Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial.

BACKGROUND: More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group). METHODS: In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications. RESULTS: In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found. CONCLUSION: Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay. CLINICAL TRIAL REGISTRATION: EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).

The association of the perioperative fluid balance and cardiopulmonary complications in emergency gastrointestinal surgery: exploration of a randomized trial.

BACKGROUND: The association between perioperative fluid administration and risk of complications following emergency surgery is poorly studied. We tested the association between the perioperative fluid balance and postoperative complications following emergency surgery for gastrointestinal obstruction or perforation. METHODS: We performed a re-assessment of data from the Goal-directed Fluid Therapy in Urgent Gastrointestinal Surgery Trial (GAS-ART) studying intra-operative stroke volume optimization and postoperative zero-balance fluid therapy versus standard fluid therapy. The cohort was divided into three groups at a perioperative fluid balance (FB) of low < 0 L, moderate 0-2 L, or high > 2 L. We used a propensity adjusted logistic regression to analyse the association with cardiopulmonary (primary outcome), renal, infectious, and wound healing complications. Further, the risk of complications was explored on a continuous scale of the FB. RESULTS: We included 303 patients: 44 patients belonged to the low-FB group, 108 to the moderate-FB group, and 151 to the high-FB group. The median [interquartile range] perioperative FB was -0.9 L [-1.4, -0.6], 0.9 L [0.5, 1.3], and 3.8 L [2.7, 5.3]. The risk of cardiopulmonary complications was significantly higher in the High-FB group 3.4 (1.5-7.6), p = 0.002 (odds ratio (95% confidence interval). On a continuous scale of the fluid balance, the risk of cardiopulmonary complications was minimal at -1 L to 1 L. CONCLUSION: Following emergency surgery for gastrointestinal obstruction or perforation, a fluid balance < 2.0 L was associated with decreased risk of cardiopulmonary complications without increasing renal complications.

Complications and Their Association with Mortality Following Emergency Gastrointestinal Surgery-an Observational Study.

PURPOSE: Emergency gastrointestinal surgery is followed by a high risk of major complications and death. This study aimed to investigate which complications showed the strongest association with death following emergency surgery for gastrointestinal obstruction or perforation. METHODS: We retrospectively included adults who had undergone emergency gastrointestinal surgery for radiologically verified obstruction or perforation at three Danish hospitals between 2014 and 2015. The exposure variables comprised 16 predefined Clavien-Dindo-graded complications. Cox regression with delayed entry was used to analyze the association of these complications with 90-day mortality. We adjusted for hospital, age, American Society of Anesthesiologists classification, pre-operative Sepsis-2 score, cardiac comorbidity, renal comorbidity, hypertension, active cancer, bowel obstruction or perforation, and the surgical procedure. Subgroup analyses were done for patients with gastrointestinal obstruction or perforation. RESULTS: Of the 349 included patients, 281 (80.5%) experienced at least one complication. The risk of death was 20.6% (14) for patients with no complications and varied between 21 and 57% for patients with complications. Renal impairment (hazard ratio (HR): 6.8 (95%CI: 3.7-12.4)), arterial thromboembolic events (HR 4.8 (2.3-9.9)), and atrial fibrillation (HR 4.4 (2.8-6.8)) showed the strongest association with 90-day mortality. Atrial fibrillation was the only complication significantly associated with death in patients with gastrointestinal obstruction as well as perforation. CONCLUSION: This study of patients undergoing emergency gastrointestinal surgery revealed that renal impairment, arterial thromboembolic events, and atrial fibrillation had the strongest association with death. Atrial fibrillation may serve as an in-situ marker of patients needing escalation of care.

Perioperative fluid administration and complications in emergency gastrointestinal surgery-an observational study.

BACKGROUND: The fluid balance associated with a better outcome following emergency surgery is unknown. The aim of this study was to explore the association of the perioperative fluid balance and postoperative complications during emergency gastrointestinal surgery. METHODS: We retrospectively included patients undergoing emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 2.5 L divided the cohort in a conservative and liberal group. Outcome was Clavien-Dindo graded complications registered 90 days postoperatively. We used logistic regression adjusted for age, sex, American Society of Anesthesiologists' classification, use of epidural analgesia, use of vasopressor, type of surgery, intraabdominal pathology, and hospital. Predicted risk of complications was demonstrated on a continuous scale of the fluid balance. RESULTS: We included 342 patients operated between July 2014 and July 2015 from three centers. The perioperative fluid balance was 1.6 L IQR [1.0 to 2.0] in the conservative vs. 3.6 L IQR [3.0 to 5.3] in the liberal group. Odds ratio of overall 2.6 (95% CI 1.5 to 4.4), p < 0.001, and cardiopulmonary complications 3.2 (95% CI 1.9 to 5.7), p < 0.001, were increased in the liberal group. A perioperative fluid balance of 0-2 L was associated with minimal risk of cardiopulmonary complications compared to 1.5-3.5 L for renal complications. CONCLUSION: We found a perioperative fluid balance above 2.5 L to be associated with an increased risk of overall and cardiopulmonary complications following emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 0-2 L was associated with the lowest risk of cardiopulmonary complications and 1.5-3.5 L for renal complications.

Goal-directed fluid therapy in urgent GAstrointestinal Surgery-study protocol for A Randomised multicentre Trial: The GAS-ART trial.

INTRODUCTION: Intravenous fluid therapy during gastrointestinal surgery is a life-saving part of the perioperative care. Too little fluid may lead to hypovolaemia, decreased organ perfusion and circulatory shock. Excessive fluid administration increases postoperative complications, worsens pulmonary and cardiac function as well as the healing of surgical wounds. Intraoperative individualised goal-directed fluid therapy (GDT) and zero-balance therapy (weight adjusted) has shown to reduce postoperative complications in elective surgery, but studies in urgent gastrointestinal surgery are sparse. The aim of the trial is to test whether zero-balance GDT reduces postoperative mortality and major complications following urgent surgery for obstructive bowel disease or perforation of the gastrointestinal tract compared with a protocolled standard of care. METHODS/ANALYSIS: This study is a multicentre, randomised controlled trial with planned inclusion of 310 patients. The randomisation procedure is stratified by hospital and by obstructive bowel disease and perforation of the gastrointestinal tract. Patients are allocated into either 'the standard group' or 'the zero-balance GDT group'. The latter receive intraoperative GDT (guided by a stroke volume algorithm) and postoperative zero-balance fluid therapy based on body weight and fluid charts. The protocolled treatment continues until free oral intake or the seventh postoperative day.The primary composite outcome is death, unplanned reoperations, life-threatening thromboembolic and bleeding complications, a need for mechanical ventilation or dialysis. Secondary outcomes are additional complications, length of hospital stay, length of stay in the intensive care unit, length of mechanical ventilation, readmissions and time to death. Follow-up is 90 days.We plan intention-to-treat analysis of the primary outcome. ETHICS AND DISSEMINATION: The Danish Scientific Ethics Committee approved the GAS-ART trial before patient enrolment (J: SJ-436). Enrolment of patients began in August 2015 and is proceeding. We expect to publish the GAS-ART results in Summer 2019. TRIAL REGISTRATION NUMBER: EudraCT 2015-000563-14.

Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial.

PURPOSE: We assessed the effects of a protocol restricting resuscitation fluid vs. a standard care protocol after initial resuscitation in intensive care unit (ICU) patients with septic shock. METHODS: We randomised 151 adult patients with septic shock who had received initial fluid resuscitation in nine Scandinavian ICUs. In the fluid restriction group fluid boluses were permitted only if signs of severe hypoperfusion occurred, while in the standard care group fluid boluses were permitted as long as circulation continued to improve. RESULTS: The co-primary outcome measures, resuscitation fluid volumes at day 5 and during ICU stay, were lower in the fluid restriction group than in the standard care group [mean differences -1.2 L (95 % confidence interval -2.0 to -0.4); p < 0.001 and -1.4 L (-2.4 to -0.4) respectively; p < 0.001]. Neither total fluid inputs and balances nor serious adverse reactions differed statistically significantly between the groups. Major protocol violations occurred in 27/75 patients in the fluid restriction group. Ischaemic events occurred in 3/75 in the fluid restriction group vs. 9/76 in the standard care group (odds ratio 0.32; 0.08-1.27; p = 0.11), worsening of acute kidney injury in 27/73 vs. 39/72 (0.46; 0.23-0.92; p = 0.03), and death by 90 days in 25/75 vs. 31/76 (0.71; 0.36-1.40; p = 0.32). CONCLUSIONS: A protocol restricting resuscitation fluid successfully reduced volumes of resuscitation fluid compared with a standard care protocol in adult ICU patients with septic shock. The patient-centred outcomes all pointed towards benefit with fluid restriction, but our trial was not powered to show differences in these exploratory outcomes. TRIAL REGISTRATION: NCT02079402.

[Post-partum posterior reversible encephalopathy syndrome]. / Post partum posteriort reversibeltencefalopati-syndrom .

Posterior reversible encephalopathy syndrome (PRES) is a complex clinical condition with vasogenic subcortical oedema caused by hypertension. Oedema is often seen on magnetic resonance imaging. The wide clinical spectrum ranges from headaches to vision loss and even death. Early diagnosis and treatment is important for the reversibility of the condition. In this case report we emphasize the importance of blood pressure control in a post-partum woman, who had a rather complicated pregnancy. The symptoms of PRES were not recognized immediately because of failure to use and acknowledge a blood pressure test.