The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy

Abstract

IntroductionOptimal fluid balance is critical to minimize anastomotic edema in patients undergoing pancreaticoduodenectomy. We examined the effects of decreased fluid administration on rates of postoperative pancreatic leak and delayed gastric emptying.MethodsRetrospective study of 105 patients undergoing pancreaticoduodenectomy at a single institution from January 2015 through July 2016. Stroke volume variation (SVV) was tracked and titrated during the procedure. A comparative analysis of postoperative complications was performed between patients with a median SVV < 12 during the extirpative and reconstructive phases of the procedure compared with patients with an SVV ≥ 12.ResultsOf 64 patients who met selection criteria, 42 (65.6%) had a SVV < 12 and 22 (34.4%) had a SVV ≥ 12. Patients with an SVV ≥ 12 during the extirpative phase of the procedure had lower rates of postoperative pancreatic leaks compared to patients with an SVV < 12 (5.9% vs 21.3%)). Patients with an SVV ≥ 12 during the extirpative phase had lower rates of postoperative delayed gastric emptying compared to patients with an SVV < 12 (41.2% vs 46.8%).ConclusionGoal-directed fluid restriction before the reconstructive phase of pancreaticoduodenectomy may contribute to lower postoperative rates of pancreatic leak and delayed gastric emptying.

Lack of Impact of Nil-Per-Os (NPO) Time on Goal-Directed Fluid Delivery in First Case versus Afternoon Case Starts: A Retrospective Cohort Study

“…Some of those additional factors contributing to this finding may include patient pathology, condition, higher EBL, epidural vasoplegia, and greater insensible loss typical of more complex surgery as previously noted, though this result remains difficult to interpret in such a broad and multifactorial setting. Nevertheless, the variables affecting this previous result, namely, possible different ASA classifications among the AM vs. PM patient groups [4,16,17], the possible differential epidural placement for different cases [18,19], the possible difference in the number of laparoscopic procedures in the AM vs PM groups [20,21], different possible urine loss in cases of differing nature [22,23], possible different patient demographics in weight [23][24][25] or in age [26][27][28], the different pragmatic scheduling need for surgical procedures of longer duration in the AM vs the PM groups [29][30][31], and the possible different hemodynamic heat rate parameter between surgical cases of different nature among the AM vs PM groups [21,32,33], have all been accounted for in the literature with evidence showing the clear benefit of following the GDFT algorithm. In some regards these limitations result from and are common to how operating rooms actually run.…”

“…Inclusion criteria for the study were adult patients age 18 or over having open or laparoscopic abdominal procedures (colectomy, adrenalectomy, gastrectomy, hepatic resection, Whipple or pancreatic procedures, nephrectomy, cystectomy, abdominoperineal resection, or gynecologic oncology procedures). For each identified case, we pulled: case, date and time; procedure; patient demographics (including gender, height, weight, age, American Society of Anesthesiologists Patient Score); patient comorbidities (including hypertension, congestive heart failure, renal failure, and dialysis); NPO time; whether or not the patient received an epidural or arterial line; intraoperative data (including urine output, estimated blood loss, total crystalloid and colloid, blood administration, median and minimum heart rate, median and minimum mean arterial pressure).…”

Lack of impact of nil-per-os (NPO) time on goal-directed fluid delivery in first case versus afternoon case starts: a retrospective cohort study

“…Some of those additional factors contributing to this finding may include patient pathology, condition, higher EBL, epidural vasoplegia, and greater insensible loss typical of more complex surgery as previously noted, though this result remains difficult to interpret in such a broad and multifactorial setting. Nevertheless, the variables affecting this previous result, namely, possible different ASA classifications among the AM vs. PM patient groups [4, 16, 17], the possible differential epidural placement for different cases [18, 19], the possible difference in the number of laparoscopic procedures in the AM vs PM groups [20, 21], different possible urine loss in cases of differing nature [22, 23], possible different patient demographics in weight [23–25] or in age [26–28], the different pragmatic scheduling need for surgical procedures of longer duration in the AM vs the PM groups [29–31], and the possible different hemodynamic heat rate parameter between surgical cases of different nature among the AM vs PM groups [21, 32, 33], have all been accounted for in the literature with evidence showing the clear benefit of following the GDFT algorithm. In some regards these limitations result from and are common to how operating rooms actually run.…”

Lack of Impact of NPO Time on Goal-Directed Fluid Therapy Resuscitation in AM versus PM Case Starts: A Retrospective Cohort Study

“…AM starts actually received more fluid than PM starts; this may reflect patient pathology, condition, and greater insensible loss typical of more complex surgery as previously noted, though this result remains difficult to interpret in such a broad and multifactorial setting. Nevertheless, the variables affecting this previous result, namely, possible different ASA classifications among the AM vs. PM patient groups [16][17][18] , the possible differential epidural placement for different cases [19][20] , the possible difference in the number of laparoscopic procedures in the AM vs PM groups [21][22] , different possible urine loss in cases of differing nature [23][24] , possible different patient demographics in weight [25][26][27] or in age [28][29][30] , the different pragmatic scheduling need for surgical procedures of longer duration in the AM vs the PM groups [31][32][33] , and the possible different hemodynamic heat rate parameter between surgical cases of different nature among the AM vs PM groups [34][35][36] , have all been accounted for in the literature with evidence showing the clear benefit of following the GDFT algorithm and therefore this indeed shows the reason for the establishment of the fluid therapy algorithm as a highly encouraged tool to be used for fluid resuscitation. Ultimately, all of these differences most likely reflect typical surgical scheduling practices and may actually better guide practical application of our results to fluid administration in AM and PM case starts in real world environments.…”