Top

Intensive Care Medicine

Published in:

01-05-2005 | Original

Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial

Authors: Tamas Szakmany, Ildiko Toth, Zsolt Kovacs, Tamas Leiner, Andras Mikor, Tamas Koszegi, Zsolt Molnar

Published in: Intensive Care Medicine | Issue 5/2005

Abstract

Objective

To compare intrathoracic blood volume (ITBV) guided fluid management and central venous pressure (CVP) guided therapy in ameliorating the progression of early systemic inflammatory response in patients undergoing major surgery.

Design

Prospective, randomized clinical trial.

Patients

Forty patients undergoing major abdominal surgery were randomized into CVP and ITBV groups.

Interventions

In the CVP group the target CVP was 8–12 mmHg while in the ITBV group the goal was to keep the ITBV between 850 and 950 ml/m² during the operation.

Measurements and results

Hemodynamic parameters were determined by single arterial thermodilution. Measurements were repeated every 30 min intraoperatively. Serum procalcitonin (PCT) and C-reactive protein (CRP) was monitored preoperatively, on ICU admission, and then daily for 3 days. Serum TNF-α levels were measured intraoperatively hourly and then daily for 3 days. There was no significant difference between the two groups regarding hemodynamic parameters at any assessment point. In the overall population changes in the stroke volume index showed a significant correlation with changes in CVP and ITBV. TNF-α levels remained in the normal range intraoperatively and during the three postoperative days in both groups. Preoperatively normal PCT and CRP levels increased significantly postoperatively, without significant differences between the groups.

Conclusions

ITBV guided fluid therapy did not alter the magnitude of inflammatory response as monitored by serum PCT, CRP, and TNF-α in the early postoperative period.

Tandon S, Batchelor A, Bullock R, Gascoigne A, Griffin M, Hayes N, Hing J, Shaw I, Warnell I, Baudouin SV (2001) Peri-operative risk factors for acute lung injury after elective oesophagectomy. Br J Anaesth 86:633–638

Szakmany T, Molnar Z. Procalcitonin levels do not predict mortality following major abdominal surgery (2003) Can J Anaesth 50:1082–1083

Bennett-Guerrero E, Welsby I, Dunn TJ, Young LR, Wahl TA, Diers TL, Phillips-Bute BG, Newman MF, Mythen MG (1999) The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg 89:514–519

Sinclair S, James S, Singer M (1997) Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 315:909–912PubMed

Garrison RN, Wilson MA, Matheson PJ, Spain DA (1996) Preoperative saline loading improves outcome after elective, noncardiac surgical procedures. Am Surg 62:223–231

Boldt J, Muller M, Heesen M, Neumann K, Hempelmann GG (1996) Influence of different volume therapies and pentoxifylline infusion on circulating soluble adhesion molecules in critically ill patients. Crit Care Med 24:385–391

Wilson RJ, Woods I (2001) Cardiovascular optimization for high-risk surgery. Curr Opin Crit Care 7:195–199

De Backer D, Creteur J, Vincent JL (2003) Perioperative optimization and right heart catheterization: what technique in which patient? Crit Care 7:201–202

Bryson GL (2003) Best evidence in anesthetic practice. Goal-directed therapy with the pulmonary artery catheter is not better than standard therapy. Can J Anaesth 50:614–616

10.

Della Rocca G, Costa MG, Coccia C, Pompei L, Di Marco P, Vilardi V, Pietropaoli P (2003) Cardiac output monitoring: aortic transpulmonary thermodilution and pulse contour analysis agree with standard thermodilution methods in patients undergoing lung transplantation. Can J Anaesth 50:707–711

11.

Della Rocca G, Costa MG, Coccia C, Pompei L, Pietropaoli P (2002) Preload and haemodynamic assessment during liver transplantation: a comparison between the pulmonary artery catheter and transpulmonary indicator dilution techniques. Eur J Anaesthesiol 19:868–875

12.

Della Rocca G, Costa GM, Coccia C, Pompei L, Di Marco P, Pietropaoli P (2002) Preload index: pulmonary artery occlusion pressure versus intrathoracic blood volume monitoring during lung transplantation. Anesth Analg 95:835–843

13.

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M (2001) Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377CrossRefPubMed

14.

Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ (1995) Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 23:1638–1652CrossRefPubMed

15.

Mythen MG, Webb AR (1994) Intra-operative gut mucosal hypoperfusion is associated with increased post-operative complications and cost. Intensive Care Med 20:99–104

16.

Shoemaker WC, Wo CC, Thangathurai D, Velmahos G, Belzberg H, Asensio JA, Demetriades D (1999) Hemodynamic patterns of survivors and nonsurvivors during high risk elective surgical operations. World J Surg 23:1264–1270

17.

Anonymous (1999) Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology 90:896–905

18.

Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS (2002) Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 97:820–826CrossRefPubMed

19.

Price J, Sear J, Venn R (2002) Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database Syst Rev CD003004

20.

Mythen MG, Webb AR (1995) Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 130:423–429PubMed

21.

Sakka SG, Ruhl CC, Pfeiffer UJ, Beale R, McLuckie A, Reinhart K, Meier-Hellmann A (2000) Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med 26:180–187CrossRefPubMed

22.

Lichtwarck-Aschoff M, Beale R, Pfeiffer UJ (1996) Central venous pressure, pulmonary artery occlusion pressure, intrathoracic blood volume, and right ventricular end-diastolic volume as indicators of cardiac preload. J Crit Care 11:180–188

23.

Kumar A, Anel R, Bunnell E, Habet K, Zanotti S, Marshall S, Neumann A, Ali A, Cheang M, Kavinsky C, Parrillo JE (2004) Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 32:691–699

24.

Molnar Z, Szakmany T, Koszegi T (2003) Prophylactic N-acetylcysteine decreases serum CRP but not PCT levels and microalbuminuria following major abdominal surgery. A prospective, randomised, double-blinded, placebo-controlled clinical trial. Intensive Care Med 29:749–755

25.

Buttenschoen K, Buttenschoen DC, Berger D, Vasilescu C, Schafheutle S, Goeltenboth B, Seidelmann M, Beger HG (2001) Endotoxemia and acute-phase proteins in major abdominal surgery. Am J Surg 181:36–43

26.

Lindberg M, Hole A, Johnsen H, Asberg A, Rydning A, Myrvold HE, Bjerve KS (2002) Reference intervals for procalcitonin and C-reactive protein after major abdominal surgery. Scand J Clin Lab Invest 62:189–194

27.

Assicot M, Gendrel D, Carsin H, Raymond J, Guilbaud J, Bohuon C (1993) High serum procalcitonin concentrations in patients with sepsis and infection. Lancet 341:515–518CrossRefPubMed

28.

Dandona P, Nix D, Wilson MF (1994) Procalcitonin increase after endotoxin injection in normal subjects. J Clin Endocrinol Metab 79:1605–1608

29.

Meisner M, Tschaikowsky K, Hutzler A, Schick C Schutler J (1998) Postoperative plasma concentrations of procalcitonin after different types of surgery. Intensive Care Med 24:680–684

30.

Mimoz O, Benoist JF, Edouard AR, Assicot M, Bohuon C, Samii K (1998) Procalcitonin and C-reactive protein during the early posttraumatic systemic inflammatory response syndrome. Intensive Care Med 24:185–188CrossRef

31.

Fries M, Kunz D, Gressner AM, Rossaint R, Kuhlen R (2003) Procalcitonin serum levels after out-of-hospital cardiac arrest. Resuscitation 59:105–109CrossRefPubMed

32.

Tracey KJ, Lowry SF, Cerami A (1988) Cachectin: a hormone that triggers acute shock and chronic cachexia. J Infect Dis 157:413–420

33.

Ackermann M, Reuter M, Flohe S, Bahrami S, Redl H, Schade FU (2001) Cytokine synthesis in the liver of endotoxin-tolerant and normal rats during hemorrhagic shock. J Endotoxin Res 7:105–112

34.

Tang GJ, Kuo CD, Yen TC, Kuo HS, Chan KH, Yien HW, Lee TY (1996) Perioperative plasma concentrations of tumor necrosis factor-alpha and interleukin-6 in infected patients. Crit Care Med 1996 24:423–428

35.

Okamura JM, Miyagi JM, Terada K, Hokama Y (1990) Potential clinical applications of C-reactive protein J Clin Lab Anal 4:231–235

36.

Thompson D, Milford-Ward A, Whicher JT (1992) The value of acute phase protein measurements in clinical practice. Ann Clin Biochem 29:123–131

37.

Pettila V, Pentti J, Pettila M, Takkunen O, Jousela I (2002) Predictive value of antithrombin III and serum C-reactive protein concentration in critically ill patients with suspected sepsis. Crit Care Med 30:271–275

38.

Odegard A, Lundbom J, Myhre HO, Hatlinghus S, Bergh K, Waage A, Bjerve KS, Mollnes TE, Aadahl P, Lie TA, Videm V (2000) The inflammatory response following treatment of abdominal aortic aneurysms: a comparison between open surgery and endovascular repair. Eur J Vasc Endovasc Surg 19:536–544

Title: Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial
Authors: Tamas Szakmany
Ildiko Toth
Zsolt Kovacs
Tamas Leiner
Andras Mikor
Tamas Koszegi
Zsolt Molnar
Publication date: 01-05-2005
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 5/2005
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-005-2606-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial

Abstract

Objective

Design

Patients

Interventions

Measurements and results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Design

Patients

Interventions

Measurements and results

Conclusions

Please log in to get access to this content

Other articles of this Issue 5/2005

May 2005

Concurrent bacterial infection and prolonged mechanical ventilation in infants with respiratory syncytial virus lower respiratory tract disease

The cyclopentenone prostaglandin 15-deoxyΔ12,14-prostaglandin J2 attenuates the development of zymosan-induced shock

Failure of new antifungals to control Candida thrombophlebitis

Effects of levosimendan on systemic and regional hemodynamics in septic myocardial depression

Bedside colonoscopy for critically ill patients with acute lower gastrointestinal bleeding