Haemodynamic goal-directed therapy and postoperative infections: earlier is better. a systematic review and meta-analysis

Dalfino, Lidia; Giglio, Mariateresa; Puntillo, Filomena; Marucci, Massimo; Brienza, Nicola

doi:10.1186/cc10284

Cited by 143 publications

(77 citation statements)

References 71 publications

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“…There is consistent evidence that an optimisation strategy can improve outcomes as long as it is delivered before the onset of cell ischaemia and organ failure [125,126]. Recent evidence for immunomodulating effects are conflicting [127,128], and some workers have demonstrated other benefits e.g. on gastro-intestinal function [129].…”

Section: Managing the Circulation And Shockmentioning

confidence: 99%

The principles and conduct of anaesthesia for emergency surgery

Gray

Morris

2012

Anaesthesia

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SummaryIn this second article we examine the principles underlying delivery of the components of anaesthesia. Topics considered include anaesthetic technique, management of the airway and lung ventilation, induction and maintenance of anaesthesia, patient monitoring including the place of cardiac output devices. We summarise recent research on the management of shock and sepsis syndromes including goal directed therapy and examine some controversies around intravenous fluid therapy. Finally, we discuss intra-operative awareness and challenges during emergence including perioperative cognitive dysfunction. Choice of anaesthetic techniqueOptimal anaesthetic technique is dependent upon an individualised assessment of patient and surgical requirements. Prospective, randomised, controlled trials of rival anaesthetic techniques, e.g. the GALA trial, are rare [1]. Emergency anaesthesia lacks this evidence base and extrapolations from meta-analyses typically fail to reach clear recommendations for clinicians [2]. The nature of surgery, patient co-morbidities, and urgency will frequently decide the anaesthetic choice but clinicians should remain mindful of the options of local or regional anaesthesia and sedation in appropriate patients, especially when a 'lesser' procedure becomes feasible e.g. percutaneous drainage. Management and protection of the airway including pulmonary aspirationThe fourth National Audit Project (NAP4) of the Royal College of Anaesthetists recorded the epidemiology and management of airway complications in UK practice and is essential reading [3]. It is emphasised that 25% of emergency airway management takes place outside operating theatres and since publication, several resources and recommendations have become available [4][5][6]. In the UK, out-of-theatre tracheal intubation frequently occurs in the absence of essential staff and equipment and capnography was not used in nearly a third of cases in a large observational study [7].Both difficult laryngoscopy and difficult tracheal intubation are more common in emergency patients, often outside the theatre setting [8,9]. One American study of non-theatre emergency tracheal intubation by experienced practitioners identified difficulties in over 10%, with over 4% suffering complications [10]. Predictors of complications included multiple attempts and poor views at laryngoscopy and intubation in a ward or emergency department setting. Human factors are increasingly recognised in airway complications and an unfamiliar environment during airway management is likely to be important [3].

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Section: Managing the Circulation And Shockmentioning

confidence: 99%

The principles and conduct of anaesthesia for emergency surgery

Gray

Morris

2012

Anaesthesia

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“…Interest was generated by Shoemaker et al [72], who demonstrated morbidity and mortality benefits, when a goal-directed approach was applied to the perioperative care of high-risk surgical patients. Some subsequent studies have shown reduced risk of infective complications [73], AKI [74], cardiovascular complications [75], pneumonia, and hospital length of stay [74]. However, others have found no benefit, in abdominal aortic surgery [76] or colorectal surgery [77].…”

Section: Goal-directed Approachesmentioning

confidence: 99%

Volume Management and Resuscitation in Thoracic Surgery

Ashes

Slinger

2014

Curr Anesthesiol Rep

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Lung injury following thoracic surgery is a major cause of morbidity and mortality. A consistent risk factor is excessive perioperative fluid administration, not only following pneumonectomy, but also after lesser lung resections and esophageal surgery. Recent insights into the pathophysiology of lung injury after thoracic surgery include the role of the endothelial glycocalyx, pulmonary endothelium, lung lymphatics, and right ventricular dysfunction. While a restrictive approach to fluid administration may reduce the risk of lung injury, there are concerns regarding the risks of acute kidney injury with this approach. Goal-directed approaches may be applied to the thoracic surgical population, and lung ultrasound appears to be a promising new technique to further guide perioperative fluid therapy. There is a paucity of data to guide the choice of crystalloid or colloid solution. Further research is required regarding prevention, diagnosis, and treatment of lung injury following thoracic surgery.

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“…In this issue of Anaesthesia, Stevens et al [1] provide more evidence for the complexity of tramadol usage. Tramadol was only licensed in the UK 30 years ago, yet in its short lifetime it has attracted a disproportionate amount of attention.…”

Section: Editorialmentioning

confidence: 99%

“…It has been suggested that early goal-directed haemodynamic optimisation, for instance by continuously measuring and optimising stroke volume, may lead to a decreased infection rate, fewer unwanted cardiac events and faster recovery of bowel function, with a reduction in postoperative morbidity [1][2][3][4]. However, the recommendation of the routine use of oesophageal Doppler in major surgery continues to generate ongoing discussion [5][6][7][8].…”

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confidence: 99%