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"Emergency medicine" №5(92), 2018

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Perioperative infusion therapy with different volume protocols in patients with moderate surgical risk undergoing emergency laparotomy

Authors: O.V. Kravets
State Institution “Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine”, Dnipro, Ukraine

Categories: Medicine of emergency

Sections: Clinical researches

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Summary

З метою оцінки ефективності ліберального та рестриктивного протоколів перiопераційної інфузійної терапії при невідкладнiй лапаратомії нами було обстежено 100 хворих. Ступінь операційно-анестезіологічного ризику відповідав IIЕ классу за шкалою АSA, хірургічного ризику за шкалою POSSUM — 1–5 % (середній ризик). Усім хворим проведено передопераційну підготовку впродовж 2 годин в умовах відділення інтенсивної терапії в об’ємі 2870 ± 540 мл у 1-й групі та 1733 ± 340 мл у 2-й, при розрахунковому інфузійному навантаженні 80–120 та 40–60 мл/кг/добу відповідно. Хворі були обстежені клінічно, інструментально і лабораторно. У дослідженні доведено, що гостра хірургічна патологія в пацієнтів із середнім хірургічним ризиком супроводжується початковим збереженням нормального загального об’єму рідини на фоні дефіциту об’єму плазми з розвитком гіповолемії, внутрішньоклітинної дегідратації та інтерстиціального набряку. Це приводить до відносної гіпердинамії шляхом збільшення загального периферичного опору судин і частоти серцевих скорочень. Застосування рестриктивної стратегії перiопераційної інфузійної терапії дозволяє відновити фізіологічні об’єми водних секторів організму і сформувати нормодинамічний тип кровообігу з 3-ї доби післяопераційного періоду.

С целью оценки эффективности либерального и рестриктивного протоколов периоперационной инфузионной терапии при неотложной лапаратомии нами было обследовано 100 больных. Степень операционно-анестезиологического риска соответствовала IIЕ классу по шкале АSA, хирургического риска по шкале POSSUM — 1–5 % (средний риск). Всем больным проведена предоперационная подготовка на протяжении 2 часов в условиях отделения интенсивной терапии в объеме 2870 ± 540 мл в 1-й группе и 1733 ± 340 мл во 2-й, при расчетной инфузионной нагрузке 80–120 мл и 40–60 мл/кг/сут соответственно. Больные были обследованы клинически, инструментально и лабораторно. В исследовании доказано, что острая хирургическая патология у пациентов со средним хирургическим риском сопровождается исходным сохранением нормального общего объема жидкости на фоне дефицита объема плазмы с развитием гиповолемии, внутриклеточной дегидратации и интерстициального оте­ка. Это приводит к относительной гипердинамии путем увеличения общего периферического сопротивления и частоты сердечных сокращений. Применение рестриктивной стратегии периоперационной инфузионной терапии позволяет восстановить физиологические объемы водных секторов организма и сформировать нормодинамический тип кровообращения с 3-х суток послеоперационного периода.

To assess the effectiveness of the liberal and restrictive protocol of perioperative infusion therapy in emergency laparotomy, we examined 100 patients. The degree of surgical and anesthetic risk according to the ASA scale was IIE, the surgical risk on the POSSUM scale was 1–5 % and corresponded to the average surgical risk. All patients underwent preoperative preparation for 2 hours in the intensive care unit in the volume of 2870 ± 540 ml and 1733 ± 340 ml, respectively, in groups, with a calculated infusion load of 80–120 and 40–60 ml/kg/day. Patients were examined clinically, instrumentally and laboratorially. The study proved that acute surgical pathology in patients with moderate surgical risk is accompanied by the maintenance of a normal total volume of fluid with a significant redistribution of water sectors in the body such as plasma deficiency with development of hypovolemia, formation of intracellular dehydration, the initial increase in the volume of the interstitial space. The change in water sectors is combined with the development of relative hyperdynamia due to an increase in the total peripheral resistance and heart rate. The use of a restrictive strategy of infusion therapy in patients with moderate surgical risk allows restoring the physiological volumes of water sectors in the body and forms a normodynamic type of circulation from day 3 of postoperative period.


Keywords

рестриктивний протокол; ліберальний протокол; перiопераційна інфузійна терапія; водні сектори; центральна гемодинаміка; ургентна лапаратомія

рестриктивный протокол; либеральный протокол; периоперационая инфузионная терапия; водные сектора; центральная гемодинамика; ургентная лапаратомия

restrictive protocol; liberal protocol; perioperative infusion therapy; water sectors; central hemodynamics; emergency laparatomy

Introduction

Urgent surgery may be associated with a significant rate of complications, many оf which are аvоidаblе. Pеriоpеrаtivе cоmplicаtiоns strоngly cоrrеlаtе with lоng-tеrm mоrtаlity аnd mоrbidity and gеnеrаtе incrеаsеd hеаlthcаrе cоsts. The аvеrаgе cоmplicаtiоn rаtе mаy vаry frоm 5 to 64 %, аnd mоrtаlity rаtеs are high, too (30–80 %) [3–6]. Fluid аdministrаtiоn before, during аnd аftеr аbdоminаl surgеry is an еssеntiаl pаrt оf pоstоpеrаtivе cаrе tо mаintаin the fluid аnd biоchеmicаl bаlаncе in a patient. Аbdоminаl surgiсаl prоcеdurеs аre аssоciаtеd with dеhydrаtiоn, bоwеl prеpаrаtiоn аnd intrа- and pоstоpеrаtivе fluid and еlеctrоlytе lоss [2]. Cоncеrns аbоut perioperative fluid dеficiency, suppоrt оf circulаtiоn аnd cаrdiаc functiоn аftеr gеnerаl аnеsthеsiа, cоntrоl оf pоstоpеrаtivе circulаtiоn, аvоidаncе оf blооd trаnsfusiоn аnd prеsеrvаtiоn оf urinе оutput аrе аll issuеs thаt аre thоught tо аccоunt fоr the аdministrаtiоn оf thеsе еxcеssivе аmоunts оf fluid [1–4]. Liberal or trаditiоnаl intrаvеnоus fluid rеgimеns thаt аrе аdministеrеd during аbdоminаl surgеry dеlivеr up to 7 litеrs оf fluid оn dаy of surgеry. Such rеgimеns cаn lеаd tо tissuе еdеmа аnd wеight gаin оf 3 to 6 kg. Sоmе smаll triаls hаve shоwn thаt а mоrе rеstrictivе fluid rеgimеn lеd tо fеwеr cоmplicаtiоns, а shоrtеr hоspitаl stаy, аnd rеcеnt cоnsеnsus stаtеmеnts suppоrt fluid rеstrictiоn. Аnоthеr cоncеpt hаs rеcеntly bееn rаisеd thаt pеriоpеrаtivе rеstrictivе fluid thеrаpу, аlsо rеfеrrеd tо аs а nеаr-zеrо pеriоpеrаtivе fluid bаlаncе оr а zеrо-bаlаncе аpprоаch, mаy bе bеnеficiаl [5].
The purpose of the study was to compare the effectiveness of the restrictive and liberal protocol of perio–perative infusion therapy in patients undergoing emergency laparatomy.

Materials and methods

Having agreed with the local ethics committee and obtained the informed consents, 100 patients were exa–mined (46 men and 44 women with an average age of 60 ± 11 years). Acute cases of emergency laparotomy were: strangulated inguinal hernia (n = 16), strangulated ventral hernia (n = 18), acute intestinal obstruction (n = 20), perforated gastric ulcer (n = 28), perforated ulcer of the duodenum (n = 10), peritonitis (n = 8).
Inclusion criteria: the patient’s age more than 45 years and less than 75 years; emergency laparotomy; predicted intraoperative blood loss less than 500 ml; American Society of Anesthesiologists (ASA) IІІ; diabetes mellitus in the stage of compensation.
Exclusion criteria: the patient’s age less than 45 years and more than 75 years; gastrointestinal bleeding; ASA І–ІІ–IV; diabetes mellitus in the stage of decompensation; pregnancy and lactation; allergic reactions to any component of drug therapy; patient’s refusal to participate in the study.
All patients were examined according to the protocol of the Ministry of Health of Ukraine No. 297 (02.04.2010). At the same time, concomitant pathology was identified: ischemic heart failure (n = 46), diabetes mellitus type II in remission (n = 12), chronic bronchitis in remission (n = 24), excessive body weight (obesity class I–II) (n = 21), community-acquired pneumonia (n = 4).
Preoperative treatment was carried out in the intensive care unit according to the standards of professional protocols (Ministry of Health of Ukraine, 2008): perioperative fluid management, prevention of thrombosis and wound infections. Hypovolemia was managed using infusion ba–lanced crystalloid solutions. To determine the seve–rity of hypovolemia, we used the test of tissue hydrophilicity by Shelestiuk which corresponded to degree II. Patients were divided into two groups by blinding. In group 1 (n = 50), liberal regimen of fluid аdministrаtiоn was applied pеriоpеrаtively. Infusion volume was 80–120 ml/kg/day. Patients of group 2 (n = 50) received treatment of hypovolemia according to restrictive regimen — 40–60 ml/kg/day. 
Thus, 25 % of the calculated amount of volume deficit were infused during the first hour of treatment. In the absence of hemodynamic effects of infusion, we administered vasopressors (norepinephrine, phenylephrine) under ge–neral principles. Next 25 % were infused during two hours of treatment (including intraoperative). Full restoration of volume deficit (last 50 %) was carried out by the end of the first day of treatment. After a complete volume restoration, infusion therapy was performed under general principles.
Surgical intervention was performed with the total intravenous anesthesia in both groups. The average duration of the operation was 60.6 ± 20.3 minutes.
We studied the clinical parameters of systemic hemodynamics: blood pressure, mean arterial pressure, heart rate (HR) and routine clinical laboratory tests (general blood and urine analysis, coagulogram, biochemical blood test). The central and peripheral hemodynamic para–meters (cardiac index (CI), general peripheral vascular resistance (GPVR)) were determined by the method of integral rheography using Diamant apparatus. The follo–wing indicators of water sectors were studied: the volume of extracellular fluid (ECF), the volume of intracellular fluid, the total volume of fluid, plasma volume by the method of noninvasive bioelectric integral evaluation of the body structure using the Diamant monitor complex.
ASA and POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbi–dity) scales were used for stratification of surgical risk.
Postoperative complications were assessed according to Clavien-Dindo classification (2009). Control points: before surgery, 1, 3, 5–7, 10–14, 28–30 days after surgery.
The observation was conducted in accordance with the requirements of the ethical committee. Statistical processing of the results was carried out using the MS Excel 2007, Statistica 6 software package. The data are presented in the form M ± m. P-values lower than 0.05 were statistically significant.

Results and discussion

The analysis showed an initial reduction of intracellular fluid and plasma volumes by 4.0 ± 0.2 % and 5.0 ± 0.2 % below norm in group 1 and 4.3 ± 0.1 % and 5.2 ± 0.3 % in group 2, respectively, in patients undergoing emergency laparatomy before the infusion correction. It correspon–ded to degree II of dehydration and was associated with an increase of ECF by 6.0 ± 0.1 % and 6.1 ± 0.2 %, respectively, in groups 1 and 2. The total volume of liquid saved was within the normal range. Relative hyperdynamia (CI exceeded normal values by 11.0 ± 0.8 % and 13.0 ± 0.6 %) was supported by vasospasm (GPVR was higher than norm by 18.0 ± 1.3 % and 19.0 ± 1.4 %, respectively, in groups) and tachycardia (HR was higher than norm — by 13.0 ± 1.5 % and 12.0 ± 1.8 %). It maintained the blood pressure at the level of norm.
After preoperative infusion therapy with balanced crystalloid solutions in a total volume of 2870 ± 540 ml according to liberal protocol of infusion therapy and 1733 ± 340 ml — to restrictive protocol during 2 hours, we noted a further increase in the incidence of heart fai–lure in groups — to 9.0 ± 1.0 % and 8.0 ± 1.0 % above the norm, respectively, restoration of plasma volume and ECF to normal values against a background of increased total volume of fluid — by 4.0 ± 1.4 % and 2.5 ± 1.1 % of normal rates. In that time, restoration of volumes in water sectors was accompanied by stabilization of indices of central hemodynamics up to normodynamics with preservation of moderate tachycardia.
Patients of group 1 had the general volume of infusion of 6360 ± 450 ml in the first postoperative day. Water sectors did not differ from those before laparotomy, however, we marked a relative hypodynamia of circulation (CI — 78 % of the norm), increased GPVR — by 62 % of the norm, HR — by 26 % and mean arterial pressure maintenance about physiological norm. From day 3 to 7 of observation, hypodynamic type of hemodynamics was saved. The most expressed vasospasm was on the third postoperative day (GPVR is 66 % higher than norm) and remained to day 10. It combined with development of hypodynamic type of circulation on day 5 of observation, when the CI decreased by 24 % of normal level.
On day 1 of observation, the total infusion volume in patients of group 2 amounted to 4360 ± 450 ml. The volumes of water sectors did not differ significantly from those by the end of the preoperative infusion preparation, we noted the formation of a normodynamic type of blood circulation (CI corresponded to 98 % of the norm), GPVR was higher than norm by 2 %, and the preservation of blood pressure values occurred within the physiological norm. Оn the third postoperative day, water sectors in the body did not differ significantly from the normal values. It lasted until the end of the follow-up. From day 3 to 14 of treatment, the parameters of central hemodynamics also corresponded to the norm.

Conclusions

1. Acute surgical pathology in patients with moderate surgical risk is accompanied by the maintenance of a normal total volume of fluid with a significant redistribution of water sectors in the body:
— deficiency of plasma with the development of hypovolemia;
— formation of intracellular dehydration;
— an initial increase in the volume of the interstitial space.
2. The change in water sectors is combined with the development of relative hyperdynamia due to an increase in the total peripheral resistance and heart rate.
3. The use of a restrictive strategy of infusion therapy in patients with moderate surgical risk allows restoring the physiological volumes of water sectors in the body and forms a normodynamic type of circulation from day 3 of postoperative period.
Conflicts of interests. Authors declare no conflicts of interests that might be construed to influence the results or interpretation of their manuscript.

Bibliography

1. Mythen M.G., Swart M., Acheson N., Crawford R., Jones K., Kuper M. et al. Perioperative fluid management: Consensus statement from the enhanced recovery partnership // Perioperative Medicine. 2012; 1: 2. [PUBMED: 24764518].
2. Rahbari N.N., Zimmermann J.B., Schmidt T., Koch M., Weigand M.A., Weitz J. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery // British Journal of Surgery. 2009; 96(4): 331-41. [PUBMED: 19283742].
3. Nisanevich V., Felsenstein I., Almogy G., Weissman C., Einav S., Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery // Anesthesiology. 2005; 103(1): 25-32.
4. Hartog C., Reinhart K. CONTRA: Hydroxyethyl starch solutions are unsafe in critically ill patients // Intensive Care Med. 2009; 35(8): 1337-42. http://dx.doi.org/10.1007/s00134-009-1521-5. 27.
5. Mythen M., Vercueil A. Fluid balance // Vox Sang. 2004; 87, Suppl. 1: 77-81.
6. Sark Y., Vincent J.L., Reinhart K., Groeneveld J., Michalopoulos A., Sprung C.L., Artigas A., Ranieri V.M.; Sepsis Occurrence in Acutely Ill Patients Investigators. High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury // Chest. 2005; 128: 3098-3108.

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