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

ArticleinJournal of the American College of Surgeons 216(6) · April 2013with18 Reads
DOI: 10.1016/j.jamcollsurg.2013.02.011 · Source: PubMed
Abstract
Background: 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. Results: 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. Conclusions: 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.
  • [Show abstract] [Hide abstract] ABSTRACT: Multidisciplinary management of colorectal liver metastases allows an increase of about 20% in the resection rate of liver metastases. It includes chemotherapy, interventional radiology and surgery. In 2013, the preliminary results of the in-situ split of the liver associated with portal vein ligation (ALLPS) are promising with unprecedented mean hypertrophy up to 70% at day 9. However, the related morbidity of this procedure is about 40% and hence should be performed in the setting of study protocol only. For pancreatic cancer, the future belongs to the use of adjuvant and neo adjuvant therapies in order to increase the resection rate. Laparoscopic and robot-assisted surgery is still in evolution with significant benefits in the reduction of cost, hospital stay, and postoperative morbidity. Finally, enhanced recovery pathways (ERAS) have been validated for colorectal surgery and are currently assessed in other fields of surgery like HPB and upper GI surgery.
    Article · Jan 2014
  • [Show abstract] [Hide abstract] 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.
    Article · May 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Objective: To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery. Background: EDA is mainstay of multimodal pain management within enhanced recovery pathways [enhanced recovery after surgery (ERAS)]. For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious. Methods: A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle. Results: Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range [IQR], 3-7.5 days) in EDA patients and 4 days (IQR, 3-6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications [19 (33%) vs 35 (54%); P = 0.029] but a similar hospital stay [5 days (IQR, 4-8 days) vs 7 days (IQR, 4.5-12 days); P = 0.434]. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted. Conclusions: Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery.
    Article · Aug 2014
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