Efficacy of a pre-operative anaemia clinic in patients undergoing elective abdominal cancer surgery.

BACKGROUND: Pre-operative iron deficiency anaemia (IDA) is common in patients undergoing elective major abdominal surgery and is associated with increased risk of perioperative complications. However, widespread implementation of pre-operative anaemia management is lacking. Guidelines recommend investigation of anaemia preferably 4-6 weeks before surgery to allow time for correction. However, this is not always feasible in abdominal cancer surgery with short time to surgery and may be influenced by concomitant chemotherapy. The objective of this study was to assess the efficacy of implementing a pre-operative screening and treatment programme for IDA in elective abdominal cancer surgery patients, with short duration to surgery and concomitant use of chemotherapy. METHODS: All patients scheduled for elective abdominal cancer surgery with IDA were included. Anaemia was defined according to the World Health Organization-criteria and iron deficiency as a transferrin saturation <0.20. The primary outcome was change in haemoglobin (Hb) between iron infusion and surgery in patients receiving pre-operative intravenous iron infusion. RESULTS: Of 178 diagnosed IDA patients 134 (75%) received intravenous iron, 103 pre-operatively (58%) at median day 17 (interquartile range: 9-27) before surgery while 31 (17%) received post-operative intravenous iron treatment. The pre-operative Hb increased 0.89 g/dL (95% CI: 0.64-1.13, p < .001) compared to a decrease of 0.4 g/dL (95% CI: 0.19-0.58, p < .001) in 75 patients not treated pre-operatively. Patients diagnosed with severe anaemia had the largest pre-operative Hb increase. Iron infusion >2 weeks pre-operatively resulted in a greater Hb increment of 1.13 g/dL (95% CI: 0.81-1.45) compared to iron infusion ≤2 weeks before surgery 0.48 g/dL (95% CI: 0.16-0.81). Hb increased by 0.64 g/dL (95% CI 0.19-1.21) in patients receiving chemotherapy ≤31 days prior to surgery. CONCLUSION: In patients scheduled for abdominal cancer surgery, including in patients with concomitant chemotherapy, pre-operative IDA management is feasible and results in a significant pre-operative Hb increase compared to patients not treated. On the day of surgery 25% patients treated pre-operatively were no longer anaemic.

Impact of Albumin on Coagulation Competence and Hemorrhage During Major Surgery: A Randomized Controlled Trial.

For patients exposed to a massive blood loss during surgery, maintained coagulation competence is important. It is less obvious whether coagulation competence influences bleeding during elective surgery where patients are exposed to infusion of a crystalloid or a colloid. This randomized controlled trial evaluates whether administration of 5% human albumin (HA) or lactated Ringer solution (LR) affects coagulation competence and in turn blood loss during cystectomy due to bladder cancer. Forty patients undergoing radical cystectomy were included to receive either 5% HA (n = 20) or LR (n = 20). Nineteen patients were analyzed in the HA group and 20 patients in the lactated Ringer group. Blinded determination of the blood loss was similar in the 2 groups of patients: 1658 (800-3300) mL with the use of HA and 1472 (700-4330) mL in the lactated Ringer group (P = 0.45). Yet, by thrombelastography (TEG) evaluated coagulation competence, albumin affected clot growth (TEG-angle 69 ±â€Š5 vs 74°â€Š±â€Š3°, P < 0.01) and strength (TEG-MA: 59 ±â€Š6 vs 67 ±â€Š6 mm, P < 0.001) more than LR. Furthermore, by multivariate linear regression analyses reduced TEG-MA was independently associated with the blood loss (P = 0.042) while administration of albumin was related to the changes in TEG-MA (P = 0.029), aPPT (P < 0.022), and INR (P < 0.033). This randomized controlled trial demonstrates that administration of HA does not affect the blood loss as compared to infusion of LR. Also the use of HA did not affect the need for blood transfusion, the incidence of postoperative complications, or the hospital in-stay. Yet, albumin decreases coagulation competence during major surgery and the blood loss is related to TEG-MA rather than to plasma coagulation variables.

Plasma pro-atrial natriuretic peptide to indicate fluid balance during cystectomy: a prospective observational study.

OBJECTIVES: During surgery the volume of administered fluid is debated. Pro-atrial natriuretic peptide (proANP) is released by atrial distension, and we evaluated the relationship between changes in proANP associated with perioperative fluid balance. DESIGN: Prospective observational study. SETTING: One university/tertiary centre. PARTICIPANTS: The study included patients who underwent radical cystectomy. Plasma for determination of proANP was obtained before surgery, after resection of the bladder, and at the end of surgery for 20 robotic-assisted radical cystectomy (RARC) and 20 open radical cystectomy (ORC) procedures. RESULTS: The blood loss was 1871 (95% CI 1267 to 2475) vs 589 mL (378 to 801) in the ORC and RARC groups (p=0.001), respectively, and fluid balance was positive by 1518 mL (1215 to 1821) during ORC, and by 1858 mL (1461 to 2255) during RARC (p=0.163). Yet, at the end of ORC, plasma proANP was reduced by 23% (14% to 32%, p=0.001), while plasma proANP did not change significantly during RARC. Thus, plasma proANP was associated both with the perioperative blood loss (r= -0.475 (0.632 to -0.101), p=0.002), and with fluid balance (r=0.561 (0.302 to 0.740), p=0.001), indicating that a stable plasma proANP required a fluid surplus by 2.4 L (2.0 to 2.7). CONCLUSIONS: There was a correlation between intraoperative haemorrhage and a decrease in plasma proANP and, taking plasma proANP to indicate filling of the heart, about 2.5 L surplus volume of lactated Ringer's solution appears to maintain cardiac preload during cystectomy. TRIAL REGISTRATION NUMBER: EudraCT (2012-005040-20), Results.

Coagulation competence for predicting perioperative hemorrhage in patients treated with lactated Ringer's vs. Dextran--a randomized controlled trial.

BACKGROUND: Perioperative hemorrhage may depend on coagulation competence and this study evaluated the influence of coagulation competence on blood loss during cystectomy due to bladder cancer. METHODS: Forty patients undergoing radical cystectomy were included in a randomized controlled trial to receive either lactated Ringer's solution or Dextran 70 (Macrodex ®) that affects coagulation competence. RESULTS: By thrombelastography evaluated coagulation competence, Dextran 70 reduced "maximal amplitude" (MA) by 25 % versus a 1 % reduction with the administration of lactated Ringer's solution (P <0.001). Blinded evaluation of the blood loss was similar in the two groups of patients - 2339 ml with the use of Dextran 70 and 1822 ml in the lactated Ringer's group (P = 0.27). Yet, the blood loss was related to the reduction in MA (r = -0.427, P = 0.008) and by multiple regression analysis independently associated with MA (P = 0.01). Thus, 11 patients in the dextran group (58 %) developed a clinical significant blood loss (>1500 ml) compared to only four patients (22 %) in the lactated Ringer's group (P = 0.04). CONCLUSIONS: With the use of Dextran 70 vs. lactated Ringer's solution during cystectomy, a relation between hemorrhage and coagulation competence is demonstrated. Significant bleeding develops based on an about 25 % reduction in thrombelastography determined maximal amplitude. A multivariable model including maximal amplitude discriminates patients with severe perioperative bleeding during cystectomy. TRIAL REGISTRATION: The study was accepted on January 7(th), 2013 at www.clinicaltrialsregister.eu EudraCT 2012-005040-20.

Hydroxyethyl starch reduces coagulation competence and increases blood loss during major surgery: results from a randomized controlled trial.

OBJECTIVE: This study evaluated whether administration of hydroxyethyl starch (HES) 130/0.4 affects coagulation competence and influences the perioperative blood loss. BACKGROUND: Artificial colloids substitute blood volume during surgery; with the administration of HES 130/0.4 (Voluven, Fresenius Kabi, Uppsala, Sweden) only a minor effect on coagulation competence is expected. METHODS: Eighty patients were scanned for enrollment in the study, and 40 patients fulfilled the inclusion criteria. Two patients withdrew their consent to participate in the study, and 5 patients were excluded. Thus, 16 patients were randomized to receive lactated Ringer's solution and 17 to receive HES 130/0.4. RESULTS: Among the patients receiving HES 130/0.4, thrombelastography indicated reduced clot strength (P < 0.001) and blinded evaluation of the perioperative blood loss was 2.2 (range 0.5 to 5.0) versus 1.4 (range 0.5 to 2.4) L in the patients who received HES 130/0.4 or lactated Ringer, respectively (P < 0.038). The patients in the lactated Ringer's group, however, received more fluid (P < 0.0001) than those in the HES 130/0.4 group. There was no significant difference between the 2 groups with regard to frequency of reoperations or the length of hospital stay, but use of HES 130/0.4 was both more expensive and less efficacious than the use of lactated Ringer. CONCLUSIONS: Administration of HES 130/0.4 reduced clot strength and perioperative hemorrhage increased by more than 50%, while administration of lactated Ringer's solution provoked an approximately 2.5 times greater positive volume balance at the end of surgery.

Tracheal intubation with a flexible fibreoptic scope or the McGrath videolaryngoscope in simulated difficult airway scenarios: a randomised controlled manikin study.

BACKGROUND: Flexible fibreoptic endoscopic (FFE) intubation is considered the 'gold-standard' when difficult airway management is anticipated. Several videolaryngoscopes have been developed to facilitate intubation by laryngoscopy. OBJECTIVE: The aim of the study was to compare the performance of the McGrath series 5 videolaryngoscope (McGrath videolaryngoscope) and the FFE for tracheal intubation in manikins with a simulated difficult airway, hypothesizing that the McGrath videolaryngoscope intubation would prove faster than FFE intubation. DESIGN: A randomised controlled study. SETTING: The Danish Institute for medical simulation between December 2009 and June 2010. PARTICIPANTS: Twenty-eight anaesthesia residents participating in the Danish mandatory 3-day airway management course. INTERVENTIONS: All participants received instructions and training in the use of the McGrath videolaryngoscope and FFE. The participants then performed tracheal intubation on a SimMan manikin once with the McGrath videolaryngoscope and once with the FFE in three difficult airway scenarios: (1) pharyngeal obstruction; (2) pharyngeal obstruction and cervical rigidity; (3) tongue oedema. MAIN OUTCOME MEASURES: We measured successful intubations, defined as intubation within 120  s, and time to tracheal intubation. RESULTS: The trachea was intubated within 120  s with the McGrath videolaryngoscope in 25 out of 27 (93%), 25 out of 28 (89%) and 18 out of 28 (64%) occasions compared with 11 out of 28 (40%), 11 out of 28 (40%) and 16 out of 28 (57%) with the FFE in scenarios (1), (2) and (3), respectively. Time to tracheal intubation was shorter with the McGrath videolaryngoscope in scenarios (1) and (2) than with the FFE (Wilcoxon signed rank sum test, P < 0.0001). CONCLUSION: The McGrath videolaryngoscope is a valuable device with higher success rate and a quicker performance in simulated difficult airways. In patients, videolaryngoscopy may have a role in difficult airway algorithms, but the optimal device has yet to be found.

Does goal-directed fluid therapy affect postoperative orthostatic intolerance?: A randomized trial.

BACKGROUND: Early mobilization is important for postoperative recovery but is limited by orthostatic intolerance (OI) with a prevalence of 50% 6 h after major surgery. The pathophysiology of postoperative OI is assumed to include hypovolemia besides dysregulation of vasomotor tone. Stroke volume-guided fluid therapy, so-called goal-directed therapy (GDT), corrects functional hypovolemia, and the authors hypothesized that GDT reduces the prevalence of OI after major surgery and assessed this in a prospective, double-blinded trial. METHODS: Forty-two patients scheduled for open radical prostatectomy were randomized into standard fluid therapy (control group) or GDT groups. Both groups received a fixed-volume crystalloid regimen supplemented with 1:1 replacement of blood loss with colloid, and in addition, the GDT group received colloid to obtain a maximal stroke volume (esophageal Doppler). The primary outcome was the prevalence of OI assessed with a standardized mobilization protocol before and 6 h after surgery. Hemodynamic and hormonal orthostatic responses were evaluated. RESULTS: Twelve (57%) versus 15 (71%) patients in the control and GDT groups (P = 0.33), respectively, demonstrated OI after surgery, group difference 14% (CI, -18 to 45%). Patients in the GDT group received more colloid during surgery (1,758 vs. 1,057 ml; P = 0.001) and reached a higher stroke volume (102 vs. 89 ml; P = 0.04). OI patients had an increased length of hospital stay (3 vs. 2 days; P = 0.02) and impaired hemodynamic and norepinephrine responses on mobilization. CONCLUSION: GDT did not reduce the prevalence of OI, and patients with OI demonstrated impaired cardiovascular and hormonal responses to mobilization.