Assessment of the state of water sectors and central hemodynamics during restrictive protocol of perioperative infusion therapy in patients undergoing emergency laparotomy
Background. Abdominal acute surgical pathology is an acute condition requiring emergency surgical intervention. The lack of objective instrumental-laboratory data on the patient’s condition, the uncertainty in exact extent of surgical interventions, the difficulty of conducting a prognostic assessment are the factors that increase the risk of postoperative complications with high mortality rate (30–80 %). The purpose of the study was to evaluate the effectiveness of the restrictive protocol of perioperative infusion therapy in patients undergoing emergency laparotomy. Materials and methods. Having agreed with the local Ethics Committee and obtained the informed consents, 30 patients, who needed emergency laparotomy, were examined. Preoperative treatment was performed in the intensive care unit according to the Standards of professional protocols (the Ministry of Health of Ukraine, 2008): perioperative fluid management, prevention of thrombosis and wound infections. Hypovolemia was treated by infusion of balanced crystalloid solutions. The hypovolemia severity was determined by using the test of tissue hydrophilia by Shelestiuk and corresponded to the degree II. Infusion volume was 40–60 ml/kg/day. Thus, 25 % of the calculated amount of volume deficit were infused during the first hour of treatment. In the absence of hemodynamic effects of infusion volume, we administered the vasopressors (norepinephrine, phenylephrine) in accordance with general practices. The next 25 % were infused during two hours of treatment (including intraoperative period). Full restoration of volume deficit (last 50 %) was carried out by the end of the first day of treatment. After fluid volume was restored to the full and normovolemia (postoperatively) was achieved, infusion therapy was performed in accordance with general practices. We studied the clinical parameters of systemic hemodynamic, central and peripheral hemodynamic parameters and water sectors of the body. Scoring scales ASA and POSSUM were used for stratification of surgical risk. Control points were before surgery, days 1, 3, 5–7, 10–14, 28–30 after surgery. Results. The results of the study proved that acute surgical pathology in patients with moderate surgical risk is accompanied by the maintenance of a normal total volume of fluid with a significant redistribution of the water sectors of the body, such as plasma deficit with the development of hypovolemia, intracellular dehydration, the initial increase in the volume of the interstitial space. The change in water sectors is combined with the development of relative hyperdynamia due to an increase in the total peripheral resistance and heart rate. Conclusions. Acute surgical pathology in patients with moderate surgical risk is accompanied by the maintenance of a normal total volume of fluid with a significant redistribution of the water sectors of the body, particularly deficit of plasma with the development of hypovolemia, formation of intracellular dehydration, the initial increase in the volume of the interstitial space. The use of a restrictive strategy of infusion therapy in patients with moderate surgical risk allows restore the physiological volumes of the water sectors of the body and form a normodynamic type of circulation from the 3rd day of postoperative period.
Mythen M.G., Swart M., Acheson N., Crawford R., Jones K., Kuper M. et al. Perioperative fluid management: Consensus statement from the enhanced recovery partnership // Perioperative Medicine. — 2012. — 1. — 2. [PUBMED: 24764518]
Rahbari N.N., Zimmermann J.B., Schmidt T., Koch M., Weigand M.A., Weitz J. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery // British Journal of Surgery. — 2009. — 96(4). — P. 331-41. [PUBMED: 19283742]
Nisanevich V., Felsenstein I., Almogy G., Weissman C., Einav S., Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery // Anesthesiology. — 2005. — 103(1). — P. 25-32.
Hartog C., Reinhart K. CONTRA: Hydroxyethyl starch solutions are unsafe in critically ill patients // Intensive Care Med. — 2009. — 35(8). — P. 1337-42. doi: 10.1007/s00134-009-1521-5. 27.
Mythen M., Vercueil A. Fluid balance // Vox Sang. — 2004. — 87 Suppl. — P. 77-81.
Sark Y., Vincent J.L., Reinhart K., Groeneveld J., Michalopoulos A., Sprung C.L., Artigas A., Ranieri V.M. Sepsis Occurrence in Acutely Ill Patients Investigators: High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury // Chest. — 2005. — 128. — P. 3098-3108.
Copyright (c) 2018 EMERGENCY MEDICINE
This work is licensed under a Creative Commons Attribution 4.0 International License.
© Publishing House Zaslavsky, 1997-2019