Background. Goal-directed fluid therapy (GDT) guided by functional parameters of preload, such as... more Background. Goal-directed fluid therapy (GDT) guided by functional parameters of preload, such as stroke volume variation (SVV), seems to optimize hemodynamics and possibly improves clinical outcome. However, this strategy is believed to be rather fluid aggressive, and, furthermore, during surgery requiring thoracotomy, the ability of SVV to predict volume responsiveness has raised some controversy. So far it is not known whether GDT is associated with pulmonary fluid overload and a deleterious reduction in pulmonary function in thoracic surgery requiring one-lung-ventilation (OLV). Therefore, we assessed the perioperative course of extravascular lung water index (EVLWI) and p a O 2 /F i O 2 -ratio during and after thoracic surgery requiring lateral thoracotomy and OLV to evaluate the hypothesis that fluid therapy guided by SVV results in pulmonary fluid overload. Methods. A total of 27 patients (group T) were enrolled in this prospective study with 11 patients undergoing lung surgery (group L) and 16 patients undergoing esophagectomy (group E). Goal-directed fluid management was guided by SVV (SVV < 10%). Measurements were performed directly after induction of anesthesia (baseline-BL), 15 minutes after implementation OLV (OLVimpl15), and 15 minutes after termination of OLV (OLVterm15). In addition, postoperative measurements were performed at 6 (6postop), 12 (12postop), and 24 (24postop) hours after surgery. EVLWI was measured at all predefined steps. The p a O 2 /F i O 2ratio was determined at each point during mechanical ventilation (group L: BL-OLVterm15; group E: BL-24postop). Results. In all patients (group T), there was no significant change (P > 0.05) in EVLWI during the observation period (BL: 7.8 ± 2.5, 24postop: 8.1 ± 2.4 mL/kg). A subgroup analysis for group L and group E also did not reveal significant changes of EVLWI. The p a O 2 /F i O 2ratio decreased significantly during the observation period (group L: BL: 462 ± 140, OLVterm15: 338 ± 112 mmHg; group E: BL: 389 ± 101, 24postop: 303 ± 74 mmHg) but remained >300 mmHg except during OLV. Conclusions. SVV-guided fluid management in thoracic surgery requiring lateral thoracotomy and one-lung ventilation does not result in pulmonary fluid overload. Although oxygenation was reduced, pulmonary function remained within a clinically acceptable range.
The pleth variability index (PVI) is derived from analysis of the plethysmographic curve and is c... more The pleth variability index (PVI) is derived from analysis of the plethysmographic curve and is considered to be a noninvasive parameter for prediction of volume responsiveness. The aim of our prospective clinical study was to evaluate if volume responsiveness can be predicted by PVI in patients undergoing cardiac surgery after cardiopulmonary bypass. Eighteen patients were prospectively studied. Directly after cardiac surgery, PVI, stroke volume variation (SVV), and cardiac index (CI) were recorded. Colloid infusion (4 ml/kg body weight) was used for volume loading, and volume responsiveness was defined as increase of CI more than 10 %. SVV and PVI measures were found to be highly correlated at r = 0.80 (p &amp;amp;amp;amp;lt; 0.001). Receiver operating characteristics curve (ROC) analysis resulted in an area under the curve of 0.87 for SVV and 0.95 for PVI, which values did not differ statistically significant from each other (p &amp;amp;amp;amp;gt; 0.05). The optimal threshold value given by ROC analysis was ≥11 % for SVV with a sensitivity and specificity of 100 % and 72.2 %. For PVI, optimal threshold value was ≥16 % with a sensitivity and specificity of 100 % and 88.9 %. Positive and negative predictive values estimating an increase of CI ≥10 % for SVV were 44.4 % and 100 % and 66.7 % and 100 % for PVI. For consideration of fluid responsiveness PVI is as accurate as SVV in patients after cardiopulmonary bypass. Methodological limitations such as instable cardiac rhythm after cardiopulmonary bypass and right- or left ventricular impairment seem to be responsible for low specificity and positive predictive values in both parameters PVI and SVV.
The International Journal of Medical Robotics and Computer Assisted Surgery, 2011
Robotic-assisted laparoscopic prostatectomy (RALP) is usually performed in steep Trendelenburg po... more Robotic-assisted laparoscopic prostatectomy (RALP) is usually performed in steep Trendelenburg position, which can be associated with cardiac impairment due to positioning and capnoperitoneum. This study investigated haemodynamic consequences and cardiac function in this type of surgery and evaluated the hypothesis that steep Trendelenburg position and capnoperitoneum results in haemodynamic and ventricular impairment. 10 patients (ASA I-III) scheduled for RALP in steep Trendelenburg position with capnoperitoneum were prospectively studied. Heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) were recorded. Stroke volume variation (SVV) and cardiac output (CO) were measured using pulse-contour analysis. Further, cardiac function was assessed using trans-oesophageal echocardiography before positioning (T1) and 10 min (T2) and 60 min (T3) after implementation of steep Trendelenburg position and capnoperitoneum. HR did not change statistically. MAP (T1, 69.7 ± 1.55; T2, 82.9 ± 3.05; T3, 79.4 ± 2.18 mmHg), CVP (T1, 7.7 ± 1.3; T2, 17.3 ± 2.01; T3, 16.9 ± 1.66 mmHg) and CO (T1, 4.0 ± 0.15; T2, 4.9 ± 0.26; T3, 4.9 ± 0.36 l/min) increased significantly at T2 and T3. Echocardiography showed no deterioration of left or right ventricular function. In one patient with pre-existing mitral valve insufficiency (I°) an aggravation of the insufficiency (III°) was observed. No other valve dysfunctions were observed. The steep Trendelenburg position may improve haemodynamic function and does not deteriorate left or right ventricular function during RALP. However, mitral valve insufficiency may be aggravated by positioning and capnoperitoneum.
Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011
Purpose To report the management of a 38-yr-old patient with known Marfan syndrome who presented ... more Purpose To report the management of a 38-yr-old patient with known Marfan syndrome who presented with acute Stanford type A dissection of the aorta in the 34 th week of pregnancy. Clinical features A Cesarean delivery was performed under deep general anesthesia with high-dose opioid administration to avoid tachycardia and hypertension during tracheal intubation and obstetric surgery. Delivery took place less than five minutes after induction of anesthesia, and tracheal intubation of the newborn was required due to opioid-induced hypoventilation. Subsequently, aortic arch repair was performed in the mother after connection to extracorporal bypass. Despite extensive replacement of coagulation factors, severe vaginal bleeding persisted after weaning from extracorporal bypass, and the bleeding stopped only after a hysterectomy was performed. Postoperatively, after a short period in the
Background. Goal-directed fluid therapy (GDT) guided by functional parameters of preload, such as... more Background. Goal-directed fluid therapy (GDT) guided by functional parameters of preload, such as stroke volume variation (SVV), seems to optimize hemodynamics and possibly improves clinical outcome. However, this strategy is believed to be rather fluid aggressive, and, furthermore, during surgery requiring thoracotomy, the ability of SVV to predict volume responsiveness has raised some controversy. So far it is not known whether GDT is associated with pulmonary fluid overload and a deleterious reduction in pulmonary function in thoracic surgery requiring one-lung-ventilation (OLV). Therefore, we assessed the perioperative course of extravascular lung water index (EVLWI) and p a O 2 /F i O 2 -ratio during and after thoracic surgery requiring lateral thoracotomy and OLV to evaluate the hypothesis that fluid therapy guided by SVV results in pulmonary fluid overload. Methods. A total of 27 patients (group T) were enrolled in this prospective study with 11 patients undergoing lung surgery (group L) and 16 patients undergoing esophagectomy (group E). Goal-directed fluid management was guided by SVV (SVV < 10%). Measurements were performed directly after induction of anesthesia (baseline-BL), 15 minutes after implementation OLV (OLVimpl15), and 15 minutes after termination of OLV (OLVterm15). In addition, postoperative measurements were performed at 6 (6postop), 12 (12postop), and 24 (24postop) hours after surgery. EVLWI was measured at all predefined steps. The p a O 2 /F i O 2ratio was determined at each point during mechanical ventilation (group L: BL-OLVterm15; group E: BL-24postop). Results. In all patients (group T), there was no significant change (P > 0.05) in EVLWI during the observation period (BL: 7.8 ± 2.5, 24postop: 8.1 ± 2.4 mL/kg). A subgroup analysis for group L and group E also did not reveal significant changes of EVLWI. The p a O 2 /F i O 2ratio decreased significantly during the observation period (group L: BL: 462 ± 140, OLVterm15: 338 ± 112 mmHg; group E: BL: 389 ± 101, 24postop: 303 ± 74 mmHg) but remained >300 mmHg except during OLV. Conclusions. SVV-guided fluid management in thoracic surgery requiring lateral thoracotomy and one-lung ventilation does not result in pulmonary fluid overload. Although oxygenation was reduced, pulmonary function remained within a clinically acceptable range.
The pleth variability index (PVI) is derived from analysis of the plethysmographic curve and is c... more The pleth variability index (PVI) is derived from analysis of the plethysmographic curve and is considered to be a noninvasive parameter for prediction of volume responsiveness. The aim of our prospective clinical study was to evaluate if volume responsiveness can be predicted by PVI in patients undergoing cardiac surgery after cardiopulmonary bypass. Eighteen patients were prospectively studied. Directly after cardiac surgery, PVI, stroke volume variation (SVV), and cardiac index (CI) were recorded. Colloid infusion (4 ml/kg body weight) was used for volume loading, and volume responsiveness was defined as increase of CI more than 10 %. SVV and PVI measures were found to be highly correlated at r = 0.80 (p &amp;amp;amp;amp;lt; 0.001). Receiver operating characteristics curve (ROC) analysis resulted in an area under the curve of 0.87 for SVV and 0.95 for PVI, which values did not differ statistically significant from each other (p &amp;amp;amp;amp;gt; 0.05). The optimal threshold value given by ROC analysis was ≥11 % for SVV with a sensitivity and specificity of 100 % and 72.2 %. For PVI, optimal threshold value was ≥16 % with a sensitivity and specificity of 100 % and 88.9 %. Positive and negative predictive values estimating an increase of CI ≥10 % for SVV were 44.4 % and 100 % and 66.7 % and 100 % for PVI. For consideration of fluid responsiveness PVI is as accurate as SVV in patients after cardiopulmonary bypass. Methodological limitations such as instable cardiac rhythm after cardiopulmonary bypass and right- or left ventricular impairment seem to be responsible for low specificity and positive predictive values in both parameters PVI and SVV.
The International Journal of Medical Robotics and Computer Assisted Surgery, 2011
Robotic-assisted laparoscopic prostatectomy (RALP) is usually performed in steep Trendelenburg po... more Robotic-assisted laparoscopic prostatectomy (RALP) is usually performed in steep Trendelenburg position, which can be associated with cardiac impairment due to positioning and capnoperitoneum. This study investigated haemodynamic consequences and cardiac function in this type of surgery and evaluated the hypothesis that steep Trendelenburg position and capnoperitoneum results in haemodynamic and ventricular impairment. 10 patients (ASA I-III) scheduled for RALP in steep Trendelenburg position with capnoperitoneum were prospectively studied. Heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) were recorded. Stroke volume variation (SVV) and cardiac output (CO) were measured using pulse-contour analysis. Further, cardiac function was assessed using trans-oesophageal echocardiography before positioning (T1) and 10 min (T2) and 60 min (T3) after implementation of steep Trendelenburg position and capnoperitoneum. HR did not change statistically. MAP (T1, 69.7 ± 1.55; T2, 82.9 ± 3.05; T3, 79.4 ± 2.18 mmHg), CVP (T1, 7.7 ± 1.3; T2, 17.3 ± 2.01; T3, 16.9 ± 1.66 mmHg) and CO (T1, 4.0 ± 0.15; T2, 4.9 ± 0.26; T3, 4.9 ± 0.36 l/min) increased significantly at T2 and T3. Echocardiography showed no deterioration of left or right ventricular function. In one patient with pre-existing mitral valve insufficiency (I°) an aggravation of the insufficiency (III°) was observed. No other valve dysfunctions were observed. The steep Trendelenburg position may improve haemodynamic function and does not deteriorate left or right ventricular function during RALP. However, mitral valve insufficiency may be aggravated by positioning and capnoperitoneum.
Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011
Purpose To report the management of a 38-yr-old patient with known Marfan syndrome who presented ... more Purpose To report the management of a 38-yr-old patient with known Marfan syndrome who presented with acute Stanford type A dissection of the aorta in the 34 th week of pregnancy. Clinical features A Cesarean delivery was performed under deep general anesthesia with high-dose opioid administration to avoid tachycardia and hypertension during tracheal intubation and obstetric surgery. Delivery took place less than five minutes after induction of anesthesia, and tracheal intubation of the newborn was required due to opioid-induced hypoventilation. Subsequently, aortic arch repair was performed in the mother after connection to extracorporal bypass. Despite extensive replacement of coagulation factors, severe vaginal bleeding persisted after weaning from extracorporal bypass, and the bleeding stopped only after a hysterectomy was performed. Postoperatively, after a short period in the
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