• Colloids
• Fluid therapy
• Goal-directed therapy
• Ischemia/reperfusion
• Microcirculation

• Humans
• Animals
• Swine
• Crystalloid Solutions
• Microcirculation
• Goals
• Fluid Therapy/methods
• Hydroxyethyl Starch Derivatives/pharmacology
• Hydroxyethyl Starch Derivatives/therapeutic use
• Ischemia/therapy
• Colloids/therapeutic use
• Reperfusion Injury
• Reperfusion
• Isotonic Solutions/pharmacology
• Isotonic Solutions/therapeutic use

Intraoperative fluid management is important for the prevention of perioperative morbidity and mortality. Our study aimed to investigate the perioperative feasibility and benefits of Goal-Directed Fluid Management (GDFM) using noninvasive hemodynamic monitoring in gynecologic oncology patients with acute blood loss and severe fluid loss. We assessed the effects of GDFM on hemodynamics, organ perfusion, complications, and mortality outcomes.

This randomized prospective study included 104 patients over the age of 18 years, including 56 patients with endometrial cancer and 48 patients with ovarian cancer who had open surgery. The anesthetic approach was standardized for all patients. We compared the perioperative results of the subjects who were randomized into GDFM (n = 51) and Liberal Fluid Management (LFM) (n = 53) groups using a computer program.

The median perioperative crystalloid replacement (2000 vs. 2700; p < 0.001) and total volume of fluid (2260 vs. 3200; p < 0.001) were lower in the GDFM group compared to the LFM group. The hemodynamic findings and the HCO₃ and lactate levels of the GDFM group did not significantly change perioperatively. The heart rate, mean arterial pressure, and HCO₃ levels of the LFM group decreased and serum lactate levels increased perioperatively. The hospitalization rate in ICU (7.8% vs. 28.3%; p = 0.010), rate of patients with comorbidity conditions indicated in ICU (2% vs. 17%; p = 0.024), and rate of complications (17.6% vs. 35.8%; p = 0.047) were lower in the GDFM group compared to the LFM group.

The amount of intraoperatively administered crystalloid solution and complication rates were significantly lower in gynecologic oncologic surgery patients who received GDFM. Besides, hemodynamic findings, and lactate levels of the GDFM group did not change significantly during the perioperative period.

• Adult
• Crystalloid Solutions
• Female
• Fluid Therapy/methods
• Genital Neoplasms, Female/surgery
• Goals
• Hemodynamic Monitoring
• Hemodynamics
• Humans
• Lactates
• Middle Aged
• Prospective Studies

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

• anaesthesia
• anastomosis, surgical
• colorectal surgery
• complications
• gastrointestinal

• Cardiovascular risk
• MINS
• Major abdominal surgery
• NT-proBNP
• Supplemental oxygen

• Biomarkers
• Humans
• Middle Aged
• Natriuretic Peptide, Brain
• Oxygen
• Peptide Fragments
• Prospective Studies
• Risk Assessment

• anastomotic leak
• biomarkers
• colorectal cancer
• intestinal anastomosis
• precision medicine

• EP/K-34510/1 Engineering and Physical Sciences Research Council
• NA Bowel and Cancer Research

Dynamic parameters of preload have been widely recommended to guide fluid therapy based on the principle of fluid responsiveness and with regard to cardiac output. An equally important aspect is however to also avoid volume-overload. This accounts particularly when capillary leakage is present and volume-overload will promote impairment of microcirculatory blood flow. The aim of this study was to evaluate, whether an impairment of intestinal microcirculation caused by volume-load potentially can be predicted using pulse pressure variation in an experimental model of ischemia/reperfusion injury. The study was designed as a prospective explorative large animal pilot study. The study was performed in 8 anesthetized domestic pigs (German landrace). Ischemia/reperfusion was induced during aortic surgery. 6 h after ischemia/reperfusion-injury measurements were performed during 4 consecutive volume-loading-steps, each consisting of 6 ml kg⁻¹ bodyweight⁻¹. Mean microcirculatory blood flow (mean Flux) of the ileum was measured using direct laser-speckle-contrast-imaging. Receiver operating characteristic analysis was performed to determine the ability of pulse pressure variation to predict a decrease in microcirculation. A reduction of ≥ 10% mean Flux was considered a relevant decrease. After ischemia–reperfusion, volume-loading-steps led to a significant increase of cardiac output as well as mean arterial pressure, while pulse pressure variation and mean Flux were significantly reduced (Pairwise comparison ischemia/reperfusion-injury vs. volume loading step no. 4): cardiac output (l min⁻¹) 1.68 (1.02–2.35) versus 2.84 (2.15–3.53), p = 0.002, mean arterial pressure (mmHg) 29.89 (21.65–38.12) versus 52.34 (43.55–61.14), p < 0.001, pulse pressure variation (%) 24.84 (17.45–32.22) versus 9.59 (1.68–17.49), p = 0.004, mean Flux (p.u.) 414.95 (295.18–534.72) versus 327.21 (206.95–447.48), p = 0.006. Receiver operating characteristic analysis revealed an area under the curve of 0.88 (CI 95% 0.73–1.00; p value < 0.001) for pulse pressure variation for predicting a decrease of microcirculatory blood flow. The results of our study show that pulse pressure variation does have the potential to predict decreases of intestinal microcirculatory blood flow due to volume-load after ischemia/reperfusion-injury. This should encourage further translational research and might help to prevent microcirculatory impairment due to excessive fluid resuscitation and to guide fluid therapy in the future.

Perioperative subcutaneous tissue oxygen tension (PsqO₂) is substantially reduced in obese surgical patients. Goal-directed fluid therapy optimizes cardiac performance and thus tissue perfusion and oxygen delivery. We therefore tested the hypothesis that intra- and postoperative PsqO₂ is significantly reduced in obese patients undergoing standard fluid management compared to goal-directed fluid administration.

We randomly assigned 60 obese patients (BMI ≥ 30 kg/m²) undergoing laparoscopic bariatric surgery to receive either esophageal Doppler-guided goal-directed fluid management or conventional fluid treatment. Our primary outcome parameter was intra- and postoperative PsqO₂ measured with a polarographic electrode in the subcutaneous tissue of the upper arm. A random effects linear regression model was used to analyze the effect of intervention.

Overall, mean (± SD) PsqO₂ was significantly higher in obese patients receiving goal-directed therapy compared to conventional fluid therapy (65.8 ± 28.0 mmHg vs. 53.7 ± 21.7, respectively; repeated measures design adjusted difference: 13.0 mmHg [95% CI 2.3 to 23.7; p = 0.017]). No effect was seen intraoperatively (69.6 ± 27.9 mmHg vs. 61.4 ± 28.8, difference: 9.7 mmHg [95% CI -3.8 to 23.2; p = 0.160]); however, goal-directed fluid management improved PsqO₂ in the early postoperative phase (63.1 ± 27.9 mmHg vs. 48.4 ± 12.5, difference: 14.5 mmHg [95% CI 4.1 to 24.9; p = 0.006]). Intraoperative fluid requirements did not differ between the two groups.

Goal-directed fluid therapy improved subcutaneous tissue oxygenation in obese patients. This effect was more pronounced in the early postoperative period.

The study was registered at ClinicalTrials.gov (NCT 01052519).

• Goal-directed fluid therapy
• Laparoscopic surgery
• Obesity
• Tissue oxygen tension

Excessive perioperative fluid administration may result in iatrogenic endothelial dysfunction and tissue edema, transducing inflammatory markers into the bloodstream. Colloids remain longer in the circulation, requiring less volume to reach similar hemodynamic endpoints compared to crystalloids. Thus, we tested the hypothesis that a goal-directed colloid regimen attenuates the inflammatory response compared to a goal-directed crystalloid regime.

Patients undergoing moderate- to high-risk open abdominal surgery were randomly assigned to goal-directed lactated Ringer’s solution (n = 58) or a hydroxyethyl starch 6% 130/0.4 (n = 62) fluid regimen. Our primary outcome was perioperative levels of pro- and anti-inflammatory cytokines. Secondary outcome was perioperative levels of white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT) and lipopolysaccharide-binding protein (LBP). Measurements were performed preoperatively, immediate postoperatively, on postoperative day one, two and four.

The areas under the curve of Interleukin (IL) 6 (p = 0.60), IL 8 (p = 0.46), IL 10 (p = 0.68) and tumor necrosis factor α (p = 0.47) levels did not differ significantly between the groups. WBC, CRP and PCT values were also comparable. LBP, although significantly higher in the crystalloid group, remained in the normal range. Patients assigned to crystalloids received a median (IQR) amount of 3905 mL (2880–5288) of crystalloid. Patients assigned to colloids received 1557 mL (1207–2116) of crystalloid and 1250 mL (750–1938) of colloid.

Cytokine and inflammatory marker levels did not differ between goal-directed crystalloid and colloid administration after moderate to high-risk abdominal surgery.

ClinicalTrials.gov (NCT00517127). Registered 16th August 2007.

• HES
• colloid
• fluid therapy
• horse
• hypoalbuminemia
• resuscitation

In vascular surgery with aortic cross-clamping, ischemia/reperfusion injury induces systemic haemodynamic and microcirculatory disturbances. Different anaesthetic regimens may have a varying impact on tissue perfusion. The aim of this study was to explore changes in microvascular perfusion in patients undergoing elective open abdominal aortic aneurysm repair under balanced or total intravenous anaesthesia.

Prospective observational study. Patients undergoing elective open infrarenal abdominal aortic aneurysm repair received balanced (desflurane + remifentanil, n = 20) or total intravenous anaesthesia (TIVA, propofol + remifentanil using target-controlled infusion, n = 20) according to the clinician’s decision. A goal-directed haemodynamic management was applied in all patients. Measurements were obtained before anaesthesia induction (baseline) and at end-surgery and included haemodynamics, arterial/venous blood gases, sublingual microvascular flow and density (incident dark field illumination imaging), peripheral muscle tissue oxygenation and microcirculatory reactivity (thenar near infrared spectroscopy with a vascular occlusion test).

The two groups did not differ for baseline characteristics, mean aortic-clamping time and requirement of vasoactive agents during surgery. Changes in mean arterial pressure, systemic vascular resistance index, haemoglobin and blood lactate levels were similar between the two groups, while the cardiac index increased at end-surgery in patients undergoing balanced anaesthesia. The sublingual microcirculation was globally unaltered in the TIVA group at end-surgery, while patients undergoing balanced anaesthesia showed an increase in the total and perfused small vessel densities (from 16.6 ± 4.2 to 19.1 ± 5.4 mm/mm², p < 0.05). Changes in microvascular density were negatively correlated with changes in the systemic vascular resistance index. The area of reactive hyperaemia during the VOT increased in the balanced anaesthesia group (from 14.8 ± 8.1 to 25.6 ± 14.8%*min, p < 0.05). At end-surgery, the tissue haemoglobin index in the TIVA group was lower than that in the balanced anaesthesia group.

In patients undergoing elective open abdominal aortic aneurysm repair with a goal-directed hemodynamic management, indices of sublingual or peripheral microvascular perfusion/oxygenation were globally preserved with both balanced anaesthesia and TIVA. Patients undergoing balanced anaesthesia showed microvascular recruitment at end-surgery.

NCT03510793, https://www.clinicaltrials.gov, date of registration April 27th 2018, retrospectively registered.

• Anaesthesia
• Aortic surgery
• Haemodynamics
• Ischemia/reperfusion injury
• Microcirculation

Fluids are by far the most commonly administered intravenous treatment in patient care. During critical illness, fluids are widely administered to maintain or increase cardiac output, thereby relieving overt tissue hypoperfusion and hypoxia.

Until recently, because of their excellent safety profile, fluids were not considered “medications”. However, it is now understood that intravenous fluid should be viewed as drugs. They affect the cardiovascular, renal, gastrointestinal and immune systems. Fluid administration should therefore always be accompanied by careful consideration of the risk/benefit ratio, not only of the additional volume being administered but also of the effect of its composition on the physiology of the patient. Apart from the need to constantly assess fluid responsiveness, it is also important to periodically reconsider the type of fluid being administered and the evidence regarding the relationship between specific disease states and different fluid solutions.

The current review presents the state of the art regarding fluid solutions and presents the existing evidence on routine fluid management of critically ill patients in specific clinical settings (sepsis, Adult Respiratory Distress Syndrome, major abdominal surgery, acute kidney injury and trauma).

The online version of this article (10.1186/s12871-018-0669-3) contains supplementary material, which is available to authorized users.

• Colloid
• Critically ill
• Crystalloid
• Fluids
• Intensive care unit
• Resuscitation

• Microcirculation
• bowel anastomosis
• experimental surgery

Currently, there is no consensus about the optimum intraoperative fluid therapy strategy. There is growing body of evidence supports the beneficial effects of adopting “Goal-directed therapy” over either the “liberal” or “restrictive” fluid therapy strategies. In this narrative review, we have presented the evidence to support the optimum strategy for intraoperative therapy. In conclusion, whatever the intravenous fluid replacement strategy used, the anesthesiologist must be prepared to adjust the composition and rate of the fluids administered to provide sufficient intravascular fluid volume for adequate perfusion of vital organs without overwhelming the glycocalyx function with fluid overloads.

• Anesthesia
• fluid therapy
• goal-directed
• intraoperative
• liberal
• monitoring
• restrictive

• Fluid therapy
• lung function
• one-lung ventilation (OLV)
• stroke volume variation (SVV)

• Abdomen/surgery
• Body Fluid Compartments/physiology
• Cardiac Output/drug effects
• Colloids/therapeutic use
• Crystalloid Solutions
• Endothelium, Vascular/physiopathology
• Fluid Therapy/methods
• Fluid Therapy/standards
• Glycocalyx/physiology
• Hemodynamics/drug effects
• Humans
• Isotonic Solutions/therapeutic use
• Perioperative Care/methods
• Perioperative Care/standards
• Postoperative Complications/physiopathology
• Postoperative Complications/prevention & control
• Postoperative Complications/therapy
• Stress, Physiological
• Water-Electrolyte Imbalance/physiopathology
• Water-Electrolyte Imbalance/prevention & control
• Water-Electrolyte Imbalance/therapy

• Fluid Therapy
• Humans
• Hydroxyethyl Starch Derivatives
• Intraoperative Care
• Plasma Substitutes

• colloids
• hypovolemia
• safety
• sepsis
• side effects

• Fluid
• Glycocalyx
• Hydrostatic pressure
• Microcirculation
• Sepsis
• Surgery
• Trauma

Volume resuscitation with hydroxyethyl starch (HES) is controversially discussed and we recently showed that HES perfusion impairs endothelial and epithelial intestinal barrier integrity. Here we investigated whether Albumin containing HES solutions are superior to HES alone in maintaining intestinal barrier function.

An isolated perfused model of the mouse small intestine was used to investigate the effects of: (i) 3 % Albumin (Alb), (ii) 3 % HES or (iii) 1.5 % HES/1.5 % Albumin (HES/Alb). Intestinal morphology, cell damage, metabolic functions, fluid shifts and endothelial/epithelial barrier permeability were evaluated. Potentially involved signaling mechanisms (Erk1/2, Akt and Stat5 phosphorylation) were screened.

HES induced histomorphological damage (p < 0.01 vs. Alb), by trend elevated the amount of luminal intestinal fatty acid binding protein and reduced galactose uptake (p < 0.001 vs. Alb). Luminal and lymphatic flow rates were increased (p < 0.001 vs. Alb), while vascular flow was decreased (p < 0.001 vs. Alb) during HES perfusion. HES also increased the vascular to luminal FITC-dextran transfer (p < 0.001 vs. Alb), pointing towards a fluid shift from the vascular to the luminal and lymphatic compartments during HES perfusion. Addition of Alb (HES/Alb) reversed all adverse effects of HES (p < 0.05 vs. HES), restored barrier integrity (p < 0.05 vs. HES) and improved metabolic function of the intestine (p < 0.001 vs. HES; p < 0.05 vs. Alb). Mechanistically, HES/Alb perfusion resulted in an increased phosphorylation of Erk1/2 and Akt kinases (p < 0.001 vs. HES), while Stat5 remained unchanged.

Albumin supplementation abrogates the adverse effects of HES in the intestine and underlying mechanism may function via phosphorylation of Erk1/2 and Akt. Albumin containing HES solutions are superior to HES alone and may improve the suitability of HES in the clinic.

The online version of this article (doi:10.1186/s12967-016-0810-3) contains supplementary material, which is available to authorized users.

To investigate the effects of normal saline (0.9% NaCl) and 6% Hydroxyethyl Starch 130/0.4(HES) solution on Ischemia/Reperfusion (I/R) injury in patients undergoing knee arthroscopy operations with spinal anesthesia using a tourniquet.

The study comprised 48 ASA I-II patients undergoing knee arthroscopy with spinal anesthesia using a tourniquet. The patients were randomised into two groups and after standard monitoring two venous lines were introduced to obtain blood samples and to give intravenous therapy. In the control group (Group A) (n=21) 0.9% NaCl, 10 ml/kg/hours and in the study group (Group B) (n=19) 6% Hydroxyethyl Starch 130/0.4, 10 ml/kg/hours infusion were administered. Spinal anesthesia was applied with 12.5 mg hyperbaric bupivacaine to all patients. The tourniquet was applied and the operation was started when the sensorial block level reached T10 dermatome. Blood xanthine oxidase (XO) and malondialdehyde (MDA) levels as an indicator of ischemia and reperfusion injury were measured in samples before fluid infusion (t1), before tourniquet application (t2), 1 minute before tourniquet release (t3), and at 5 (t4) and 15 (t5) minutes after tourniquet release.

No difference was observed between the two groups in respect of demographic parameters, the highest block level, duration before tourniquet application and tourniquet duration (p>0.05). The MDA level after tourniquet application and 15 minutes after tourniquet release was lower in Group B (p<0.05). XO levels were not different (p>0.05).

In this study 6% Hydroxyethyl Starch 130/0.4 solution reduced MDA level which is an indicator of lipid peroxidation. 6% Hydroxyethyl Starch 130/0.4 solution may be beneficial for Ischemia/reperfusion injuries.

• Intravenos fluids
• Ischemia/Reperfusion injury
• Malondialdehyde
• Xanthine oxidase

• HES 130/0.4
• inflammatory mediators
• intestinal mucosal barrier
• resuscitation
• sepsis

• Cirugía
• Espectroscopia cercana a infrarrojos
• Goal-directed therapy
• Haemodynamic
• Hemodinámica
• Near-infrared spectroscopy
• Surgery
• Terapia dirigida por objetivos
• Test de oclusión vascular
• Vascular occlusion test

• Colloids
• Coloides
• Crystalloids
• Derivados de Hidroxietil Amido
• Fluid therapy
• Hidratacão
• Hidratacão guiada por objetivos
• Hydroxyethyl starch
• Meta-analysis
• Metanálise
• Objective-guided fluid therapy
• Revisão sistemática
• Soluções Isotônicas
• Systematic review

• Adult
• Colloids/administration & dosage
• Colloids/adverse effects
• Crystalloid Solutions
• Fluid Therapy/adverse effects
• Fluid Therapy/methods
• Humans
• Isotonic Solutions/administration & dosage
• Isotonic Solutions/adverse effects
• Randomized Controlled Trials as Topic
• Surgical Procedures, Operative/methods

• Fluid responsiveness
• Fluid resuscitation
• Goal-directed fluid therapy
• Perioperative fluids

• Animals
• Endothelium, Vascular/drug effects
• Endothelium, Vascular/metabolism
• Female
• Hydroxyethyl Starch Derivatives/adverse effects
• In Vitro Techniques
• Intestinal Mucosa/drug effects
• Intestinal Mucosa/metabolism
• Intestine, Small/blood supply
• Intestine, Small/cytology
• Intestine, Small/drug effects
• Intestine, Small/metabolism
• Lactic Acid/metabolism
• Mice
• Mice, Inbred C57BL
• Perfusion
• Permeability/drug effects
• Pyruvic Acid/metabolism

• Anesthesia
• Enhanced Recovery
• Esophageal cancer
• Esophagectomy
• Perioperative complications
• Perioperative management

• Anesthesia
• Anesthesiology/methods
• Esophageal Neoplasms/surgery
• Esophagectomy
• Humans