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Intraoperative fluid administration is associated with perioperative outcomes in pancreaticoduodenectomy: a single center retrospective analysis.

ABSTRACT: Recent studies on perioperative fluid administration in patients undergoing major abdominal surgery have suggested that increased fluid loads are associated with worse perioperative outcomes. However, results of retrospective analyses of the relationship between intraoperative fluid (IOF) administration and perioperative outcomes in patients undergoing pancreaticoduodenectomy (PD) are conflicted. We sought to investigate this relationship in patients undergoing PD at our academic center.A retrospective analysis of 124 patients undergoing PD from 2007 to 2012 was performed. IOF administration rate (ml/kg/hr) was correlated with perioperative outcomes. Outcomes were also stratified by preoperative serum albumin level.Regression analyses were performed comparing independent perioperative variables, including IOF rate, to four outcomes variables: length of stay, severity of complications, number of complications per patient, and 30-day mortality. Both univariate and multivariate regression analyses showed IOF rate correlated with one or more perioperative outcomes. Patients with an albumin ? 3.0?g/dl who received more than the median IOF rate experienced more severe complications, while patients with an albumin >3.0?g/dl did not.Increased IOF administration is associated with worse perioperative outcomes in patients undergoing PD. Patients with low preoperative serum albumin levels (? 3.0?g/dl) may be a group particularly sensitive to volume overload.

SUBMITTER: Eng OS

PROVIDER: S-EPMC5481842 | biostudies-literature | 2013 Sep

REPOSITORIES: biostudies-literature

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Intraoperative fluid administration is associated with perioperative outcomes in pancreaticoduodenectomy: a single center retrospective analysis.

Eng Oliver S OS Goswami Julie J Moore Dirk D Chen Chunxia C Gannon Christopher J CJ August David A DA Carpizo Darren R DR

Journal of surgical oncology 20130801 4

<h4>Background</h4>Recent studies on perioperative fluid administration in patients undergoing major abdominal surgery have suggested that increased fluid loads are associated with worse perioperative outcomes. However, results of retrospective analyses of the relationship between intraoperative fluid (IOF) administration and perioperative outcomes in patients undergoing pancreaticoduodenectomy (PD) are conflicted. We sought to investigate this relationship in patients undergoing PD at our acade ...[more]

PMID: 23907788

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Project description:BackgroundWith increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes.Study designPatients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defined as the facility cost of single-use surgical items and instruments, plus facility charges for multiuse equipment. Multivariate logistic regression was used to test associations between ISC and patient outcomes using repeated measures at the surgeon level.ResultsThere were 249 patients who met inclusion criteria. Median ISC was $1,882 (interquartile range [IQR] $1,497 to $2,281). Case volume for 6 surgeons ranged from 18 to 66. Median surgeon-specific ISC ranged from $1,496 to $2,371. Greater case volume was associated with decreased ISC (p < 0.001). Overall, ISC was not predictive of postoperative complications (p = 0.702) or total hospitalization expenditures (p = 0.195). At the surgeon level, surgeon-specific ISC was not associated with the surgeon-specific incidence of severe complication or any wound infection (p > 0.227 for both), but was associated with delayed gastric emptying (p = 0.004) and postoperative pancreatic fistula (p < 0.001).ConclusionsIn a single-institution cohort of 249 pancreaticoduodenectomies, high-volume surgeons tended to be low-cost surgeons. Across the cohort, ISC was not associated with outcomes. At the surgeon level, associations were noted between ISC and complications, but these may be attributable to unmeasured differences in the postoperative management of patients. These findings suggest that quality improvement efforts to restructure resource use toward more cost-effective practice may not affect patient outcomes, although prospective monitoring of safety and effectiveness must be of the utmost concern.

Project description:Hypothermia due to anaesthetic-induced impairment of thermoregulatory control and exposure to a cool environment is common in surgical patients. Peripheral vasodilation due to neuroaxial blockade may aggravate hypothermia. There is few data on perioperative hypothermia in patients undergoing thoracic surgery under combined general and regional anesthesia. We reviewed all thoracic surgical patients between 2006 and 2011 to determine the incidence and extent of hypothermia with or without an epidural anesthesia and evaluated its effect.Around 339 patients underwent lung resection procedures with intraoperative forced-air warming: 197 with general and epidural anesthesia (GA?+?EPI), 199 with general anesthesia alone (GA). Statistical analyses were performed to determine the association between hypothermia (T?<?36°C) and transfusion requirements, length of stay (LOS) in the intensive care unit (ICU), hospital LOS, and in hospital mortality.The overall incidence of hypothermia was 64.3%. Multivariate regression analysis revealed three significant risk factors for the development of hypothermia: long induction time (P?=?.011), small body surface area (P?=?.003), and application of more fluid intraoperatively (P?<?.001). Factors determining the extent of hypothermia were: receiving an open thoracotomy (P?=?.009), placement and use of an epidural catheter (P?=?.002), and a lower body mass index (BMI) (P?<?.001). Additional epidural anesthesia reduced core temperature by 0.26°C (95% CI -0.414 to -0.095°C, P?<?.05). There was no difference in transfusion requirements, ICU LOS or mortality between both groups. Hospital LOS was longer in patients with hypothermia.More than half of all thoracic patients suffered from hypothermia. A long induction time, small body surface area, and large intraoperative fluid application were independent risk factors for the development of perioperative hypothermia. Additional epidural anesthesia to general anesthesia did not increase the incidence of hypothermia but decreased body core temperature to an-albeit not clinically significant-degree. Patients scheduled for thoracic surgery will probably benefit from an additional period of prewarming prior to induction to reduce the high incidence of perioperative hypothermia.

Project description:We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. "precision" fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.

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Intraoperative fluid administration is associated with perioperative outcomes in pancreaticoduodenectomy: a single center retrospective analysis.

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Intraoperative fluid administration is associated with perioperative outcomes in pancreaticoduodenectomy: a single center retrospective analysis.

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