RESUMEN
The current S1 guidelines on the intraoperative clinical application of hemodynamic monitoring in patients scheduled for noncardiac surgery are presented based on a case report under the aspect of an optimized intraoperative anesthesiological management. The S1 guidelines were developed with the aim of identifying the questions on the intraoperative hemodynamic monitoring and management which are important for the routine daily clinical practice, to discuss them in a guideline group and to answer them based on the current state of scientific knowledge. The guidelines were written under the auspices of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and published by the AWMF in 2023 under the register number 001/049.
Asunto(s)
Monitorización Hemodinámica , Monitoreo Intraoperatorio , Humanos , Monitoreo Intraoperatorio/métodos , Monitorización Hemodinámica/métodos , Procedimientos Quirúrgicos Operativos/efectos adversos , Hemodinámica/fisiologíaRESUMEN
BACKGROUND: To implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study. METHODS: Adult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction. RESULTS: Sixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54-74 ml; colloids: 67.5 (60-75.25 ml) and total volume infused (crystalloids: 2575 (2000-4210) ml; colloids: 2435 (1760-3480) ml; and controls: 2210 (1658-3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3-55.2%) for crystalloids and 49.2% (95%CI 40.4-58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1-74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6-42.9); colloids: 43% (95%CI 34.4-52.0); and controls: 62% (95%CI 52.6-69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay. CONCLUSIONS: Perioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01753050.
Asunto(s)
Fluidoterapia , Objetivos , Adulto , Humanos , Estudios Prospectivos , Estudios Retrospectivos , Fluidoterapia/métodos , Soluciones Cristaloides , Coloides/uso terapéutico , ArtroplastiaRESUMEN
An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/normas , Cuidados Críticos/normas , Cirugía Torácica/normas , Fármacos Cardiovasculares/uso terapéutico , Alemania , Guías como Asunto , Monitorización Hemodinámica , HumanosRESUMEN
Venous saturation is an important parameter to assess the ratio between oxygen delivery and oxygen consumption for both intensive care medicine and during perioperative care. Mixed venous saturation (SvO2) is the most reliable parameter in this setting. Due to the high invasiveness of measuring mixed venous saturation, the less invasive central venous saturation (ScvO2) has been entrenched for determining the balance of oxygen delivery and consumption. However, central venous saturation is inferior compared to mixed venous saturation as it does not cover the lower part of the body, including splanchnic perfusion. Nevertheless, studies have shown that central venous saturation is a reliable marker for goal-directed therapy in intensive care medicine, especially in patients with septic or hemorrhagic shock. Furthermore, central venous saturation has deep impact as a prognostic factor concerning morbidity and mortality. It has to be mentioned that not only decreased venous saturations but also elevated venous saturations are associated with poor outcome. Besides mixed venous and central venous saturation, intensivists and anesthesiologists focus on the central venous-arterial pCO2 difference (dCO2). An elevated dCO2 is associated with poor outcome in patients after cardiac surgery or patients with sepsis. Yet, further investigations have to be performed to implement the dCO2 as a reliable marker in daily routine.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Consumo de Oxígeno , Oxígeno , Sepsis , Choque Séptico , Cuidados Críticos , Humanos , Oxígeno/sangreRESUMEN
Monoplane hemodynamic TEE (hTEE) monitoring (ImaCor(®) ClariTEE(®)) might be a useful alternative to continuously evaluate cardiovascular function and we aimed to investigate the feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients. After IRB approval we reviewed the electronic data of cardiac surgery patients admitted to our intensive care between 01/01/2012 and 30/06/2013 in a case-controlled matched-pairs design. Patients were eligible for the study when they presented a sustained hemodynamic instability postoperatively with the clinical need of an extended hemodynamic monitoring: (a) hTEE (hTEE group, n = 18), or (b) transpulmonary thermodilution (control group, n = 18). hTEE was performed by ICU residents after receiving an approximately 6-h hTEE training session. For hTEE guided hemodynamic optimization an institutional algorithm was used. The hTEE probe was blindly inserted at the first attempt in all patients and image quality was at least judged to be adequate. The frequency of hemodynamic examinations was higher (ten complete hTEE examinations every 2.6 h) in contrast to the control group (one examination every 8 h). hTEE findings, including five unexpected right heart failure and one pericardial tamponade, led to a change of current therapy in 89% of patients. The cumulative dose of epinephrine was significantly reduced (p = 0.034) and levosimendan administration was significantly increased (p = 0.047) in the hTEE group. hTEE was non-inferior to the control group in guiding norepinephrine treatment (p = 0.038). hTEE monitoring performed by ICU residents was feasible and beneficially influenced the postoperative management of cardiac surgery patients.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Ecocardiografía Doppler en Color/métodos , Ecocardiografía Transesofágica/métodos , Hemodinámica , Monitoreo Fisiológico/métodos , Cuidados Posoperatorios/métodos , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Taponamiento Cardíaco/diagnóstico por imagen , Taponamiento Cardíaco/etiología , Taponamiento Cardíaco/fisiopatología , Taponamiento Cardíaco/terapia , Fármacos Cardiovasculares/administración & dosificación , Ecocardiografía Doppler en Color/instrumentación , Ecocardiografía Transesofágica/instrumentación , Educación de Postgrado en Medicina , Diseño de Equipo , Estudios de Factibilidad , Femenino , Alemania , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Humanos , Unidades de Cuidados Intensivos , Internado y Residencia , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/instrumentación , Cuidados Posoperatorios/educación , Cuidados Posoperatorios/instrumentación , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Tiempo , Transductores , Resultado del TratamientoRESUMEN
BACKGROUND: Trials suggest that the use of i.v. hydroxyethyl starch (HES) solutions is associ-ated with increased risk of death and acute kidney injury (AKI) in critically ill patients. It is uncertain whether similar adverse effects occur in surgical patients. METHODS: Systematic review and meta-analysis of trials in which patients were randomly allocated to 6% HES solutions or alternative i.v. fluids in patients undergoing surgery. Ovid Medline, Embase, Cinhal, and Cochrane Database of Systematic Reviews were searched for trials comparing 6% HES with clinically relevant non-starch comparator. The primary end-point was hospital mortality. Secondary endpoints were requirement for renal replacement therapy (RRT) and author-defined AKI. Pre-defined subgroups were cardiac and non-cardiac surgery. RESULTS: Four hundred and fifty-six papers were identified; of which 19 met the inclusion criteria. In total, 1567 patients were included in the analysis. Dichotomous outcomes were expressed as a difference of proportions [risk difference (RD)]. There was no difference in hospital mortality [RD 0.00, 95% confidence interval (CI) -0.02, 0.02], requirement for RRT (RD -0.01, 95% CI -0.04, 0.02), or AKI (RD 0.02, 95% CI -0.02 to 0.06) between compared arms overall or in predefined subgroups. CONCLUSIONS: We did not identify any differences in the incidence of death or AKI in surgical patients receiving 6% HES. Included studies were small with low event rates and low risk of heterogeneity. Narrow CIs suggest that these findings are valid. Given the absence of demonstrable benefit, we are unable to recommend the use of 6% HES solution in surgical patients.
Asunto(s)
Lesión Renal Aguda/epidemiología , Mortalidad Hospitalaria , Derivados de Hidroxietil Almidón/efectos adversos , Sustitutos del Plasma/efectos adversos , Complicaciones Posoperatorias/epidemiología , Humanos , Derivados de Hidroxietil Almidón/administración & dosificación , Incidencia , Infusiones Intravenosas , Sustitutos del Plasma/administración & dosificación , Complicaciones Posoperatorias/mortalidad , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: The use of nerve stimulation is a common standard procedure for peripheral nerve blocks. However, ultrasound guidance is increasingly being used as an alternative. This study explored the relationship between needle positioning defined by ultrasound guidance and the electrical nerve stimulation before and after injection of 5% glucose solution (G5%). PATIENTS AND METHODS: After obtaining permission from the ethics committee, 60 patients were enrolled in the study and the results from 51 patients could be analyzed. For sonographically defined correct needle placement the lowest electrical threshold of the elicited motor responses before and after injection of 1 ml G5% was determined. RESULTS: In 76% of cases nerve structures could be visualized with high quality and 90% of the blocks were successful. Only 29% of patients with a successful block showed a motor response with a stimulation current < or = 0.5 mA. There was a relationship only between the quality of the visualization and the success of the blockade. Addition of G5% did not result in significant changes in stimulation thresholds. CONCLUSION: With the protocol used the success of a blockade depends only on the quality of visualization. With correct ultrasound-guided needle tip positioning the electrical information seems to be skewed and doubtful.