• Humans
• Female
• Coronary Artery Bypass, Off-Pump/methods
• Coronary Artery Bypass, Off-Pump/adverse effects
• Male
• Middle Aged
• Aged
• Spectroscopy, Near-Infrared/methods
• Postoperative Complications/prevention & control
• Oxygen Saturation/physiology
• Single-Blind Method
• Hemodynamic Monitoring/methods
• Oximetry/methods
• Oxygen/metabolism
• Hemodynamics
• Treatment Outcome
• Perioperative Care/methods

• Humans
• Fluid Therapy/methods
• Female
• Male
• Postoperative Complications/etiology
• Postoperative Complications/epidemiology
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Middle Aged
• Aged
• Retrospective Studies
• Prospective Studies
• Pancreas/surgery
• Treatment Outcome

• Humans
• Female
• Aged
• Male
• Cardiac Output/physiology
• Fluid Therapy/methods
• Digestive System Surgical Procedures/adverse effects
• Postoperative Complications/prevention & control
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Hemodynamics/physiology
• Aged, 80 and over
• Cardiotonic Agents/therapeutic use
• Cardiotonic Agents/administration & dosage
• Algorithms
• Elective Surgical Procedures/adverse effects

• National Institute for Health and Care Research

• gastric cancer
• long-term survival
• perioperative blood transfusion
• transfusion trend
• transfusion trigger

• Humans
• Stomach Neoplasms/surgery
• Stomach Neoplasms/mortality
• Male
• Female
• Middle Aged
• Blood Transfusion/statistics & numerical data
• Gastrectomy
• Hemoglobins/analysis
• Hemoglobins/metabolism
• Aged
• Retrospective Studies
• China/epidemiology
• Adult

• arterial waveform analysis
• cardiac output
• fluid responsiveness
• goal-directed haemodynamic therapy
• perioperative outcomes
• stroke volume

• Humans
• Algorithms
• Cardiac Output/physiology
• Clinical Trials as Topic/methods
• Fluid Therapy/methods
• Goals
• Hemodynamics/physiology
• Perioperative Care/methods
• Precision Medicine/methods
• Precision Medicine/trends
• Research Design

• dynamic parameter
• fluid resuscitation
• mortality
• norepinephrine
• sepsis
• shock duration
• static parameter
• ultrasound

• Humans
• Fluid Therapy/methods
• Male
• Female
• Sepsis/therapy
• Sepsis/mortality
• Middle Aged
• Resuscitation/methods
• Aged
• Central Venous Pressure
• Single-Blind Method
• Vena Cava, Inferior

• hemorrhagic shock
• shock index
• surgical site infection
• trauma laparotomy
• trauma resuscitation
• trauma surgery

• Humans
• Surgical Wound Infection/epidemiology
• Surgical Wound Infection/etiology
• Laparotomy/adverse effects
• Risk Factors
• Retrospective Studies
• Incidence

• T32 GM008792 NIGMS NIH HHS

• gynecologic oncologic surgery
• healthcare resource utilization
• intraoperative hypotension
• length of stay
• machine learning

• DIEP flap
• breast cancer
• breast cancer care
• breast reconstruction
• dobutamine
• epigastric perforator
• flap oxygenation
• flap surgery
• fluid therapy
• goal-directed therapy
• implant-based surgery
• oxygenation
• perioperative care
• tissue oxygenation
• treatment algorithm

• Goal-directed fluid therapy
• Meta-analysis
• One-lung ventilation
• Postoperative complications
• Pulmonary protection

• Humans
• Thoracic Surgery
• One-Lung Ventilation/adverse effects
• Goals
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Fluid Therapy/adverse effects

• calculated plasma volume status
• microcirculation
• organ injury

• Clinical trials
• critical care
• outcomes

• Humans
• Critical Care
• Outcome Assessment, Health Care

• Northern Ireland Clinical Trials Unit
• nihr imperial biomedical research centre
• NIHR Research Professorship

• Emergency surgical procedures/adverse effects
• Hemodynamics/physiology
• Intraoperative/methods
• Postoperative complications/prevention and control
• Prospective studies

• Aged
• Humans
• Middle Aged
• Cardiac Output
• Digestive System Surgical Procedures
• Fluid Therapy/methods
• Hemodynamics
• Laparotomy
• Multicenter Studies as Topic
• Randomized Controlled Trials as Topic

• MC_UU_00004/07 Medical Research Council
• HTA 15/80/54 Health Technology Assessment Programme

• General Anesthesia
• Gynecologic Neoplasm
• Hypotension/prevention & control
• Intraoperative Complications/diagnosis
• Machine Learning

• continuous cardiac output monitoring
• general anaesthesia
• goal-directed fluid therapy
• intraoperative fluid therapy
• network meta-analysis
• perioperative fluid management
• systematic literature review

• Cardiovascular dynamics
• hemodynamics
• microcirculation
• monitoring
• perfusion
• surgery

• Emergency laparotomy
• Fluid administration
• Goal-directed therapy
• Haemodynamics
• Overhydration
• Preload dependency

To evaluate whether goal-directed fluid therapy (GDFT) reduces the risk of renal injury in critical illness.

MEDLINE via PubMed, EMBASE, CENTRAL and CBM was searched from inception to 13 March 2022, for studies comparing the effect of GDFT with usual care on renal function in critically ill patients. GDFT was defined as a protocolized intervention based on hemodynamic and/or oxygen delivery parameters. A fixed or random effects model was applied to calculate the pooled odds ratio (OR) based on heterogeneity through the included studies.

A total of 28 studies with 9,019 patients were included. The pooled data showed that compared with usual care, GDFT reduced the incidence of acute kidney injury (AKI) in critical illness (OR 0.62, 95% confidence interval (CI) 0.47 to 0.80, p< 0.001). Sensitivity analysis with only low risk of bias studies showed the same result. Subgroup analyses found that GDFT was associated with a lower AKI incidence in both postoperative and medical patients. The reduction was significant in GDFT aimed at dynamic indicators. However, no significant difference was found between groups in RRT support (OR 0.88, 95% CI 0.74 to 1.05, p= 0.17). GDFT tended to increase fluid administration within the first 6 h, decrease fluid administration after 24 h, and was associated with more vasopressor requirements.

This meta-analysis suggests that GDFT aimed at dynamic indicators may be an effective way to prevent AKI in critical illness. This may indicate a benefit from early adequate fluid resuscitation and the combined effect of vasopressors.

• Acute kidney injury
• critical care
• fluid therapy
• meta-analysis
• systematic review

• Acute kidney injury
• Enhanced recovery pathways
• Gastrointestinal tumor
• Preventive measures
• Risk factors
• Treatment

• Cardiac output
• Fluid therapy
• Meta-analysis
• Postoperative complications

Assessment of microcirculatory functional capacity is considered to be of prime importance for therapy guidance and outcome prediction in critically ill intensive care patients. Here, we show determination of skin microcirculatory oxygen delivery and consumption rates to be a feasible approach at the patient’s bedside. Real time laser-doppler flowmetry (LDF) and white light spectrophotometry (WLS) were used for assessment of thenar skin microperfusion, regional Hb and postcapillary venous oxygen saturation before and after forearm ischemia. Adapted Fick’s principle equations allowed for calculation of microcirculatory oxygen delivery and uptake. Patient groups with expected different microcirculatory status were compared [control (n = 20), sepsis-1/2 definition criteria identified SIRS (n = 10) and septic shock patients (n = 20), and the latter group further classified according to sepsis-3 definition criteria in sepsis (n = 10) and septic shock (n = 10)], respectively. In otherwise healthy controls, microcirculatory oxygen delivery and uptake approximately doubled after ischemia with maximum values (mDO2max and mVO2max) significantly lower in SIRS or septic patient groups, respectively. Scatter plots of mVO2max and mDO2max values defined a region of unphysiological low values not observed in control but in critically ill patients with the percentage of dots within this region being highest in septic shock patients. LDF and WLS combined with vasoocclusive testing reveals significant differences in microcirculatory oxygen delivery and uptake capacity between control and critically ill patients. As a clinically feasible technique for bedside determination of microcirculatory oxygen delivery and uptake, LDF and WLS combined with vasoocclusive testing holds promise for monitoring of disease progression and/or guidance of therapy at the microcirculatory level to be tested in further clinical trials.

ClinicalTrials.gov: NCT01530932.

• Fluid Management
• Haemodynamic Monitoring
• Hyperspectral Imaging
• Microcirculation
• Pancreatic Surgery
• Tissue Water Content

• Universitätsklinikum Essen (8912)

• goal-directed therapy
• oxygen debt
• oxygen delivery

• Complications
• hemodynamics
• microcirculation
• perfusion
• postoperative
• surgery

• oxygen delivery
• proteomics
• randomised controlled trial
• sepsis
• skin
• surgery
• wound infection

The goal of resuscitative fluid therapy is to rapidly expand circulating blood volume in order to restore tissue perfusion. Although this therapy often serves to improve macrohemodynamic parameters, it can be associated with adverse effects on the microcirculation and endothelium. The endothelial surface layer (ESL) provides a protective barrier over the endothelium and is important for regulating transvascular fluid movement, vasomotor tone, coagulation, and inflammation. Shedding or thinning of the ESL can promote interstitial edema and inflammation and may cause microcirculatory dysfunction. The pathophysiologic perturbations of critical illness and rapid, large-volume fluid therapy both cause shedding or thinning of the ESL. Research suggests that restricting the volume of crystalloid, or “clear” fluid, may preserve some ESL integrity and improve outcome based on animal experimental models and preliminary clinical trials in people. This narrative review critically evaluates the evidence for the detrimental effects of resuscitative fluid therapy on the ESL and provides suggestions for future research directions in this field.

• colloid
• crystalloid
• endothelial surface layer
• endothelium
• fluid therapy
• glycocalyx
• shock

• Kidney injury
• perioperative
• surgery
• treatment
• trials

• Anastomotic leakage
• Esophagectomy
• Gastric tube
• Monitoring
• Perfusion
• Sidestream darkfield microscopy

• Adult
• Aged
• Female
• Humans
• Male
• Middle Aged
• Anastomotic Leak/etiology
• Esophagectomy/adverse effects
• Microcirculation
• Microscopy/methods
• Perfusion Imaging/methods
• Pilot Projects
• Plastic Surgery Procedures/methods
• Prospective Studies
• Stomach/blood supply
• Stomach/surgery
• Intraoperative Care/methods

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.

The incidence of acute kidney injury (AKI) remains high after partial nephrectomy. Ischemia-reperfusion injury produced by renal hilum clamping during surgery might have contributed to the development of AKI. In this study we tested the hypothesis that goal-directed fluid and blood pressure management may reduce AKI in patients following partial nephrectomy.

This was a pilot randomized controlled trial. Adult patients who were scheduled to undergo partial nephrectomy were randomized into two groups. In the intervention group, goal-directed hemodynamic management was performed from renal hilum clamping until end of surgery; the target was to maintain stroke volume variation < 6%, cardiac index 3.0–4.0 L/min/m² and mean arterial pressure > 95 mmHg with crystalloid fluids and infusion of dobutamine and/or norepinephrine. In the control group, hemodynamic management was performed according to routine practice. The primary outcome was the incidence of AKI within the first 3 postoperative days.

From June 2016 to January 2017, 144 patients were enrolled and randomized (intervention group, n = 72; control group, n = 72). AKI developed in 12.5% of patients in the intervention group and in 20.8% of patients in the control group; the relative reduction of AKI was 39.9% in the intervention group but the difference was not statistically significant (relative risk 0.60, 95% confidence interval [CI] 0.28–1.28; P = 0.180). No significant differences were found regarding AKI classification, change of estimated glomerular filtration rate over time, incidence of postoperative 30-day complications, postoperative length of hospital stay, as well as 30-day and 6-month mortality between the two groups.

For patients undergoing partial nephrectomy, goal-directed circulatory management during surgery reduced postoperative AKI by about 40%, although not significantly so. The trial was underpowered. Large sample size randomized trials are needed to confirm our results.

Clinicaltrials.gov identifier: NCT02803372. Date of registration: June 6, 2016.

The online version contains supplementary material available at 10.1186/s12871-021-01288-8.

• Acute kidney injury
• Hemodynamic management
• Partial nephrectomy

• conducted responses
• critical illness
• heterogeneity
• microvascular networks
• oxygen transport

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

Perioperative goal-directed haemodynamic therapy (GDHT), defined as the administration of fluids with or without inotropes or vasoactive agents against explicit measured goals to augment blood flow, has been evaluated in many randomised controlled trials (RCTs) over the past four decades. Reported post-operative pulmonary complications commonly include chest infection or pneumonia, atelectasis, acute respiratory distress syndrome or acute lung injury, aspiration pneumonitis, pulmonary embolism, and pulmonary oedema. Despite the substantial clinical literature in this area, it remains unclear whether their incidence is reduced by GDHT. This systematic review aims to determine the effect of GDHT on the respiratory outcomes listed above, in surgical patients.

We searched the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, and clinical trial registries up until January 2020. We included all RCTs reporting pulmonary outcomes. The primary outcome was post-operative pulmonary complications and secondary outcomes were specific pulmonary complications and intra-operative fluid input. Data synthesis was performed on Review Manager and heterogeneity was assessed using I² statistics.

We identified 66 studies with 9548 participants reporting pulmonary complications. GDHT resulted in a significant reduction in total pulmonary complications (OR 0.74, 95% CI 0.59 to 0.92). The incidence of pulmonary infections, reported in 45 studies with 6969 participants, was significantly lower in the GDHT group (OR 0.72, CI 0.60 to 0.86). Pulmonary oedema was recorded in 23 studies with 3205 participants and was less common in the GDHT group (OR 0.47, CI 0.30 to 0.73). There were no differences in the incidences of pulmonary embolism or acute respiratory distress syndrome. Sub-group analyses demonstrated: (i) benefit from GDHT in general/abdominal/mixed and cardiothoracic surgery but not in orthopaedic or vascular surgery; and (ii) benefit from fluids with inotropes and/or vasopressors in combination but not from fluids alone. Overall, the GDHT group received more colloid (+280 ml) and less crystalloid (−375 ml) solutions than the control group. Due to clinical and statistical heterogeneity, we downgraded this evidence to moderate.

This systematic review and meta-analysis suggests that the use of GDHT using fluids with inotropes and/or vasopressors, but not fluids alone, reduces the development of post-operative pulmonary infections and pulmonary oedema in general, abdominal and cardiothoracic surgical patients. This evidence was graded as moderate.

PROSPERO registry reference: CRD42020170361

• Fluid therapy
• Goal-directed
• Surgery

• Bispectral index
• Cardiopulmonary bypass
• Cerebral oxygen saturation
• Goal-directed therapy
• Mean arterial pressure

• arterial pressure
• goal-directed therapy
• haemodynamic monitoring
• high-risk surgery
• intraoperative hypotension
• mortality
• perioperative outcomes

Background: The β₂-adrenoceptor agonist dopexamine may possess anti-inflammatory actions which could reduce organ injury during endotoxemia and laparotomy. Related effects on leucocyte-endothelial adhesion remain unclear.

Methods: Thirty anesthetized Wistar rats underwent laparotomy followed by induction of endotoxemia with lipopolysaccharide and peptidoglycan (n = 24) or sham (n = 6). Animals received dopexamine at 0.5 or 1 μg kg⁻¹ min⁻¹ (D0.5 and D1), salbutamol at 0.1 μg kg⁻¹ min⁻¹, or saline vehicle (Sham and Control) for 5 h. Intravital microscopy was performed in the ileum of the small intestine to assess leucocyteendothelial adhesion, arteriolar diameter, and functional capillary density. Global hemodynamics and biochemical indices of renal and hepatic function were also measured.

Results: Endotoxemia was associated with an increase in adherent leucocytes in post-capillary venules, intestinal arteriolar vasoconstriction as well-reduced arterial pressure and relative cardiac index, but functional capillary density in the muscularis was not significantly altered. Dopexamine and salbutamol administration were associated with reduced leucocyte-endothelial adhesion in post-capillary venules compared to control animals. Arteriolar diameter, arterial pressure and relative cardiac index all remained similar between treated animals and controls. Functional capillary density was similar for all groups. Control group creatinine was significantly increased compared to sham and higher dose dopexamine.

Conclusions: In a rodent model of laparotomy and endotoxemia, β₂-agonists were associated with reduced leucocyte-endothelial adhesion in post-capillary venules. This effect may explain some of the anti-inflammatory actions of these agents.

• adrenergic β2 receptor agonists
• dopexamine
• inflammation
• microcirculation
• surgery

• ERAS
• Hypovolemia
• Morbidity
• Mortality
• Perioperative fluid management

• patient-centred outcomes
• postoperative complications
• postoperative recovery
• surgery

• acute kidney injury
• renal biomarkers
• kidney disease improving global outcomes
• remote ischemic preconditioning
• renal replacement therapy
• sepsis
• creatinine
• neutrophil gelatinase-associated lipocalin
• kidney injury molecule-1
• adenosine

• Acute Kidney Injury/diagnosis
• Acute Kidney Injury/physiopathology
• Acute Kidney Injury/therapy
• Humans
• Perioperative Care/methods

• R01 HL133900 NHLBI NIH HHS
• P01 HL114457 NHLBI NIH HHS
• R01 HL109233 NHLBI NIH HHS
• R01 DK097075 NIDDK NIH HHS
• R01 DK109574 NIDDK NIH HHS
• R01 HL119837 NHLBI NIH HHS

• Goal-directed fluid therapy
• cardiac index
• colorectal surgery
• tissue oxygen saturation

Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery, and role of fluids and inotropes. We therefore update a previous analysis, including all studies published in the meanwhile, to clarify the clinical impact of this strategy on acute kidney injury.

Randomized controlled trials enrolling adult patients undergoing major surgery were considered. GDT was defined as perioperative monitoring and manipulation of hemodynamic parameters to reach normal or supranormal values by fluids alone or with inotropes. Trials comparing the effects of GDT and standard hemodynamic therapy were considered. Primary outcome was acute kidney injury, whichever definition was used. Meta-analytic techniques (analysis software RevMan, version 5.3) were used to combine studies, using random-effect odds ratios (OR) and 95% confidence intervals (CI). Trial sequential analyses were performed including all trials and considering only low risk of bias trials. Sixty-five trials with an overall sample of 9308 patients were included. OR for the development of renal injury was 0.64 (95% CI, 0.62–0.87; p = 0.0003), with no statistical heterogeneity. Trial sequential analyses and sensitivity analysis including studies with low risk of bias confirmed the main results. A significant decrease in renal injury rate was observed in studies that adopted cardiac output and oxygen delivery as hemodynamic target and that used both fluids and inotropes. The postoperative kidney injury rate was significantly lower in trials enrolling “high-risk” patients and major abdominal and orthopedic surgery.

The present meta-analysis suggests that targeting GDT to perioperative systemic oxygen delivery, by means of fluids and inotropes, can be the best way to improve renal perfusion and oxygenation in high-risk patients undergoing major abdominal and orthopedic surgery.

The online version of this article (10.1186/s13054-019-2516-4) contains supplementary material, which is available to authorized users.

• Cardiac output
• Fluid therapy
• High-risk patients
• Oxygen delivery
• Perioperative hemodynamic optimization
• Postoperative acute renal injury