| BackgroundsPerioperative fluid therapy is one of the most controversial topics in perioperative management, because it significantly affects the organ function and therefore the prognosis of patients. Recently studies have shown that perioperative goal-directed fluid therapy (GDFT) with maximization of flow-related hemodynamic variables can reduce postoperative complications, shorten the duration of hospital as well as ICU stay and sebsequently reduce the total cost of hospitalization. Therefore, GDFT has been increasingly used in the perioperative fluid therapy, ranging from laparotomy surgery, craniotomy surgery, thoracotomy surgery to spinal surgery. With the advances of surgical techniques, laparoscopy takes the fancy of surgeons owing to its virtues of minor trauma, less pain, and faster recovery. However, the pathophysiologic changes due to pneumoperitoneum and frequent position changes make anesthetic management complex. Moreover, it is difficult to estimate the blood loss and the visceral injury, both of which are high risk factors of anesthesia. So far, there is scarce literature on the application of GDFT during the laparoscopic surgery, so whether GDFT can bring favorable clinical outcome is also unknown.ObjectivesThe study aims to perform GDFT for patients who will schedule for laparoscopic radical resection for colorectal cancer, so as to evaluate the effects of GDFT on the prognosis and gastrointestinal recovery in these patients, as well as to provide an individual fluid optimization protocol. We also postulate that GDFT will reduce the complications caused by inappropriate fluid infusion, shorten the duration of hospital stay, and avoid oxygen debt, all of which will speed up the rehabilitation. At last but not the least, we also wish the study could provide the theoretical basis for enhanced recovery programs (ERAS) in this type of surgery.MethodsAfter approval from the local ethics committee (Guangdong Provincial Hospital of TCM, Guangzhou, China), written informed consent was obtained from patients undergoing laparoscopic radical resection surgery for colorectal cancer. We included50patients with ASA physical status between I to III from March2013to Febrary2014. Patients were allocated into either a goal directed therapy group using a cardiac index based on intraoperative optimization protocol (FloTrac-Vigileo TM, group G, n=25) or a standard management group (group C, n=25), based on standard monitoring data. The primary endpoint was morbidity in30days after surgery. The secondary endpoints were length of hospital stay (LOS), recovery of gastrointestinal function, postoperative mobilization and microcirculatory perfusion et al.OutcomesBoth groups were comparable in basic demographic parameters, co-morbidities, American Society of Anesthesiologists levels, duration of operation and anesthesia and surgical procedure performed.The group G received a significant larger amount of colloid infusions (848.00±260.00ml vs.614.00±254.53,P=0.007), the volume of infused crystalloids, the total volume, the fluid balance and blood loss did not differ statistically between two groups. There was a trend towards maintaining higher diuresis during the study period in the group G (759.20±207.24ml vs.598.00±226.33ml,P=0.031).The group G maintained a higher intraoperative MAP (73.26±5.75mmHg vs.66.83±8.30mmHg,P=0.018), mean CI (2.63±0.24L·min-1·m2vs.2.34±0.26L· min-1·m-2,P=0.014) and mean SVI (40.39±5.07ml vs.33.89±4.90ml,P=0.039), but lower mean SVV (10.44±2.60vs.13.24±3.28, P=0.000). There was no difference between two groups in mean HR and mean CVP.A remarkable increase in duration of hypotension (18.04±6.96min vs.41.88±19.68min,P=0.018) and CI<2.5L· min-1· m-2(26.04±8.31min vs.53.36±28.69min, P=0.020) was observed in the group C compared with group G intraoperatively. A lower dosage of vasoconstrictors (Aramine:0.156±0.15mg vs.1.28±0.69mg, P=0.000) was found in group G, but a higher dosage of inotropes (Dobutamine:3.20±0.57μg· kg-1· min-1vs.1.43±0.68μg· kg-1· min-1, P=0.000) was found in the group G. There was no difference between two groups in the dosage of vasodilators (Nitroglycerin).Serum lactate concentration at the end of the surgery in the group G was lower (0.50±0.19mmol/L vs.1.02±0.15mmol/L, P<0.001), in the contrary, oxygen delivery index (440.64±78.32ml· min-1· m-2vs.349.48±82.40ml· min-1· m-2, P <0.010) at the end of surgery in the group G was higher.An advance in the time of flatus after surgery was observed in the group G compared with group C (18.31±5.30h vs.25.60±6.01h, P=0.025). Patients in the group G were also able to tolerate porridge significantly earlier than those in the group C (20.28±4.83h vs.27.38±6.15h, P=0.036). Also, mobilization after surgery in the group G was in advance compared with group C (1.08±0.24d vs.1.72±0.41d, P=0.020). The frequency of postoperative nausea and vomiting was lower in the group G (1.00±0.82vs.2.00±0.76, P=0.000and0.52±0.59vs.1.32±0.95, P=0.001, respectively).The incidence of complications Grade I in the30-day postoperative period was lower in the group G (24%vs.60%, P=0.010). The incidence of severe complications was no difference between two groups. The patients in the group G had a reduced postoperative LOS compared with group C (6.08±.87d vs.7.20±1.76d, P=0.034).ConclusionsIntraoperative goal-directed fluid therapy based on Vigileo-FlotacTM improved the microcirculatory perfusion of patients undergoing laparoscopic radical resection for colorectal cancer, enhanced the hemodynamic stability intraoperatively, decreased the dosage of vasoconstrictors, fastened the recovery of gastrointestinal function, shortened the post-operative LOS, and reduced the incidence of complication Grade I in the30-day postoperative period. |
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