Fluid administration in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: neither too much nor too little

Abstract Introduction Intraoperative fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy plays an important role in postoperative morbidity. Studies have found an association between overload fluid therapy and increased postoperative complications, advising restrictive intraoperative fluid therapy. Our objective in this study was to compare the morbidity associated with restrictive versus non-restrictive intraoperative fluid therapy. Methods Retrospective analysis of a database collected prospectively in the Anesthesiology Service of Virgen del Rocío Hospital, from December 2016 to April 2019. One hundred and six patients who underwent complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were divided into two cohorts according to Fluid Therapy received 1. Restrictive ≤ 9 mL.kg-1.h-1 (34 patients), 2. Non-restrictive ≥ 9 mL.kg-1.h-1 (72 patients). Percentage of major complications (Clavien-Dindo grade III-IV) and length hospital stay were the main outcomes variables. Results Of the 106 enrolled patients, 68.9% were women; 46.2% had ovarian cancer, 35.84% colorectal cancer, and 7.5% peritoneal cancer. The average fluid administration rate was 11 ± 3.58 mL.kg-1.h-1. The restrictive group suffered a significantly higher percentage of Clavien-Dindo grade III-IV complications (35.29%) compared with the non-restrictive group (15.27%) (p= 0.02). The relative risk associated with restrictive therapy was 1.968 (95% confidence interval: 1.158-3.346). We also found a significant difference for hospital length of stay, 20.91 days in the restrictive group vs 16.19 days in the non-restrictive group (p= 0.038). Conclusions Intraoperative fluid therapy restriction below 9 mL.kg-1.h-1 in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was associated with a higher percentage of major postoperative complications.

Impact of frailty in surgical emergencies. A comparison of four frailty scales.

INTRODUCTION: Frailty is a geriatric syndrome, leading to declines in homeostatic reserve and physical resistance. It has been considered as a risk factor for falls, fractures, need of institutionalization, length of stay and mortality. Our aim was to evaluate the relationship between frailty, 30-day postoperative mortality and morbidity, for elderly patients undergoing surgical emergencies. MATERIAL AND METHODS: Prospective, observational cohort Study (September 2017-April 2019), using four different frailty scales (Clinical Frailty Scale, FRAIL scale, TRST and Share-FI) as a risk factor of 30-day postoperative outcomes, for patients older than 70 years undergoing emergency surgery. We analyzed diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first 30 days or until discharge. RESULTS: 92 patients were included, with a mean age was 78.7 years (SD 6.3). Frailty prevalence varied since 14.1% obtained using FRAIL scale, to 25%, 29.2% and 30.4%, from Clinical Frailty Scale, TRST and Share-FI, respectively. All four frailty scales show statistical differences to predict major complication and mortality in our sample. FRAIL scale showed the highest sensitivity-specificity pair to predict mortality in our sample (AUC = 0.870). TRST and FRAIL scales showed the strongest measure of association (OR 7.69 and 5.92, respectively) for major complications. Regarding need for admission to the ICU, hospital stay or reoperation rate, only FRAIL scale showed a statistically significant association. CONCLUSION: Frailty represents a predictive marker of mortality and major complications, in surgical emergencies. FRAIL score, shows the strongest relationship with mortality and complications, compared to other frailty scales.