Hypotension during Fluid-restricted Abdominal Surgery

Hiltebrand, Luzius B.; Koepfli, E; Kimberger, Oliver; Sigurðsson, Gísli H.; Brandt, Sebastián

doi:10.1097/aln.0b013e31820bfc81

Cited by 61 publications

(24 citation statements)

References 29 publications

(37 reference statements)

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“…Furthermore, using an experimental model of abdominal surgery, Hiltebrand et al . found that treatment of hypotension with norepinephrine had no adverse effects on microcirculatory perfusion or tissue oxygen tension in the intestinal tract, proving that administering low to moderate doses of norepinephrine to increase perioperative blood pressure does not adversely affect peripheral tissue perfusion [35]. …”

Section: Discussionmentioning

confidence: 99%

Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

et al. 2014

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IntroductionAltered peripheral perfusion is strongly associated with poor outcome in critically ill patients. We wanted to determine whether repeated assessments of peripheral perfusion during the days following surgery could help to early identify patients that are more likely to develop postoperative complications.MethodsHaemodynamic measurements and peripheral perfusion parameters were collected one day prior to surgery, directly after surgery (D0) and on the first (D1), second (D2) and third (D3) postoperative days. Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient (Tskin-diff). Generalized linear mixed models were used to predict severe complications within ten days after surgery based on Clavien-Dindo classification.ResultsWe prospectively followed 137 consecutive patients, from among whom 111 were included in the analysis. Severe complications were observed in 19 patients (17.0%). Postoperatively, peripheral perfusion parameters were significantly altered in patients who subsequently developed severe complications compared to those who did not, and these parameters persisted over time. CRT was altered at D0, and PPI and Tskin-diff were altered on D1 and D2, respectively. Among the different peripheral perfusion parameters, the diagnostic accuracy in predicting severe postoperative complications was highest for CRT on D2 (area under the receiver operating characteristic curve = 0.91 (95% confidence interval (CI) = 0.83 to 0.92)) with a sensitivity of 0.79 (95% CI = 0.54 to 0.94) and a specificity of 0.93 (95% CI = 0.86 to 0.97). Generalized mixed-model analysis demonstrated that abnormal peripheral perfusion on D2 and D3 was an independent predictor of severe postoperative complications (D2 odds ratio (OR) = 8.4, 95% CI = 2.7 to 25.9; D2 OR = 6.4, 95% CI = 2.1 to 19.6).ConclusionsIn a group of patients assessed following major abdominal surgery, peripheral perfusion alterations were associated with the development of severe complications independently of systemic haemodynamics. Further research is needed to confirm these findings and to explore in more detail the effects of peripheral perfusion–targeted resuscitation following major abdominal surgery.

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Section: Discussionmentioning

confidence: 99%

Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

et al. 2014

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“…In our analysis, however, vasopressor therapy and arterial lactate were similar in the SSC- and nSSC-groups. Recently, the administration of norepinephrine in pigs to achieve a mean arterial pressure of 75 mmHg compared with 60 mmHg in the control group did not reduce hepatic arterial blood flow, hepatic venous oxygen saturation, or mesenterial lactate concentration [39]. Furthermore, increasing norepinephrine to achieve a higher mean arterial pressure in vasodilatory shock after cardiac surgery or sepsis did not reduce intestinal mucosal perfusion, tissue oxygenation, or microvascular flow [40,41].…”

Section: Discussionmentioning

confidence: 99%

Abdominal obesity and prolonged prone positioning increase risk of developing sclerosing cholangitis in critically ill patients with influenza A-associated ARDS

et al. 2012

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BackgroundSecondary sclerosing cholangitis is a severe disease of the biliary tract. Over the last decade, several cases of sclerosing cholangitis in critically ill patients (SC-CIP) were reported. Reports in the literature so far are characterized by a wide variety of underlying causes of critical illness, thereby hindering a risk-factor analysis. We report on a homogenous cohort of critically ill patients with influenza A (H1N1) pneumonia and severe acute respiratory distress syndrome (ARDS), of whom a subgroup developed sclerosing cholangitis, allowing for probing of risk factors associated with SC-CIP.MethodsTwenty-one patients (5 female, 16 male, 46.3 ± 10.8 years) with severe ARDS due to H1N1 pneumonia were retrospectively divided into two groups, characterized by the presence (n = 5) and absence of SC-CIP (n = 16). A large array of clinical data, laboratory parameters, and multi-detector computed tomography-derived measures were compared.ResultsBoth patient groups showed severe pulmonary impairment. Severity of disease on admission day and during the first 14 days of treatment showed no difference. The patients developing SC-CIP had a higher body mass index (BMI) (37.4 ± 6.0 kg/m2 vs. 29.3 ± 6.8 kg/m2; P = 0.029) and a higher volume of intraperitoneal fat (8273 ± 3659 cm3 vs. 5131 ± 2268 cm3; P = 0.033) and spent a longer cumulative period in the prone position during the first 14 days (165 ± 117 h vs. 78 ± 61 h; P = 0.038).ConclusionOur results suggest that obesity, intraperitoneal fat volume, and a longer cumulative duration spent in the prone position may put patients with ARDS at risk of developing SC-CIP. These results lead us to propose that the prone position should be carefully deployed, particularly in abdominally obese patients, and that frequent checks be made for early hepatic dysfunction.

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“…70 However, several animal studies suggest that treatment of intraoperative hypotension with norepinephrine does not cause any reduction of gut blood flow in the presence of normovolemia. 71,72 An ideal fluid regimen for major procedures, including esophageal surgery, is individualized and optimizes cardiac output and oxygen delivery while avoiding excessive fluid administration. There is some evidence that fluid therapies designed to achieve individualized and specific flow-related hemodynamic endpoints such as stroke volume or cardiac index (collectively referred to as goal-directed fluid therapy) may provide a superior alternative to fixed regimens or those based on static measures of cardiac filling, such as central venous pressure, which do not predict fluid responsiveness or correlate with circulating blood volume after transthoracic esophagectomy.…”

Section: Fluids Inflammation and The Glycocalyxmentioning

confidence: 99%

Perioperative Lung Protection Strategies in One-lung and Two-lung Ventilation

Slinger¹

2015

ASA Refresher Courses in Anesthesiology

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Hypotension during Fluid-restricted Abdominal Surgery

Abstract: In this model of abdominal surgery in which clinical conditions were imitated as close as possible, treatment of perioperative hypotension with norepinephrine had no adverse effects on microcirculatory blood flow or tissue oxygen tension in the intestinal tract.

Cited by 61 publications

References 29 publications

Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

Abdominal obesity and prolonged prone positioning increase risk of developing sclerosing cholangitis in critically ill patients with influenza A-associated ARDS

Perioperative Lung Protection Strategies in One-lung and Two-lung Ventilation

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