BACKGROUND:Goal-directed haemodynamic therapy (GDHT) aims to optimize haemodynamic variables. However, its effectiveness in reducing postoperative complications in major abdominal surgery, particularly when targeting both arterial pressure and flow variables, remains unclear. This meta-analysis addresses this by evaluating GDHT using uncalibrated pulse contour (uPC) methods. METHODS:We conducted a systematic review and meta-analysis of randomized controlled trials (RCT) in adult patients undergoing major abdominal surgery who received GDHT using uncalibrated pulse contour (uPC) methods for cardiac output monitoring, with predefined targets for both blood flow and blood pressure. The primary outcome was postoperative complications; secondary outcomes included postoperative acute kidney injury (AKI), hospital length of stay (EH), intraoperative fluid administration and mortality. RESULTS:Initial search retrieved 860 reports, with 12 RCTs (1367 patients) meeting the inclusion criteria. Our meta-analysis showed a significant reduction in postoperative complications (RR 0.78, 95% CI 0.68-0.90), AKI (RR 0.7, 95% CI 0.51-0.97), and hospital LOS (SMD -0.30, 95% CI -0.54 to -0.06) with uPC-guided GDHT. No significant differences were observed in intraoperative fluid volume and mortality. CONCLUSIONS:Implementing GDHT in major abdominal surgery with predefined arterial pressure and blood flow targets significantly reduces postoperative morbidity and hospital EH without increasing intraoperative fluid administration.

Objective: To evaluate the clinical impact of optimizing stroke volume (SV) through fluid administration as part of goal-directed hemodynamic therapy (GDHT) in adult patients undergoing elective major abdominal surgery. Methods: This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered in the PROSPERO database in January 2024. The intervention was defined as intraoperative GDHT based on the optimization or maximization of SV through fluid challenges, or by using dynamic indices of fluid responsiveness, including stroke volume variation, pulse pressure variation, and plethysmography variation index compared to usual fluid management. The primary outcome was postoperative complications. Secondary outcome variables included postoperative acute kidney injury (AKI), length of stay (LOS), intraoperative fluid administration, and 30-day mortality. Results: A total of 29 randomized controlled trials (RCTs) met the inclusion criteria. There were no significant differences in the incidence of postoperative complications (RR 0.89; 95% CI, 0.78 to 1.00), postoperative AKI (OR 0.97; (95% IC, 0.55 to 1.70), and mortality (OR 0.80; 95% CI, 0.50 to 1.29). GDHT was associated with a reduced LOS compared to usual care (SMD: -0.17 [-0.32; - 0.03]). The subgroup in which hydroxyethyl starch was used for hemodynamic optimization was associated with fewer complications (RR 0.79; 95% CI, 0.65 to 0.94), whereas the subgroup of patients in whom crystalloids were used was associated with an increased risk of postoperative complications (RR 1.08; 95% CI, 1.04 to 1.12). Conclusions: In adults undergoing major surgery, goal-directed hemodynamic therapy focused on fluid-based stroke volume optimization did not reduce postoperative morbidity and mortality. (c) 2024 Sociedad Espanola de Anestesiolog & imath;a, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Antecedentes El objetivo de la terapia hemodinámica guiada por objetivos (THGO) es optimizar las variables hemodinámicas. Sin embargo, sigue siendo incierta su efectividad para reducir las complicaciones postoperatorias de la cirugía abdominal mayor, y en particular cuando se persiguen variables de presión y flujo arterial. Este metaanálisis aborda esta cuestión, evaluando la THGO mediante métodos no calibrados de contorno del pulso (uPC). Métodos Realizamos una revisión sistemática y metaanálisis de ensayos controlados aleatorizados (ECA) en pacientes adultos sometidos a cirugía abdominal mayor, que recibieron THGO mediante métodos no calibrados de contorno del pulso (uPC) para monitorización del gasto cardiaco, con objetivos predefinidos para presión sanguínea y flujo sanguíneo. El resultado primario fueron las complicaciones postoperatorias; los resultados secundarios incluyeron insuficiencia renal aguda (IRA) postoperatoria, duración de la estancia hospitalaria (EH), administración intraoperatoria de líquidos y mortalidad. Resultados La búsqueda inicial recuperó 860 informes, cumpliendo 12 ECA (1.367 pacientes) los criterios de inclusión. Nuestro metaanálisis reflejó una reducción significativa de las complicaciones postoperatorias (RR: 0,78; IC95%: 0,68-0,90), IRA (RR: 0,7; IC95%: 0,51-0,97) y estancia hospitalaria (DM: −0,30; IC95%: −0,54 a −0,06) con THGO guiada por uPC. No se observaron diferencias significativas en cuanto a volumen de líquidos intraoperatorios y mortalidad. Conclusiones Implementar la THGO en la cirugía abdominal con objetivos predefinidos de presión arterial y flujo sanguíneo reduce significativamente la morbilidad postoperatoria y la EH, sin incrementar la administración de líquidos intraoperatorios.

Objetivo Evaluar el impacto clínico de optimizar el volumen sistólico (VS) mediante la administración de líquidos como parte de una terapia hemodinámica guiada por objetivos (THGO) en pacientes adultos sometidos a cirugía abdominal mayor electiva. Métodos Esta revisión sistemática y metaanálisis se realizó de acuerdo con la declaración Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) y fue registrada en la base de datos PROSPERO en enero de 2024. La intervención fue definida como THGO intraoperatoria basada en la optimización o maximización del VS mediante retos de fluidos, o mediante el uso de índices dinámicos de capacidad de respuesta a los líquidos, incluyendo la variación del VS, de la presión de pulso y del índice pletismográfico, en comparación con el manejo de líquidos habitual. El resultado primario fueron las complicaciones posoperatorias. Las variables del resultado secundario incluyeron insuficiencia renal aguda (IRA) posoperatoria, estancia hospitalaria posoperatoria (EHP), administración de líquidos intraoperatoria y mortalidad a 30 días. Resultados Un total de 29 ensayos controlados aleatorizados (ECA) cumplieron con los criterios de inclusión. No se observaron diferencias significativas en cuanto a la incidencia de complicaciones posoperatorias (ratios de riesgo [RR] 0,89; intervalo de confianza [IC] 95%, 0,78 a 1), IRA posoperatoria (odds ratio [OR] 0,97; IC 95%, 0,55 a 1,70) y mortalidad (OR 0,80; IC 95%, 0,50 a 1,29). La THGO estuvo asociada con una reducción de la EHP, en comparación con los cuidados habituales (diferencia media estándar [DME]: −0,17 [−0,32; -0,03]). El subgrupo en el que se utilizó hidroxietil-almidón (HEA) para la optimización hemodinámica estuvo asociado a menores complicaciones (RR 0,79; IC 95%, 0,65 a 0,94), mientras que el subgrupo de pacientes en los que se utilizaron cristaloides estuvo vinculado con un incremento del riesgo de complicaciones posoperatorias (RR 1,08; IC 95%, 1,04 a 1,12). Conclusiones En los adultos sometidos a cirugía mayor, la THGO dirigida a la optimización del VS con líquidos no redujo la morbilidad y la mortalidad posoperatorias.

Background: Intraoperative fluid administration is a ubiquitous intervention in surgical patients. But inadequate fluid administration may lead to poor postoperative outcomes. Fluid challenges (FCs), in or outside the so-called goal-directed fluid therapy, allows testing the cardiovascular system and the need for further fluid administration. Our primary aim was to evaluate how anesthesiologists conduct FCs in the operating room in terms of type, volume, variables used to trigger a FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC. Methods: This was a planned substudy of an observational study conducted in 131 centers in Spain in patients undergoing surgery. Results: A total of 396 patients were enrolled and analyzed in the study. The median [inter -quartile range] amount of fluid given during a FC was 250 mL (200-400). The main indication for FC was a decrease in systolic arterial pressure in 246 cases (62.2%). The second was a decrease in mean arterial pressure (54.4%). Cardiac output was used in 30 patients (7.58%), while stroke volume variation in 29 of 385 cases (7.32%). The response to the initial FC did not have an impact when prescribing further fluid administration. Conclusions: The current indication and evaluation of FC in surgical patients is highly variable. Prediction of fluid responsiveness is not routinely used, and inappropriate variables are frequen-tly evaluated for assessing the hemodynamic response to FC, which may result in deleterious effects. & COPY; 2023 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.

•El uso de pruebas de volumen en España es muy escaso.•No se evalúan adecuadamente las pruebas de volumen.•No parece existir un seguimiento adecuado de la información aportada por las pruebas de volumen.

La investigación sobre fluidoterapia y monitorización hemodinámica perioperatorias es difícil y costosa. Los objetivos del presente estudio fueron resumir y priorizar estas cuestiones, en orden de importancia investigadora. Cuestionario estructurado electrónico Delphi a lo largo de tres rondas entre 30 expertos en fluidoterapia y monitorización hemodinámica identificados a través del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia de la Sociedad Española de Anestesiología y Reanimación. Se identificaron 77 cuestiones, que se clasificaron en orden de priorización. Las cuestiones se categorizaron en temas de cristaloides, coloides, monitorización hemodinámica y otros. Se categorizaron 31 cuestiones como de prioridad investigadora esencial, para determinar si los algoritmos de optimización hemodinámica intraoperatorios basados en el índice de predicción de hipotensión invasivo o no invasivo frente a otras estrategias de manejo podrían reducir la incidencia de complicaciones postoperatorias, así como si el uso de biomarcadores del estrés renal junto con un protocolo de fluidoterapia dirigido por objetivos podría reducir la estancia hospitalaria y la incidencia de insuficiencia renal aguda en pacientes adultos sometidos a cirugía no cardiaca, lográndose el más alto consenso. El Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia de la Sociedad Española de Anestesiología y Reanimación utilizará estos resultados para la realización de investigación. Research on perioperative fluid therapy and hemodynamic monitoring is difficult and expensive. The objectives of the present study were to summarize and prioritize these issues, in order of research importance. research importance. Structured electronic Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Subcommittee on Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Resuscitation. 77 issues were identified, which were ranked in order of prioritization. The were categorized into crystalloid, colloid, hemodynamic monitoring and others. and others. Thirty-one issues were categorized as of essential research priority, to determine whether intraoperative hemodynamic optimization algorithms based on the index of invasive or noninvasive hypotension prediction index versus other management strategies could reduce the incidence of postoperative reduce the incidence of postoperative complications, as well as whether the use of biomarkers of renal stress in conjunction biomarkers of renal stress in conjunction with a goal-directed fluid therapy protocol could reduce hospital stay and the hospital stay and the incidence of acute renal failure in adult patients undergoing non-cardiac surgery, and whether the non-cardiac surgery, achieving the highest consensus. The Subcommittee on Fluid Therapy and Hemodynamic Monitoring of the Section of Hemostasis, Transfusion Medicine and Fluid Therapy of the Spanish Society of Anesthesiology and Resuscitation of the Spanish Society of Anesthesiology and Resuscitation will use these results for further research.

Background: Research on perioperative fluid therapy and hemodynamic monitoring is difficult and expensive. The objectives of the present study were to summarize and prioritize these issues, in order of research importance. research importance.Methods: Structured electronic Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Subcommittee on Fluid The-rapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Resuscitation.Results: 77 issues were identified, which were ranked in order of prioritization. The were cate-gorized into crystalloid, colloid, hemodynamic monitoring and others. and others. Thirty-one issues were categorized as of essential research priority, to determine whether intraoperative hemodynamic optimization algorithms based on the index of invasive or noninvasive hypo -tension prediction index versus other management strategies could reduce the incidence of postoperative reduce the incidence of postoperative complications, as well as whether the use of biomarkers of renal stress in conjunction biomarkers of renal stress in conjunction with a goal-directed fluid therapy protocol could reduce hospital stay and the hospital stay and the incidence of acute renal failure in adult patients undergoing non-cardiac surgery, and whether the non-cardiac surgery, achieving the highest consensus.Conclusions: The Subcommittee on Fluid Therapy and Hemodynamic Monitoring of the Section of Hemostasis, Transfusion Medicine and Fluid Therapy of the Spanish Society of Anesthesiology and Resuscitation of the Spanish Society of Anesthesiology and Resuscitation will use these results for further research.& COPY; 2023 Sociedad Espan & SIM;ola de Anestesiologi & PRIME;a, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espan & SIM;a, S.L.U. All rights reserved.

Las pruebas de evaluación de la coagulación en niños siguen realizándose con frecuencia en muchos países, para evaluar el riesgo de hemorragia. El objetivo de este estudio fue valorar el manejo de la prolongación inesperada del tiempo de tromboplastina parcial activada (APTT) y el tiempo de protrombina (PT) en niños previa a la cirugía electiva, y el riesgo hemorrágico perioperatorio.Se incluyó a los niños con APTT y/o PT prolongados que acudieron a consulta de anestesia preoperatoria desde enero del 2013 a diciembre del 2018. Se agrupó a los pacientes en función de si habían sido derivados a Hematología o habían sido programados para cirugía sin pruebas adicionales. El resultado primario fue comparar las complicaciones hemorrágicas perioperatorias.Se evaluó para elegibilidad a 1.835 niños. Presentaron resultados anormales 102 de ellos (5,6%) y el 45% fue derivado a Hematología previo a la cirugía. Los trastornos hemorrágicos significativos estuvieron asociados a a una historia hemorrágica (personal y/o familiar) positiva, odds ratio de 51 (IC 95% de 4,8 a 538,5, p = 0,0011). No se encontró diferencia en términos de resultados de hemorragia perioperatoria entre los grupos. Se observó un coste adicional de 181 € por paciente y una mediana de demora preoperatoria de 43 días en los pacientes derivados a Hematología.Nuestros resultados sugieren que la derivación a Hematología tiene un valor limitado en niños asintomáticos con APTT y/o PT prolongados. Las complicaciones hemorrágicas fueron similares entre los pacientes derivados y los no derivados a Hematología. Una historia familiar positiva de hemorragia puede ayudar a identificar a los pacientes con mayor riesgo de sangrado, por lo que debería guiar la petición de los análisis de coagulación y la derivación a Hematología. Esfuerzos adicionales son necesarios para estandarizar las herramientas preoperatorias de evaluación hemorrágica en niños.Coagulation screening tests in children are still frequently performed in many countries to evaluate bleeding risk. The aim of this study was to assess the management of unexpected prolongations of the activated partial thromboplastin time (APTT) and prothrombine time (PT) in children prior to elective surgery, and the perioperative hemorrhagic outcomes.Children with prolonged APTT and/or PT who attended a preoperative anesthesia consultation from January 2013 to December 2018 were included. Patients were grouped according to whether they were referred to a Hematologist or were scheduled to undergo surgery without further investigation. The primary endpoint was to compare perioperative bleeding complications.1835 children were screened for eligibility. 102 presented abnormal results (5.6%). Of them, 45% were referred to a Hematologist. Significant bleeding disorders were associated with a positive bleeding history, odds ratio of 51 (95% CI 4.8 to 538.5, P = 0.0011). No difference in perioperative hemorrhagic outcomes were found between the groups. An additional cost of 181 euros per patient and a preoperative median delay of 43 days was observed in patients referred to Hematology.Our results suggest that hematology referral has limited value in asymptomatic children with a prolonged APTT and/or PT. Hemorrhagic complications were similar among patients referred and not referred to Hematology. A positive personal or family bleeding history can help identify patients with a higher bleeding risk, thus it should guide the need for coagulation testing and hematology referral. Further efforts should be made to standardize preoperative bleeding assessments tools in children.

En un esfuerzo por estandarizar el manejo perioperatorio y mejorar los resultados posoperatorios de los pacientes adultos sometidos a cirugía, el Ministerio de Sanidad, a través del Grupo Español de Rehabilitación Multimodal (GERM) y el Instituto Aragonés de Ciencias de la Salud, en colaboración con diversas sociedades científicas españolas, y sobre la base de la evidencia disponible, publicó en 2021 la guía Recuperación intensificada en cirugía del adulto (RICA). Dicho documento incluye 12 medidas perioperatorias relacionadas con la fluidoterapia y la monitorización hemodinámica. La administración de fluidos y la monitorización hemodinámica no son sencillas, pero están directamente relacionadas con los resultados de los pacientes.

Background: Intraoperative arterial hypotension is associated with poor postoperative outcomes. The Hypotension Prediction Index, developed from machine learning, predicts the occurrence of arterial hypotension from the analysis of the arterial pressure waveform. The use of this index can reduce the duration and severity of intraoperative hypotension in adults undergoing noncardiac surgery. Methods: We will conduct a multicenter, randomized, controlled trial (N=80) in high-risk surgical patients scheduled for elective major abdominal surgery. All participants will be randomly assigned to a control or intervention group. Hemodynamic management in the control group will be based on standard hemodynamic parameters. Hemodynamic management of patients in the intervention group will be based on functional hemodynamic parameters provided by the HemoSphere platform (Edwards Lifesciences Corp.), including dynamic arterial elastance, dP/dt max and the Hypotension Prediction Index. Tissue oxygen saturation will be non-invasively and continuously recorded by using near-infrared spectroscopy technology. Biomarkers of acute kidney stress (cTIMP2 and IGFBP7) will be obtained before and after surgery. The primary outcome will be intraoperative time-weighted average of a mean arterial pressure < 65mmHg. Discussion: The aim of the study is to determine whether a goal-directed algorithm based on the prevention of arterial hypotension using the Hypotension Prediction Index reduces the duration and severity of intraoperative hypotension when compared with the recommended standard therapy and if this intraoperative strategy is associated with better tissue oxygenation and organ perfusion. Trial registration: ClinicalTrials.gov, NCT04301102. Registered on March 10, 2020.

Background: The optimal regimen for intravenous administration of intraoperative fluids remains unclear. Our goal was to analyze intraoperative crystalloid volume administration practices and their association with postoperative outcomes. Methods: We extracted clinical data from two multicenter observational studies including adult patients undergoing colorectal surgery and total hip (THA) and knee arthroplasty (TKA). We analyzed the distribution of intraoperative fluid administration. Regression was performed using a general linear model to determine factors predictive of fluid administration. Patient outcomes and intraoperative crystalloid utilization were summarized for each surgical cohort. Regression models were developed to evaluate associations of high or low intraoperative crystalloid with the likelihood of increased postoperative complications, mainly acute kidney injury (AKI) and hospital length of stay (LOS). Results: 7,580 patients were included. The average adjusted intraoperative crystalloid infusion rate across all surgeries was to 7.9 (SD 4) mL/kg/h. The regression model strongly favored the type of surgery over other patient predictors. We found that high fluid volume was associated with 40% greater odds ratio (OR 1.40; 95% confidence intervatl .01-1.95, p = 0.044) of postoperative complications in patients undergoing THA, while we found no associations for the other types of surgeries, AKI and LOS Conclusions: A wide variability was observed in intraoperative crystalloid volume administration; however, this did not affect postoperative outcomes. (C) 2020 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.

High blood pressure is very common and predisposes to cardiovascular events, renal failure, cognitive risk and premature death. There are insufficient data to provide guidance on the ideal blood pressure values for elective anesthesia and surgery. In this review, we will examine the physiology of blood pressure and its regulation, the implications of high blood pressure for anesthesia and surgery, as well as the pathophysiology of perioperative hypertension.

La presión arterial elevada es muy común y predispone a eventos cardiovasculares, insuficiencia renal, riesgo cognitivo y muerte prematura. Hay escasez de datos que brinden orientación sobre los valores ideales de presión arterial para la anestesia electiva y la cirugía. En esta revisión, examinaremos la fisiología de la presión arterial y su regulación, las implicaciones de la presión arterial elevada para la anestesia y la cirugía, así como la fisiopatología de la hipertensión perioperatoria.