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The New England Journal of Medicine Jun 2018Guidelines to promote the early recovery of patients undergoing major surgery recommend a restrictive intravenous-fluid strategy for abdominal surgery. However, the... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Guidelines to promote the early recovery of patients undergoing major surgery recommend a restrictive intravenous-fluid strategy for abdominal surgery. However, the supporting evidence is limited, and there is concern about impaired organ perfusion.
METHODS
In a pragmatic, international trial, we randomly assigned 3000 patients who had an increased risk of complications while undergoing major abdominal surgery to receive a restrictive or liberal intravenous-fluid regimen during and up to 24 hours after surgery. The primary outcome was disability-free survival at 1 year. Key secondary outcomes were acute kidney injury at 30 days, renal-replacement therapy at 90 days, and a composite of septic complications, surgical-site infection, or death.
RESULTS
During and up to 24 hours after surgery, 1490 patients in the restrictive fluid group had a median intravenous-fluid intake of 3.7 liters (interquartile range, 2.9 to 4.9), as compared with 6.1 liters (interquartile range, 5.0 to 7.4) in 1493 patients in the liberal fluid group (P<0.001). The rate of disability-free survival at 1 year was 81.9% in the restrictive fluid group and 82.3% in the liberal fluid group (hazard ratio for death or disability, 1.05; 95% confidence interval, 0.88 to 1.24; P=0.61). The rate of acute kidney injury was 8.6% in the restrictive fluid group and 5.0% in the liberal fluid group (P<0.001). The rate of septic complications or death was 21.8% in the restrictive fluid group and 19.8% in the liberal fluid group (P=0.19); rates of surgical-site infection (16.5% vs. 13.6%, P=0.02) and renal-replacement therapy (0.9% vs. 0.3%, P=0.048) were higher in the restrictive fluid group, but the between-group difference was not significant after adjustment for multiple testing.
CONCLUSIONS
Among patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury. (Funded by the Australian National Health and Medical Research Council and others; RELIEF ClinicalTrials.gov number, NCT01424150 .).
Topics: Abdomen; Acute Kidney Injury; Aged; Blood Loss, Surgical; Digestive System Surgical Procedures; Female; Fluid Therapy; Follow-Up Studies; Humans; Hypotonic Solutions; Male; Middle Aged; Postoperative Complications; Rehydration Solutions; Risk Factors
PubMed: 29742967
DOI: 10.1056/NEJMoa1801601 -
World Journal of Emergency Surgery :... Sep 2022Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment... (Review)
Review
BACKGROUND
Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team.
MATERIAL AND METHODS
An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript.
CONCLUSION
Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.
Topics: Abdomen; Analgesics; Anesthesia; Humans; Pain, Postoperative; Perioperative Care; United States
PubMed: 36131311
DOI: 10.1186/s13017-022-00455-7 -
Peritoneal Dialysis International :... Jan 2021(1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings .
SUMMARY STATEMENTS
(1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings .
GUIDELINE 2: ACCESS AND FLUID DELIVERY FOR ACUTE PD IN ADULTS
(2.1) Flexible peritoneal catheters should be used where resources and expertise exist .(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving .(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak .(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills .(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically .(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography .(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique .(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation .(2.10) A closed delivery system with a Y connection should be used . In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered .(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices .
GUIDELINE 3: PERITONEAL DIALYSIS SOLUTIONS FOR ACUTE PD
(3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used (. Where these solutions are not available, the use of lactate containing solutions is an alternative .(3.2) Commercially prepared solutions should be used . However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased .(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above .(3.4) Potassium levels should be measured daily . Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate
GUIDELINE 4: PRESCRIBING AND ACHIEVING ADEQUATE CLEARANCE IN ACUTE PD
(4.1) Targeting a weekly / of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes . This dose may not be necessary for most patients with AKI and targeting a weekly / of 2.2 has been shown to be equivalent to higher doses . Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h .(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes .(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance .(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h / and creatinine clearance measurement is recommended to assess adequacy when clinically indicated .(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine .
UNLABELLED
The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.
Topics: Acute Kidney Injury; Adult; Dialysis Solutions; Humans; Peritoneal Dialysis; Peritoneum; Peritonitis
PubMed: 33267747
DOI: 10.1177/0896860820970834 -
Chirurgia (Bucharest, Romania : 1990) Dec 2021Abdominal sepsis remains the second most common source of sepsis, a life-threatening condition that became a global health priority in the medical field research. Open... (Review)
Review
Abdominal sepsis remains the second most common source of sepsis, a life-threatening condition that became a global health priority in the medical field research. Open abdomen is part of the damage control surgery, a life-saving strategy in a well-selected group of surgical patients with severe abdominal sepsis and intra-abdominal hypertension. Definitions and recommendations in the management of abdominal sepsis and open abdomen have gradually evolved, as a reflection of the progress of both the comprehension of physiopathological mechanisms involved in sepsis and the technology of different temporary abdominal closure systems. The aim of this paper is to make an up-to-date literature narrative review of the definitions and current practice guidelines in abdominal sepsis, with illustration of clinical experience in the management of open abdomen wounds. In the past decades, progress has been made in the management of abdominal sepsis, with greatly ameliorated survival rates. Rapid diagnosis, extensive comprehension of the physiopathological mechanisms of sepsis, adapted fluid resuscitation, antimicrobial therapy and damage-control surgery, orchestrated by a multy-disciplinary team, play an equally important role in the prognosis of a patient.
Topics: Abdomen; Gastrointestinal Diseases; Humans; Intra-Abdominal Hypertension; Sepsis; Treatment Outcome
PubMed: 35274608
DOI: No ID Found -
Ugeskrift For Laeger Apr 2024A focused point-of-care abdominal ultrasound is an examination performed at the patient's location and interpreted within the clinical context. This review gives an... (Review)
Review
A focused point-of-care abdominal ultrasound is an examination performed at the patient's location and interpreted within the clinical context. This review gives an overview of this examination modality. The objective is to rapidly address predefined dichotomised questions about the presence of an abdominal aortic aneurysm, gallstones, cholecystitis, hydronephrosis, urinary retention, free intraperitoneal fluid, and small bowel obstruction. FAUS is a valuable tool for emergency physicians to promptly confirm various conditions upon the patients' arrival, thus reducing the time to diagnosis and in some cases eliminating the need for other imaging.
Topics: Humans; Ultrasonography; Aortic Aneurysm, Abdominal; Hydronephrosis; Abdomen; Gallstones; Cholecystitis; Intestinal Obstruction; Urinary Retention; Point-of-Care Systems
PubMed: 38704706
DOI: 10.61409/V10230649 -
Anesthesiology Aug 2018
Topics: Abdomen; Colloids; Crystalloid Solutions; Fluid Therapy; Goals
PubMed: 30020189
DOI: 10.1097/ALN.0000000000002292 -
Saudi Medical Journal Feb 2017To determine whether perioperative fluid restrictive administration can reduce specific postoperative complications in adults undergoing major abdominal... (Review)
Review
To determine whether perioperative fluid restrictive administration can reduce specific postoperative complications in adults undergoing major abdominal surgery. Methods: We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, Google scholar, and article reference lists (up to December 2015) for studies that assessed fluid therapy and morbidity or mortality in patients undergoing major abdominal surgeries. The quality of the trials was assessed using the Jadad scoring system, and a meta-analysis of the included randomized, controlled trials was conducted using Review Manager software, version 5.2. Results: Ten studies with a total of 1160 patients undergoing major abdominal surgeries were included. We found that perioperative restrictive fluid therapy could reduce the risk of postoperative infectious complications (odds ratio [OR]=0.54, 95% confidence interval [CI]: 0.39-0.74, p=0.0001, I2=37%), pulmonary complications (OR=0.49, 95% CI: 0.26-0.93, p=0.03, I2=50%), and cardiac complications (OR=0.45, 95% CI: 0.29-0.69, p=0.0003, I2=48%), but had no effect on the risk of gastrointestinal complications (OR=0.87, 95% CI: 0.51-1.46, p=0.59, I2=0%), renal complications (OR=0.76, 95% CI: 0.43-1.34, p=0.35, I2=0%), and postoperative mortality (OR=0.62, 95% CI: 0.25-1.50, p=0.29, I2=0%). Conclusion: Perioperative restrictive fluid administration was superior to liberal fluid administration in reducing the infectious, pulmonary and cardiac complications after major abdominal surgeries.
Topics: Abdomen; Drinking; Fluid Therapy; Humans; Perioperative Period; Postoperative Complications
PubMed: 28133683
DOI: 10.15537/smj.2017.2.15077 -
Anaesthesiology Intensive Therapy 2015Appropriate open abdomen treatment is one of the key elements in the management of patients who require decompressive laparotomy or in whom the abdomen is left open... (Review)
Review
Appropriate open abdomen treatment is one of the key elements in the management of patients who require decompressive laparotomy or in whom the abdomen is left open prophylactically. Apart from fluid control and protection from external injury, fluid evacuation and facilitation of early closure are now the goals of open abdomen treatment. Abdominal negative pressure therapy has emerged as the most appropriate method to reach these goals. Especially when combined with strategies that allow progressive approximation of the fascial edges, high closure rates can be obtained. Intra-abdominal pressure measurement can be used to guide the surgical strategy and continued attention to intra-abdominal hypertension is necessary. This paper reviews recent advances as well as identifying the remaining challenges in patients requiring open abdomen treatment. The new classification system of the open abdomen is an important tool to use when comparing the efficacy of different strategies, as well as different systems of temporary abdominal closure.
Topics: Abdomen; Abdominal Cavity; Humans; Intra-Abdominal Hypertension; Laparotomy; Lower Body Negative Pressure
PubMed: 25973658
DOI: 10.5603/AIT.a2015.0023 -
British Journal of Anaesthesia Sep 2022Chiu and colleagues report a retrospective analysis describing the 5-yr trend in both intraoperative fluid and vasopressor administration in 32 250 patients undergoing...
Chiu and colleagues report a retrospective analysis describing the 5-yr trend in both intraoperative fluid and vasopressor administration in 32 250 patients undergoing elective abdominal surgery within the Multicenter Perioperative Outcomes Group (MPOG) database from 2015 to 2019, and exploring the association between these two factors and acute kidney injury. Modelling predicted the lowest risk for acute kidney injury when the administered crystalloid volume was 15-20 ml kg h, and an 80% increase in risk for acute kidney injury as intraoperative vasopressor use increased from 0 to 0.04 μg kg min of norepinephrine equivalents. Although these results are consistent with those of a large, randomised trial (REstrictive Versus LIbEral Fluid Therapy in Major Abdominal Surgery [RELIEF]) published in 2018, the mean intraoperative volume of crystalloid administered in the current study declined monotonically through every year included, from 6.4 ml kg h in 2015 to 5.5 ml kg h in 2019. These new findings support the broad generalisability of the RELIEF trial; highlight the complexity of the relationship between intravenous crystalloid volume infused, arterial pressure, and acute kidney injury; and demonstrate the ongoing challenge of translating high-quality evidence into clinical practice.
Topics: Abdomen; Acute Kidney Injury; Crystalloid Solutions; Fluid Therapy; Humans; Retrospective Studies; Vasoconstrictor Agents
PubMed: 35927095
DOI: 10.1016/j.bja.2022.06.016 -
Medicina (Kaunas, Lithuania) Jun 2022Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic... (Review)
Review
Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors' own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric-rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.
Topics: Abdomen; Acute Disease; Humans; Intra-Abdominal Hypertension; Pancreatitis; Prognosis
PubMed: 35744049
DOI: 10.3390/medicina58060785