Preoperative Fluid Resuscitation Research Articles

Longer preoperative fluid resuscitation decreased anesthetic fluid interventions in 297 dogs undergoing surgery for gastrointestinal foreign body obstruction.

The objectives were to (1) compare the impact of preoperative fluid resuscitation on anesthetic parameters and interventions and (2) assess the impact of preoperative resuscitation duration on the integrity of intestinal tissue and postoperative complications in dogs with gastrointestinal foreign body obstruction. Medical records from 1 academic hospital were reviewed for 297 client-owned dogs that underwent gastrointestinal foreign body obstruction surgery between May 2017 and August 2022. Data collected included the following: signalment, preoperative fluid resuscitation, surgical findings, anesthetic parameters and interventions, postoperative complications, and timing of the first meal. Variables for preoperative length of fluid resuscitation (hours), total preoperative fluid bolus (mL/kg), and preoperative fluid rate (mL/kg/d) were changed to categorical variables. Associations between anesthetic interventions, postoperative outcomes, preoperative fluid resuscitation length, and total fluid bolus were assessed with ordered logistic regression. Shorter preoperative fluid resuscitation length was associated with higher anesthetic fluid rates (P = .033) and fluid boluses performed (P = .023). Increased total volume of preoperative fluid boluses was associated with anesthetic synthetic colloid use (P = .028). There was insufficient evidence to claim an association between the impact of preoperative fluid resuscitation length and intestinal wall compromise (perforation, P = .912; enterectomy performed, P = .711). Shorter preoperative fluid resuscitation was associated with increased anesthetic fluid interventions but not the need for more complex surgeries. Longer fluid resuscitation periods are associated with fewer anesthetic interventions in dogs.

Significant variations in preoperative fluid resuscitation volumes delivered to elderly hip fracture patients at six level 1 trauma centers: an observational descriptive study.

Objective:To describe the variations in administration of preoperative (preop) fluids and in the volumes of fluid administered among geriatric hip fracture patients requiring surgical repair.Design:Observational descriptive.Setting:Six Level 1 trauma centers.Patients:A total of 595 patients aged ≥65 with ICD-10 codes indicating hip fracture and surgical repair were identified. Of these, 87.9% (n = 525) received preop fluid. The median volume of preop fluid delivered was 1500 mL (IQR: 1000–2250 mL).Intervention:None.Main Outcome Measures:Receipt of preop fluids; median volume of fluid received.Results:Receipt of preop fluid was significantly different by inter-hospital transfer, facility, BMI, hospital length of stay, and postop fluid volume. Age, sex, time to surgery, time to ambulation, and hospital disposition were not associated with preop fluid. There were significant differences in median preop fluid volumes by facility and postop fluid volume.Conclusion:This descriptive study of current practices among geriatric trauma patients with isolated hip fractures revealed significant differences in the use of preop fluid resuscitation and the resuscitation volumes administered. Treating facility may be the most substantial source of variation highlighting the need for a guideline on fluid resuscitation. These observed variations may be a result of patient characteristics or provider discretion and should be evaluated further.

Pre-operative fluid resuscitation in the emergency general surgery septic patient: does it really matter?

ObjectiveEmergency general surgery (EGS) patients presenting with sepsis remain a challenge. The Surviving Sepsis Campaign recommends a 30 mL/kg fluid bolus in these patients, but recent studies suggest an association between large volume crystalloid resuscitation and increased mortality. The optimal amount of pre-operative fluid resuscitation prior to source control in patients with intra-abdominal sepsis is unknown. This study aims to determine if increasing volume of resuscitation prior to surgical source control is associated with worsening outcomes.MethodsWe conducted an 8-year retrospective chart review of EGS patients undergoing surgery for abdominal sepsis within 24 h of admission. Patients in hemorrhagic shock and those with outside hospital index surgeries were excluded. We grouped patients by increasing pre-operative resuscitation volume in 10 ml/kg intervals up to > 70 ml/kg and later grouped them into < 30 ml/kg or ≥ 30 ml/kg. A relative risk regression model compared amounts of fluid administration. Mortality was the primary outcome measure. Secondary outcomes were time to operation, ventilator days, and length of stay (LOS). Groups were compared by quick Sequential Organ Failure Assessment (qSOFA) and SOFA scoring systems.ResultsOf the 301 patients included, the mean age was 55, 51% were male, 257 (85%) survived to discharge. With increasing fluid per kg (< 10 to < 70 ml/kg), there was an increasing mortality per decile, 8.8% versus 31.6% (p = 0.004). Patients who received < 30 mL/kg had lower mortality (11.3 vs 21%) than those who received > 30 ml/kg (p = 0.02). These groups had median qSOFA scores (1.0 vs. 1.0, p = 0.06). There were no differences in time to operation (6.1 vs 4.9 h p = 0.11), ventilator days (1 vs 3, p = 0.08), or hospital LOS (8 vs 9 days, p = 0.57). Relative risk regression correcting for age and physiologic factors showed no significant differences in mortality between the fluid groups.ConclusionsGreater pre-operative resuscitation volumes were initially associated with significantly higher mortality, despite similar organ failure scores. However, fluid volumes were not associated with mortality following adjustment for other physiologic factors in a regression model. The amount of pre-operative volume resuscitation was not associated with differences in time to operation, ventilator days, ICU or hospital LOS.

Management and Outcomes of Acute Surgical Patients at a District Hospital in Uganda with Non-physician Emergency Clinicians.

Acute surgical care services in rural Sub-Saharan Africa suffer from human resource and systemic constraints. Developing emergency care systems and task sharing aspects of acute surgical care addresses many of these issues. This paper investigates the degree to which specialized non-physicians practicing in a dedicated Emergency Department contribute to the effective and efficient management of acute surgical patients. This is a retrospective review of an electronic quality assurance database of patients presenting to an Emergency Department in rural Uganda staffed by non-physician clinicians trained in emergency care. Relevant de-identified clinical data on patients admitted directly to the operating theater from 2011 to 2014 were analyzed in Microsoft Excel. Overall, 112 Emergency Department patients were included in the analysis and 96% received some form of laboratory testing, imaging, medication, or procedure in the ED, prior to surgery. 72% of surgical patients referred by ED received preoperative antibiotics, and preoperative fluid resuscitation was initiated in 65%. Disposition to operating theater was accomplished within 3h of presentation for 73% of patients. 79% were successfully followed up to assess outcomes at 72h. 92% of those with successful follow-up reported improvement in their clinical condition. The confirmed mortality rate was 5%. Specialized non-physician clinicians practicing in a dedicated Emergency Department can perform resuscitation, bedside imaging and laboratory studies to aid in diagnosis of acute surgical patients and arrange transfer to an operating theater in an efficient fashion. This model has the potential to sustainably address structural and human resources problems inherent to Sub-Saharan Africa's current acute surgical care model and will benefit from further study and expansion.

Audit of preoperative fluid resuscitation in perforation peritonitis patients using Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity.

Context:Debate continues regarding fluid (crystalloid vs. colloid) of choice for resuscitation. Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) may be used to compare the benefits of preoperative fluid resuscitation with crystalloids and colloids in peritonitis patients.Aims:The aim of this study is to compare crystalloid and colloid for preoperative resuscitation using morbidity, mortality, length of hospital stay (LOS), and time taken to resuscitate as the outcome parameters.Settings and Design:This was a prospective randomized clinical trial.Subjects and Methods:One hundred and seven peritonitis patients were prospectively randomized to fluid resuscitation by crystalloid (Group A) and colloid (Group B) solutions. Physiological score component of POSSUM was recorded before and after fluid resuscitation; operative score component was recorded at discharge/death. These scores were then used to calculate the predicted morbidity and mortality before and after the fluid resuscitation.Statistical Analysis Used:Effect on morbidity and mortality were compared by repeated measure analysis of variance, and its significance was tested by Tukey's test. LOS and time taken to resuscitate were compared using unpaired t-test. Significance was taken at 5%.Results:Fluid resuscitation improved mean predicted morbidity by 0.095 and 0.137 in Group A and Group B, respectively. Similarly, fluid resuscitation improved predicted mortality by 0.145 and 0.185 in Group A and Group B, respectively. These changes were statistically significant. Improvement in morbidity and mortality appeared greater in Group B. No difference was found in the two groups for LOS and time to resuscitate.Conclusions:Preoperative fluid resuscitation using either crystalloid or colloidal solutions decreases morbidity as well as mortality in peritonitis patients.

Implementation of a care pathway for infantile hypertrophic pyloric stenosis reduces length of stay and increases parent satisfaction

Introduction Infantile hypertrophic pyloric stenosis (IHPS) is a common surgical condition, but there are no guidelines regarding preoperative fluid resuscitation. Our aim was to evaluate a novel consensus care pathway for IHPS, incorporating a standardized fluid and electrolyte replacement regime. Methods One hundred patients were initially reviewed and compared to thirty-three patients following the introduction of a clinical pathway, whereby infants requiring electrolyte correction received 150 ml/kg/24 h of 0.45% saline, 5% dextrose and 10 mmol KCl, with systematic blood sampling until correction was achieved. We measured time to electrolyte correction, time to surgery and total length of hospitalization. Data were described using the median and interquartile range, and differences between the groups’ categorical and continuous data were described using Chi-squared and the Mann–Whitney U–tests, respectively. Results Time in hours taken to correct electrolytes was reduced: 25(16.5–42) versus 9.5(4.5–24.75) p = 0.004. Time to surgery from admission in uncorrected patients decreased from 50(40.25–66.75) to 39(28.75–41.75) p = 0.018. Subsequently, there was a reduction in total length of stay: 94(71–93.5) versus 75(64.5–93.5) p = 0.025. Parental satisfaction increased from 77% in the pre-pathway group to 83% in the pathway group. Conclusion A consensus care pathway for IHPS reduces the time taken to correct preoperative electrolyte abnormalities, decreases length of hospitalization and improves parental satisfaction.

Effects of preoperative administration of hypertonic saline or pentastarch solution on hematologic variables and long-term survival of surgically managed horses with colic.

To compare the effects of preoperatively administered pentastarch (10% concentration in isotonic saline [0.9% NaCl] solution) and hypertonic saline (7.2% NaCl) solutions on PCV and circulating total protein (TP) concentration in horses with colic undergoing emergency exploratory laparotomy and to assess survival rates of horses that received each treatment. Prospective, randomized study. 100 horses with signs of abdominal pain and PCV ≥ 0.46 L/L. Procedures-Horses received a 4 mL/kg (1.8 mL/lb) dose of pentastarch solution (n = 50) or hypertonic saline solution (50) over a 10- to 20-minute period before anesthetic induction. Blood samples were collected at the time of evaluation and ≤ 5 minutes after fluid resuscitation; changes in PCV and TP concentration were compared. Survival was evaluated by Kaplan-Meier and Cox proportional hazards analyses. Age, weight, sex, PCV, and heart rate on initial examination were similar between treatment groups. Hypertonic saline solution treatment resulted in a significantly greater reduction in PCV (median change, -0.14 L/L) than did pentastarch treatment (median change, -0.07 L/L). Reduction in TP concentration was also significantly greater after hypertonic saline solution treatment (median change, -16 g/L) than after pentastarch treatment (median change, -2 g/L). Long-term survival was not significantly different between groups. Despite a greater reduction in preanesthetic hemoconcentration following administration of hypertonic saline solution (4 mL/kg infusion, once), no difference in overall long-term survival was found between horses that received this treatment and those that received an equal volume of pentastarch solution. Findings suggested that, in a clinical setting, either of these fluids would be appropriate for preoperative fluid resuscitation in horses with colic.

Beyond the Firstborn Son

Infantile hypertrophic pyloric stenosis is a long-trusted friend of the pediatrician and pediatric surgeon. The presentation of this disease is predictable, with development of progressive, projectile, nonbilious vomiting in a 2- to 6-week-old otherwise healthy infant. Most often it occurs in boys and firstborns, with white individuals being at increased risk. The diagnosis is easily confirmed by either physical examination or ultrasonography. The associated hypochloremic, hypokalemic, metabolic alkalosis is sufficiently characteristic that it predictably appears on medical school and board examinations. The preoperative fluid resuscitation is well known and used to teach medical students basic renal physiology. Most importantly, a brief operation (performed either laparoscopically or through a limited incision) returns a healthy infant to the arms of the relieved, new parents. 1 What more could one ask for from a disease?

A Prospective Randomised Study to Compare the Effects of Preoperative Hypertonic Saline or Pentastarch on Haematological Variables and Long‐Term Survival of Surgical Colic Cases

AimsTo compare the effects of hypertonic saline and pentastarch on packed cell volume (PCV) and total protein (TP) immediately preoperatively and on long‐term survival of horses undergoing emergency exploratory laparotomy.MethodsOne hundred horses presenting to the Philip Leverhulme Equine Hospital between 2004 and 2008 with signs of abdominal pain and PCV ≥45% were recruited. Horses were randomly allocated to receive 4 ml/kg bwt of either hypertonic saline (HS; Vetivex, 7.2%; n = 49) or pentastarch (PS; Haes‐Steril, 10%; n = 51) preanaesthesia. Blood samples were collected at presentation and post fluid resuscitation. Horse survival was tracked for 4 years following the final recruited case.ResultsThere were no significant differences between treatment groups at presentation for: age (HS, mean 13 ± 6 years; PS, mean 14 ± 6 years); body mass (HS, median 516 [130–698] kg; PS, median 525 [312–660] kg); sex (HS, 1 stallion, 34 geldings, 16 mares; PS, 2 stallions, 32 geldings, 15 mares); baseline PCV (HS, median 52 [46–70]%; PS, median 50 [45–70]%); baseline TP (HS, median 72 [46–103] g/l; PS, median 72 [50‐106] g/l); and heart rate (HS, mean 80 ± 20 beats/min; PS, mean 77 ± 18 beats/min) at presentation. Hypertonic saline treatment resulted in a significantly greater reduction in both PCV (HS, mean 13 ± 7%; PS mean 7 ± 5%; P&lt;0.001) and TP (HS, median 16 [6–32] g/l; PS, median 2 [‐8 to 17] g/l; P&lt;0.001), compared with pentastarch. There was no significant difference in long‐term survival between treatments (Cox proportional hazards model, P = 0.73).Conclusions and practical significanceDespite the greater reduction in haemoconcentration and likely reduction in blood viscosity incurred by HS, no benefit to overall long‐term survival was demonstrated. In a clinical setting, either of these fluids remains appropriate for preoperative fluid resuscitation in colic horses.AcknowledgementsAll the veterinary anaesthetists who assisted in data‐gathering.Ethical animal researchPermission for this study was granted by the Ethical Review Committee of the University of Liverpool's Veterinary School. Signed owner consent was obtained for all cases. Sources of funding: None. Competing interests: None.

A comparative analysis of nasogastric and intravenous fluid resuscitation in patients with malignant obstructive jaundice prior to endoscopic biliary drainage

Background:An alternative to intravenous is nasogastric fluid administration through normal functioning gut. Though not common, this practice has significance in mass causalities and elective situations.Aim:The study was designed to compare nasogastric and intravenous fluid resuscitation in malignant obstructive jaundice (OJ) and their effect on endotoxemia.Materials and Methods:Sixty patients with malignant OJ undergoing endoscopic biliary drainage were randomized into two groups. A total of 4 l of fluid (Ringer's lactate) was administered to Group A through nasogastric tube and to Group B through intravenous route for 48 h. Vital parameters, serum bilirubin, serum creatinine, creatinine clearance rate, electrolytes, and endotoxemia were monitored.Results:Significant improvement in blood pressure (Group A, P = 0.014; Group B, P = 0.020) and significant decrease in serum bilirubin level (Group A, P = 0.001; Group B, P > 0.0001) was observed in both groups after resuscitation. Significantly decreased (P = 0.036) post hydration endotoxin level was observed in Group A as compared to Group B. Febrile events were significantly higher (P = 0.023) in Group B as compared to Group A (6 vs 0). Electrolyte abnormalities were found more in Group B, however statistically insignificant.Conclusion:In OJ patient undergoing biliary drainage, preoperative fluid resuscitation through nasogastric tube may be helpful in reducing postoperative septic complications and endotoxemia.

On admission haemoglobin in patients with hip fracture

Several authors have identified on admission haemoglobin level as the most useful predictor of transfusion risk in patients with a hip fracture. A low postoperative haemoglobin unexplained by perioperative blood loss is not uncommon in these patients. The drop in haemoglobin after re-hydration prior to surgery should depend not only on the degree of dehydration but also on the amount of blood lost in the fracture. We could find no study in the English literature estimating the magnitude of this fall in haemoglobin after re-hydration prior to surgery. We conducted a prospective study to estimate the magnitude of fall in haemoglobin after re-hydration prior to surgery by repeating the full blood count after at least 12 h of preoperative fluid resuscitation in 127 patients with hip fracture (75 consecutive at one centre and 52 consecutive at another). The average preoperative drop in haemoglobin was 2.23 gram/decilitre (g/dL) ( p-value = 0.00) in subtrochanteric fractures, 1.1 g/dL ( p-value = 0.001) in intertrochanteric fractures and 0.7 g/dL ( p-value = 0.02) in intracapsular fractures. Fifteen patients with a haemoglobin level >9 g/dL on admission were found to have a haemoglobin level <9 g/dL on repeat test and were prevented from going to theatre without arrangements for perioperative transfusion during this study. Their predicted average postoperative haemoglobin without perioperative blood transfusion was calculated to be 6.5 g/dL. The on admission haemoglobin level was found to be falsely reassuring and could lead to a very low postoperative haemoglobin level. This could prove to be dangerous for many patients especially if remains undetected for several hours. We recommend that all patients with subtrochanteric fractures, and all patients with intertrochanteric or intracapsular fractures with a haemoglobin of less than 12 g/dL on admission have a repeat haemoglobin level performed prior to their surgery.

Factors Affecting Morbidity/Mortality of Emergency General Surgery

Introduction/Background: Emergency status has been documented as adversely affecting the outcome of general surgery. However, the predictors of increased morbidity and mortality of emergency general surgery (EGS) are unclear, including the possibility of modifying these factors. This study aims to determine the predictive factors for postoperative complications of EGS. Methods: A retrospective study of all randomly selected Brigham and Women's Hospital (BWH) American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients who had an EGS procedure from January 1, 2007 to December 31, 2008 were selected for this study. BWH IRB approved this study. The study applied the inclusion and exclusion criteria as defined by ACS NSQIP using select preoperative and all postoperative data variables. Additional non-ACS NSQIP data points were added and analyzed as possible predictors of poor outcomes. These included blood glucose levels closest to the time of surgical incision, length of time from ED arrival to incision, total volume of intravenous fluids (IVF) administered within 24 hours prior to incision, and time of antibiotic administration prior to incision. Our primary outcomes were whether or not the patient had experienced any of the pre-defined ACS NSQIP postoperative occurrences within 30 days and/or died while hospitalized for the target emergency procedure. Univariate statistical analyses were done using Wilcoxon signed rank sum test for continuous variables and Chi square test/Fisher Exact test for categorical variables. Multivariate analyses were done to identify independent predictors using logistic regression. Results: We identified 263 cases. 46.4% were male. 60 (22.8%) had complications, and 25 (9.5%) died within 30 days. Those without complications had a mean age of 51 years while those with complications had a mean age of 66 years. The most common procedures were appendectomies (22.4%), colectomies (18.6%) and enterectomies (17.1%). The most common postoperative occurrences were prolonged ventilator support>48hrs (12%), unplanned intubations (6%), and superficial incisional infections (5%). In univariate analyses, age (p<0.0001), male gender (p<0.001), length of operation (p<0.0001), preoperative blood transfusion (p<0.001), elevated blood glucose (p=0.026), elevated BUN (p<0.0001), functional health status (p=0.007), ASA (p<0.001), presence of COPD (p=0.002), and history of smoking (p=0.009) were found to be significant predictors of postoperative complications. Length of time from ED arrival to time of incision (p=0.42), total volume of IVF administered within 24 hours prior to incision (p=0.19), and time of antibiotic administration prior to incision (p=0.74) were not found to be significant. Multivariate analyses using stepwise logistic regression found male gender (OR 2.01, 95% CI 1.05, 4.10), smoking (OR 2.69, 1.15, 6.26), elevated BUN (OR 1.04, 95% CI 1.02, 1.06), and length of operation time (OR 1.001, 95% CI 1.000, 1.003) to be independent predictors for postoperative complications. Conclusions: Emergency general surgery patients who develop postoperative complications are more likely to be male, smokers, have a higher preoperative BUN, and experience longer operative times. Preoperative fluid resuscitation to address elevated BUN and experienced surgical teams to decrease operative times are potential targets to improve outcomes in emergency general surgery patients.

Reversible attenuation of voltage of QRS complexes and P waves and shortening of QRS duration and QTc interval consequent to large perioperative intravenous fluid infusions

A 39-year-old woman with a gangrenous pyelonephritis and septic shock underwent a nephrectomy, in preparation for which, she received large preoperative fluid resuscitation. Quantitative evaluation of her serial standard electrocardiograms (ECGs) revealed reversible attenuation of voltage in association with peripheral edema (PERE), with the latter being eventually completely abolished. The transient low-voltage ECG (LVECG) (attenuated amplitudes of QRS complexes) was associated with parallel transient attenuation of the amplitude of P waves and shortening of the QRS duration and QTc, whereas the P-wave duration increased. Awareness of these ECG changes with PERE of varying pathophysiologic mechanisms is useful, ensuring avoidance of improper procedural and laboratory testing and correct measurement of wave amplitudes and ECG time intervals for proper ECG diagnosis. In addition, these ECG associations can be used as indices of the presence and course of PERE postoperatively, as well as in a large variety of medical settings.

Acute Appendicitis in Infants: Still a Diagnostic Dilemma

Acute Appendicitis in Infants: Still a Diagnostic Dilemma