The effect of intraoperative goal-directed fluid therapy in patients under anesthesia for gastrointestinal surgery

BACKGROUND Intraoperative fluid management is an important aspect of anesthesia mana-gement in gastrointestinal surgery.Intraoperative goal-directed fluid therapy(GDFT)is a method for optimizing a patient's physiological state by monitoring and regulating fluid input in real-time.AIM To evaluate the efficacy of intraoperative GDFT in patients under anesthesia for gastrointestinal surgery.METHODS This study utilized a retrospective comparative study design and included 60 patients who underwent gastrointestinal surgery at a hospital.The experimental group(GDFT group)and the control group,each comprising 30 patients,received intraoperative GDFT and traditional fluid management strategies,respectively.The effect of GDFT was evaluated by comparing postoperative recovery,com-plication rates,hospitalization time,and other indicators between the two patient groups.RESULTS Intraoperative blood loss in the experimental and control groups was 296.64±46.71 mL and 470.05±73.26 mL(P<0.001),and urine volume was 415.13±96.72 mL and 239.15±94.69 mL(P<0.001),respectively.The postoperative recovery time was 5.44±1.1 days for the experimental group compared to 7.59±1.45 days(P<0.001)for the control group.Hospitalization time for the experimental group was 10.87±2.36 days vs 13.65±3 days for the control group(P<0.001).The visual analogue scale scores of the experimental and control groups at 24 h and 48 h INTRODUCTION Gastrointestinal surgery is one of the most common procedures in the field of general surgery[1],involving the stomach,intestines,liver,pancreas,spleen,and other internal abdominal organs[2,3].With advancements in surgical technology and anesthesia methods,the safety and success rates of surgery have significantly improved[4,5].However,intraop-erative fluid management remains a critical challenge[6].Traditional fluid management strategies often rely on experience and basic physiological parameters,which may lead to excessive or insufficient fluid input,thereby affecting postoperative recovery and complication rates.Intraoperative goal-directed fluid therapy(GDFT)is an emerging fluid management strategy that dynamically adjusts fluid input volume by monitoring the patient's hemodynamic parameters in real-time to optimize the patient's physiological state[7,8].GDFT has shown superiority in many surgical fields;however,its application in gastrointestinal surgery requires further research and verification[9,10].The application of intraoperative GDFT in clinical settings has gradually increased in recent years[11,12].Studies have demonstrated that GDFT can optimize tissue perfusion and oxygenation by precisely controlling fluid input and reducing the occurrence of postoperative complications[13,14].For example,in cardiac and major vascular surgeries,GDFT significantly reduced the incidence of postoperative acute kidney injury and cardiovascular events[15,16].Similarly,in abdominal surgery,GDFT effectively reduced postoperative infections and expedited recovery[17].However,studies on the utilization of GDFT in gastrointestinal surgery are relatively limited and they are confounded by contradictory findings[18].Traditional fluid management strategies typically rely on estimating fluid input volume based on the patient's weight,preoperative status,and basic physiological parameters[19].However,this method lacks real-time dynamic adjustment,which may result in either insufficient or excessive fluid input,consequently affecting postoperative recovery.Insufficient fluid input can lead to hypovolemia and inadequate tissue perfusion,whereas excessive fluid input can cause tissue edema and postoperative complications,such as pulmonary edema and heart failure.GDFT involves dynamically adjusting fluid input volume by monitoring the patient's hemodynamic parameters in real-time,such as cardiac output,pulse pressure variability,and central venous pressure.Commonly used monitoring equipment include esophageal Doppler and pulse wave profile analyzers[20].These devices provide real-time hemo-dynamic data to assist anesthesiologists in tailoring fluid therapy to a patient's specific condition.Firstly,the patient's volume responsiveness is assessed by preloading fluid;secondly,fluid input volume is dynamically adjusted based on real-time monitoring data;finally,vasoactive and inotropic drugs are administered in combination to further optimize the patient’s hemodynamic status.Through personalized fluid management,GDFT can more accurately maintain intraop-erative hemodynamic stability and reduce complications[21].Gastrointestinal surgery involves procedures on multiple organs,often requiring prolonged operative times and extensive tissue trauma,which presents challenges for intraop-erative fluid management.Surgical procedures can lead to significant bleeding and fluid loss,requiring prompt and effective fluid replenishment.In addition,the slow recovery of gastrointestinal function after surgery and susceptibility to complications such as intestinal obstruction and delayed gastric emptying elevate the necessity for postoperative fluid management.

Effects of fluid therapy combined with a preoperative glucose load regimen on postoperative recovery in patients with rectal cancer

BACKGROUND Patients with rectal cancer undergoing radical resection often have poor post-operative recovery due to preoperative fasting and water deprivation and the removal of diseased tissue,and have a high risk of complications.Therefore,it is of great significance to apply appropriate rehydration regimens to patients un-dergoing radical resection of rectal cancer during the perioperative period to improve the postoperative outcomes of patients.AIM To analyze the effects of goal-directed fluid therapy(GDFT)with a preoperative glucose load regimen on postoperative recovery and complications in patients undergoing radical resection for rectal cancer.METHODS Patients with rectal cancer who underwent radical resection(n=184)between January 2021 and December 2023 at our hospital were randomly divided into either a control group or an observation group(n=92 in each group).Both groups received a preoperative glucose load regimen,and routine fluid replacement and GDFT were additionally implements in the control and observation groups,res-pectively.The operative conditions,blood levels of lactic acid and inflammatory markers,postoperative recovery,cognitive status,hemodynamic indicators,brain oxygen metabolism,and complication rates were compared between the groups.RESULTS The colloidal fluid dosage,total infusion,and urine volume,as well as time to first exhaust,time to food intake,and postoperative length of hospital stay,were lower in the observation group(P<0.05).No significant differences were observed between the two groups in terms of operation time,bleeding volume,crystalloid liquid consumption,time to tracheal extubation,complication rate,heart rate,or mean arterial pressure(P>0.05).Compared with the control group,in the ob-servation group the lactic acid level was lower immediately after the surgery(P<0.05);the Mini-Mental State Examination score was higher on postoperative day 3(P<0.05);the pulse pressure variability(PPV)was lower at 30 min after pneumoperitoneum(P<0.05),though the differences in the PPV of the two groups was not significant at the remaining time points(P>0.05);tumor necrosis factor-αand interleukin-6 levels were lower on postoperative day 3(P<0.05);and the left and right regional cerebral oxygen saturation was higher immediately after the surgery and 30 min after pneumoperitoneum(P<0.05).CONCLUSION GDFT combined with the preoperative glucose load regimen is a safe and effective treatment strategy for im-proving postoperative recovery and risk of complications in patients with rectal cancer undergoing radical re-section.

Intraoperative Blood Pressure Lability Acts as a Key Mediator in the Impacts of Goal-Directed Fluid Therapy on Postoperative Complications in Patients Undergoing Major Spine Surgery

Objective Although goal-directed fluid therapy(GDFT)has been proven to be effective in reducing the incidence of postoperative complications,the underlying mechanisms remain unknown.The aim of this study was to examine the mediating role of intraoperative hemodynamic lability in the association between GDFT and the incidence of postoperative complications.We further tested the role of this mediation effect using mean arterial pressure,a hemodynamic indicator.Methods This secondary analysis used the dataset of a completed nonrandomized controlled study to investigate the effect of GDFT on the incidence of postoperative complications in patients undergoing posterior spine arthrodesis.We used a simple mediation model to test whether there was a mediation effect of average real variability between the association of GDFT and postoperative complications.We conducted mediation analysis using the mediation package in R(version 3.1.2),based on 5,000 bootstrapped samples,adjusting for covariates.Results Among the 300 patients in the study,40%(120/300)developed postoperative complications within 30 days.GDFT was associated with fewer 30-day postoperative complications after adjustment for confounders(odds ratio:0.460,95%CI:0.278,0.761;P=0.003).The total effect of GDFT on postoperative complications was-0.18(95%CI:-0.28,-0.07;P<0.01).The average causal mediation effect was-0.08(95%CI:-0.15,-0.04;P<0.01).The average direct effect was-0.09(95%CI:-0.20,0.03;P=0.17).The proportion mediated was 49.9%(95%CI:18.3%,140.0%).Conclusions The intraoperative blood pressure lability mediates the relationship between GDFT and the incidence of postoperative complications.Future research is needed to clarify whether actively reducing intraoperative blood pressure lability can prevent postoperative complications.

Perioperative restricted fluid therapy preserves immunological function in patients with colorectal cancer

AIM: To investigate the effect of perioperative restricted fluid therapy on circulating CD4+/CD8+ T lymphocyte ratio, percentage of regulatory T cells (Treg) and postoperative complications in patients with colorectal cancer.

Goal-directed fluid therapy in gastrointestinal cancer surgery:A prospective randomized study

Objective:To investigate the effects of perioperative goal-directed fluid therapy(GDFT)on intraoperative fluid balance,postoperative morbidity,and mortality.Methods:This is a prospective randomized study,and 90 patients who underwent elective open gastrointestinal cancer surgery between April 2017 and May 2018 were included.Patients were randomized into 2 groups that received liberal fluid therapy(the LFT group,n=45)and goal-directed fluid therapy(the GDFT group,n=45).Patients’Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity(CR-POSSUM)physiological score,Charlson Comorbidity Index(CCI),perioperative vasopressor and inotrope use,postoperative AKIN classification,postoperative intensive care unit(ICU)hospitalization,hospital stay,and 30-day mortality were recorded.Results:The volume of crystalloid used perioperatively and the total volume of fluid were significantly lower in the GDFT group compared to the LFT group(P<0.05).CR-POSSUM physiological score and CCI were significantly higher in the GDFT group(P<0.05).Although perioperative vasopressor and inotrope use was significantly higher in the GDFT group(P<0.05),postoperative acute kidney injury development was not affected.Postoperative mortality was determined to be similar in both groups(P>0.05).Conclusion:Although GDFT was demonstrated to be a good alternative method to LFT in open gastrointestinal cancer surgery,and it can prevent perioperative fluid overload,and the postoperative results are comparable in the two groups.

Effect of perioperative fluid therapy on early phase prognosis after liver transplantation

BACKGROUND: Although liver transplantation (LT) has made rapid progress, early pulmonary complications still occur. More attention should be paid to fluid therapy that may be an important factor leading to these complications. It is necessary to investigate the correlation between intraoperative and postoperative fluid therapy and early pulmonary complications after LT, then attempt to provide a reasonable fluid therapy in the perioperative period. METHODS: Sixty-two patients who had undergone Ff were enrolled and analyzed retrospectively. Based on early phase prognosis after LT, the 62 patients were divided into a non-pulmonary complication group and a pulmonary complication group. Twenty perioperative variables were analyzed in both groups to screen out several factors causing early pulmonary complications, then the parameters reflecting postoperative recovery were analyzed. RESULTS: The pulmonary complication group had 29 patients (46.77%), 3 (4.84%) of whom died during the perioperative period. Using monofactorial analysis for each variable, the two groups differed in the following variables: preoperative lung function, volume of intraoperative transfusion, volume of intraoperative bleeding, and volume of intraoperative net fluid retention and fluid balance (<=-500 ml) in >= 2 of the first 3 days after operation. Analysis of the relationship between multivariate factors and pulmonary complications after LT by logistic multivariate regression analysis showed that preoperative lung function, volume of intraoperative bleeding, and fluid balance (<=-500 ml) in >=-2 of the first 3 days after operation were influential factors. CONCLUSIONS: It is important to maintain fluid balance during the perioperative period of LT. If the hemodynamics are stable, appropriate negative fluid balance in the first 3 days after operation apparently decreases the incidence of early pulmonary complications after LT. These measures are associated with better postoperative recovery.

Individualized peri-operative fluid therapy facilitating early-phase recovery after liver transplantation

AIM:To investigate the correlation between peri-operative fluid therapy and early-phase recovery after liver transplantation(LT) by retrospectively reviewing 102 consecutive recipients.METHODS:Based on whether or not the patients had pulmonary complications,the patients were categorized into non-pulmonary and pulmonary groups.Twentyeight peri-operative variables were analyzed in both groups to screen for the factors related to the occurrence of early pulmonary complications.RESULTS:The starting hemoglobin(Hb) value,an intra-operative transfusion > 100 mL/kg,and a fluid balance ≤-14 mL/kg on the first day and the second or third day post-operatively were significant factors for early pulmonary complications.The extubation time,time to initial passage of flatus,or intensive care unit length of stay were significantly prolonged in patients who had not received an intra-operative transfusion ≤ 100 mL/kg or a fluid balance ≤-14 mL/kg on the first day and the second or the third day post-operatively.Moreover,these patients had poorer results in arterial blood gas analysis.CONCLUSION:It is important to offer a precise and individualized fluid therapy during the peri-operative period to the patients undergoing LT for cirrhosis-associated hepatocellular carcinoma.

A retrospective study of fluid therapy for 100 patients of liver transplantation

Objective： To review the evolution of fluid therapy （IOFT） during liver transplantation （LTX） based on clinical experience in our institute over 7 years. Methods： All patient records （n= 130） of LTX from 1996 to 2003 were examined. After excluding patients with co-morbidities 100 cases were found suitable for IOFT analysis. All patients had undergone LTX and follow-up under the same surgical team. Based on IOFT records we tried to identify distinct patterns of practice evolving over 7 years. Intraoperarive hemodynamics （IOHD） and long-term outcome records were examined. Results： Retrospectively, 3 types of IOFT were found. Group A （n= 18, period 1996-1997） received high amounts of crystallolds; group B （n=24, period 1998-2000） received high amounts of plasma and albumin; and group C （n=58, period 2001-2003） received lower amounts of albumin and plasma and recommended amounts of 6% hydroxyethyl starch 200/0. 5 （HES） and high amounts of vasopressors, lntraoperatively, group A exhibited the highest levels of central venous and pulmonary artery pressures in the neo-hepatic stage （P〈0.05）. Postoperatively, the patients in group C had the shortest time to extubation ; the values for group A,B,C were （15.8±11）, （17.3±10.2） and （7.98±3.2） h respectively（P〈0.05）. At the end of one-year follow-up, the patients in group C had the lowest mortality （group A, B, C were 27. 78%, 29. 17% and 6.25% respectively; P〈0. 05）. Conclusion： In our institute over the years the use of crystalloids, albumin and plasma during IOFT of LTX is gradually replaced to a large extent by HES. The improvements in IOHD and long term outcomes are likely to be related to improved surgical experience of our team. Nevertheless, the shift in IOFT practices might be associated with an beneficial effect on IOHD or long term outcome. Treatment with proper amount of liquid and vasoactive drugs may be a better method of fluid thera- py.

Effect of Goal-Directed Fluid Therapy on Lung Function, Cognitive Function and Inflammatory Response in Patients Undergoing Radical Esophageal Cancer Surgery under One-Lung Ventilation

Objective: To explore the effects of goal-directed fluid therapy (GDFT) on lung function, cognitive function and inflammatory response in patients undergoing radical esophageal cancer surgery under one-lung ventilation. Methods: Sixty-seven patients undergoing radical esophageal cancer surgery were divided into GDFT group (GDFT therapy) and control group (conventional liquid therapy). The changes in patients’ pulmonary function, cognitive function and inflammatory response were evaluated. Results: Both alveolar-arterial oxygen partial pressure difference [P(A-a)O2] and respiratory index (RI) increased at one-lung ventilation for 30 minutes (T2) and decreased at one-lung ventilation for 60 minutes (T3), and after surgery (T4) in the two groups, and the GDFT group was lower than the control group (P < 0.05);theoxygenation index (OI) of the two groups decreased at T2, T3, and T4 compared with that at T1 (before one-lung ventilation), and the GDFT group was higher than the control group (P < 0.05). At T4 and T5, the tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), central nervous system specific protein (S100β), and neuron specific enolase (NSE) in the GDFT group were lower compared to the control group (P < 0.05), while interleukin-10 (IL-10) was higher compared to the control group (P < 0.05);the incidence of perioperative neurocognitive disorder (PND) in the GDFT group was lower than that in the control group (P < 0.05). Conclusion: GDFT can help prevent lung injury during radical esophageal cancer surgery under one-lung ventilation, reduce the body’s inflammatory response, and reduce the incidence of perioperative cognitive disorder to a certain extent.

Research of goal-directed fluid therapy on laparoscopic liver resection

Objective To explore the application effect of goal-directed fluid therapy(GDFT)on laparoscopic liver resection.Methods From July 2023 to December 2023,48 patients who underwent laparoscopic liver resection were randomly divided into the GDFT group and the CLCVP(controlled low central venous pressure)group.The patients in the GDFT group were guided by stroke volume variability(SVV)during surgery,while those in the CLCVP group were guided by a controlled low central venous pressure technique during fluid replacement surgery.Intraoperative bleeding volume,fluid replacement volume,urine output,liver blood flow obstruction time,postoperative exhaust time,length of hospital stays,and incidence of complications were recorded and compared between the two groups of patients.Results There was a difference between the two groups in terms of crystal fluid,colloid fluid,total fluid volume,and urine volume(P>0.05).However,the bleeding volume in the GDFT group(515.61±246.71)mL was lower than that in the CLCVP group(389.37±187.35)mL(P<0.05);and the blockade time of liver blood flow in the GDFT group(46.33±7.26)min was shorter than that of the CLCVP group(41.84±6.24)min(P<0.05);the postoperative exhaust time of patients in the GDFT group(4.86±1.24)d was shorter than that of patients in the CLCVP group(6.42±1.05)d(P<0.05);the hospitalization days of patients in the GDFT group(9.21±2.15)d were fewer than those in the CLCVP group(11.04±4.29)d(P<0.05).There were no statistically significant differences in the incidence of postoperative complications between the two groups of patients(P>0.05).Conclusion GDFT guided by SVV can stabilize intraoperative hemodynamics in patients undergoing laparoscopic liver resection,reduce intraoperative bleeding,and reduce liver blood flow blockage time.It is safer and more reliable than traditional fluid therapy.

Effect of inferior vena cava respiratory variability-guided fluid therapy after laparoscopic hepatectomy:a randomized controlled clinical trial

Background:After major liver resection,the volume status of patients is still undetermined.However,few concerns have been raised about postoperative fluid management.We aimed to compare gut function recovery and short-term prognosis of the patients after laparoscopic liver resection(LLR)with or without inferior vena cava(IVC)respiratory variability-directed fluid therapy in the anesthesia intensive care unit(AICU).Methods:This randomized controlled clinical trial enrolled 70 patients undergoing LLR.The IVC respiratory variability was used to optimize fluid management of the intervention group in AICU,while the standard practice of fluid management was used for the control group.The primary outcome was the time to flatus after surgery.The secondary outcomes included other indicators of gut function recovery after surgery,postoperative length of hospital stay(LOS),liver and kidney function,the severity of oxidative stress,and the incidence of severe complications associated with hepatectomy.Results:Compared with patients receiving standard fluid management,patients in the intervention group had a shorter time to anal exhaust after surgery(1.5±0.6 days vs.2.0±0.8 days)and lower C-reactive protein activity(21.4[95%confidence interval(CI):11.9-36.7]mg/L vs.44.8[95%CI:26.9-63.1]mg/L)24 h after surgery.There were no significant differences in the time to defecation,serum concentrations of D-lactic acid,malondialdehyde,renal function,and frequency of severe postoperative complications as well as the LOS between the groups.Conclusion:Postoperative IVC respiratory variability-directed fluid therapy in AICU was facilitated in bowel movement but elicited a negligible beneficial effect on the short-term prognosis of patients undergoing LLR.Trial Registration:ChiCTR-INR-17013093.

Goal-directed Fluid Therapy May Improve Hemodynamic Stability of Parturient with Hypertensive Disorders of Pregnancy Under Combined Spinal Epidural Anesthesia for Cesarean Delivery and the Well-being of Newborns

Background： Hypotension induced by combined spinal epidural anesthesia in parturient with hypertensive disorders of pregnancy （HDP） can easily compromise blood supply to vital organs including uteroplacental perfusion and result in fetal distress. The aim of this study was to investigate whether the goal-directed fluid therapy （GDFT） with LiDCOrapid system can improve well-being of both HDP parturient and their babies. Methods： Fifty-two stable HDP parturient scheduled for elective cesarean delivery were recruited. After loading with 10 ml/kg lactated Ringer＇s solution （LR）, parturient were randomized to the GDFT and control group. In the GDFT group, individualized fluid therapy was guided by increase in stroke volume （ASV） provided via LiDCO rapid system. The control group received the routine fluid therapy. The primary endpoints included maternal hypotension and the doses of vasopressors administered prior to fetal delivery. The secondary endpoints included umbilical blood gas abnormalities and neonatal adverse events. Results： The severity of HDP was similar between two groups. The total LR infusion （P 〈 0.01） and urine output （P 〈 0.05） were higher in the GDFT group than in the control group. Following twice fluid challenge tests, the systolic blood pressure, mean blood pressure, cardiac output and SV in the GDFT group were significantly higher, and the heart rate was lower than in the control group. The incidence of maternal hypotension and doses of phenylephrine used prior to fetal delivery were significantly higher in the control group than in the GDFT group （P 〈 0.01）. There were no differences in the Apgar scores between two groups. In the control group, the mean values of pH in umbilical artery/vein were remarkably decreased （P 〈 0.05）, and the incidences of neonatal hypercapnia and hypoxemia were statistically increased （P 〈 0.05） than in the GDFT group. Conclusions： Dynamic responsiveness guided fluid therapy with the LiDCOrapid system may provide potential benefits to stable HDP parturient and their babies.

Bioreactance-guided fluid therapy for excision of a giant brain tumor in an infant under general anesthesia:A case report and literature review

Pediatric patients are more likely to suffer from brain tumors.Surgical resection is often the optimal treatment.Perioperative management of pediatric brain tumor resection brings great challenges to anesthesiologists,especially for fluid therapy.In this case,the infant-patient was only 69-day-old,weighed 6 kg,but she was facing a gaint brain tumor(7.9 cm×8.1 cm×6.7 cm)excision.The infant was at great risks such as hemorrhagic shock,cerebral edema,pulmonary edema,congestive heart failure,coagulation dysfunction,etc.However,we tried to use the parameters obtained by bioreactance-based NICOM^(■)device(Cheetah Medical)to guide the infant’s intraoperative fluid therapy,and successfully avoided these complications and achieved a good prognosis.

Fluid resuscitation in acute pancreatitis

Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors&#x02019; recommendations, for predicted severe or severe pancreatitis based on the available evidence.

Perioperative fluid management in major hepatic resection: an integrative review

BACKGROUND: Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES: A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms 'surgery', 'anesthesia', 'starch', 'hydroxyethyl starch derivatives', 'albumin', 'gelatin', 'liver resection', 'hepatic resection', 'fluids', 'fluid therapy', 'crystalloid', 'colloid', 'saline', 'plasma-Lyte', 'plasmalyte', 'hartmann's', 'acetate', and 'lactate'. Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS: A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed.CONCLUSIONS: Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.

The Effect of Non-Invasive Goal Directed Fluid Administration on Graft Function in Deceased Donor Renal Transplantation: A Pilot Study

Background: Non-invasive goal directed fluid therapy during deceased donor renal transplant (CRT) may reduce the incidence of delayed graft function. Plethysmograph Variability Index (PVI) has been shown to predict fluid responsiveness during surgery. This pilot study evaluated the feasibility of goal directed fluid administration protocol based upon PVI studying the incidence of delayed graft function (DGF) in renal transplant recipients. Methods: Twenty patients underwent primary CRT. The Control group received intravenous fluid (IVF) at a calculated constant rate. The Treatment group received a baseline IVF infusion throughout the surgery. PVI values greater than 13% were treated with 250 ml boluses of IVF. Primary end point was DGF;total IVF administration and urinary biomarker NGAL levels were secondary endpoints. Results: Treatment group at every time point received significantly less IVF. There was no significant difference in incidence of DGF between the groups. 2 patients in the Control group and 6 in the Treatment group developed DGF. NGAL was not associated with the group assignment or total IVF given (p < 0.2). Conclusions: The effectiveness of goal directed fluid therapy with non-invasive dynamic parameters has not been validated in renal transplant surgery and larger prospective studies are needed to determine its utility in renal transplantation.

Management of Rhabdomyolysis and Acute Renal Failure Following Strenuous Exercise in Young Adult: A Case Report

Introduction: Rhabdomyolysis is severe and life threating condition in which skeletal muscles are damaged by dissolution of striped muscles. Acute kidney injury (AKI) has been widely reported (13% - 50%) as a complication of Rhabdomyolysis in which the main pathophysiological mechanisms are intra-renal vasoconstriction, intraluminal cast formation (Tamm-Horsefall) and direct myoglobin toxicity. In this report we are going to describe the management of Acute Kidney Injury due to Rhabdomyolysis that is not responding to vigorous rehydration. Objective: Reporting about acute renal failure induced by Rhabdomyolysis due to Excessive Exercise and dehydration in young patient. Case Report: A 20 years male came to the outpatient clinic complaining of sever lower limb pain, back pain and vomiting. He was anuric and hypertensive (BP = 150/90 mmHg) with serum creatinine and urea levels of 15.72 mg/dl and 235 mg/dl, respectively. The diagnosis was based on the laboratory finding of creatine kinase = 3127 IU/l. The patient, then, has been referred to the emergency department. The Management plan was based on two arms: Emergency Management with Urgent Hemodialysis for AKI and high fluid replacement therapy. Patient started to recover after three hemodialysis sessions but the peak of recovery was noted after starting manual fluid replacement therapy with a target urine output of greater than 2 ml/kg, a urine pH of greater than 6. Manual fluid replacement therapy consisted of loop diuretics, intravenous fluids and intravenous sodium bicarbonate 1.26%. Full recovery was noted after one month of hospital admission with inpatient care and regular follow-up. A follow-up after one month has been set to assess the patient progression and monitor his kidney functions. Relevance and Impact: Home messages and lessons are;Firstly, young adults are vulnerable to Rhabdomyolysis, second, the diagnosis of Rhabdomyolysis can be made on the clinical bases but a confirmatory laboratory test of Creatine Kinase is mandatory, and lastly’ acute kidney injury needs to be treated urgently. Also, reducing the risk of infection is one of the management objectives to achieve recovery.

Carbachol promotes gastrointestinal function during oral resuscitation of burn shock

AIM: To investigate the effect of carbachol on gastrointestinal function in a dog model of oral resuscitation for burn shock. METHODS: Twenty Beagle dogs with intubation of the carotid artery, jugular vein and jejunum for 24 h were subjected to 35% total body surface area fullthickness burns, and were divided into three groups: no fluid resuscitation (NR, n = 10), in which animals did not receive fluid by any means in the first 24 h postburn; oral fluid resuscitation (OR, n = 8), in which dogs were gavaged with glucose-electrolyte solution (GES) with volume and rate consistent with the Parkland formula; and oral fluid with carbachol group (OR/CAR, n = 8), in which dogs were gavaged with GES containing carbachol (20 μg/kg), with the same volume and rate as the OR group. Twenty-four hours after burns, all animals were given intravenous fluid replacement, and 72 h after injury, they received nutritional support. Hemodynamicand gastrointestinal parameters were measured serially with animals in conscious and cooperative state. RESULTS: The mean arterial pressure, cardiac output and plasma volume dropped markedly, and gastrointestinal tissue perfusion was reduced obviously after the burn injury in all the three groups. Hemodynamic parameters and gastrointestinal tissue perfusion in the OR and OR/CAR groups were promoted to pre-injury level at 48 and 72 h, respectively, while hemodynamic parameters in the NR group did not return to pre-injury level till 72 h, and gastrointestinal tissue perfusion remained lower than pre-injury level until 120 h post-burn. CO 2 of the gastric mucosa and intestinal mucosa blood flow of OR/CAR groups were 56.4 ± 4.7 mmHg and 157.7 ± 17.7 blood perfusion units (BPU) at 24 h postburn, respectively, which were significantly superior to those in the OR group (65.8 ± 5.8 mmHg and 127.7 ± 11.9 BPU, respectively, all P < 0.05). Gastric emptying and intestinal absorption rates of GES were significantly reduced to the lowest level (52.8% and 23.7% of pre-injury levels) in the OR group at about 2 and 4 h post-burn, and did not return to 80% of pre-injury level until 24 h. In the first 24 h postburn, the rate of gastric emptying and intestinal water absorption were elevated by a mean 15.7% and 11.5%, respectively, in the OR/CAR group compared with the OR group. At 5 days, the mortality in the NR group was 30% (3/10), 12.5% in the OR group (1/8), and none in the OR/CAR group. CONCLUSION: Carbachol had a beneficial effect on oral resuscitation of burn shock by promoting gastric emptying and intestinal absorption in our canine model.

Perioperative"remote"acute lung injury:recent update

Perioperative acute lung injury（ALI） is a syndrome characterised by hypoxia and chest radiograph changes.It is a serious post-operative complication,associated with considerable mortality and morbidity.In addition to mechanical ventilation,remote organ insult could also trigger systemic responses which induce ALI.Currently,there are limited treatment options available beyond conservative respiratory support.However,increasing understanding of the pathophysiology of ALI and the biochemical pathways involved will aid the development of novel treatments and help to improve patient outcome as well as to reduce cost to the health service.In this review we will discuss the epidemiology of peri-operative ALI;the cellular and molecular mechanisms involved on the pathological process;the clinical considerations in preventing and managing perioperative ALI and the potential future treatment options.

Intraoperative Goal-Directed Therapies in Femoral and Pelvic Osteotomies in Children and In-Hospital Postoperative Outcomes

Background: Femoral and pelvic osteotomies are potential hemorrhagic interventions where transfusion requirements can be necessary. Objective: We undertook a secondary analysis of patients who underwent femoral and pelvic osteotomy in the initial cohort. The objective of this secondary analysis was to describe intraoperative and postoperative outcomes and to describe intraoperative management in these patients in terms of blood product management and fluid and hemodynamic therapy with the aim of implementing optimization management protocols for postoperative outcome improvement. Methods: A secondary analysis of patients who underwent femoral and pelvic osteotomy surgery was included in the initial retrospective study. Results: There were eighteen patients with a mean age of 104 ± 47.1 months. Four (22.2%) patients had intraoperative and/or postoperative complications. One patient (5.6%) had an intraoperative hemorrhagic shock, two patients (11.1%) had postoperative neurologic failure, and one patient (5.6%) had postoperative wound sepsis. The transfusion rate was 50% in nine patients. Conclusion: Femoral and pelvic osteotomies are interventions where blood, transfusion and fluid requirements can be increased;thus, this implies the necessity of a global patient blood management protocol with point-of-care tests and fluid- and hemodynamic-guided protocols with validated tools in children for intraoperative and postoperative outcome optimization.