The Effect of Targeted Fluid Therapy with PVI on Acute Kidney Injury in Laparoscopic Colorectal Surgery

Year 2023, Volume: 76 Issue: 3, 271 - 277, 30.06.2024

Sevcan Büyük Süheyla Karadağ Erkoç , Cihangir Akyol , Ali Abbas Yılmaz

Abstract

Objectives: Laparoscopic approaches are preferred for colorectal surgeries because they have proven advantages in the literature. However, increased intra-abdominal pressure and hypo/hypervolemia adversely affect tissue perfusion. In this study, we aimed to improve postoperative outcomes with targeted fluid therapy using Pleth variability index (PVI) and to demonstrate its effect on kidneys using neutrophil gelatinase associated lipocalin (NGAL).

Materials and Methods: This study was a prospective randomized control, single-centred study. Twenty-nine patients who underwent elective laparoscopic colorectal surgery were included. Patients were randomized into 2 groups, as Group-1 receiving targeted fluid therapy with PVI (n=15) and Group 2 receiving conventional fluid therapy (n=14). 500 mL of crystalloid bolus and 2 mL/kg/hour of maintenance fluid were applied to the PVI group. When the PVI>14%, a 250 mL of crystalloid bolus was administered. In the group receiving, conventional fluid therapy “4-2-1 rule” was used. Plasma NGAL samples were received at pre-insufflation (T0), post-insufflation 6th (T1) and 12th (T2) hours.

Results: When the given fluids were compared between the groups, we detected significantly diminished results for Group 1 (p<0.001). The increase between basal NGAL and 6th hour, 12th hour NGAL were statistically significant in both groups (p<0.05). While there were no postoperative complications in Group 1, respiratory complications were seen in 2 patients and wound infection in 1 patient in Group 2.

Conclusion: Targeted fluid therapy with PVI had no significant effect on NGAL associated acute kidney injury. Nevertheless, there were no postoperative complications in these patients. We think that fluid therapy with PVI can be used in laparoscopic colorectal surgeries to avoid complications caused by fluid load.

Keywords

Laparoscopic Colorectal Surgery , Acute Kidney Injury , PVI , NGAL

Ethical Statement

Ethical approval was obtained from Ankara University Faculty of Medicine, Clinical Research Ethics Committee (decision no: 15-823-16, date: 10.10.2016).

Laparoskopik Kolorektal Cerrahide PVI ile Hedefe Yönelik Sıvı Tedavisinin Akut Böbrek Hasarı Üzerine Etkisi

Abstract

Amaç: Kolorektal cerrahilerde, laparoskopik uygulamalar, literatürde kanıtlanmış birçok avantajı olması nedeniyle tercih edilmektedir. Ancak intraabdominal basınç artışı ve hipo/hipervolemi doku perfüzyonunu olumsuz etkilemektedir. Bu çalışmada, Pleth değişkenlik indeksi (Pleth variability index-PVI) monitörizasyonu ile hedefe yönelik sıvı tedavisi yaparak hem postoperatif sonuçları iyileştirmeyi hem de nötrofil jelatinaz ilişkili lipokalini (NGAL) kullanarak bu yaklaşımın böbrekler üzerindeki etkisini göstermeyi amaçladık.

Gereç ve Yöntem: Bu çalışma tıp fakültemizin genel cerrahi ameliyathanelerinde, prospektif randomize kontrollü, tek merkezli olarak gerçekleştirildi. Elektif laparoskopik kolorektal cerrahi geçirmiş, 29 hasta dahil edildi. Hastalar, Grup 1 (n=15) PVI ile hedefe yönelik sıvı tedavisi alanlar ve Grup 2 (n=14), konvansiyonel sıvı tedavisi alanlar şeklinde randomize edildi. Genel anestezi indüksiyonu sonrası PVI grubuna 500 mL kristaloid bolusu ve 2 mL/kg/saat idame sıvı uygulandı. PVI>%14 olduğunda 250 mL kristaloid bolusu verildi. Standart sıvı tedavisi alan grupta ise 4-2-1 kuralına göre konvansiyonel sıvı tedavisi yapıldı. Bütün hastalarda plazma NGAL örnekleri insuflasyon öncesi (T0), insuflasyon sonrası 6. (T1) ve 12. (T2) saatlerde alındı.

Bulgular: Gruplar arasındaki verilen sıvılar karşılaştırıldığında Grup 1’de verilen sıvı volümü anlamlı olarak daha az bulundu (p<0,001). NGAL değerlerindeki artış her iki grupta benzerdi. Bazal NGAL ile 6. saat NGAL arasındaki artış ve bazal NGAL ile 12. saat NGAL arasındaki artış istatistiksel olarak anlamlı bulundu (p<0,05). Grup 1’de postoperatif hiç komplikasyon izlenmezken Grup 2’de 2 hastada solunumsal komplikasyonlar, 1 hastada yara yeri enfeksiyonu görüldü.

Sonuç: PVI ile hedefe yönelik sıvı tedavisinin, NGAL ile gösterilebilen akut böbrek hasarı üzerine, belirgin etkisi olmadı. Bununla birlikte bu hastalarda postoperatif komplikasyon görülmedi. Laparoskopik kolorektal cerrahilerde PVI monitörizasyonu ile sıvı tedavisinin, sıvı yükünün getirdiği komplikasyonlardan kaçınmak amacı ile kullanılabileceğini düşünmekteyiz.

Keywords

Laparoskopik Kolorektal Cerrahi , Akut Böbrek Hasarı , PVI , NGAL

Ethical Statement

Ankara Üniversitesi Tıp Fakültesi, Klinik Araştırmalar Etik Kurulu’ndan etik onay (karar no: 15-823-16, tarih: 10.10.2016) alınmıştır.

References

• 1. Joris JL: Anesthesia for laparoscopic surgery. In Miller RD (ed): Anesthesia, Churchill Livingstone, 5 th ed. Philadelphia, 2000. p. 2003-2023
• 2. Diebel LN, Wilson RF, Dulchavsky SA, et al. Effect of increased intraabdominal pressure on hepatic arterial, portal venous, and hepatic microcirculatory blood flow. J Trauma. 1992;33:279-282.
• 3. Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R204-R212.
• 4. Goren O, Matot I. Perioperative acute kidney injury. Br J Anaesth. 2015;115 Suppl 2:ii3-ii14.
• 5. Mishra J, Dent C, Tarabishi R, et al. Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet. 2005;365:1231-1238.
• 6. Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006;97:755-757.
• 7. Cannesson M, Desebbe O, Rosamel P, et al. Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theatre. Br J Anaesth. 2008;101:200-206.
• 8. Noblett SE, Snowden CP, Shenton BK, et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069-1076.
• 9. Hashikura Y, Kawasaki S, Munakata Y, et al. Effects of peritoneal insufflation on hepatic and renal blood flow. Surg Endosc. 1994;8:759-761.
• 10. Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R204-R212.
• 11. Van Biesen W, Vanholder R, Lameire N. Defining acute renal failure: RIFLE and beyond. Clin J Am Soc Nephrol. 2006;1:1314-1319.
• 12. Devarajan P. Neutrophil gelatinase-associated lipocalin: a promising biomarker for human acute kidney injury. Biomark Med. 2010;4:265-280.
• 13. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31:783-800.
• 14. Armaly Z, Abassi Z. Deleterious Effects of Increased Intra-Abdominal Pressure on Kidney Function , Advances in Nephrology. 2014;731657:1-15.
• 15. Türkmen F, Berber İ, Işıtmangil G, et al. The Predictive Value of NGAL in Radiocontrast-Induced Neph- ropathy. Turkish Nephrology Dialysis and Transplantation Journal, 2013;22:163-166.
• 16. Forget P, Lois F, de Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management. Anesth Analg. 2010;111:910-914.
• 17. He Y, Wang J, Bian H, et al. BMI as a Predictor for Perioperative Outcome of Laparoscopic Colorectal Surgery: a Pooled Analysis of Comparative Studies. Dis Colon Rectum. 2017;60:433-445.
• 18. Muñoz JL, Gabaldón T, Miranda E, et al. Goal-Directed Fluid Therapy on Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients. Obes Surg. 2016;26:2648-2653.
• 19. Lopes MR, Oliveira MA, Pereira VO, et al. Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care. 2007;11:R100.
• 20. Colquhoun D, Turrentine F, Rea K, et al. Implementing an Health System Wide Enhanced Recovery Program for Patients Undergoing Colorectal Surgery. The Anesthesiologists American Society of Anesthesiologists. 2014;A2010.