recorded during the study period. The incidence of hyponatremia in children receiving DDAVP for prophylaxis of intraoperative bleeding following oropharyngeal surgery is high. The degree of hyponatremia is related to the perioperative fluid volume administered. A protocol for DDAVP administration, perioperative fluid resuscitation, and postoperative sodium monitoring that aims to reduce the incidence of hyponatremia in this population is proposed.

Major elective gastrointestinal surgery: does fluid restriction improve outcome?

Controversy regarding fluid therapy for major surgery dates back to the 1950s and is largely based on two differing concepts: the first, that the metabolic and stress response to surgery causes water and sodium retention, and the second, that there is redistribution of fluid into a hypothetical ‘third space’ leading to a fall in intravascular volume. Aggressive perioperative fluid resuscitation is the standard of care provided by many anaesthetists, however, evidence seems to suggest that this is flawed. Unfortunately, the answer is not as simple as following a restrictive fluid regimen.

A Systematic Review of Buffered Versus Non-Buffered Perioperative Fluid Resuscitation and Urine Output

A Systematic Review of Buffered Versus Non-Buffered Perioperative Fluid Resuscitation and Urine Output

Fournier’s Gangrene

Fournier's gangrene is the result of a highly lethal and rapidly progressive necrotizing infection of the perineal and genital fascia, with gangrene of the overlying skin. The infection is generally polymicrobial and probably synergistic in nature. Anorectal, genitourinary, and traumatic infections are the most common causes of Fournier's gangrene. The cutaneous manifestations of Fournier's gangrene are merely "the tip of the iceberg" because the infection spreads aggressively along recognized fascial planes. Perioperative fluid resuscitation, cardiopulmonary support, antibiotic therapy, and nutritional support are of major importance in management of the disease; however, examination under anesthesia with aggressive surgical débridement remains the most important aspect of treatment. Multiple surgical procedures may be necessary to bring the infection under control. In the majority of instances, the testes, glans penis, bladder, and rectum are spared destruction because of their separate blood supplies. Diversion of the fecal and urinary streams may not always be necessary but should always be considered on a case-by-case basis. The value of hyperbaric oxygenation in Fournier's gangrene remains unproven, but there are theoretical reasons why it may be beneficial, at least in some cases. Despite optimal medical and surgical management, the mortality rate in Fournier's gangrene still exceeds 40% in many series.