Low Versus Standard Urine Output Targets in Patients Undergoing Major Abdominal Surgery: A Randomized Noninferiority Trial.

OBJECTIVE: To determine whether a low perioperative minimum urine output target is safe and fluid sparing when compared with the standard target. BACKGROUND: A minimum hourly urine output of 0.5 mL/kg is a key target guiding perioperative fluid therapy. Few data support this standard practice, which may contribute to perioperative fluid overloading. METHODS: We randomized patients without significant risk factors for acute kidney injury undergoing elective colectomy to a minimum urine output target of 0.2 mL/kg/h (low group) or 0.5 mL/kg/h (standard group) from induction of anesthesia until 8 AM 2 days after surgery. Maintenance fluids were standardized and additional fluids administered to achieve the targets. Primary outcome was noninferiority for urine neutrophil gelatinase-associated lipocalin on the day after surgery. RESULTS: Between November 21, 2011 and July 11, 2013, 40 participants completed the study. The low group received 3170 mL (95% confidence interval 2380-3960) intravenous fluids versus 5490 mL (95% confidence interval 4570-6410) in the standard group (P = 0.0004), and was noninferior for neutrophil gelatinase-associated lipocalin [14.7 µg/L (interquartile range 7.60-28.9) vs 18.4 µg/L (interquartile range 8.30-21.2); Pnoninferiority = 0.0011], serum cystatin C (Pnoninferiority < 0.0001), serum creatinine (Pnoninferiority = 0.0004), and measured glomerular filtration (Pnoninferiority = 0.0003). Effective renal plasma flow increased in both groups after surgery, and more in the standard group (Pnoninferiority = 0.125). CONCLUSIONS: A perioperative urine output target of 0.2 mL/kg/h is noninferior to the standard target of 0.5 mL/kg/h and results in a large intravenous fluid sparing. This target should be adopted in surgical patients without significant kidney injury risk factors.

Optimizing colonoscopy preparation: the role of dosage, timing and diet.

PURPOSE OF REVIEW: The focus of this review is to review recent literature on colonoscopy preparation, in order to determine what regime currently results in the highest rates of adequate bowel cleansing, in terms of the substance used, its dosing, timing and the role of dietary restrictions during preparation. RECENT FINDINGS: Recent data have emphasized that poor bowel preparation is frequent and results in significant healthcare costs and risks to patients in terms of missed neoplasia, which may be particularly important in the proximal colon. Polyethylene glycol (PEG) preparation is superior to, and safer, than sodium phosphate preparation, and results are further improved by split-dose regimes. Regular diet until dinner, the day before colonoscopy does not impair preparation in the context of split-dose PEG regimes. SUMMARY: Available data indicate that the optimal colonoscopy preparation regime is the split-dose PEG regime with regular diet until dinner. Strategies for patients with difficulties in achieving adequate bowel cleansing with standard regimes remains a difficulty. The role of adjuncts, such as bisacodyl, is also less defined.

Early closure of temporary loop ileostomies: a systematic review.

A temporary loop ileostomy is a common surgical procedure to protect colorectal anastomoses. The aim of this systematic review was to determine whether early closure of a defunctioning loop ileostomy (<2 weeks from index operation) is safe and reduces stoma-related morbidity. A systematic literature search was conducted using Ovid MEDLINE, EMBASE, Cochrane Collaboration, and the Cumulative Index to Nursing and Allied Health (CINAHL®) databases to identify all publications from January 1996 to March 2014 that reported the outcomes of early ileostomy closure. The following search terms (and their variations) were used as both medical subject headings (MeSH terms) and text words: ileostomy, surgical stoma, stoma, early, reversal, closure. No language restrictions were applied. The main outcomes of interest were stoma-related complications and postclosure complications. Studies that included pediatric patients (<18 years of age), small cohorts (<10 participants), case reports, conference abstracts, reviews, and letters; studies involving defunctioning colostomies or other types of small bowel stomas; and studies where results from closure of an ileostomy at >14 days could not be separated from early closure results were excluded. Where multiple studies were reported by the same institution and/or authors, only the most recent was included. This search strategy identified 4 studies (2 retrospective case series, 1 prospective nonrandomized study, and 1 randomized controlled trial), yielding a pooled population of 142 patients, ages 18-89 years old. Three studies reported indication for ileostomy; colorectal cancer accounted for 96 patients (78%). Time to ileostomy closure ranged from 8-14 days. No reported deaths were related to ileostomy closure. Wound infections were reported in 3 studies and were the most common complications, affecting 24 patients (19.8%). Of the 2 studies that reported ileostomy-related complications, 4 patients (3.6%) experienced a stoma-related complication before closure. Ileus or small bowel obstruction (SBO) occurred in 7 patients (4.9%). Compared to traditionally timed closure (8-12 weeks), reported stoma-related complication rates were lower in patients undergoing early closure. Both mortality and ileus/SBO rates also compare favorably with traditionally timed closure; however, wound infection rates appear to be increased. Additional studies to accurately define which individuals stand to benefit from early closure, as well as to further evaluate the impact of early ileostomy closure on quality of life and health care costs, are warranted.