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Debas SA, Chekol WB, Zeleke ME, Mersha AT. Delayed ambulation in adult patients after major abdominal surgery in Northwest Ethiopia: a multicenter prospective follow up study. Sci Rep 2025; 15:13382. [PMID: 40251300 PMCID: PMC12008419 DOI: 10.1038/s41598-025-97933-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Accepted: 04/08/2025] [Indexed: 04/20/2025] Open
Abstract
Abdominal surgery is associated with prolonged hospitalization, reduced physical activity levels, and prolonged bed rest. Delayed ambulation is a major problem after abdominal surgery which result in prolonged hospital stay. Ambulation was defined as delayed if the patient could not walk more than 10 m without assistance on postoperative day one within 24 h of surgery. Although abdominal surgery is performed for a variety of surgical procedures in a day to day practice the incidence and factors associated with delayed ambulation after major abdominal surgery have not been well investigated in the study area. Therefore, the aim of this study was to assess the incidence and factors associated with delayed ambulation after major abdominal surgery. A multicenter, prospective follow up study was conducted from March 28, to June 5, 2023, on 422 participants. Patients were taken consecutively, and data were collected by using a semi-structured questionnaire. Data were entered into Epi Data version 4.6 Software and exported to SPSS version 26 for analysis. Both descriptive and analytic statistics were used. Both bivariable and multivariable logistic regression were used. Variables with a p-value less than < 0.2 in the bivariable analysis were fitted into the multivariable analysis. Both the crude odds' ratio (COR) and Adjusted Odds Ratio (AOR) with 95% Confidence Interval were calculated to show the strength of association. Variables with a p-value of < 0.05 were considered as statistically significant. The overall incidence of delayed ambulation after major abdominal surgery was 48.1% (95%CI:43.4-52.6). Having severe pain (AOR:3.23, 95%CI:1.09-9.55), dizziness (AOR:7.21, 95%CI:3.49-14.91), nasogastric tube (AOR:2.36, 95%CI:1.05-5.34), drain (AOR:3.27, 95%CI:1.52-7.04), fatigue (AOR:7.62, 95%CI:3.71-15.66), intraoperative fluid used > 2000 ml (AOR:2.54, 95%CI:1.03-6.24), duration of surgery > 2-hour (AOR:3.96, 95%CI:1.87-8.38) and blood loss > 500 ml (AOR:2.68, 95%CI:1.24-5.79) were significantly associated with delayed ambulation. Nearly half of the patients were unable to ambulate at postoperative day one after major abdominal surgery. Adopting a zero fluid balance approach, minimizing surgical duration and blood loss, timely removal of drains and catheters, and prioritizing postoperative pain management is recommended.
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Affiliation(s)
- Simachew Amogne Debas
- Department of Anesthesia, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Wubie Birlie Chekol
- Department of Anesthesia, College of Medicine and Health Science, Gondar University, Gondar, Ethiopia
| | - Mulualem Endeshaw Zeleke
- Department of Anesthesia, College of Medicine and Health Science, Gondar University, Gondar, Ethiopia
| | - Abraham Tarekegn Mersha
- Department of Anesthesia, College of Medicine and Health Science, Gondar University, Gondar, Ethiopia
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Lee G, Patel HV, Srivastava A, Ghodoussipour S. Updates on enhanced recovery after surgery for radical cystectomy. Ther Adv Urol 2022; 14:17562872221109022. [PMID: 35844831 PMCID: PMC9280843 DOI: 10.1177/17562872221109022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.
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Affiliation(s)
- Grace Lee
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Hiren V. Patel
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Arnav Srivastava
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, Room 4561, New Brunswick, NJ 08903, USA
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Cagini L, Andolfi M, Potenza R, Ceccarelli S, Vannucci J, Berti V, Reboldi G, Puma F. Microalbuminuria assessment after thoracic surgery: Early identification of complication risks. CLINICAL RESPIRATORY JOURNAL 2020; 14:564-570. [PMID: 32056371 DOI: 10.1111/crj.13169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 01/23/2020] [Accepted: 02/10/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Microalbuminuria (MA) is considered a reflection of systemic capillary leak and an early marker of acute stress reaction to the surgical insult, proportional to the severity of the initiating condition and predictive of the individual response to surgical stress. OBJECTIVES We conducted a prospective study to assess for the variation of MA within 4 days after thoracic surgery. We correlated observed MA levels with both their respective PaO2 /FiO2 respiratory ratio and the onset of postoperative complications. METHODS This single-centre study enrolled 255 consecutive patients having an American Society of Anaesthesiologists (ASA) score ≤ 3. The mean age was 62 years with 67% male. All patients were scheduled for elective pulmonary resection. MA was measured in urine samples as the albumin-to-creatinine ratio (A/C), prior to, at and after extubation up to 96 hours. PaO2 /FiO2 was measured at extubation and on the first postoperative day. RESULTS Overall, preoperative A/C levels resulted normal, with a significant average increase at extubation which peaked 6 hours later (P < 0.001). Larger postoperative A/C increases were observed in patients who developed postoperative complications, compared to those without these complications (P < 0.019). Moreover, patients undergoing major open pulmonary resections had larger postoperative A/C increases, compared to those undergoing minor video-assisted thoracic surgery resections (P < 0.006). At the time of extubation, A/C was inversely related to the PaO2 /FiO2 ratio (r = -0.25; P = 0.038). Peak A/C > 61 mg/g (P = 0.0003) was associated with postoperative cardio-pulmonary complications (OR 3.85; P = 0.003). CONCLUSION Within 6 hours after extubation, MA assessment may be a rapid and relatively inexpensive method for better predicting perioperative risk in an ASA score ≤ 3 population.
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Affiliation(s)
- Lucio Cagini
- Department of Medicine, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy.,Thoracic Surgery Unit, Department of Surgical Science, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Marco Andolfi
- Department of Medicine, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy.,Thoracic Surgery Unit, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Rossella Potenza
- Thoracic Surgery Unit, Department of Surgical Science, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Silvia Ceccarelli
- Thoracic Surgery Unit, Department of Surgical Science, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Jacopo Vannucci
- Thoracic Surgery Unit, Department of Surgical Science, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Valeria Berti
- Thoracic Surgery Unit, Department of Surgical Science, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Gianpaolo Reboldi
- Department of Medicine, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Francesco Puma
- Thoracic Surgery Unit, Department of Surgical Science, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
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Matsuyama S, Miki R, Kittaka H, Nakayama H, Kikuta S, Ishihara S, Nakayama S. Preoperative fluid restriction for trauma patients with hemorrhagic shock decreases ventilator days. Acute Med Surg 2018; 5:154-159. [PMID: 29657727 PMCID: PMC5891115 DOI: 10.1002/ams2.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/05/2017] [Indexed: 11/05/2022] Open
Abstract
Aim In recent years, with the concept of damage control resuscitation, hemostasis and preoperative fluid restriction have been carried out, but there is controversy regarding the effectiveness of fluid restriction. Methods From April 2007 to March 2013, 101 trauma patients presented with hemorrhagic shock (systolic blood pressure ≤90 mmHg) at the prehospital or emergency department and were admitted to Hyogo Emergency Medical Center (Hyogo, Japan). They underwent emergency hemostasis by surgery and transcatheter arterial embolization. We compared two groups in a historical cohort study, the aggressive fluid resuscitation (AR) group, which included 59 cases treated in the period April 2007-March 2010, and the fluid restriction (FR) group, which included 42 cases treated in the period April 2010-March 2013. Results There was no difference between both groups in patient background (heart rate, 110 b.p.m.; systolic blood pressure, 70 mmHg). The Injury Severity Score was 34 (AR) versus 38 (FR) (not significant). Preoperative infusion volume of crystalloid significantly decreased, from 2310 mL (AR) to 1025 mL (FR) (P ≤ 0.01). There was no difference in mortality (36% [AR] versus 41% [FR]). Ventilator days significantly decreased, from 8.5 days (AR) to 5.5 days (FR) (P = 0.02). Conclusions Preoperative fluid restriction for trauma patients with hemorrhagic shock did not improve mortality, but it decreased ventilator days by reducing the perioperative plus water balance and it might contribute to perioperative intensive care.
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Exploration of Fluid Dynamics in Perioperative Patients Using Bioimpedance Analysis. J Gastrointest Surg 2016; 20:1020-7. [PMID: 26715560 DOI: 10.1007/s11605-015-3063-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/17/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Perioperative fluid restriction is advocated to reduce complications after major surgeries. Current methods of monitoring body fluids rely on indirect volume markers that may at times be inadequate. In our study, bioimpedance analysis (BIA) was used to explore fluid dynamics, in terms of intercompartmental shift, of perioperative patients undergoing operation for hepato-pancreato-biliary (HPB) diseases. METHODS A retrospective review was conducted, examining 36 patients surgically treated for HPB diseases between March 2010 and August 2012. Body fluid compartments were estimated via BIA at baseline (1 day prior to surgery), immediately after surgery, and on postoperative day 1, recording fluid balance during and after procedures. Patients were stratified by net fluid status as balanced (≤500 mL) or imbalanced (>550 mL) and outcomes of BIA compared. RESULTS Mean net fluid balance volumes in balanced (n = 16) and imbalanced (n = 20) patient subsets were 231.41 ± 155.44 and 1050.18 ± 548.77 mL, respectively. Total body water (TBW) (p = 0.091), extracellular water (ECW) (p = 0.125), ECW/TBW (p = 0.740), and intracellular water (ICW) (p = 0.173) did not fluctuate significantly in fluid-balanced patients. Although TBW (p = 0.069) in fluid-imbalanced patients did not change significantly (relative to baseline), ECW (p = 0.001), ECW/TBW (p = 0.019), and ICW (p = 0.012) showed significant postoperative increases. CONCLUSION The exploration of fluid dynamics using BIA has shown importance of balanced fluid management during perioperative period. Increased ECW/TBW in fluid-imbalanced patients suggests possible causality for the development of ascites or fluid collections during postoperative period in patients undergoing HPB operations.
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Whitehead K, Cortes Y, Eirmann L. Gastrointestinal dysmotility disorders in critically ill dogs and cats. J Vet Emerg Crit Care (San Antonio) 2016; 26:234-53. [PMID: 26822390 DOI: 10.1111/vec.12449] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 07/21/2015] [Accepted: 08/30/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review the human and veterinary literature regarding gastrointestinal (GI) dysmotility disorders in respect to pathogenesis, patient risk factors, and treatment options in critically ill dogs and cats. ETIOLOGY GI dysmotility is a common sequela of critical illness in people and small animals. The most common GI motility disorders in critically ill people and small animals include esophageal dysmotility, delayed gastric emptying, functional intestinal obstruction (ie, ileus), and colonic motility abnormalities. Medical conditions associated with the highest risk of GI dysmotility include mechanical ventilation, sepsis, shock, trauma, systemic inflammatory response syndrome, and multiple organ failure. The incidence and pathophysiology of GI dysmotility in critically ill small animals is incompletely understood. DIAGNOSIS A presumptive diagnosis of GI dysmotility is often made in high-risk patient populations following detection of persistent regurgitation, vomiting, lack of tolerance of enteral nutrition, abdominal pain, and constipation. Definitive diagnosis is established via radioscintigraphy; however, this diagnostic tool is not readily available and is difficult to perform on small animals. Other diagnostic modalities that have been evaluated include abdominal ultrasonography, radiographic contrast, and tracer studies. THERAPY Therapy is centered at optimizing GI perfusion, enhancement of GI motility, and early enteral nutrition. Pharmacological interventions are instituted to promote gastric emptying and effective intestinal motility and prevention of complications. Promotility agents, including ranitidine/nizatidine, metoclopramide, erythromycin, and cisapride are the mainstays of therapy in small animals. PROGNOSIS The development of complications related to GI dysmotility (eg, gastroesophageal reflux and aspiration) have been associated with increased mortality risk. Institution of prophylaxic therapy is recommended in high-risk patients, however, no consensus exists regarding optimal timing of initiating prophylaxic measures, preference of treatment, or duration of therapy. The prognosis for affected small animal patients remains unknown.
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Affiliation(s)
- KimMi Whitehead
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, NJ, 07452
| | - Yonaira Cortes
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, NJ, 07452
| | - Laura Eirmann
- the Nutrition Department (Eirmann), Oradell Animal Hospital, Paramus, NJ, 07452
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Wuethrich PY, Burkhard FC. Improved perioperative outcome with norepinephrine and a restrictive fluid administration during open radical cystectomy and urinary diversion. Urol Oncol 2015; 33:66.e21-4. [DOI: 10.1016/j.urolonc.2014.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/22/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
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Restrictive Deferred Hydration Combined with Preemptive Norepinephrine Infusion during Radical Cystectomy Reduces Postoperative Complications and Hospitalization Time. Anesthesiology 2014; 120:365-77. [DOI: 10.1097/aln.0b013e3182a44440] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
Anesthetics and neuraxial anesthesia commonly result in vasodilation/hypotension. Norepinephrine counteracts this effect and thus allows for decreased intraoperative hydration. The authors investigated whether this approach could result in reduced postoperative complication rate.
Methods:
In this single-center, double-blind, randomized, superiority trial, 166 patients undergoing radical cystectomy and urinary diversion were equally allocated to receive 1 ml·kg−1·h−1 of balanced Ringer’s solution until the end of cystectomy and then 3 ml·kg−1·h−1 until the end of surgery combined with preemptive norepinephrine infusion at an initial rate of 2 µg·kg−1·h−1 (low-volume group; n = 83) or 6 ml·kg−1·h−1 of balanced Ringer’s solution throughout surgery (control group; n = 83). Primary outcome was the in-hospital complication rate. Secondary outcomes were hospitalization time, and 90-day mortality.
Results:
In-hospital complications occurred in 43 of 83 patients (52%) in the low-volume group and in 61 of 83 (73%) in the control group (relative risk, 0.70; 95% CI, 0.55–0.88; P = 0.006). The rates of gastrointestinal and cardiac complications were lower in the low-volume group than in the control group (5 [6%] vs. 31 [37%]; relative risk, 0.16; 95% CI, 0.07–0.39; P < 0.0001 and 17 [20%] vs. 39 [48%], relative risk, 0.43; 95% CI, 0.26–0.60; P = 0.0003, respectively). The median hospitalization time was 15 days [range, 11, 27d] in the low-volume group and 17 days [11, 95d] in the control group (P = 0.02). The 90-day mortality was 0% in the low-volume group and 4.8% in the control group (P = 0.12).
Conclusion:
A restrictive-deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy and urinary diversion significantly reduced the postoperative complication rate and hospitalization time.
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Colorectal surgery in cirrhotic patients. ScientificWorldJournal 2014; 2014:239293. [PMID: 24550693 PMCID: PMC3914319 DOI: 10.1155/2014/239293] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 11/07/2013] [Indexed: 02/07/2023] Open
Abstract
Patients with cirrhosis have a greater risk of morbidity and mortality following colorectal surgery. Therefore, preoperative medical optimization and risk assessment using criteria such as the MELD score are vital in preventing complications. Some risk factors include age, urgency of surgery, and ASA score. Postoperative morbidity and mortality are related to portal hypertension, ascites, infection, and anastomotic and stomal complications. This review highlights the assessment of risk and perioperative management of cirrhotic patients undergoing colorectal surgery.
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The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr 2013; 33:6-13. [PMID: 24308897 DOI: 10.1016/j.clnu.2013.11.010] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 11/12/2013] [Accepted: 11/15/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND & AIMS Age-related physiological changes predispose even the healthy older adult to fluid and electrolyte abnormalities which can cause morbidity and mortality. The aim of this narrative review is to highlight key aspects of age-related pathophysiological changes that affect fluid and electrolyte balance in older adults and underpin their importance in the perioperative period. METHODS The Web of Science, MEDLINE, PubMed and Google Scholar databases were searched using key terms for relevant studies published in English on fluid balance in older adults during the 15 years preceding June 2013. Randomised controlled trials and large cohort studies were sought; other studies were used when these were not available. The bibliographies of extracted papers were also searched for relevant articles. RESULTS Older adults are susceptible to dehydration and electrolyte abnormalities, with causes ranging from physical disability restricting access to fluid intake to iatrogenic causes including polypharmacy and unmonitored diuretic usage. Renal senescence, as well as physical and mental decline, increase this susceptibility. Older adults are also predisposed to water retention and related electrolyte abnormalities, exacerbated at times of physiological stress. Positive fluid balance has been shown to be an independent risk factor for morbidity and mortality in critically ill patients with acute kidney injury. CONCLUSIONS Age-related pathophysiological changes in the handling of fluid and electrolytes make older adults undergoing surgery a high-risk group and an understanding of these changes will enable better management of fluid and electrolyte therapy in the older adult.
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Hughes S, Leary A, Zweizig S, Cain J. Surgery in elderly people: Preoperative, operative and postoperative care to assist healing. Best Pract Res Clin Obstet Gynaecol 2013; 27:753-65. [DOI: 10.1016/j.bpobgyn.2013.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 01/14/2013] [Accepted: 02/07/2013] [Indexed: 11/28/2022]
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Gouveia V, Marcelino P, Reuter DA. The role of transesophageal echocardiography in the intraoperative period. Curr Cardiol Rev 2013; 7:184-96. [PMID: 22758616 PMCID: PMC3263482 DOI: 10.2174/157340311798220511] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 02/18/2011] [Accepted: 02/21/2011] [Indexed: 12/17/2022] Open
Abstract
The goal of hemodynamic monitoring and management during major surgery is to guarantee adequate organ perfusion, a major prerequisite for adequate tissue oxygenation and thus, end-organ function. Further, hemodynamic monitoring should serve to prevent, detect, and to effectively guide treatment of potentially life-threatening hemodynamic events, such as severe hypovolemia due to hemorrhage, or cardiac failure. The ideal monitoring device does not exist, but some conditions must be met: it should be easy and operator-independently to use; it should provide adequate, reproducible information in real time. In this review we discuss in particular the role of intraoperative use of transesophageal echocardiography (TOE). Although TOE has gained special relevance in cardiac surgery, its role in major non cardiac surgery is still to be determined. We particularly focus on its ability to provide measurements of cardiac output (CO), and its role to guide fluid therapy. Within the last decade, concepts oriented on optimizing stroke volume and cardiac output mainly by fluid administration and guided by continuous monitoring of cardiac output or so called functional parameters of cardiac preload gained particular attention. Although they are potentially linked to an increased amount of fluid infusion, recent data give evidence that such pre-emptive concepts of hemodynamic optimization result in a decrease in morbidity and mortality. As TOE allows a real time direct visualization of cardiac structures, other potentially important advantages of its use also outside the cardiac surgery operation room can be postulated, namely the ability to evaluate the anatomical and functional integrity of the left and the right heart chambers. Finally, a practical approach to TOE monitoring is presented, based on a local experience.
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Affiliation(s)
- Veronica Gouveia
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Itzehoe, Germany.
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Xie YB, Wang CF, Zhao DB, Shan Y, Bai XF, Sun YM, Chen YT, Zhao P, Tian YT. Risk factors associated with postoperative hospital stay after pancreaticoduodenectomy: a retrospective study. Chin Med J (Engl) 2013; 126:3685-3689. [PMID: 24112164 DOI: 10.3760/cma.j.issn.0366-6999.20130826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
Abstract
BACKGROUND Postoperative hospital stay after pancreaticoduodenectomy (PD) is relatively longer than after other gastrointestinal operations. The aim of the current study was to investigate the risk factors associated with prolonged hospital stay after PD. METHODS Patients who had PD at the Cancer Hospital of Chinese Academy of Medical Sciences between December 2008 and November 2012 were selected for this retrospective study. Clinical and pathological data were collected and analyzed. The primary outcome was postoperative length of stay. Normal discharge or recovery was defined as a postoperative hospital stay of no more than 10 days; otherwise it was defined as delayed discharge or recovery (including hospital death). RESULTS A total of 152 patients were enrolled in the present study. Postoperative hospital stay was (19.7 ± 7.7) days (range 7-57). Of the 152 patients, 67 were discharged within the normal time and 85 had delayed discharge. Postoperative complications occurred in 62.5% (95/152), and the mortality rate was 3.29% (5/152). Multiple regression analysis showed that delayed discharge was significantly associated with postoperative complications (adjusted odds ratio (OR) 10.40, 95% confidence interval (CI) 3.58-30.22), age (adjusted OR 4.09, 95% CI 1.16-14.39), body mass index (BMI) (adjusted OR 4.40, 95% CI 1.19-16.23), surgical procedure (adjusted OR 26.14, 95% CI 4.94-153.19), blood transfusion (adjusted OR 7.68, 95% CI 2.09-28.27), and fluid input (adjusted OR 3.47, 95% CI 1.24-11.57). CONCLUSIONS Postoperative complications increase the time to postoperative hospital discharge. The length of hospital stay after PD is also associated with age, BMI, blood transfusion, surgical procedure, and fluid input. Further studies with more patients are needed in future.
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Affiliation(s)
- Yi-bin Xie
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
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Papagiannopoulos IA, Sideris VI, Boschmann M, Koutsoni OS, Dotsika EN. Anthropometric, Hemodynamic, Metabolic, and Renal Responses during 5 Days of Food and Water Deprivation. ACTA ACUST UNITED AC 2013; 20:427-33. [DOI: 10.1159/000357718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Gao T, Li N, Zhang JJ, Xi FC, Chen QY, Zhu WM, Yu WK, Li JS. Restricted intravenous fluid regimen reduces the rate of postoperative complications and alters immunological activity of elderly patients operated for abdominal cancer: a randomized prospective clinical trail. World J Surg 2012; 36:993-1002. [PMID: 22402971 DOI: 10.1007/s00268-012-1516-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Perioperative fluid restriction can lead to better clinical outcomes and reduced complications. However, whether perioperative fluid restriction can alter the patient's postoperative cellular immunity is unknown. Therefore, a randomized, prospective clinical study was designed to determine whether fluid restriction improves immunological outcome in elderly patients who undergo gastrointestinal surgery for cancer removal. METHODS A total of 179 patients aged 65 years or older were recruited for the study and were randomly assigned to receive the restricted fluid regimen (R group) or the standard fluid regimen (S group). Postoperative T-lymphocyte subpopulations (CD3(+), CD4(+), and CD8(+)) frequencies and monocyte HLA-DR expression was investigated. Perioperative complications and cellular immunity changes were analyzed comparatively between the two groups. RESULTS The restricted intravenous fluid regimen was associated with significantly less postoperative complications (1.5 complications/patient vs. S group: 2.2 complications/patient), especially for infection complications (15% vs. S group: 27%, p = 0.04). Circulating CD3(+) T-cells were suppressed after surgery in both treatment groups, but the cell frequency (cell/μL) was higher in the R group (746 vs. S group: 480 at postoperative day (POD) 2, p = 0.022; 878 vs. 502 at POD 3, p = 0.005; 892 vs. 674 at POD 5, p = 0.042). Similarly, the HLA-DR expression (% of all T cells) in monocytes were decreased in both groups, but the expression remained higher in the R group (66.20 vs. S group: 51.97 at POD 1, p = 0.029; 68.19 vs. 51.26 at POD 2, p = 0.039; 72.19 vs. 57.45 at POD 3, p = 0.014; 73.92 vs. 60.46 at POD 5, p = 0.036). Multivariate analysis suggested that perioperative CD3(+) T cell changes were associated with the development of postoperative complications [odds ratio (OR) = 1.963; 95% confidence interval (CI) 1.019-3.782; p = 0.044] and postoperative infections (OR = 3.106; 95% CI 1.302-7.406; p = 0.011). CONCLUSIONS In elderly gastrointestinal cancer patients, cellular immunity is better preserved by the perioperative fluid restriction regimen. The better preserved cellular immunological function is correlated with a reduced perioperative complications rate.
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Affiliation(s)
- Tao Gao
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Ning Li
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Juan-Juan Zhang
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Feng-Chan Xi
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Qi-Yi Chen
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Wei-Ming Zhu
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Wen-Kui Yu
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China.
| | - Jie-Shou Li
- Department of General Surgery, Nanjing General Hospital of Nanjing Military Command Affiliated to Medical College of Nanjing University, Nanjing, 210002, Jiangsu Province, China
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Jiang GQ, Chen P, Bai DS, Tan JW, Su H, Peng MH. Individualized peri-operative fluid therapy facilitating early-phase recovery after liver transplantation. World J Gastroenterol 2012; 18:1981-6. [PMID: 22563181 PMCID: PMC3337576 DOI: 10.3748/wjg.v18.i16.1981] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 12/22/2011] [Accepted: 12/31/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the correlation between peri-operative fluid therapy and early-phase recovery after liver transplantation (LT) by retrospectively reviewing 102 consecutive recipients.
METHODS: Based on whether or not the patients had pulmonary complications, the patients were categorized into non-pulmonary and pulmonary groups. Twenty-eight peri-operative variables were analyzed in both groups to screen for the factors related to the occurrence of early pulmonary complications.
RESULTS: The starting hemoglobin (Hb) value, an intra-operative transfusion > 100 mL/kg, and a fluid balance ≤ -14 mL/kg on the first day and the second or third day post-operatively were significant factors for early pulmonary complications. The extubation time, time to initial passage of flatus, or intensive care unit length of stay were significantly prolonged in patients who had not received an intra-operative transfusion ≤ 100 mL/kg or a fluid balance ≤ -14 mL/kg on the first day and the second or the third day post-operatively. Moreover, these patients had poorer results in arterial blood gas analysis.
CONCLUSION: It is important to offer a precise and individualized fluid therapy during the peri-operative period to the patients undergoing LT for cirrhosis-associated hepatocellular carcinoma.
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Corcoran T, Rhodes JEJ, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg 2012; 114:640-51. [PMID: 22253274 DOI: 10.1213/ane.0b013e318240d6eb] [Citation(s) in RCA: 290] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Both "liberal" and "goal-directed" (GD) therapy use a large amount of perioperative fluid, but they appear to have very different effects on perioperative outcomes. We sought to determine whether one fluid management strategy was superior to the others. METHODS We selected randomized controlled trials (RCTs) on the use of GD or restrictive versus liberal fluid therapy (LVR) in major adult surgery from MEDLINE, EMBASE, PubMed (1951 to April 2011), and Cochrane controlled trials register without language restrictions. Indirect comparison between the GD and LVR strata was performed. RESULTS A total of 3861 patients from 23 GD RCTs (median sample size = 90, interquartile range [IQR] 57 to 109) and 1160 patients from 12 LVR RCTs (median sample size = 80, IQR36 to 151) were considered. Both liberal and GD therapy used more fluid compared to their respective comparative arm, but their effects on outcomes were very different. Patients in the liberal group of the LVR stratum had a higher risk of pneumonia (risk ratio [RR] 2.2, 95% confidence interval [CI] 1.0 to 4.5), pulmonary edema (RR 3.8, 95% CI 1.1 to 13), and a longer hospital stay than those in the restrictive group (mean difference [MD] 2 days, 95% CI 0.5 to 3.4). Using GD therapy also resulted in a lower risk of pneumonia (RR 0.7, 95% CI 0.6 to 0.9) and renal complications (0.7, 95% CI 0.5 to 0.9), and a shorter length of hospital stay (MD 2 days, 95% CI 1 to 3) compared to not using GD therapy. Liberal fluid therapy was associated with an increased length of hospital stay (4 days, 95% CI 3.4 to 4.4), time to first bowel movement (2 days, 95% CI 1.3 to 2.3), and risk of pneumonia (RR ratio 3, 95% CI 1.8 to 4.8) compared to GD therapy. CONCLUSION Perioperative outcomes favored a GD therapy rather than liberal fluid therapy without hemodynamic goals. Whether GD therapy is superior to a restrictive fluid strategy remains uncertain.
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Affiliation(s)
- Tomas Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Level 4, North Block, Wellington Street, Perth, Western Australia.
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Affiliation(s)
- Stephan R Thilen
- Department of Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Ave., Box 359724, Room 7EH74, Seattle, WA 98104, USA.
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Melis M, Marcon F, Masi A, Sarpel U, Miller G, Moore H, Cohen S, Berman R, Pachter HL, Newman E. Effect of intra-operative fluid volume on peri-operative outcomes after pancreaticoduodenectomy for pancreatic adenocarcinoma. J Surg Oncol 2011; 105:81-4. [DOI: 10.1002/jso.22048] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 07/05/2011] [Indexed: 01/04/2023]
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21
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Surgical intensive care unit - essential for good outcome in major abdominal surgery? Langenbecks Arch Surg 2011; 396:417-28. [PMID: 21369847 DOI: 10.1007/s00423-011-0758-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 02/16/2011] [Indexed: 02/03/2023]
Abstract
PURPOSE Surgical intensive care units (ICU) play a pivotal role in perioperative care of patients undergoing major abdominal surgery. Differences in quality of care provided by medical staff in ICUs may be linked to improved outcome. This review aims to elucidate the relationship between quality of care at various ICUs and patient outcome, with the ultimate aim of identifying key measures for achieving optimal outcome. METHODS We reviewed the literature in PubMed to identify current ICU structural and process concepts and variations before evaluating their respective impact on quality of care and outcome in major abdominal surgery. RESULTS ICU leadership, nurse and physician staffing, and provision of an intermediate care unit are important structural components that impact on patients' outcome. A "mixed ICU" model, with intensivists primarily caring for the patients in close cooperation with the primary physician, seems to be the most effective ICU model. Surgeons' involvement in intensive care is essential, and a close cooperation between surgeons and anesthesiologists is vital for good outcome. Current general process concepts include early mobilization, enteral feeding, and optimal perioperative fluid management. To decrease failure-to-rescue rates, procedure-specific intensive care processes are particularly focused on the early detection, assessment, and timely and consistent treatment of complications. CONCLUSIONS Several structures and processes in the ICU have an impact on outcome in major abdominal surgery. ICU structures and care processes connected with optimal outcome could be transmitted to other centers to improve outcome, independent of procedure volume.
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A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc 2010; 69:488-98. [PMID: 20515521 DOI: 10.1017/s0029665110001734] [Citation(s) in RCA: 198] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The terminology used for describing intervention groups in randomised controlled trials (RCT) on the effect of intravenous fluid on outcome in abdominal surgery has been imprecise, and the lack of standardised definitions of the terms 'standard', 'restricted' and 'liberal' has led to some confusion and difficulty in interpreting the literature. The aims of this paper were to clarify these definitions and to use them to perform a meta-analysis of nine RCT on primarily crystalloid-based peri-operative intravenous fluid therapy in 801 patients undergoing elective open abdominal surgery. Patients who received more or less fluids than those who received a 'balanced' amount were considered to be in a state of 'fluid imbalance'. When 'restricted' fluid regimens were compared with 'standard or liberal' fluid regimens, there was no difference in post-operative complication rates (risk ratio 0.83 (95% CI 0.49, 1.39, P = 0.47) [corrected] or length of hospital stay (weighted mean difference (WMD) - 1.77 (95% CI - 4.36, 0.81) d, P = 0.18). However, when the fluid regimens were reclassified and patients were grouped into those who were managed in a state of fluid 'balance' or 'imbalance', the former group had significantly fewer complications (risk ratio 0·59 (95% CI 0·44, 0·81), P=0·0008) and a shorter length of stay (WMD -3·44 (95% CI -6·33, -0·54) d, P=0·02) than the latter. Using imprecise terminology, there was no apparent difference between the effects of fluid-restricted and standard or liberal fluid regimens on outcome in patients undergoing elective open abdominal surgery. However, patients managed in a state of fluid balance fared better than those managed in a state of fluid imbalance.
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EISELE JASON, McCLARAN JANETKOVAK, RUNGE JEFFREYJ, HOLT DAVIDE, CULP WILLIAMT, LIU SERENA, LONG FENELLA, BERGMAN PHILIPJ. Evaluation of Risk Factors for Morbidity and Mortality after Pylorectomy and Gastroduodenostomy in Dogs. Vet Surg 2010; 39:261-7. [DOI: 10.1111/j.1532-950x.2009.00629.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Serclová Z, Dytrych P, Marvan J, Nová K, Hankeová Z, Ryska O, Slégrová Z, Buresová L, Trávníková L, Antos F. Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clin Nutr 2009; 28:618-24. [PMID: 19535182 DOI: 10.1016/j.clnu.2009.05.009] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 03/27/2009] [Accepted: 05/11/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Studies have shown the value of using fast-track postoperative recovery. Standard procedures (non-fast-track strategies) remain in common use for perioperative care. Few prospective reports exist on the outcome of fast-tracking in Central Europe. The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection. PATIENTS AND METHODS One hundred and five patients with ASA score I-II scheduled for open intestinal resection in the period April 2005-December 2007 were randomly selected for the fast-track group (FT) and non-fast-track group (non-FT). A designed protocol was used in the FT group with the emphasis on an interdisciplinary approach. The control group (non-FT) was treated by standard established procedures. Postoperative pain, rehabilitation, gastrointestinal functions, postoperative complications, and post-op length of stay were recorded. RESULTS Of 105 patients, 103 were statistically analyzed. Patients in the FT group (n=51) and non-FT group (n=52) did not differ in age, surgical diagnosis, or procedure. The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions (bowel movement after 1.3 days vs. 3.1, p<0.001). Food tolerance was significantly better in the FT group and rehabilitation was also faster. Hospital stay was shorter in the FT group - median seven days (95% CI 7.0-7.7) versus ten days (95% CI 9.5-11.3) in non-FT (p<0.001). Postoperative complications within 30 postoperative days were also significantly lower in the FT group (21.6 vs. 48.1%, p=0.003). There were no deaths and no patients were readmitted within 30 days. CONCLUSIONS Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay. We conclude that the FT strategy is safe and effective in improving postoperative outcomes.
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Affiliation(s)
- Zuzana Serclová
- Surgical Department, University Hospital Bulovka, Prague, Czech Republic.
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Schober P, Loer SA, Schwarte LA. Perioperative hemodynamic monitoring with transesophageal Doppler technology. Anesth Analg 2009; 109:340-53. [PMID: 19608800 DOI: 10.1213/ane.0b013e3181aa0af3] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Invasive cardiac output (CO) monitoring, traditionally performed with transpulmonary thermodilution techniques, is usually reserved for high-risk patients because of the inherent risks of these methods. In contrast, transesophageal Doppler (TED) technology offers a safe, quick, and less invasive method for routine measurements of CO. After esophageal insertion and focusing of the probe, the Doppler beam interrogates the descending aortic blood flow. On the basis of the measured frequency shift between the emitted and received ultrasound frequency, blood flow velocity is determined. From this velocity, combined with the simultaneously measured systolic ejection time, CO and other advanced hemodynamic variables can be calculated, including estimations of preload, afterload, and contractility. Numerous studies have validated TED-derived CO against reference methods. Although the agreement of CO values between TED and the reference methods is limited (95% limits of agreement: median 4.2 L/min, interquartile range 3.3-5.0 L/min), TED has been shown to accurately follow changes of CO over time, making it a useful device for trend monitoring. TED can be used to guide perioperative intravascular volume substitution and therapy, with vasoactive or inotropic drugs. Various studies have demonstrated a reduced postoperative morbidity and shorter length of hospital stay in patients managed with TED compared with conventional clinical management, suggesting that it may be a valuable supplement to standard perioperative monitoring. We review not only the technical basis of this method and its clinical application but also its limitations, risks, and contraindications.
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Affiliation(s)
- Patrick Schober
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
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Risk of death after emergency repair of abdominal wall hernias. Still waiting for improvement. Langenbecks Arch Surg 2009; 395:551-6. [PMID: 19513743 DOI: 10.1007/s00423-009-0515-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 05/27/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE The precise importance of factors affecting morbidity and mortality in patients with complicated abdominal wall hernias undergoing emergency surgical repair has been not completely elucidated. PATIENTS AND METHODS A retrospective multicentric study of all patients (n = 402) with abdominal wall hernia who underwent urgent operations over 1-year period was conducted in ten hospitals. Logistic regression analysis was used to evaluate variables that affect morbidity and mortality. RESULTS Thirty-five percent of patients had inguinal hernia, 22% femoral hernia, 20% umbilical hernia, and 15% incisional hernia. Mesh repair was used in 92.5% of cases. Intestinal resection was required in 49 patients. Perioperative complications occurred in 130 patients, and 18 patients died (mortality rate 4.5%). Complications and mortality rate were significantly higher in the group of intestinal resection. Patients older than 70 years also showed more complications, required intestinal resection more frequently, and had a higher mortality rate than younger patients. In the logistic regression analysis, age over 70 years, intestinal resection, and American Society of Anesthesiologists (ASA) III/IV class emerged as independent predictors of a poor outcome. Based in our results, we propose a simple schema to calculate risk of death in these patients. CONCLUSION Using multivariate logistic regression analysis, probabilities of death after complicated abdominal wall hernia surgery are increased in patients with: age over 70 years, high ASA class, and associated intestinal resection. Guidelines should be developed to improve prognosis in these patients.
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Using ventilation-induced plethysmographic variations to optimize patient fluid status. Curr Opin Anaesthesiol 2008; 21:772-8. [DOI: 10.1097/aco.0b013e32831504ca] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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