Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial.

BACKGROUND: It is unclear whether optimising intraoperative cardiac index can reduce postoperative complications. We tested the hypothesis that maintaining optimised postinduction cardiac index during and for the first 8 h after surgery reduces the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. METHODS: In three German and two Spanish centres, high-risk patients having elective major open abdominal surgery were randomised to cardiac index-guided therapy to maintain optimised postinduction cardiac index (cardiac index at which pulse pressure variation was <12%) during and for the first 8 h after surgery using intravenous fluids and dobutamine or to routine care. The primary outcome was the incidence of a composite outcome of moderate or severe complications within 28 days after surgery. RESULTS: We analysed 318 of 380 enrolled subjects. The composite primary outcome occurred in 84 of 152 subjects (55%) assigned to cardiac index-guided therapy and in 77 of 166 subjects (46%) assigned to routine care (odds ratio: 1.87, 95% confidence interval: 1.03-3.39, P=0.038). Per-protocol analyses confirmed the results of the primary outcome analysis. CONCLUSIONS: Maintaining optimised postinduction cardiac index during and for the first 8 h after surgery did not reduce, and possibly increased, the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. Clinicians should not strive to maintain optimised postinduction cardiac index during and after surgery in expectation of reducing complications. CLINICAL TRIAL REGISTRATION: NCT03021525.

Survey on the Updated German S3 Guideline for Intensive Care in Cardiac Surgery Patients.

BACKGROUND: The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). METHODS: An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. RESULTS: A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). CONCLUSION: Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.

Preoperative routine measurement of NT-proBNP predicts postoperative morbidity after non-cardiac surgery with intermediate or high surgical risk: an observational study.

BACKGROUND: Chronic heart failure (HF) is a common clinical condition associated with adverse outcomes in elderly patients undergoing non-cardiac surgery. This study aimed to estimate a clinically applicable NT-proBNP cut-off that predicts postoperative 30-day morbidity in a non-cardiac surgical cohort. METHODS: One hundred ninety-nine consecutive patients older than 65 years undergoing elective non-cardiac surgery with intermediate or high surgical risk were analysed. Preoperative NT-proBNP was measured, and clinical events were assessed up to postoperative day 30. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection at postoperative day 30. Secondary endpoints included perioperative fluid balance and incidence, duration, and severity of perioperative hypotension. RESULTS: NT-proBNP of 443 pg/ml had the highest accuracy in predicting the composite endpoint; a clinical cut-off of 450 pg/ml was implemented to compare clinical endpoints. Although 35.2% of patients had NT-proBNP above the threshold, only 10.6% had a known history of HF. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection. Event rates were significantly increased in patients with NT-proBNP > 450 pg/ml (70.7% vs. 32.4%, p < 0.001), which was due to the incidence of cardiac rehospitalisation (4.4% vs. 0%, p = 0.018), ADHF (20.1% vs. 4.0%, p < 0.001), AKI (39.8% vs. 8.3%, p < 0.001), and infection (46.3% vs. 24.4%, p < 0.01). Perioperative fluid balance and perioperative hypotension were comparable between groups. Preoperative NT-proBNP > 450 pg/ml was an independent predictor of the CME in a multivariable Cox regression model (hazard ratio 2.92 [1.72-4.94]). CONCLUSIONS: Patients with NT-proBNP > 450 pg/ml exhibited profoundly increased postoperative morbidity. Further studies should focus on interdisciplinary approaches to improve outcomes through integrated interventions in the perioperative period. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00027871, 17/01/2022.

Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies.

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).

Vasopressor Therapy in Cardiac Surgery-An Experts' Consensus Statement.

Hemodynamic conditions with reduced systemic vascular resistance commonly are observed in patients undergoing cardiac surgery and may range from moderate reductions in vascular tone, as a side effect of general anesthetics, to a profound vasodilatory syndrome, often referred to as vasoplegic shock. Therapy with vasopressors is an important pillar in the treatment of these conditions. There is limited guidance on the appropriate choice of vasopressors to restore and optimize systemic vascular tone in patients undergoing cardiac surgery. A panel of experts in the field convened to develop statements and evidence-based recommendations on clinically relevant questions on the use of vasopressors in cardiac surgical patients, using a critical appraisal of the literature following the GRADE system and a modified Delphi process. The authors unanimously and strongly recommend the use of norepinephrine and/or vasopressin for restoration and maintenance of systemic perfusion pressure in cardiac surgical patients; despite that, the authors cannot recommend either of these drugs with respect to the risk of ischemic complications. The authors unanimously and strongly recommend against using dopamine for treating post-cardiac surgery vasoplegic shock and against using methylene blue for purposes other than a rescue therapy. The authors unanimously and weakly recommend that clinicians consider early addition of a second vasopressor (norepinephrine or vasopressin) if adequate vascular tone cannot be restored by a monotherapy with either norepinephrine or vasopressin and to consider using vasopressin as a first-line vasopressor or to add vasopressin to norepinephrine in cardiac surgical patients with pulmonary hypertension or right-sided heart dysfunction.

[Comments on the updated German S3 guidelines on intravascular volume therapy in adults]. / Kommentar zur aktualisierten S3-Leitlinie zur intravasalen Volumentherapie beim Erwachsenen.

The German S3 guidelines on intravascular volume therapy in adults were updated in September 2020. Based on updated evidence recommendations for the diagnosis of isotonic dehydration and for fluid therapy with crystalloids and colloids in peri-interventional and intensive care medicine were proposed.

Hypotension Prediction Index based protocolized haemodynamic management reduces the incidence and duration of intraoperative hypotension in primary total hip arthroplasty: a single centre feasibility randomised blinded prospective interventional trial.

The "Hypotension Prediction Index (HPI)" represents a newly introduced monitoring-tool that aims to predict episodes of intraoperative hypotension (IOH) before their occurrence. In order to evaluate the feasibility of protocolized care according to HPI monitoring, we hypothesized that HPI predicts the incidence of IOH and reduces the incidence and duration of IOH. This single centre feasibility randomised blinded prospective interventional trial included at total of 99 patients. One group was managed by goal-directed therapy algorithm based on HPI (HPI, n = 25), which was compared to a routine anaesthetic care cohort (CTRL, n = 24) and a third historic control group (hCTRL, n = 50). Primary endpoints included frequency (n)/h, absolute and relative duration (t (min)/% of total anaesthesia time) of IOH. Significant reduction of intraoperative hypotension was recorded in the HPI group compared to the control groups (HPI 48%, CTRL 87.5%, hCTRL 80%; HPI vs. CTRL, respectively hCTRL p < 0.001). Perioperative quantity of IOH was significantly reduced in the interventional group compared to both other study groups (HPI: 0 (0-1), CTRL: 5 (2-6), hCTRL: 2 (1-3); p < 0.001). Same observations were identified for absolute (HPI: 0 (0-140) s, CTRL: 640 (195-1315) s, hCTRL 660 (180-1440) s; p < 0.001) and relative duration of hypotensive episodes (minutes MAP ≤ 65 mmHg in  % of total anaesthesia time; HPI: 0 (0-1), CTRL: 6 (2-12), hCTRL 7 (2-17); p < 0.001). The HPI algorithm combined with a protocolized treatment was able to reduce the incidence and duration of hypotensive events in patients undergoing primary hip arthroplasty.Trial registration: NCT03663270.

Prevalence, Diagnosis, Perioperative Monitoring and Treatment of Right Ventricular Dysfunction and/or Pulmonary Arterial Hypertension in Cardiac Surgical Patients in Germany-A Postal Survey.

Background Sparse data are available on the prevalence of right ventricular dysfunction and/or pulmonary arterial hypertension in patients scheduled for cardiac surgery in Germany as well as on the intensity and modalities used for diagnosis, perioperative monitoring, and treatment of these comorbidities. Methods A postal survey including questions on the prevalence of preoperative right ventricular dysfunction and/or pulmonary arterial hypertension in patients undergoing cardiac surgery in 2009 was sent to 81 German heart centers. Total 47 of 81 (58%) heart centers returned the questionnaires. The centers reported data on 51,095 patients, and 49.8% of the procedures were isolated coronary artery bypass grafting. Results Data on the prevalence of preoperative pulmonary hypertension and/or right ventricular dysfunction were not available in 54% and 64.6% of centers. In the remaining hospitals, 19.5% of patients presented right heart dysfunction and 10% pulmonary arterial hypertension. Preoperative echocardiography was performed in only 45.3% of the coronary artery bypass grafting cases. Preoperative pharmacologic treatment of pulmonary hypertension or right ventricular dysfunction with oral sildenafil, inhaled prostanoids, or nitric oxide was initiated in 71% and 95.7% of the centers, respectively. Intra- and postoperative treatment was most frequently accomplished with phosphodiesterase-III inhibitors. Conclusion The prevalence of preoperative right heart dysfunction and pulmonary arterial hypertension in cardiac surgical patients in Germany seems to be substantial. However, in more than 50% of the patients, no preoperative data on right ventricular function and pulmonary arterial pressure are available. This may lead to underestimation of perioperative risk and inappropriate management of this high-risk population.

High central venous saturation after cardiac surgery is associated with increased organ failure and long-term mortality: an observational cross-sectional study.

INTRODUCTION: Central venous saturation (ScvO2) monitoring has been suggested to address the issue of adequate cardiocirculatory function in the context of cardiac surgery. The aim of this study was to determine the impact of low (L) (<60%), normal (N) (60%-80%), and high (H) (>80%) ScvO2 measured on intensive care unit (ICU) admission after cardiac surgery. METHODS: We conducted a retrospective, cross-sectional, observational study at three ICUs of a university hospital department for anaesthesiology and intensive care. Electronic patient records of all adults who underwent cardiac surgery between 2006 and 2013 and available admission measurements of ScvO2 were examined. Patients were allocated to one of three groups according to first ScvO2 measurement after ICU admission: group L (<60%), group N (60%-80%), and group H (>80%). Primary end-points were in-hospital and 3-year follow-up survival. RESULTS: Data from 4,447 patients were included in analysis. Low and high initial measurements of ScvO2 were associated with increased in-hospital mortality (L: 5.6%; N: 3.3%; H: 6.8%), 3-year follow-up mortality (L: 21.6%; N: 19.3%; H: 25.8%), incidence of post-operative haemodialysis (L: 11.5%; N: 7.8%; H: 15.3%), and prolonged hospital length of stay (L: 13 days, 9-22; N: 12 days, 9-19; H: 14 days, 9-21). After adjustment for possible confounding variables, an initial ScvO2 above 80% was associated with adjusted hazard ratios of 2.79 (95% confidence interval (CI) 1.565-4.964, P <0.001) for in-hospital survival and 1.31 (95% CI 1.033-1.672, P = 0.026) for 3-year follow-up survival. CONCLUSIONS: Patients with high ScvO2 were particularly affected by unfavourable outcomes. Advanced haemodynamic monitoring may help to identify patients with high ScvO2 who developed extraction dysfunction and to establish treatment algorithms to improve patient outcome in these patients.

Central Venous-Arterial pCO2 Difference Identifies Microcirculatory Hypoperfusion in Cardiac Surgical Patients With Normal Central Venous Oxygen Saturation: A Retrospective Analysis.

OBJECTIVE: Parameters such as central venous oxygen saturation (ScvO2) are used increasingly to monitor adequate hemodynamic treatment. However, it still remains challenging to identify patients with assumed adequate circulatory status quantified by ScvO2 who suffer from macro- and microcirculatory hypoperfusion. The authors hypothesized that central venous-arterial pCO2 difference (dCO2) could serve as an additional parameter to evaluate the adequacy of perfusion in cardiac surgery patients. DESIGN: Retrospective data analysis of a prospective interventional study. SETTING: University medical center. PARTICIPANTS: Patients undergoing surgery with cardiopulmonary bypass. INTERVENTIONS: The dCO2 was measured postoperatively. The patients with an ScvO2≥70% were divided into 2 groups, the high-dCO2 group (≥8 mmHg) and the low-dCO2 group (<8 mmHg). MEASUREMENTS AND MAIN RESULTS: Sixty patients were included in this analysis. Twenty-five patients had ScvO2≥70%, 4 patients were assigned to the high-dCO2 group. Patients of the high-dCO2 group had significantly longer intensive care unit (ICU) stays (4 d; 1-29 v 1 d; 1-1; p = 0.02), significantly prolonged need for mechanical ventilation (41.5 h; 11-263.5; v 10 h; 7-11; p = 0.03), and higher cardiovascular complication rates in the ICU on postoperative days 3, 4, and 5 (p = 0.02). The mixed venous saturation (SvO2) after 1 hour in the ICU was significantly lower, lactate levels were significantly higher, and the plasma disappearance rate of indocyanine green was significantly lower after 1 hour in the ICU (14.6%/min; 11.6-19.8%/min v 23.6%/min; 22.5-27.3%/min; p = 0.02) in the high-dCO2 group. Cytokines increased significantly postoperatively in the high-dCO2 group. CONCLUSIONS: The authors described dCO2 as a routinely available tool to detect global and microcirculatory hypoperfusion in postoperative cardiac surgical patients. The authors showed that in patients with an ScvO2≥70%, a high dCO2 (≥8 mmHg) was associated with increased postoperative lactate levels and decreased splanchnic function. These findings were associated with a longer need for mechanical ventilation and longer ICU stay.

[Echocardiography for hemodynamic monitoring on ICU?]. / Echokardiografie - Echokardiografie als Monitoring auf der Intensivstation?

A goal-directed hemodynamic therapy (GDT) using volume substitution and/or cardiovascular agents in order to increase stroke volume and consecutively tissue oxygenation has been shown to reduce perioperative complications. Previous hemodynamic monitoring devices mostly are only able to detect a restriction in several parameters of cardiovascular function not always diagnostically conclusive to their pathophysiological cause. However, this is mandatory for GDT. In this context, discontinuous transthoracic (TTE) and transesophageal (TEE) echocardiography is gaining clinical relevance. In addition, recently there exists the opportunity to perform a continuous hemodynamic focused transesophageal echocardiography ("hemodynamic TEE", hTEE) via a miniaturized monoplane probe. With its flexible probe tip the three most important two-dimensional views of the heart can be obtained to differentiate between aforementioned pathophysiological causes of a low cardiac output syndrome. It is introduced orally in the patient's esophagus and can remain up to 72 hours in situ. First clinical reports/studies were able to demonstrate that a short intensive training programme for physicians unexperienced in echocardiography was sufficient to adequately initiate GDT. However, further studies have to prove the clinical feasibility and the positive effect on patient's outcome.

Comparison of preoperative NT-proBNP and simple cardiac risk scores for predicting postoperative morbidity after non-cardiac surgery with intermediate or high surgical risk.

BACKGROUND: Chronic heart failure (HF) is frequent in elderly patients undergoing non-cardiac surgery. Preoperative risk stratification is vital and can be achieved using simple clinical risk scores or preoperative N-terminal prohormone of brain natriuretic peptide (NT-proBNP) measurement. This study aimed to compare the predictivity of the revised cardiac risk index (RCRI), the American University of Beirut cardiovascular risk index (AUB-HAS2), and a score proposed by Andersson et al. for postoperative 30-day morbidity to preoperative NT-proBNP. METHODS: Preoperative NT-proBNP was measured in 199 consecutive patients aged ≥ 65 years undergoing elective non-cardiac surgery with intermediate or high surgical risk. The areas under the receiver operating characteristic curve (AUCROC) for the composite morbidity endpoint (CME) comprising the incidence of any rehospitalisation, acute decompensated HF, acute kidney injury, and any infection at postoperative day 30 were assessed. Multivariable logistic regression analysis derived new scores from the simple risk scores and the NT-proBNP cut-off of 450 pg/mL. RESULTS: AUB-HAS2, but not RCRI or Andersson score, significantly predicted the CME (AUB-HAS2: AUCROC 0.646, p < 0.001; RCRI: AUCROC 0.560, p = 0.126; Andersson: AUCROC 0.487, p = 0.760). The AUCROC was comparable between preoperative NT-proBNP (0.679, p < 0.001) and AUB-HAS2 (p = 0.334). Multivariable analyses revealed a preoperative NT-proBNP ≥ 450 pg/mL to be the strongest predictor of CME among the individual score components (p < 0.001). Adding preoperative NT-proBNP improved the predictive value of AUB-HAS2 and RCRI (modified AUB-HAS2: AUCROC 0.703, p < 0.001; modified RCRI: AUCROC 0.679, p < 0.001; both p < 0.001 vs original scores). The predictive value of the modified RCRI and AUB-HAS2 was comparable to preoperative NT-proBNP alone (p = 0.988 vs modified RCRI, p = 0.367 vs modified AUB-HAS2). CONCLUSIONS: The predictive value of postoperative morbidity varies significantly between the available simple perioperative risk scores and can be enhanced by preoperative NT-proBNP. New scores, including preoperative NT-proBNP, should be evaluated in large multicentre cohorts. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00027871.

Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis.

INTRODUCTION: Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes. METHODS: Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch. RESULTS: Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ. CONCLUSION: GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.

Bench-to-bedside review: functional hemodynamics during surgery - should it be used for all high-risk cases?

The administration of a fluid bolus is done frequently in the perioperative period to increase the cardiac output. Yet fluid loading fails to increase the cardiac output in more than 50% of critically ill and surgical patients. The assessment of fluid responsiveness (the slope of the left ventricular function curve) prior to fluid administration may thus not only help in detecting patients in need of fluids but may also prevent unnecessary and harmful fluid overload. Unfortunately, commonly used hemodynamic parameters, including the cardiac output itself, are poor predictors of fluid responsiveness, which is best assessed by functional hemodynamic parameters. These dynamic parameters reflect the response of cardiac output to a preload-modifying maneuver (for example, a mechanical breath or passive leg-raising), thus providing information about fluid responsiveness without the actual administration of fluids. All dynamic parameters, which include the respiratory variations in systolic blood pressure, pulse pressure, stroke volume and plethysmographic waveform, have been repeatedly shown to be superior to commonly used static preload parameters in predicting the response to fluid loading. Within their respective limitations, functional hemodynamic parameters should be used to guide fluid therapy as part of or independently of goal-directed therapy strategies in the perioperative period.

The use of artificial intelligence and machine learning monitoring to safely administer a fluid-restrictive goal-directed treatment protocol to minimize the risk of transfusion during major spine surgery of a Jehovah's Witness: a case report.

BACKGROUND: The Hypotension Prediction Index (HPI) displays an innovative monitoring tool which predicts intraoperative hypotension before its onset. CASE PRESENTATION: We report the case of an 84-year-old Caucasian woman undergoing major spinal surgery with no possibility for the transfer of blood products given her status as a Jehovah's Witness. The hemodynamic treatment algorithm we employed was based on HPI and resulted in a high degree of hemodynamic stability during the surgical procedure. Further, the patient was not at risk for either hypo- or hypervolemia, conditions which might have caused dilution anemia. By using HPI as a tool for patient blood management, it was possible to reduce the incidence of intraoperative hypotension to a minimum. CONCLUSIONS: In sum, this HPI-based treatment algorithm represents a useful application for the treatment of complex anesthesia and perioperative patient blood management. It is a simple but powerful extension of standard monitoring for the prevention of intraoperative hypotension.

Perioperative gene expression analysis for prediction of postoperative sepsis.

BACKGROUND: Postoperative sepsis is one of the main causes of death after major abdominal surgery; however, the immunologic factors contributing to the development of sepsis are not completely understood. In this study, we evaluated gene expression in patients who developed postoperative sepsis and in patients with an uncomplicated postoperative course. METHODS: We enrolled 220 patients in a retrospective matched-pair, case-control pilot study to investigate the perioperative expression of 23 inflammation-related genes regarding their properties for predicting postoperative sepsis. Twenty patients exhibiting symptoms of sepsis in the first 14 days after surgery (case group) were matched with 20 control patients with an uncomplicated postoperative course. Matching criteria were sex, age, main diagnosis, type of surgery, and concomitant diseases. Blood samples were drawn before surgery and on the first and second postoperative days. Relative gene expression was analyzed with real-time reverse-transcription PCR. RESULTS: Significant differences (P < 0.005) in gene expression between the 2 groups were observed for IL1B (interleukin 1, beta), TNF [tumor necrosis factor (TNF superfamily, member 2)], CD3D [CD3d molecule, delta (CD3-TCR complex)], and PRF1 [perforin 1 (pore forming protein)]. Logistic regression analysis and a subsequent ROC curve analysis revealed that the combination of TNF, IL1B, and CD3D expression had a specificity and specificity of 90% and 85%, respectively, and predicted exclusion of postoperative sepsis with an estimated negative predictive value of 98.1%. CONCLUSIONS: These data suggest that gene expression analysis may be an effective tool for differentiating patients at high and low risk for sepsis after abdominal surgery.

Management of perioperative volume therapy - monitoring and pitfalls.

Over 300 million surgical procedures are performed every year worldwide. Anesthesiologists play an important role in the perioperative process by assessing the overall risk of surgery and aim to reduce the risk of complications. Perioperative hemodynamic and volume management can help to improve outcomes in perioperative patients. There has been ongoing discussion about goal-directed therapy. However, there is a consensus that fluid overload and severe fluid depletion in the perioperative period are harmful and can lead to adverse outcomes. This article provides an overview of how to evaluate the fluid responsiveness of patients, details which parameters could be used, and what limitations should be noted.

Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis

ABSTRACT Introduction: Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes. Methods: Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch. Results: Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ. Conclusion: GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.