Effects of goal-directed fluid therapy on enhanced postoperative recovery: An interventional comparative observational study with a historical control group on oesophagectomy combined with ERAS program.

BACKGROUND AND AIMS: The Enhanced Recovery after Surgery (ERAS) program has been proposed as a postoperative recovery-enhancing strategy. We frequently apply the Modified-ERAS program following oesophagectomy. This study aims to elucidate the impact of goal-directed fluid therapy (GDT) for the perioperative management of oesophageal cancer on the postoperative recovery of patients undergoing oesophagectomy. METHODS: This is an interventional before-after comparative observational study conducted at Kanagawa Cancer Centre, Japan. Patients who underwent elective oesophagectomy for oesophageal cancer were recruited. Group H (retrospectively collected) received intraoperative and postoperative management consisting of fluid administration without haemodynamic monitoring and the M-ERAS program, while Group S prospectively received management consisting of GDT and the M-ERAS program. The primary endpoint was the speed of gastrointestinal functional recovery, while secondary endpoints were the level of postoperative mobilisation, incidence of complications, postoperative length of hospital stay (LOS), and nutritional status after discharge. RESULTS: The proportion of patients who completely egested Gastrografin by postoperative day 4, the level of postoperative mobilisation, and achievement ratio for a 100-m walk on the first postoperative attempt were significantly higher in Group S than in Group H (P = 0.034, P = 0.0197, and P < 0.0001, respectively). No significant differences were observed in the postoperative LOS and incidence of complications within 30 days between the groups. The serum albumin levels at 6 months after discharge was higher in Group S than in Group H (P = 0.0002). CONCLUSIONS: The GDT-ERAS program enhanced postoperative gastrointestinal recovery and mobilisation, as well as postoperative nutritional status and protein synthesis. The program did not affect either postoperative LOS or the incidence of complications. TRIAL REGISTRATION: UMIN registration number: UMIN000013705, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000015999.

The effect of intraoperative use of high-dose remifentanil on postoperative insulin resistance and muscle protein catabolism: a randomized controlled study.

OBJECTIVE: We investigated the effect of the intraoperative use of a high dose remifentanil on insulin resistance and muscle protein catabolism. DESIGN: Randomized controlled study. PATIENTS AND INTERVENTION: Thirty-seven patients undergoing elective gastrectomy were randomly assigned to 2 groups that received remifentanil at infusion rates of 0.1 µg·kg(-1)·min(-1) (Group L) and 0.5 µg·kg(-1)·min(-1) (Group H). MAIN OUTCOME MEASURES: Primary efficacy parameters were changes in homeostasis model assessment as an index of insulin resistance (HOMA-IR) and 3-methylhistidine/creatinine (3-MH/Cr). HOMA-IR was used to evaluate insulin resistance, and 3-MH/Cr was used to evaluate the progress of muscle protein catabolism. Intraoperative stress hormones, insulin, and blood glucose were assessed as secondary endpoints. RESULTS: Eighteen patients in Group L and 19 in Group H were examined. HOMA-IR values varied within normal limits in both groups during surgery, exceeding normal limits at 12 h after surgery and being significantly elevated in Group L. There were no significant differences in the 3-MH/Cr values between the 2 groups at any time point. The stress hormones (adrenocorticotropic hormone, cortisol, and adrenaline) were significantly elevated in Group L at 60 min after the start of surgery and at the initiation of skin closure. There were no significant differences in insulin values, but blood glucose was significantly elevated in Group L at 60 min after the start of surgery and at the start of skin closure. CONCLUSION: Use of high-dose remifentanil as intraoperative analgesia during elective gastrectomy reduced postoperative insulin resistance, although it did not reduce postoperative muscle protein catabolism.

Preoperative fluid and electrolyte management with oral rehydration therapy.

PURPOSE: We hypothesized that oral rehydration therapy using an oral rehydration solution may be effective for preoperative fluid and electrolyte management in surgical patients before the induction of general anesthesia, and we investigated the safety and effectiveness of oral rehydration therapy as compared with intravenous therapy. METHODS: Fifty female patients who underwent breast surgery were randomly allocated to two groups. Before entry to the operation room and the induction of general anesthesia, 25 patients drank 1000 ml of an oral rehydration solution ("oral group") and 25 patients were infused with 1000 ml of an intravenous electrolyte solution ("intravenous group"). Parameters such as electrolyte concentrations in serum and urine, urine volume, vital signs, vomiting and aspiration, volumes of esophageal-pharyngeal fluid and gastric fluid (EPGF), and patient satisfaction with the therapy (as surveyed by a questionnaire) were assessed. RESULTS: After treatment, the serum sodium concentration and the hematocrit value, which both declined within the normal limits, were significantly higher in the oral group than in the intravenous group (sodium, 140.8 +/- 2.9 mEq x l(-1) in the oral group and 138.7 +/- 1.9 mEq x l(-1) in the intravenous group; P = 0.005; hematocrit, 39.03 +/- 4.16% in the oral group and 36.15 +/- 3.41% in the intravenous group; P = 0.01). No significant difference was observed in serum glucose values. Urine volume was significantly larger in the oral group (864.9 +/- 211.5 ml) than in the intravenous group (561.5 +/- 216.0 ml; P < 0.001). The fractional excretion of sodium (FENa), as an index of renal blood flow, was increased in both groups following treatment (0.8 +/- 0.5 in the oral group and 0.8 +/- 0.3 in the intravenous group). Patient satisfaction with the therapy favored the oral rehydration therapy, as judged by factors such as "feeling of hunger", "occurrence of dry mouth", and "less restriction in physical activity". The volume of EPGF collected following the induction of anesthesia was significantly smaller in the oral group than in the intravenous group (6.03 +/- 9.14 ml in the oral group and 21.76 +/- 30.56 ml in the intravenous group; P < 0.001). No adverse events or adverse reactions were observed in either group. CONCLUSION: The results suggest that the oral rehydration therapy with an oral rehydration solution before surgery is superior to the current preoperative intravenous therapy for the provision of water, electrolytes, and carbohydrates, and this therapy should be considered as an alternative to the intravenous therapy for preoperative fluid and electrolyte management in selected surgical patients in whom there is no reason to suspect delayed gastric emptying.

[The effect of dopamine on serum lipid concentration after propofol administration].

Propofol in emulsion formulation is widely used for operation and sedation in ICU. We retrospectively investigated the effect of dopamine on post-operative serum lipid concentrations after propofol administration. Twenty three patients with ASA physical status I or II scheduled for elective operations were enrolled in this study; 15 patients in the non-dopamine administration group (Group P) and 8 patients in the dopamine administration group (Group Dopa-P). We measured triglyceride (TG), total cholesterol (T-chol) pre-operatively, post-operatively and on post-operative day 1 and AST, ALT preoperatively and on post-operative day 1. Serum TG concentration increased significantly in post-operative measurements in Group-P (P < 0.05). But there was no significant change in TG in Group Dopa-P. Serum T-chol concentration decreased significantly post-operatively and on post-operative day 1 in both groups (P < 0.05). Serum AST and ALT concentrations increased significantly on post-operative day 1 (P < 0.05). With 10% fat infusion rates below 0.1 mg.kg-1.hr-1 (equal to propofol 10 mg.kg-1.hr-1), serum lipid concentration did not increase. But our results suggest that the serum TG concentration may increase significantly post-operatively after intra-operative propofol administration and dopamine may decrease serum TG level.