From the Department of Anesthesiology and Critical Care Medicine, Anesthesiology Service (V.A.-C., A.C.P., M.F.) the Department of Epidemiology and Biostatistics (K.S.T.) the Department of Surgery, Urology Service (G.D., H.W.H., B.H.B., E.K.C., T.F.D., S.M.D.), Memorial Sloan Kettering Cancer Center, New York, New York the Departments of Urology (G.D., H.W.H., B.H.B., E.K.C., S.M.D.) Anesthesiology (A.C.P., M.F.), Weill Cornell Medical College, New York, New York.
Anesthesiology. 2020 Aug;133(2):293-303. doi: 10.1097/ALN.0000000000003367.
Postoperative ileus is a common complication of intraabdominal surgeries, including radical cystectomy with reported rates as high as 32%. Perioperative fluid administration has been associated with improvement in postoperative ileus rates, but it is difficult to generalize because earlier studies lacked standardized definitions of postoperative ileus and other relevant outcomes. The hypothesis was that targeted individualized perioperative fluid management would improve postoperative ileus in patients receiving radical cystectomy.
This is a parallel-arm, double-blinded, single-center randomized trial of goal-directed fluid therapy versus standard fluid therapy for patients undergoing open radical cystectomy. The primary outcome was postoperative ileus, and the secondary outcome was complications within 30 days post-surgery. Participants were at least 21 yr old, had a maximum body mass index of 45 kg/m and no active atrial fibrillation. The intervention in the goal-directed therapy arm combined preoperative and postoperative stroke volume optimization and intraoperative stroke volume variation minimization to guide fluid administration, using advanced hemodynamic monitoring.
Between August 2014 and April 2018, 283 radical cystectomy patients (142 goal-directed fluid therapy and 141 standard fluid therapy) were included in the analysis. Postoperative ileus occurred in 25% (36 of 142) of patients in the goal-directed fluid therapy arm and 21% (30 of 141) of patients in the standard arm (difference in proportions, 4.1%; 95% CI, -5.8 to 13.9; P = 0.418). There was no difference in incidence of high-grade complications between the two arms (20 of 142 [14%] vs. 23 of 141 [16%]; difference in proportions, -2.2%; 95% CI, -10.6 to 6.1; P = 0.602), with the exception of acute kidney injury, which was more frequent in the goal-directed fluid therapy arm (56% [80 of 142] vs. 40% [56 of 141] in the standard arm; difference in proportions, 16.6%; 95% CI, 5.1 to 28.1; P = 0.005; P = 0.170 after adjustment for multiple testing).
Goal-directed fluid therapy may not be an effective strategy for lowering the risk of postoperative ileus in patients undergoing open radical cystectomy.
术后肠梗阻是腹部手术的常见并发症，包括根治性膀胱切除术，其报道的发生率高达 32%。围手术期液体管理与术后肠梗阻发生率的改善有关，但由于早期研究缺乏对术后肠梗阻和其他相关结局的标准化定义，因此难以推广。假设目标导向的围手术期液体管理可以改善接受根治性膀胱切除术的患者的术后肠梗阻。
这是一项平行臂、双盲、单中心的随机试验，比较了目标导向液体治疗与标准液体治疗在开放性根治性膀胱切除术中的应用。主要结局是术后肠梗阻，次要结局是术后 30 天内的并发症。参与者年龄至少 21 岁，最大体重指数为 45kg/m²，且无活动性心房颤动。目标导向治疗组的干预措施结合了术前和术后每搏量优化以及术中每搏量变异最小化，以指导液体管理，使用先进的血流动力学监测。
2014 年 8 月至 2018 年 4 月，共有 283 例根治性膀胱切除术患者（142 例接受目标导向液体治疗，141 例接受标准液体治疗）纳入分析。目标导向液体治疗组中术后肠梗阻的发生率为 25%（36/142），标准治疗组为 21%（30/141）（比例差异，4.1%；95%CI，-5.8 至 13.9；P=0.418）。两组高等级并发症的发生率无差异（142 例中有 20 例[14%]，141 例中有 23 例[16%]；比例差异，-2.2%；95%CI，-10.6 至 6.1；P=0.602），除急性肾损伤外，目标导向液体治疗组更常见（142 例中有 80 例[56%]，141 例中有 56 例[40%]；比例差异，16.6%；95%CI，5.1 至 28.1；P=0.005；经多次检验校正后 P=0.170）。
目标导向液体治疗可能不是降低开放性根治性膀胱切除术后患者术后肠梗阻风险的有效策略。
