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

Department of Visceral Surgery (Hübner), University Hospital CHUV, Lausanne, Switzerland.
Journal of the American College of Surgeons (Impact Factor: 5.12). 04/2013; 216(6). DOI: 10.1016/j.jamcollsurg.2013.02.011
Source: PubMed


Intrathecal analgesia and avoidance of perioperative fluid overload are key items within enhanced recovery pathways. Potential side effects include hypotension and renal dysfunction.

Study design:
From January 2010 until May 2010, all patients undergoing colorectal surgery within enhanced recovery pathways were included in this retrospective cohort study and were analyzed by intrathecal analgesia (IT) vs none (noIT). Primary outcomes measures were systolic and diastolic blood pressure, mean arterial pressure, and heart rate for 48 hours after surgery. Renal function was assessed by urine output and creatinine values.

One hundred and sixty-three consecutive colorectal patients (127 IT and 36 noIT) were included in the analysis. Both patient groups showed low blood pressure values within the first 4 to 12 hours and a steady increase thereafter before return to baseline values after about 24 hours. Systolic and diastolic blood pressure and mean arterial pressure were significantly lower until 16 hours after surgery in patients having IT compared with the noIT group. Low urine output (<0.5 mL/kg/h) was reported in 11% vs 29% (IT vs noIT; p = 0.010) intraoperatively, 20% vs 11% (p = 0.387), 33% vs 22% (p = 0.304), and 31% vs 21% (p = 0.478) for postanesthesia care unit and postoperative days 1 and 2, respectively. Only 3 of 127 (2.4%) IT and 1 of 36 (2.8%) noIT patients had a transitory creatinine increase >50%; no patients required dialysis.

Postoperative hypotension affects approximately 10% of patients within an enhanced recovery pathway and is slightly more pronounced in patients with IT. Hemodynamic depression persists for <20 hours after surgery; it has no measurable negative impact and therefore cannot justify detrimental postoperative fluid overload.

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    ABSTRACT: Background Enhanced recovery pathways have been shown to improve short-term outcomes after colorectal surgery. Occurrence of complications can lead to prolonged length of stay (LOS). The goal of this study was to examine whether shorter time to occurrence of complications was associated with a shorter length of hospital stay in rectal cancer patients undergoing minimally invasive surgery taking into account the perioperative pathway. Study design This retrospective study included consecutive patients undergoing rectal cancer resection from 2005 to 2011 at a single institution. Enhanced recovery pathway (ERP) was introduced in 2009. Complications and date of occurrence were reviewed. The impact of perioperative care modalities and comorbidities was evaluated using competing risk models with occurrence of complications and length of stay as time dependent outcomes measured as time from surgery. Results A total of 346 patients were included in the analysis with 78 patients treated with ERP, and 268 with established care. The overall rate of complications was 22.3% (77 patients with ileus, wound infection, leak, abscess, small bowel obstruction, reoperation for bleeding, renal failure). The median time to occurrence of a complication was 3 days post surgery. The time to complication diagnosis [days] was associated with shorter time to discharge after the advent of the complication (hazard ratio (HR) 0.84, 95% CI 0.73-0.96, p=0.01). ERP was associated with a shorter LOS for patients without complications compared to the established pathway (HR 2.81, 95% CI: 2.09-3.78, p<0.001) after adjusting for comorbidities in a competing risk model. Conclusions Early diagnosis of postoperative complications is associated with a shorter length of stay after rectal cancer surgery. ERP may facilitate a faster recovery in the presence of comorbidities.
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    Canadian Journal of Anaesthesia 11/2014; 62(2). DOI:10.1007/s12630-014-0266-y · 2.53 Impact Factor
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    Anesthesiology Clinics 03/2015; 33(1):93-123. DOI:10.1016/j.anclin.2014.11.007
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