Před deseti lety byly v časopise Critical Care publikovány výsledky randomizované prospektivní monocentrické práce zabývající se optimalizací hemodynamiky u rizikových pacientů podstupujících plánované nitrobřišní zákroky. Tento přehledový článek přináší kritické zhodnocení výsledků práce a dalšího vývoje v této problematice nazíraný s odstupem jedné dekády.
Ten years ago, the results of randomized prospective single-centrce study aimed to optimize hemodynamics in high-risk patients undergoing scheduled intra-abdominal procedures were published in Critical Care journal. This review article provides a critical assessment of the results of this work and further developments in this area, seen from a distance of one decade.
- Klíčová slova
- hemodynamická monitorace, studie SVVOPT,
- MeSH
- lidé MeSH
- peroperační monitorování metody MeSH
- peroperační péče MeSH
- pooperační komplikace prevence a kontrola MeSH
- prospektivní studie MeSH
- randomizované kontrolované studie jako téma MeSH
- tekutinová terapie * metody MeSH
- tepový objem fyziologie MeSH
- umělé dýchání MeSH
- vodní a elektrolytová rovnováha MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- abstrakt z konference MeSH
BACKGROUNDː Lowering central venous pressure (CVP) can decrease blood loss during liver resection and it is associated with improved outcomes. Multiple CVP reducing maneuvers have been described, but direct comparison of their effectiveness and safety has never been performed. METHODSː Patients undergoing resections of two or more liver segments were equally randomized to absolute fluid restriction (AR, N.=17) or relative volume redistribution group (RR, N.=17). The ease of reaching low CVP, blood loss, morbidity and mortality were assessed. Besides, the effect of Pringle maneuver and utility of stroke volume variation (SVV) were analyzed. RESULTSː Both methods of CVP reduction were equally effective (0.7±0.9 vs. 0.9±1.0 protocolized steps in the AR and RR group; P=0.356) and safe (no difference in observed blood loss, intraoperative hemodynamic parameters, lactate levels, morbidity and mortality). Patients in the AR group received smaller amount of fluids in the pre-resection period (120 (100-150) vs. 600 (500-700) mL; P<0.001), and had slightly longer hospital stay (10 [8-14] vs. 8 [7-11]; P=0.045). Low CVP was predicted by SVV>10% with 81.4% sensitivity and 77.1% specificity. Reduced blood loss and transfusion rate was observed when Pringle maneuver was used. CONCLUSIONSː In our study, absolute fluid restriction and relative volume redistribution seemed to be equally effective and safe methods of lowering CVP in patients undergoing liver resection. According to our data high SVV might be considered as a low CVP replacement. Pringle maneuver reduced blood loss and transfusion requirement.
- MeSH
- anestezie metody MeSH
- centrální žilní tlak MeSH
- hepatektomie * MeSH
- krvácení při operaci prevence a kontrola MeSH
- lidé středního věku MeSH
- lidé MeSH
- peroperační péče metody MeSH
- prospektivní studie MeSH
- tekutinová terapie metody MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
- srovnávací studie MeSH
- Publikační typ
- abstrakt z konference MeSH
The laboratory analysis provides accurate, but time consuming hemoglobin level estimation especially in the emergency setting. The reliability of time-sparing point of care devices (POCT) remains uncertain. We tested two POCT devices accuracy (HemoCue(®)201(+) and Gem(®)Premier™3000) in routine emergency department workflow. Blood samples taken from patients admitted to the emergency department were analyzed for hemoglobin concentration using a laboratory reference Beckman Coulter LH 750 (HBLAB), the HemoCue (HBHC) and the Gem Premier 3000 (HBGEM). Pairwise comparison for each device and HbLAB was performed using correlation and the Bland-Altman methods. The reliability of transfusion decision was assessed using three-zone error grid. A total of 292 measurements were performed in 99 patients. Mean hemoglobin level were 115 ± 33, 110 ± 28 and 111 ± 30 g/l for HbHC, HbGEM and HbLAB respectively. A significant correlation was observed for both devices: HbHC versus HbLAB (r(2) = 0.93, p < 0.001) and HBGEM versus HBLAB (r(2) = 0.86, p < 0.001). The Bland-Altman method revealed bias of -3.7 g/l (limits of agreement -20.9 to 13.5) for HBHC and HBLAB and 2.5 g/l (-18.6 to 23.5) for HBGEM and HBLAB, which significantly differed between POCT devices (p < 0.001). Using the error grid methodology: 94 or 91 % of values (HbHC and HbGEM) fell in the zone of acceptable difference (A), whereas 0 and 1 % (HbHC and HbGEM) were unacceptable (zone C). The absolute accuracy of tested POCT devices was low though reaching a high level of correlation with laboratory measurement. The results of the Morey´s error grid were unfavorable for both POCT devices.
- MeSH
- automatizace MeSH
- dospělí MeSH
- hematologie přístrojové vybavení metody MeSH
- hemoglobinometrie přístrojové vybavení metody MeSH
- hemoglobiny analýza chemie MeSH
- krevní transfuze MeSH
- krvácení diagnóza prevence a kontrola MeSH
- lidé středního věku MeSH
- lidé MeSH
- point of care testing * MeSH
- prospektivní studie MeSH
- reprodukovatelnost výsledků MeSH
- senioři MeSH
- urgentní lékařství přístrojové vybavení metody MeSH
- urgentní služby nemocnice MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- srovnávací studie MeSH
- Publikační typ
- abstrakt z konference MeSH
- Publikační typ
- abstrakt z konference MeSH
BACKGROUND: The use of goal directed fluid protocols in intermediate risk patients undergoing hip or knee replacement was studied in few trials using invasive monitoring. For this reason we have implemented two different fluid management protocols, both based on a novel totally non-invasive arterial pressure monitoring device and compared them to the standard (no-protocol) treatment applied before the transition in our academic institution. METHODS: Three treatment groups were compared in this prospective study: the observational (CONTROL, N = 40) group before adoption of fluid protocols and two randomized groups after the transition to protocol fluid management with the use of the continuous non-invasive blood pressure monitoring (CNAP®) device. In the PRESSURE group (N = 40) standard variables were used for restrictive fluid therapy. Goal directed fluid therapy using pulse pressure variation was used in the GDFT arm (N = 40). The influence on the rate of postoperative complications, on the hospital length of stay and other parameters was assessed. RESULTS: Both protocols were associated with decreased fluid administration and maintained hemodynamic stability. Reduced rate of postoperative infection and organ complications (22 (55 %) vs. 33 (83 %) patients; p = 0.016; relative risk 0.67 (0.49-0.91)) was observed in the GDFT group compared to CONTROL. Lower number of patients receiving transfusion (4 (10 %) in GDFT vs. 17 (43 %) in CONTROL; p = 0.005) might contribute to this observation. No significant differences were observed in other end-points. CONCLUSION: In our study, the use of the fluid protocol based on pulse pressure variation assessed using continuous non-invasive arterial pressure measurement seems to be associated with a reduction in postoperative complications and transfusion needs as compared to standard no-protocol treatment. TRIAL REGISTRATION: ACTRN12612001014842.
- MeSH
- arteriální tlak fyziologie MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- náhrada kyčelního kloubu škodlivé účinky metody MeSH
- peroperační monitorování škodlivé účinky metody MeSH
- pooperační komplikace diagnóza etiologie prevence a kontrola MeSH
- prospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- tekutinová terapie metody MeSH
- totální endoprotéza kolene škodlivé účinky metody MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
Intermittent blood pressure (BP) monitoring is the standard-of-care during low and intermediate risk anaesthesia, yet it could lead to delayed recognition of BP fluctuations. Perioperative hypotension is known to be associated with postoperative complications. Continuous, non-invasive methods for BP monitoring have been developed recently. We have tested a novel non-invasive, continuous monitor (using the volume clamp method) to assist with maintaining BP in safe ranges for patients undergoing surgery in a beach chair position. Forty adult patients undergoing thyroid gland surgery in an upright position were included in this prospective randomised controlled trial. Patients were equally allocated to the group with continuous monitoring of BP using the CNAP® Monitor and to the control group managed using an intermittent oscillometric BP cuff. The absolute and proportional time spent outside the range of ±20% of the target BP along with other hemodynamic and clinical parameters were evaluated. The continuous monitoring decreased the anaesthesia time spent below -20% pressure range [absolute: 12 min (4-20) vs. 27 min (16-34); p=0.001; relative to procedure length: 14% (7-20) vs. 33.5% (17.5-53); p=0.003]. No significant differences were observed in postoperative morbidity or in hospital length of stay. Continuous non-invasive BP monitoring via the CNAP® Monitor allows for better BP management in patients undergoing surgery in a beach chair position. In our randomised trial the time spent in hypotension was significantly shorter using continuous monitoring.
- MeSH
- anestezie metody MeSH
- anesteziologie MeSH
- dospělí MeSH
- hypotenze patofyziologie prevence a kontrola MeSH
- katetrizace MeSH
- krevní tlak * MeSH
- lidé středního věku MeSH
- lidé MeSH
- měření krevního tlaku metody MeSH
- monitorování fyziologických funkcí MeSH
- monitory krevního tlaku MeSH
- oscilometrie MeSH
- peroperační monitorování metody MeSH
- polohování pacienta MeSH
- prospektivní studie MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
- Publikační typ
- abstrakt z konference MeSH
