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BackgroundMajor abdominal surgery (MAS) is associated with increased morbidity and mortality. The main objective of our study was to evaluate the predictive value of heart-rate variability (HRV) concerning development of postoperative complications in patients undergoing MAS. The secondary objectives were to identify the relationship of HRV and use of vasoactive drugs during anesthesia, intensive care unit length of stay (ICU-LOS), and hospital length of stay (H-LOS).Patients and methodsSixty-five patients scheduled for elective MAS were enrolled in a prospective, single-center, observational study. HRV was measured by spectral analysis (SA) preoperatively during orthostatic load. Patients were divided according to cardiac autonomic reactivity (CAR; n=23) and non-cardiac autonomic reactivity (NCAR; n=30).ResultsThe final analysis included 53 patients. No significant difference was observed between the two groups regarding type of surgery, use of minimally invasive techniques or epidural catheter, duration of surgery and anesthesia, or the amount of fluid administered intraoperatively. The NCAR group had significantly greater intraoperative blood loss than the CAR group (541.7±541.9 mL vs 269.6±174.3 mL, p<0.05). In the NCAR group, vasoactive drugs were used during anesthesia more frequently (n=21 vs n=4; p<0.001), and more patients had at least one postoperative complication compared to the CAR group (n=19 vs n=4; p<0.01). Furthermore, the NCAR group had more serious complications (Clavien–Dindo ≥ Grade III n=6 vs n=0; p<0.05) and a greater number of complications than the CAR group (n=57 vs n=5; p<0.001). Significant differences were found for two specific subgroups of complications: hypotension requiring vasoactive drugs (NCAR: n=10 vs CAR: n=0; p<0.01) and ileus (NCAR: n=11 vs CAR: n=2; p<0.05). Moreover, significant differences were found in the ICU-LOS (NCAR: 5.7±3.5 days vs CAR: 2.6±0.7 days; p<0.0001) and H-LOS (NCAR: 12.2±5.6 days vs CAR: 7.2±1.7 days; p<0.0001).ConclusionPreoperative HRV assessment during orthostatic load is objective and useful for identifying patients with low autonomic physiological reserves and high risk of poor post-operative course.

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Abdominal compartment syndrome (ACS) is defined as a sustained increase of intra-abdominal pressure (IAP) above 20 mmHg followed by the development of organ dysfunction. Treatment of ACS is still a question to be discussed and surgical decompression is usually preferred. According to recent data, massive crystalloid resuscitation of shock plays a key role in the development of secondary ACS in trauma patients. As mentioned previously, a high volume of infused crystalloids and a positive fluid balance were associated with ACS development in trauma patients as well as in septic patients. Moreover, we observed that a treatment strategy based on the achievement of a negative fluid balance resulted in a dramatic decrease in IAP and an improvement in haemodynamics and ventilation. This approach has been indicated as an interesting option for non-surgical treatment, with a caution that such intervention may exacerbate gut hypoperfusion. In this report we present two patients with secondary ACS development following abdominal surgery in which the achievement of a negative fluid balance showed a similar effect. Moreover, the fluid removal procedure also seemed to be associated with an improvement in splanchnic perfusion, as measured by gastric tonometry.