Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program.

BACKGROUND: The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery. METHODS: One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients' satisfaction with pain management were also assessed. RESULTS: We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups. CONCLUSION: TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

Is Brain-Dead Donor Fluid Therapy With Colloids Associated With Better Kidney Grafts?

OBJECTIVES: Fluid therapy is required to maintain perfusion to donor organs. Recent reviews on the choices of fluids have emphasized the safety of using crystalloids, as opposed to fluid therapy with colloids, which has been reported to be either unequivocally or potentially harmful in a number of studies on various patient populations. We aimed to analyze whether the type of fluid administered to donors is connected with kidney transplant outcomes. MATERIALS AND METHODS: A total of 100 consecutive brain-dead multiorgan donors and their respective 181 kidney recipients were studied retrospectively. Data concerning donor fluid therapy, the characteristics of the donors and the recipients, and outcomes after kidney transplant were extracted from organ retrieval and patient records. Cases with early graft function were compared with cases with delayed graft function. RESULTS: Donors had received both crystalloids and colloids in most cases (84%). Fluid therapy with crystalloids alone was more common among the 40 recipients with delayed (30%) than in the 103 recipients with early graft function (11%) (P = .005). Donor age, time on renal replacement therapy before transplant, and donor fluid therapy with crystalloids alone were independent risk factors for delayed graft function in multivariate analysis. CONCLUSIONS: Our results suggest that donor fluid therapy including colloids could be beneficial instead of harmful compared with treatment with crystalloids alone. This finding needs to be evaluated in prospective studies.

Albumin-Beyond Fluid Replacement in Cardiopulmonary Bypass Surgery: Why, How, and When?

Maintaining vascular barrier competence, preventing interstitial edema, and keeping microcirculation intact is crucial to achieve an optimal outcome in cardiopulmonary bypass surgery (CPB). Blood contact with roller pumps and foreign surfaces during CPB induces shear stress and a pressure drop across the pump boot that leads to transient systemic activation of the inflammatory and hemostatic systems. Moreover, patients after CPB often need volume resuscitation using the smallest possible amount of colloid solution because of fluid overload. For this purpose, human-derived albumin may be preferred over synthetic colloids because CPB priming with albumin preserves oncotic pressure, prevents platelet adhesion, and likely induces less consumption of coagulation factors. In patients with increased bleeding or renal failure, albumin is a safe alternative because of its minimal side effects. Large, randomized clinical trials comparing the benefit of albumin versus other fluids are warranted in the future to define albumin's distinct role in select high-risk surgical populations.

Comparison of the effect of 6% hydroxyethyl starch and gelatine on cardiac and stroke volume index: a randomized, controlled trial after cardiac surgery.

BACKGROUND AND AIMS: The objective of this study was to find out the effect of various doses of hydroxyethyl starch (HES), gelatine or Ringer's acetate on cardiac and stroke volume index after cardiac surgery. MATERIAL AND METHODS: Three consecutive boluses (each 7 mL·kg(-1)) of either 6% HES 130/0.4, 4% gelatine, or Ringer's acetate solutions were administered to 45 patients postoperatively. The rate of infusions was adjusted according to haemodynamic measurements. Thereafter, infusion of the study solution (7 mL·kg(-1)) was continued for the following 12 hours. The total dose of study solution was 28 mL·kg(-1). RESULTS AND CONCLUSION: Mean (SD) cardiac and stroke volume indices were greater in the HES group [2.8 L·min(-1)·m(-2) (0.7), 34.1 (6.7) ml·m( -2)] than in the gelatine group [2.2 L·min(-1)·m( -2) (0.6), 25.8 (7.2) ml·m(-2)] after completion of 7 mL·kg(-1) of study solution. At this stage, the effect of gelatine did not differ from Ringer's acetate. After completion of 14 mL·kg(-1) and 21 mL·kg(-1) of colloids, similar cardiac and stroke volume indices were observed and the haemodynamic response was better in both colloid groups than in the Ringer's acetate group. No differences between groups were detected on the first postoperative morning. In the early postoperative phase after cardiac surgery, the effect of a single dose of HES solution on the haemodynamics was superior to the effect of gelatine or Ringer's acetate. However, after repeated administration of the study solutions, the haemodynamics in the two colloid groups appeared to be similar, but superior to the Ringer's acetate group.

Rapidly degradable hydroxyethyl starch solutions impair blood coagulation after cardiac surgery: a prospective randomized trial.

BACKGROUND: There is continuing concern about the effect of hydroxyethyl starch (HES) solutions on blood coagulation. Rapidly degradable HES solutions with more favorable effects on clot strength have therefore been developed. Because the risk of bleeding is increased after cardiopulmonary bypass, we examined whether these types of HES solutions could be administered after cardiac surgery without an alteration of coagulation. METHODS: Two new rapidly degradable HES solutions were compared with human albumin in 45 patients scheduled for elective primary cardiac surgery. After admission to the cardiac surgical intensive care unit, the patients were allocated in random order to receive either 15 mL/kg of HES solution with low molecular weight and low molar substitution (either 6% HES200/0.5 or 6% HES130/0.4) or 4% human albumin solution as a short-time (70-240 min) infusion. RESULTS: Clot formation time was prolonged and maximum clot firmness was decreased in thromboelastometry tracings after infusion of both HES solutions. This impairment in thromboelastometry tracings partly recovered (using InTEM and ExTEM coagulation activators) at 2 h after the completion of the study infusion. Platelet contribution to maximum clot firmness remained unaffected in all of the study groups. HES did not induce fibrinolysis. No changes in thromboelastometry tracings were observed after human albumin infusion. Chest tube drainage was comparable in the study groups. CONCLUSIONS: We conclude that a short-time infusion of rapidly degradable HES solutions after cardiac surgery produces impairment in fibrin formation and clot strength in thromboelastometry tracings. In this clinical setting, human albumin does not impair hemostasis.