Intrathecal Analgesia and Restrictive Perioperative Fluid Management within Enhanced Recovery Pathway: Hemodynamic Implications

Hübner, Martin; Lovely, Jenna K.; Huebner, Marianne; Slettedahl, Seth W.; Jacob, Adam K.; Larson, David W.

doi:10.1016/j.jamcollsurg.2013.02.011

Cited by 45 publications

(37 citation statements)

References 49 publications

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“… retrieval of the nasogastric tube (NGT) by the end of the procedure; multimodal opioid‐sparing pain management with preferred use of intrathecal analgesia and nonsteroidal anti‐inflammatory drugs; postoperative nausea and vomiting prophylaxis (systematic preoperative gabapentin and celecoxib administration as per January 2014); restrictive intra‐operative fluid management, in line with the recommendations of the American Society of Enhanced Recovery ; and early re‐alimentation and ambulation. …”

Section: Methodsmentioning

confidence: 99%

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Comparison of recovery and outcome after left and right colectomy

et al. 2019

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Aim The present study aimed to compare functional recovery and surgical outcomes after left and right colectomies. Method Consecutive elective left and right colon resections for benign and malignant indications, performed between 2011 and 2016 and recorded in a prospectively maintained enhanced recovery database, were analysed. Demographic and surgical items, as well as functional recovery and 30‐day complications, were compared between left‐sided and right‐sided colectomies. Multivariable analysis was performed to identify risk factors for postoperative ileus (POI). Results In total, 1001 left and 1041 right colectomies were comparable regarding demographic factors; only body mass index (BMI) was higher in patients undergoing left‐sided resections (> 30 kg/m2: 33% vs 27%, P = 0.004). Malignancy (29% vs 67%, P < 0.001) and Crohn's disease (1% vs 31%, P < 0.001) were preponderant in right colectomies, whereas diverticular disease (68% vs 1%, P < 0.001) was the most common indication for left colectomy. Compliance with the enhanced recovery pathway (ERP) was comparable. While the minimally invasive approach was the preferred approach for both sides (61% vs 64%, P = 0.158), left colectomies took longer (180 ± 80 min vs 150 ± 70 min, P < 0.001), needed more perioperative fluids (3.1 ± 1.4 l vs 2.7 ± 1.5 l, P < 0.001) and resulted in greater postoperative weight gain (3.9 ± 6.5 kg vs 2.6 ± 6 kg, P = 0.025). Crohn's disease (OR = 2.64, 95% CI: 1.27–5.46) and fluid overload (OR = 2.02, 95% CI: 1.06–3.82) were independent risk factors for POI. Conclusion Despite equal ERP compliance, postoperative ileus was higher after right‐sided colectomies. This finding was associated with Crohn's disease and fluid overload.

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Section: Methodsmentioning

confidence: 99%

“…• multimodal opioid-sparing pain management with preferred use of intrathecal analgesia [10] and nonsteroidal anti-inflammatory drugs;…”

Section: Surgical and Perioperative Carementioning

confidence: 99%

Comparison of recovery and outcome after left and right colectomy

et al. 2019

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“…82 Within an ERAS protocol, postoperative hypotension and low UOP are common within the first 24 hr, whereas renal dysfunction is extremely rare. 83 Therefore, in the absence of other concerns, detrimental postoperative fluid overload is not justified, and ''permissive oliguria'' can be tolerated. Transient hypotension in the context of neuraxial blockade is usually treated more effectively, if needed, with vasopressors rather than with fluids.…”

Section: Low Perioperative Uopmentioning

confidence: 99%

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Miller

Roche

Mythen

2014

Can J Anesth/J Can Anesth

230

137

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Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a ''zero-balance'' approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and ''permissive oliguria'' could be tolerated.Résumé La gestion périopératoire optimale des liquides est un élément important des programmes de récupération rapide après la chirurgie (RRAC). La gestion des liquides dans le cadre de la RRAC doit être vue comme un continuum au travers des phases pré-, per-et postopératoires. Chaque phase est importante pour améliorer la condition du patient et des soins sous-optimaux au cours d'une de ces phases peuvent miner les meilleures pratiques déployées tout au long de la RRAC. L'objectif de la gestion préopératoire des liquides est de faire en sorte que le patient entre en salle d'opération correctement hydraté et dans un état euvolémique. Pour y parvenir, un jeûne prolongé n'est pas recommandé et le nettoyage mécanique de l'intestin est à éviter. Les patients doivent être encouragés à absorber une boisson claire riche en hydrates de carbone, deux à trois heures avant la chirurgie. Les buts de la gestion peropératoire des liquides sont de maintenir une euvolémie centrale et d'éviter un excès de sel et d'eau. Pour y parvenir, les patients subissant une intervention chirurgicale dans le cadre d'un protocole de récupération rapide devraient avoir un programme personnalisé de gestion des liquides. Dans le cadre de ce plan, l'excès de cristalloïdes doit être évité chez tous les patients. Pour des patients à faible risque subissant une intervention c...

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“…Similarly, arterial hypotension is higher and persists in the early postoperative period [ 29 ]. Contraindications are similar to those of TEA, but the risk of severe complications associated with this technique is significantly lower [ 30 ].…”

Section: Spinal Analgesiamentioning

confidence: 99%

Choosing Analgesia to Facilitate Recovery

Cologne

Baldini

2015

The SAGES / ERAS® Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery

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Perioperative Pain and Multimodal AnalgesiaPathophysiology of Surgical Pain S urgical incision and manipulation of tissues lead to cell disruption and activation of humoral and cell-mediated inflammatory responses. A variety of intracellular chemical mediators including potassium, adenosine, prostanoids, bradykinin, nerve growth factors, cytokines, and chemokines are released from the injured tissues, then activate and sensitize peripheral nociceptors such as Aδ and c-fibers to mechanical stimuli (primary hyperalgesia). These pro-inflammatory substances together with the release of substance P and calcitonin gene-related peptide also sensitize silent Aδ nociceptors in the adjacent noninjured tissues (secondary hyperalgesia). Repeated and prolonged stimulation of peripheral nociceptors in the injured area and in the surrounding noninjured tissues leads to an increased firing of neurons at the level of the dorsal horn of the spinal cord, mediated by the activation of N -methyl-D -aspartate (NMDA) receptors (central sensitization). Clinically these pathophysiologic changes manifest with hyperalgesia, allodynia in the area of the surgical incision, with or without late persistent postsurgical pain. Descending sympathetic inhibitory pathways also take an important role at the level of the spinal cord by modulating transmission of noxious inputs. Acute surgical pain can therefore be somatic, visceral, or neuropathic depending on the type of surgery and on the surgical approach. Response to nociception contributes to activate and potentiate the stress response associated with surgery. These stress responses have consequences, such as activation of the hypothalamic-pituitary-adrenal

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Intrathecal Analgesia and Restrictive Perioperative Fluid Management within Enhanced Recovery Pathway: Hemodynamic Implications

Cited by 45 publications

References 49 publications

Comparison of recovery and outcome after left and right colectomy

Comparison of recovery and outcome after left and right colectomy

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Choosing Analgesia to Facilitate Recovery

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