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Objective:To investigate the effect of goal-directed fluid therapy(GDFT)under the guidance of LIDCOrapid hemodynamic monitor on postoperative nausea and vomiting(PONV)of patients after gynecological laparoscopic surgery.Methods:A total of 90 patients who underwent laparoscopic extensive hysterectomy under general anesthesia in Affiliated Hospital of Shandong Second Medical University from August 2020 to June 2021 were selected,and they were divided into observation group and control group as random number table,with 45 cases in each group.Patients in control group supplemented fluid according to the guidance of urine output and mean arterial pressure(MAP).Patients in observation group supplemented fluid according to GDFT under guidance of stroke volume variation(SVV).The MAP values,heart rates(HR),SVV values and cardiac index(CI)values at the 10th min after patients entered the operation room(T0),the 3rd min after anesthesia induction(T1),and the 3rd min(T2),the 30th min(T3)and the 1st h(T4)after Terndelenburg position,and the time of completing surgery(T5)were observed.In addition,the intraoperative intake and output volume of liquid,the indicators of gastrointestinal function recovery after surgery,and the length of stay also were observed.The PONV incidence of main outcome indicators,and the PONV scores of postoperative 0-6h(T6),6-12 h(T7),12-24 h(T8)and 24-48 h(T9)of secondary outcome indicators,as well as the number of patients who received the treatment of antiemetic compensation after surgery,were analyzed.Results:The PONV incidence of observation group was significantly lower than that of control group(x2=6.40,P<0.05).The PONV scores of postoperative T6 and T7 of observation group were significantly lower than those of control group(t=4.92,3.42,P<0.05),respectively.The HR and CI value at T4 of observation group were significantly higher than those of control group(t=0.73,0.64,P<0.05),while the SVV of observation group increased from T3 to T5,with significant differences(t=2.28,3.42,4.10,P<0.05),respectively.The intraoperative crystalline fluid input and total infusion volume decreased,while colloidal fluid input increased,and the differences of them between two groups were significant(t=15.10,12.36,8.19,P<0.05),respectively.The postoperative exhaust time,defecation time and feeding time of observation group were significantly earlier than these of control group(t=3.79,2.09,2.54,P<0.05),respectively.But there was no statistical difference in the length of stay between the two groups.Conclusion:GDFT,which is guided by LIDCOrapid hemodynamic monitor,may decrease the incidence of PONV of gynecological laparoscopic surgery and the severity of PONV within 12 hours after surgery.
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Objective:To investigate the impacts of stroke volume variation (SVV)-guided goal-directed fluid therapy on intraoperative signs, intestinal barrier function and prognosis in patients undergoing laparoscopic radical rectal cancer surgery.Methods:A total of 90 patients who underwent laparoscopic radical resection for rectal cancer in Peking University International Hospital from May 2020 to May 2022 were prospectively selected as subjects, and divided into SVV group (45 cases) and traditional infusion group (45 cases) by random number table method. The SVV group was given SVV-guided goal-directed fluid therapy, and the traditional infusion group was given central venous pressure (CVP)-guided goal-directed fluid therapy. The operation-related indicators (urine volume, crystalloid volume, colloid volume, total fluid volume, blood loss and operation time), intraoperative signs indicators[heart rate (HR), CVP, mean arterial pressure (MAP)], intestinal barrier function indicators [diamine oxidase (DAO), D-lactic acid], inflammatory factor levels [interleukin-10 (IL-10), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α)], and the incidence of complications were compared between the two groups.Results:There was no significant difference in the urine volume, blood loss and operation time between the two groups (all P>0.05), while the crystalloid volume, colloid volume and total fluid volume in the SVV group were greatly lower than those in the traditional infusion group (all P<0.05). There was no significant difference in HR between the two groups at different time points ( P>0.05). Compared with T 0, CVP at T 1 in the two groups was significantly decreased (all P<0.05), and increased at T 2 and T 3 compared with T 1 (all P<0.05). There was no significant difference in MAP at different time points in the SVV group (all P>0.05). The MAP at T 1, T 2 and T 3 in the traditional infusion group was significantly lower than that at T 0 (all P<0.05), and the MAP at T 1, T 2 and T 3 in the SVV group was significantly higher than that in the traditional infusion group (all P<0.05). Compared with T 0, DAO and D-lactic acid levels were significantly increased at T 1, T 3, T 4 and T 5 in the two groups (all P<0.05), and DAO and D-lactic acid levels at T 1, T 3, T 4 and T 5 in the SVV group were significantly lower than those in the traditional infusion group (all P<0.05). Compared with T 0, serum IL-10 level in the two groups was significantly decreased at T 4 ( P<0.05), and serum IL-6 and TNF-α levels were significantly increased at T 4 (all P<0.05). The serum levels of IL-10, IL-6 and TNF-α in the SVV group at T 4 were significantly different from those in the traditional infusion group (all P<0.05). Compared with T 4, the serum levels of IL-10 at T 5 were significantly increased (all P<0.05), while the levels of IL-6 and TNF-α were significantly decreased (all P<0.05), but there was no statistical significance between the two groups (all P>0.05). The incidence of postoperative infection, anastomotic fistula, vomiting and nausea in SVV group (13.33%) was significantly lower than that in traditional infusion group (35.33%) ( P<0.05). Conclusions:SVV-guided goal-directed fluid therapy for patients undergoing laparoscopic radical rectal cancer can effectively stabilize intraoperative vital signs, reduce inflammation, improve intestinal barrier function, and improve prognosis.
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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.
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Humanos , Pressão Sanguínea , Objetivos , Complicações Pós-Operatórias/epidemiologia , Hemodinâmica , Hidratação/métodosRESUMO
Objective To observe the effect of dexmedetomidine combined with goal-directed fluid therapy(GDFT)on hemodynamics and cerebral oxygen supply of patients undergoing cerebral aneurysm clipping.Methods A total of 78 patients undergoing cerebral aneurysm clipping surgery in Jinhua Municipal Central Hospital from January 2021 to December 2022 were selected and divided into control group and observation group according to random number table method,with 39 cases in each group.The patients in control group received conventional fluid therapy,and the patients in observation group received dexmedetomidine pump +GDFT.Mean arterial pressure(MAP),heart rate(HR),cardiac index(CI),brain metabolic markers,neuron specific enolase(NSE),S100β levels and mini mental status examination(MMSE)scores at different time points[before anesthesia induction(T0),immediately after tracheal intubation(T1),beginning of surgery(T2),opening meninges(T3),immediately after aneurysm clipping(T4),end of surgery(T5),24h after surgery(T6),72h after surgery(T7)],and fluid intake and outflow of two groups were compared.Results MAP at T1-T4 and CI at T1-T3 in observation group were significantly higher than those in control group(P<0.05).The colloid volume,total infusion volume and urine volume in observation group were significantly higher than those in control group(P<0.05).The serum levels of NSE and S100β at T5-T7 were significantly higher than those at T0 in both groups(P<0.05).The levels of serum NSE and S100β at T5 and T6 in observation group were significantly lower than those in control group(P<0.05).The oxygen content in jugular venous blood(CjvO2)at T1-T4 was significantly lower than that at T0 in control group(P<0.05).Cerebral oxygen extraction ratio at T1 was significantly higher than that at T0 in both groups(P<0.05).CjvO2 at T3-T4 in observation group were significantly higher than those in control group(P<0.05).At T6 and T7,MMSE scores in two groups were significantly lower than at T0 in this group(P<0.05).MMSE score at T6 of observation group was significantly higher than that of control group(P<0.05).Conclusion Dexmedetomidine combined with GDFT can effectively improve preload and brain function,stabilize intraoperative circulatory function,and improve early postoperative cognitive function in patients undergoing cerebral aneurysm clipping.
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Objective:To investigate the effect of methoxyamine combined with target guided fluid in elderly patients undergoing pancreaticoduodenectomy.Methods:90 elderly patients undergoing pancreaticoduodenectomy were randomly divided into methoxyamine group and control group, with 45 cases in each group. The patients in both groups were treated with intravenous inhalation combined anesthesia. The stroke volume variation (SVV) was maintained at 7%-10% and the central venous pressure (CVP) was 4-8 cmH 2O. In methoxyamine group, 3 μg/(kg·min) methoxyamine was continuously pumped, while the control group was pumped with the same amount of normal saline at the same speed. The intraoperative infusion volume, urine volume, bleeding volume, blood transfusion cases, intraoperative mean arterial pressure, heart rate, blood gas analysis results, B-type natriuretic peptide (BNP), creatinine, urea nitrogen level and postoperative exhaust time were compared between the two groups. Results:Compared with the control group, the patients in methoxyamine group had less infusion volume, urine volume, lower postoperative BNP level and heart rate, shorter postoperative exhaust time (all P<0.05), and higher mean arterial pressure ( P<0.05). There was no significant difference in blood loss, blood transfusion cases, PaO 2, PaCO 2, pH, creatinine and urea nitrogen between the two groups (all P>0.05). In addition, the number of patients in the methoxyamine group who used pressor drugs was less than that in the control group ( P<0.05), and the frequency of bradycardia was more than that in the control group ( P<0.05). The proportion of tachycardia and urapidil was similar in the two groups (all P>0.05). Conclusions:Methoxyamine combined with target guided fluid therapy can reduce the intraoperative infusion volume of pancreaticoduodenectomy in elderly patients, stabilize circulation, shorten postoperative exhaust time, and contribute to the recovery of gastrointestinal function.
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Enhanced recovery after surgery (ERAS) protocols termed as “fast track surgery” have now become an essential componentin the perioperative period to improve post-operative outcomes. It is both the patient and the health services who receive thebenefits of ERAS. It is a new and different approach when compared to traditional practices which aims at enhanced care ofsurgical patients. It includes pre-operative, intraoperative, and post-operative components which when applied altogether givebest possible results. Effective implementation of ERAS protocols is associated with fast recovery of gut function and reducedrate of complications. All these factors further lead to decreased post-operative hospital stay, thereby decreasing hospital costand increasing patient satisfaction.
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Objective To investigate the clinical applications of goal-directed fluid therapy for pancreatoduodenectomy. Methods A total of 40 patients undergoing pancreatoduodenectomy under general anesthesia were randomly divided into two groups, G and C, with 20 cases in each group. Goal-directed fluid therapy was used in Group G, whereas conventional fluid therapy was used in group C. The intraoperative hemodynamics, liquid management, duration of the first postoperative gastrointestinal ventilation, postoperative renal function, serum lactate, and the incidence of postoperative complications were recorded. Results Compared with group C, the CI increased and SVV decreased (P ＜ 0.05) at T3 to T5, and MAP increased at T4 to T5 (P ＜ 0.05). The amount of fluid infusion and total infusion in group G were less than that of group C (P ＜ 0.05), and the number of vasoactive drugs was greater than that of group C (P ＜ 0.05). The duration of the first postoperative gastrointestinal ventilation in group G was shorter than that of group C (P ＜ 0.05). There were no significant differences between the 2 groups for the incidence of serum lactate, BUN, Cr, and the incidence of postoperative complications (P＞ 0.05).Conclusion For major complex operations, such as pancreaticoduodenectomy, goal-directed fluid therapy can guide intraoperative fluid therapy more accurately with individual optimizations, and has more advantages in maintaining intraoperative hemodynamics stability and improving postoperative outcome.
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Objective To investigate effects of goal-directed fluid therapy on inflammatory cytokines under combined anesthesia.Methods 60 patients undergoing colorectal cancer surgery,aged 60 to 85 years old,which were classified as American Society of Anesthesiology(ASA)classⅡ~Ⅲ,were randomly assigned to Goal-directed fluid therapy group(group G,n = 30)and central venous pressure liquid management group(group C,n = 30). Life sign and BIS indexes were collected at the time points,before surgery(T1),after the start of the operation (T2),one hour after surgery(T3),after the operation(T4).Hemodynamic indexes were recorded.Two milliliter blood sample were phlebotomized for evaluation of TNF-α and IL-6 from each patient at T1,T3,T4.The infusion volume, the amount of bleeding,the operation time,anal exhaust time,and length of postoperative hospital stay were recorded. Results Comparing information between the two groups,infusion volume and colloid had an obvious decrease than that of group C(P<0.05).SVV and CVP of group G were much stable than group C.The levels of TNF-α and IL-6 of group G were lower than those of group C(P<0.01).The length of anal exhaust time and post-operative hospital stay group G were faster than that of group C(P<0.01).Conclusions Goal-directed fluid ther-apy is superior on fluid administration. It can reduce the release of IL-6 and TNF-α. It is beneficial to elderly colorectal cancer patients with hypertension.
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Objective To compare the different goal-directed fluid therapy(GDFT)strategies on the recovery of tissue perfusion and postoperative recovery in patients undergoing hepatectomy. Methods Ninety patients undergoing hepatectomy with ASA physical status Ⅱor Ⅲ were divided into three groups based on fluid treatment by random number table method:control group(conventional fluid therapy), observation group Ⅰ(GDFT filled with colloi) and observation group Ⅱ(GDFT filled with crystalloids),with 30 cases in each group.The ScvO2,Lac and Glu were tested at 5 min before anesthesia induction(T1),5 min before hepatectomy(T2),5 min after hepatectomy(T3)and the end of operation(T4). The duration of operation,fluid requirement,urinary output, bleeding volume and the use of vasoactive agent were recorded. The exhaust time, ambulation time and postoperative hospital stay were recorded. Preoperative and postoperative liver and kidney function tests and postoperative complications were followed up.Results Compared with that in control group,the amount of crystalloids[(1408.5 ± 348.4) ml vs. (1 819.4 ± 315.1) ml],the amount of colloids [(468.6 ± 193.4) ml vs. (1 009.7 ± 440.9) ml],the total volume[(1 867.3 ± 370.4)ml vs.(2 821.3 ± 264.6)ml]were all lower,first flatus time[(51.8 ± 8.5)h vs.(63.6 ± 9.2) h], ambulation time [(3.4 ± 0.7) d vs. (4.3 ± 0.7) d] and postoperative hospital stay [(7.8 ± 1.7)d vs.(10.5 ± 2.9)d]were all shorter,ScvO2at T3,T4was higher,Lac at T2-T4were lower,Glu at T3,T4was lower, and ALT and AST on the third day and the fifth day after surgery were lower in observation groupⅠ(P<0.05).Compared with those in observation groupⅠ,the amount of crystalloids [(2 014.7 ± 388.2)ml vs.(1 408.5 ± 348.4)ml]was increased,and the incidences of postoperative nausea and vomiting[33.3%(10/30)vs.10.0%(3/30)]were significantly higher than those in observation groupⅡ(P<0.05). Conclusions GDFT using colloids in hepatectomy probably improves the microcirculation and tissue oxygenation, protects liver function, promotes gastrointestinal function recovery and shortens postoperative hospital stay. It has a much lower incidence of postoperative nausea and vomiting, compared with crystalloids.
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Objective To investigate the effect of SVV guided fluid therapy on blood gas and lipopolysaccharide (LPS),procalcitonin (PCT) in patients undergoing resection of gastrointestinal tumor.Methods Sixty patients aged 60 85 years from Jan,2016 to Feb,2017 falling into ASA physical status Ⅱ or Ⅲ,scheduled for elective radical operations for gastrointestinal cancers,were includ ed and randomly divided into two groups (n =30 each) using a random number table:ScvO2 guided fluid therapy (group C),SVV guided fluid therapy (group G).MAP,HR and CVP of patients were recorded at the same time before anesthesia (T0),tumor removal (T1) and the end of surgery (T2)respectively.PH,BE,HCO3-and Lac of venous blood samples and artery blood samples at T0-T2,6 hours after surgery(T3) were recorded.Venous blood samples were collected at T0,T3 to detect LPS and PCT.Crystalloid requirements,colloid requirements,total volume,bleeding volume,peritoneal fluid volume and the use of dopamine were recorded.The time of PACU,time when the patients first exhausted and was fed after operation,length of hospital stay after operation were recorded.Results Compared with group C,BE of artery blood was obviously increased at T2,T3 in group G (P＜0.05);the Lac of artery at T2 and the Lac of artery and venous blood at T3 in group G was obvi ously decreased.LPS and PCT were decreased at T3 in group G (P＜0.05).Compared with group C,the needed colloid was increased in group G,the needed crystalloid and total volume of fluid infused were decreased in group G (P＜0.05).Compared with group C,the time of PACU starting to exhaust and feed,length of hospital was shortened in group G (P＜0.05).Conclusion SW guided goal directed fluid therapy is more conductive to maintain the acid base and reduce the incidence of in fection for the patients with gastrointestinal tumor operation,promote the recovery of gastrointestinal function and decrease the length of hopital after operations.
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Objective To evaluate the effects of goal-directed fluid therapy on the tissue perfusion of elderly patients undergoing Laparoscopic Radical Cystectomy.Methods Thirty patients aged 60-82 years with ASA physical status Ⅰ or Ⅱ who were presenting for elective laparoscopic radical cystectomy were randomly divided into routine fluid replacement group (group C,n=15) and GDFT group (group G,n=15).Patients in group C received routine fluid replacement.Patients in group G were treated under goal-directed fluid infusion strategy with a target of SVV≤13%,CI≥2.5 L·min-1·m-2 and ScvO2≥73% under the monitoring of PiCCO.The indexes of hemodynamics and tissue perfusion were collected and recorded at 7 time points: before induction of anesthesia (T1),5 minutes after intubation (T2),5 minutes after pneumoperitoneum and change positions (T3),1 hour after pneumoperitoneum (T4),5 minutes after the abdomen was opened (T5),1 hour after the abdomen was opened (T6) and the end of surgery (T7).Results Compared with group C,group G received less fluid.MAP and SVV between two groups were no statistical significance.The CI in group G in time point T4,T6 and T7 was significantly higher than that in group C (P<0.05).The HR in group G in time point T5 and T6 was significantly higher than that in group C (P<0.05).The aLac in group G in time point T4 and T5 was significantly lower than that in group C (P<0.05).Pcv-aCO2,DO2I and O2ERe between the two groups were not statistically different.Postoperative rehabilitation indexes between the two groups were not statistically significant.Conclusion The GDFT guided under SVV,CI and ScvO2 can keep the effective circulatory volume and pressure to ensure the whole body perfusion,reduce aLac and improve microcirculation without affecting the balance of oxygen supply and demand and the postoperative complication.
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Objective To observe the effect of goal-directed fluid therapy on hemodynamic and regional cerebral oxygen saturation (rSO 2 )in the elder patient undergoing one-lung ventilation. Methods Fifty-eight patients scheduled for esophagus cancer resection(44 males,14 females,aged 65-79 years,ASA physical status Ⅱ or Ⅲ),were randomly divided into two groups (n =29 each)u-sing a random number table:conventional fluid therapy group (group C)and goal-directed fluid ther-apy group (group G).Implementing radial artery puncture and internal jugular vein puncture under local anesthesia in order to monitor BP and CVP.The Flotrac/Vigileo system was used to monitor cardiac output (CO),stroke volume variation (SVV)and cardiac index (CI)in the both group.As mentioned all above,group C received conventional fluid therapy based on MAP,CVP and urine vol-ume,whereas group G received goal-directed fluid therapy (GDFT)based on SVV with the goal of CI at 2.5-4.0 L·min-1·m-2 .Intraoperative continuous monitoring of rSO 2 was performed and the sur-gery rSO 2 average (rSO 2 ),the minimal surgery rSO 2 (rSO 2min )and the maximal percentage of the decreased rSO 2 compared to baseline values (rSO 2%max )were calculated in the both group.The varia-tion of MAP,HR,CVP,SVV and CI at the onset of the monitoring (T1 ),the momment before one-lung ventilation (T2 ),30 min after one-lung ventilation (T3 ),1 h after one-lung ventilation(T4 )and the end of the surgery (T5 )were recorded.The requirement for crystalloid and colloid,total volume of fluid infused,bleeding volume,urine volume,and requirement for vasoactive agents were recorded during operaton.Results Compared with group C,MAP at T3 ,T4 and CI at T3-T5 in group G were increased significantly,while CVP at T3-T5 and SVV at T2-T5 in group G were decreased (P <0.05). The rSO 2%max in group G was significantly lower than that in group C (P <0.05).No statistically sig-nificant difference was observed in the rSO 2 and rSO 2min between the two groups.Compared with group C,the requirement for crystalloid [(668±187)ml vs (1052±221)ml and total volume of fluid infused [(1212±318)ml vs (1519±329)ml],urine volume [(211±47)ml vs (278±54)ml]and vasoactive agents [4 cases (14%)vs 14 cases (48%)]were significantly decreased (P <0.05),the requirement for colloid were increased [(544±103)ml vs (467±94)ml,P <0.05].Conclusion The goal-directed fluid therapy based on SVV stabilizes the hemodynamic effectively,improves the CI and the perfusion of brain,and maintains the cereral oxygen metabolism in the elder patient undergoing one-lung ventilation.
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Objective To compare the difference between crystalloids and colloids under goal-directed fluid therapy (GDFT) in elective hepatectomy.Methods Seventy patients undergoing hepatectomy, 42 males and 28 females, aged 18-65 years, ASA physical status Ⅱ or Ⅲ, were included and randomly divided into three groups base on fluid treatment: conventional fluid therapy (group C, n=24), goal-directed fluid therapy filled with colloids (group G1, n=23) and goal-directed fluid therapy filled with crystalloids (group G2, n=23).Group C received conventional fluid therapy mainly based on MAP while group G1 and group G2 received goal-directed fluid therapy based on MAP, stroke volume variation (SVV) and cardiac index (CI), and the Flotrac/Vigileo system was used to obtain SVV and CI in group G1 and group G2.250 ml colloids were administered if SVV>13% in group G1 while 250 ml crystalloids were administered in group G2.If CI<2.5 L·min-1·m-2, dobutamine 2.0-10.0 μg·kg-1·min-1 was given until CI≥2.5 L·min-1·m-2.The ScvO2, Lac and Glu were tested at 5 min before anesthesia induction (T1), 5 min before hepatectomy (T2), 5 min after hepatectomy (T3) and the end of operation (T4).The duration of operation, fluid requirement, urinary output, bleeding volume, and the use of vasoactive agent were recorded.The exhaust time, ambulation time and postoperative hospital stay were recorded.Preoperative and postoperative liver and kidney function tests and postoperative complications were followed up.Results Compared with group C, the total volume was lower, flatus time, ambulation time and postoperative hospital stay were shorter, ScvO2 at T3 and T4 were higher, Lac at T2-T4 were lower, Glu at T3 and T4 were lower, ALT and AST on the third day and the fifth day after surgery were lower in group G1 (P<0.05).Compared with group G1, the amount of crystalloids was increased, the incidences of postoperative nausea and vomiting were significantly higher in group G2 (P<0.05).There was no significant difference in flatus time, ambulation time and postoperative hospital stay between group G1 and group G2.Conclusion GDFT in hepatectomy propably improves the microcirculation and tissue oxygenation, protects liver function, promotes gastrointestinal function recovery and shortens postoperative hospital stay.GDFT using colloids bolus contribute to a much lower incidence of postoperative nausea and vomiting.There is no significant difference in tissue perfusion and postoperative recovery between colloids and crystalloids.
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Fluid therapy plays an important role in maintaining the stability of vital signs and the good perfusion of tissues.Therefore,it is the basis for treatment of diseases.The purpose of fluid therapy is to keep the patient's effective circulating volume,increase cardiac output,and ensure adequate tissue perfusion,which may facilitate the transport of oxygen and nutrients.Perioperative fluid therapy has gone through the progress from choosing the type of liquid to reforming the mode of fluid treatment.Since the concepts of fast track surgery and precision medicine appeared,the anesthesiologists and surgeons have pay more attention to the goal-directed fluid therapy(GDFT).GDFT aims to maintain organ perfusion and oxygen transport of tissues by regulating the amount of fluid on basis of a physiological index.As a new fluid therapy,GDFT contributes to maintaining oxygen delivery and reducing both morbidity and mortality.This article reviews the progress and challenges for GDFT.
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Abstract Background: The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. Methods: A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. Results: 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p < 0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p = 0.30). Quality sensitive analyses confirmed the main overall results. Conclusions: Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.
Resumo Justificativa: A terapia hemodinâmica alvo-dirigida (THAD) é uma abordagem focada no uso do débito cardíaco (DC) e parâmetros relacionados, como desfechos para fluidos e medicamentos para aprimorar a perfusão tecidual e o fornecimento de oxigênio. Objetivo primário: determinar os efeitos da THAD sobre as taxas de complicações no pós-operatório. Métodos: Metanálise dos efeitos da THAD em cirurgias não cardíacas de adultos sobre as complicações pós-operatórias e mortalidade, com a metodologia PRISMA. Uma busca sistemática foi feita no Medline PubMed, Embase e Biblioteca Cochrane (última atualização, outubro de 2014). Os critérios de inclusão foram estudos clínicos randômicos (ECRs) nos quais a THAD no intraoperatório foi comparada com a terapia convencional de reposição de líquidos em cirurgia não cardíaca. Os critérios de exclusão foram traumatismo e estudos de cirurgia pediátrica e aqueles que usaram cateter de artéria pulmonar. Os desfechos, primário e secundário, foram complicações pós-operatórias e mortalidade, respectivamente. Os estudos que atenderam aos critérios de inclusão foram examinados na íntegra e submetidos à análise quantitativa, análise de subgrupo pré-definido (estratificada por tipo de monitor, terapia e objetivo hemodinâmico) e análise de sensibilidade pré-definida. Resultados: 51 ECRs foram identificados inicialmente, 24 atenderam aos critérios de inclusão. Cinco ECRs foram adicionados por busca manual, resultando em 29 ECRs para análise final, incluindo 2.654 pacientes. Uma redução significativa das complicações para a THAD (RR: 0,70, IC de 95%: 0,62-0,79, p < 0,001). Nenhuma diminuição significativa na mortalidade foi observada (RR: 0,76, IC de 95%: 0,45-1,28, p = 0,30). Análises de sensibilidade qualitativa confirmaram os principais resultados gerais. Conclusões: THAD no intraoperatório com monitoração minimamente invasiva diminui as complicações no pós-operatório de cirurgia não cardíaca, embora não tenha mostrado uma redução significativa da taxa de mortalidade.
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Humanos , Procedimentos Cirúrgicos Operatórios/métodos , Hemodinâmica/efeitos dos fármacos , Cuidados Intraoperatórios/métodos , Período Intraoperatório , ObjetivosRESUMO
Background: Perioperative fluid management is essential to the practice of anaesthesia. Outcomes may be improved if fluid therapy is individualized according to the patient's fluid responsiveness. Pulse-induced continuous cardiac output (PiCCO) monitor is an invasive device that quantifies several parameters, including cardiac output (CO), stroke volume variation (SVV) and extravascular lung water (EVLW). Trans-oesophageal Doppler monitoring (TED) is another minimally invasive form and has the benefit of providing beat to beat analysis. Aim of Work: We designed this prospective, randomized comparative study to evaluate the use of PiCCO monitor from the fluid and haemodynamic point of view in comparison to TED monitor in order to maintain an adequate circulatory volume ensuring end-organ perfusion and oxygen delivery. Patients and Methods: This study was performed on 72 patients of either sex (ASA I-II), undergoing major abdominal surgery. Patients were randomly allocated into two groups; PiCCO group (n=36); where fluid management was guided by SVV & colloid boluses were given to maintain SVV below 10% and TED group (n=36); where fluid management was guided by (systolic flow time corrected for heart rate) (FTc) & colloid was infused when the (FTc) ˂ 0.35 second, the fluid challenge would be repeated until FTc raised ˃ 0.40 second with no change in SV. Laboratory parameters of organ hypoperfusion in perioperative period were recorded as well as the number of postoperative complications, mortality and length of ICU stay. Results: PiCCO group received more intraoperative colloids (P=0.001) and had lower incidence of hypotensive events (P=0.001). Postoperative lactate levels were lower in PiCCO group (P=0.04). PiCCO group showed fewer numbers of patients developed complications & overall number of postoperative complications (P=0.01). It also showed shorter duration of ICU length of stay (P=0.01). No mortality was recorded in both groups. Conclusions: During major abdominal surgery; intraoperative fluid optimization using PiCCO monitor showed more haemodynamic stability and was associated with a lower incidence of postoperative complications, organ dysfunction and infectious complications with a tendency to decrease the ICU length of stay in comparison to TED monitor.
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Objective To evaluate the effects of two fluid therapy methods guided by SVV and CVP re-spectively on intestinal barrier of colon cancer surgery with elderly patients. Methods 50 elderly patients with ASA Ⅱ~Ⅲ level were randomly divided into Group S (fluid therapy guided by SVV) and Group C (convention-al fluid therapy). Each group has 25 cases. Patients in group S were treated under goal-directed fluid infusion strategy with target of 10%≤SVV≤12%. Group C received conventional infusion characterized by monitoring central venous pressure (CVP) and mean arterial pressure (MAP). Fluid volume, surgery time, urine volume, blood loss, exhausting time, post-operative hospitalization days in Group S and Group C were recorded. MAP, HR, CVP, SVV, HCO3- of patients were recorded at the same time before anesthesia (T0), beginning of surgery (T1), one hour after surgery (T2) and ending of surgery (T3) respectively. Venous blood samples were collected at the time points of T0, T1, T2 and T3 to detect DAO and D-lactic acid levels. Results MAP and CVP at time points of T2 and T3 in Group S were obviously lower than that in Group C; total intraoperative fluid volume in Group S was obviously less than that in Group C (P < 0. 05); postoperative exhausting time and hospitalization days in Group S decreased significantly (P < 0.05) and the content of DAO and D-lactic acid in Group S were lower than that in Group C (P < 0.05). Conclusion For elderly patients with colon cancer surgery, fluid thera-py guided by SVV is better than conventional fluid therapy guided by CVP in protecting intestinal barrier.
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Objective To discuss the effects of the goal-directed fluid therapy on the haemody-namics,oxygen delivery and consumption and tissue perfusion in patients with continuous hyperther-mic peritoneal perfusion.Methods Eighty patients (61 males,19 females,aging from 30 to 60years old,ASA grade Ⅰ-Ⅲ)undergoing continuous hyperthermic peritoneal perfusion were selected and di-vided into 2 groups (n=40).Conventional liquid treatment group(group C)and Stroke Volume Vari-ation-directed liquid treatment group(group S).All patients were received general anesthesia and mo-nitored with FloTrac/Vigile systerm.MAP,HR,CVP,CI,PaO2 ,SaO2 ,PvO2 ,ScvO2 and Lac were all recorded in the time before anesthesia(T0 ),5 min after endotracheal intubation (T1 ),before CHPP (T2 ),CHPP for 30 min (T3 ),CHPP for 60 min (on the end,T4 ),30 min after CHPP (T5 ), and at the end of surgery (T6 ).According to the formula to calculate oxygen transport (DO2 I)and oxygen consumption index (VO2 I).Results Compared with group C,the amount of fluid, crystalloid solution,and urine volume were all much lower and colloidal solution was much higher in group S (P <0.05).Compared with T1 ,MAP decreased in the two groups at T3 and T4 ,yet HR in-creased and CVP decreased in group C at T4 (P <0.05).CVP increased in group C at T6 and in group S at T3-T5 .At the time points of T3 to T6 ,MAP and CI in group S were significantly higher than those in group C,while CVP and HR were much lower in group S (P <0.05).Compared with T1 , the DO2 I in group C were lower at T4 ,T5 (P <0.05),while VO2 I,O2 ER and Lac in group C in-creased at T3-T6 (P <0.05),also ScvO2 decreased at the same time (P <0.05).Compared with T1 , the VO2 I increased at T4-T6 ,but ScvO2 decreased at T3 ,T4 in group S (P <0.05).DO2 I in group S were higher than those in group C at T4 and T5 ,whereas,VO2 I,O2 ER and Lac level in group S were much lower than those in group C,and ScvO2 were significantly higher than those at T3-T6 in group C (P <0.05).Conclusion Stroke variation degree-oriented liquid treatment could effectively maintain hemodynamic stability,increase the body's oxygen supply,reduce oxygen consumption and improve tissue perfusion.
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Objective To investigate the influence of stroke volume variation (SVV)-guided fluid therapy on postoperative cognitive function in elderly patients undergoing the unilateral total knee arthroplasty(UTKA).Methods One hundred patients undergoing the UTKA were randomly di-vided into two groups,group A(SVV 4%-9%)and group B(SVV 10%-14%).The liquid manage-ment,serum markers (CRP,IL-6)and the incidences of deflating-tourniquet-related hypotension and preoperative, 5 d after surgery of the occurrence of POCD in two groups were recorded. Results There was no significant difference in general information between the two groups. Compared with group B,group A needed more fluid transfusion and had a higher 24 h urine volume. The CRP and IL-6 was significantly higher in group B than that in group A;The incidence of defla-ting-tourniquet-related hypotension in group A [22(44%)]was also lower than that in group B [43 (86%)].However,there was no significant difference in the incidence of POCD between the two groups.Conclusion Sufficient blood volume can help to reduce the incidence of deflating-tourniquet-related hypotension,and reduce the inflammatory reaction in elderly patients.
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OBJECTIVE: The optimal strategy for fluid management during gastrointestinal surgery remains unclear. Minimizing the variation in arterial pulse pressure, which is induced by mechanical ventilation, is a potential strategy to improve postoperative outcomes. We tested this hypothesis in a prospective, randomized study with lactated Ringer's solution and 6% hydroxyethyl starch solution. METHOD: A total of 60 patients who were undergoing gastrointestinal surgery were randomized into a restrictive lactated Ringer's group (n = 20), a goal-directed lactated Ringer's group (n = 20) and a goal-directed hydroxyethyl starch group (n = 20). The goal-directed fluid treatment was guided by pulse pressure variation, which was recorded during surgery using a simple manual method with a Datex Ohmeda S/5 Monitor and minimized to 11% or less by volume loading with either lactated Ringer's solution or 6% hydroxyethyl starch solution (130/0.4). The postoperative flatus time, the length of hospital stay and the incidence of complications were recorded as endpoints. RESULTS: The goal-directed lactated Ringer's group received the greatest amount of total operative fluid compared with the two other groups. The flatus time and the length of hospital stay in the goal-directed hydroxyethyl starch group were shorter than those in the goal-directed lactated Ringer's group and the restrictive lactated Ringer's group. No significant differences were found in the postoperative complications among the three groups. CONCLUSION: Monitoring and minimizing pulse pressure variation by 6% hydroxyethyl starch solution (130/0.4) loading during gastrointestinal surgery improves postoperative outcomes and decreases the discharge time of patients who are graded American Society of Anesthesiologists physical status I/II.