The effect of intraoperative goal-directed hemodynamic therapy on volume status, venous congestion, and ventricular function in elective colorectal surgery: an observational pilot study using point-of-care ultrasound

Introduction

Fluid management is an essential component of patient care during surgery. Both hypovolemia and hypervolemia in the perioperative period are associated with adverse outcomes (1,2). Goal-directed hemodynamic therapy (GDHT) is the use of fluids, vasopressors, and/or inotropes to target flow-based dynamic variables, such as stroke volume (SV), to increase organ blood flow and tissue perfusion (3) (Figure 1). The heterogeneity of trial protocols, monitoring devices used, and hemodynamic management practices make generalization difficult (4-11). Several GDHT studies in abdominal surgery target “SV optimization” by giving small fluid boluses (200–250 mL) until the SV increases by less than 10%, i.e., giving additional fluid no longer increases SV (12-19). This practice has raised concerns about hypervolemia and increased length of stay specifically in aerobically-fit patients (20-22). Point-of-care ultrasound (POCUS) provides an objective way to assess volume status in the perioperative period and may help expose venous congestion among surgery patients (23). Recently, the venous excess ultrasound (VExUS) grading system was recognized for identification of venous congestion and subsequent acute kidney injury (AKI) in cardiac surgery patients. The VExUS score is derived from a combination of inferior vena cava (IVC) diameter and hepatic, portal, and renal venous Doppler waveform patterns (24,25). At our institution, we applied a GDHT protocol as part of an enhanced recovery after surgery (ERAS) pathway for colorectal surgery. This GDHT protocol optimizes SV by targeting the SV recruited with passive leg raise (PLR) prior to surgical incision. We hypothesized that patients undergoing resuscitation with GDHT protocol would minimize organ congestion and tissue hypoperfusion in accordance with VExUS criteria. We present this article in accordance with the STROBE reporting checklist (available at https://ls.amegroups.com/article/view/10.21037/ls-24-12/rc).

Figure 1 GDHT algorithm. *, . SV, stroke volume; PLR, passive leg raise; OR, operating room; IVF, intravenous fluids; MAP, mean arterial pressure; SBP, systolic blood pressure; HTN, hypertension; GDHT, goal-directed hemodynamic therapy.

Methods

This is a prospective study of adult patients undergoing elective colorectal surgeries between January 2020 and December 2020 at Virginia Commonwealth Health System. As pioneers in the field of ERAS pathways, colorectal surgery holds unparalleled experience, making colorectal patients the preferred choice for our study. Our clinical team performed VExUS scans on a convenience sample of 19 patients preoperatively and postoperatively as part of the pathway launch to monitor venous congestion after protocol implementation.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Virginia Commonwealth University Health System’s Institutional Review Board (IRB) approved the study protocol (French + Shah; IRB #HM20019227, The Effect of Enhanced Recovery After Surgery Pathways on Postoperative Patient Outcomes) and informed patient consent was waived.

Patient selection for pathway & GDHT protocol

All adult (age ≥18 years old) patients undergoing elective open or laparoscopic surgery with Colorectal Surgical Service with planned bowel resection/manipulation and anticipated postoperative length of stay ≥1 day were enrolled in an ERAS pathway. Patients were excluded from the GDHT component of our pathway if they had chronic kidney disease stage 4 or higher, severe left ventricular (LV) dysfunction [ejection fraction (EF) ≤30%], moderate or severe valvular disease, moderate or severe right ventricular (RV) dysfunction, or known significant pulmonary hypertension.

GDHT

In the preoperative clinic, patients were given carbohydrate drinks and instructed to consume clear liquids up to 2 hours before surgery to promote adequate hydration. Prior to induction of anesthesia, patients were placed on a Baxter Starling^® SV System (Cheetah Medical Ltd., Berkshire, UK) and an “awake SV” was recorded. Following induction of general anesthesia, an “asleep SV” was recorded. A PLR was then performed to assess fluid responsiveness and this SV value was recorded as “PLR SV”. Being placed in the Trendelenburg position was considered a PLR equivalent. The highest of the 3 SV values (awake, asleep, PLR) was set as the “target SV” for the case. Fluid responsiveness was defined as SV increase ≥10%. If the patient was fluid responsive with initial PLR, a 250 mL bolus of a balanced crystalloid solution was given prior to the start of surgery. If the PLR SV was greater than 10% higher than awake or asleep, then 250 cc intravenous fluid was given as the patient was returned to supine position. For patients requiring an arterial line for surgery, an Edwards FloTrac System (Edwards Lifesciences Corp, Irvine, CA, USA) was used to obtain SV, with omission of “awake SV” because of post-induction placement. Maintenance intravenous (IV) fluids (lactated ringers or Plasmalyte^®; Baxter Healthcare Ltd., Thetford, UK) were run at 3 or 5 mL/kg/min for minimally invasive or open surgery, respectively. During the case, a greater than 10% decrease in SV prompted a 250 mL crystalloid bolus to assess fluid responsiveness. If during laparoscopy, two consecutive fluid bolus (500 mL total) failed to return the patient to target SV, the value after 500 mL of fluid was used as “laparoscopic target SV” until pneumoperitoneum was released. After fascial closure, a PLR was performed to determine if the patient had final recruitable SV. If the patient exhibited greater than 10% increase in SV, the patient was given 250 mL fluid bolus. Vasopressors were initiated if needed to maintain mean arterial pressure (MAP) ≥65 mmHg.

Ultrasound assessment

All patients had preoperative and postoperative ultrasound examinations performed by an anesthesiologist trained in transthoracic echocardiography. The preoperative exam was performed within 1 hour prior to surgery in the pre-surgical unit and the postoperative exam was performed within 1 hour following the completion of surgery in the post-anesthesia care unit by the same examiner for consistency. Images were obtained using a Philips CX50 Ultrasound System and S5-1 ultrasound transducer. All measurements were performed on the CX50 Ultrasound or using Intellispace Cardiovascular software by the same anesthesiologist for consistency. Electrocardiogram leads were placed to aid in identification of systolic and diastolic waves on hepatic vein pulsed-wave Doppler (PWD). E-point septal separation (EPSS) was measured using M-mode in the parasternal long-axis view. Mitral annular plane systolic excursion (MAPSE) and tricuspid annular systolic plane excursion (TAPSE) were measured using M-mode in the apical 4-chamber view. Left ventricular dysfunction was defined as MAPSE less than 10 mm or EPSS greater than 8 mm (26,27). Right ventricular dysfunction was defined as TAPSE less than 15 mm (28,29). The subcostal IVC view was used to imaging the IVC, hepatic veins, and portal vein. The right subcostal oblique view was used as an alternative to image the IVC, hepatic vein, or portal vein in some patients if subcostal windows were not favorable. IVC diameter was measured 1 to 2 cm proximal to the cavoatrial junction using M-mode. The degree of respiratory variation in the IVC was assessed through a sniff-test, categorizing the findings as greater than 50% collapse, less than 50% collapse, or none. Hepatic vein PWD waveform was obtained 1 to 2 cm from entry into IVC and recorded as normal (systolic greater than diastolic), systolic blunting (systolic less than diastolic), or systolic reversal (systolic flow away from IVC). The intrahepatic portal vein was interrogated using PWD and flow pattern was recorded qualitatively as continuous or pulsatile. Portal vein maximum (Vmax) and minimum velocities (Vmin) were recorded using PWD. Portal vein pulsatility fraction (PF) was calculated using PF = (Vmax − Vmin)/Vmax. VExUS grade was determined using a combination of these variables and graded as 0, 1, 2 (mild), or 3 (severe) (Figure 2).

Figure 2 . (A) Grading criteria for hepatic vein Doppler and portal vein Doppler flow. (B) Modified VExUS grading scale based on doppler findings. S, systolic; D, diastolic; VExUS, venous excess ultrasound; IVC, inferior vena cava; PF, pulsatility fraction.

Statistical analysis

Patient and ultrasound data were analyzed using R statistical software. Variables were compared using the Wilcoxon signed-rank test or the paired t-test as appropriate.

Results

From January 2020 and December 2020, pre- and post-operative VExUS scans were performed on 23 patients presenting for elective major colorectal surgery. We included 19 patients in the final analysis: 3 were excluded for incomplete ultrasound data and 1 was excluded for unanticipated same-day discharge. Patient population and procedure characteristics are displayed in Table 1. The mean age of patients was 55 [standard deviation (SD): ±16] years old; 63% of the patients were female; 37% were male. One patient had CHF with EF 45%. No patients had CKD or diagnosed liver disease. Seventeen patients were monitored with a Cheetah Starling SV System; 2 patients were monitored with an Edwards FloTrac System. Sixteen (84%) of patients had laparoscopic surgery; 3 (16%) patients had open surgery. The median duration of surgery was 164 [interquartile range (IQR), 122–190] minutes. Median intraoperative fluid intake was 2,045 mL, urine output 280 mL, and estimated blood loss 75 mL. Median intraoperative net fluid administration was 1,690 mL with a median rate of 8.7 (IQR, 5.4–12.0) mL/kg/h. No patients received blood transfusions. All patients received phenylephrine as a vasopressor at some point during the case. No patients were administered inotropes.

Comparisons of preoperative and postoperative ultrasound findings are displayed in Table 2. Mean and median changes in measurements are displayed in Table 3. There were no significant changes in EPSS [4.38 vs. 4.20 mm, P=0.73; 95% confidence interval (CI): −0.64, 0.47], TAPSE (22.0 vs. 24.0 mm, P=0.07; 95% CI: −0.15, 2.7) or IVC diameter (1.44 vs. 1.50 cm, P=0.15; 95% CI: −0.03, 0.16). Median MAPSE significantly increased pre- to postoperative (15.4 vs. 17.0 mm, P=0.02; 95% CI: 0.31, 3.60) (Figure 3). None of the patients showed qualitative change in hepatic vein Doppler flow pattern with 17 (89.5%) having normal flow, 1 (5.2%) systolic blunting, and 1 (5.2%) systolic reversal both pre- and postoperatively. The mean portal vein PF was within normal range (less than 0.3) both pre- and postoperatively and there was no significant change in portal vein PF (0.16 vs. 0.14, P=0.68; 95% CI: −0.03, 0.02). One (5.2%) patient demonstrated a qualitative change in portal vein Doppler flow pattern from continuous to pulsatile with a corresponding increase in portal vein PF (0.202 to 0.314). There was no change in VExUS score in any patients with all patients having a score of 0 both pre- and postoperatively (Table 4). Median postoperative length of stay was 5.0 (IQR, 4.0–7.25) days. No patients experienced postoperative AKI by Kidney Disease: Improving Global Outcomes (KDIGO) criteria.

Figure 3 Comparison of pre- and postoperative ultrasound findings. TAPSE, tricuspid annular systolic plane excursion; MAPSE, mitral annular plane systolic excursion; IVC, inferior vena cava.

Discussion

GDHT is increasingly utilized as a part of an ERAS pathway for colorectal surgical patients. The majority of literature on GDHT, particularly in abdominal surgery, has shown treatment of hypotension with fluid boluses or inotropic support may improve postoperative outcomes (30,31). On the other hand, recent studies show excess fluid may cause additional harm. Some GDHT protocols have raised concerns regarding “SV optimization” causing hypervolemia and prolonged length of stay in aerobically-fit patients (32-36). Therefore, it is important to be able to reliably provide adequate but not excessive resuscitation intraoperatively. While our GDHT protocol uses a “target SV” it does not aim to maximize SV. Using POCUS to obtain VExUS scores, we were able to show our GDHT protocol did not cause venous congestion in colorectal patients. There was no change in VExUS score for any of the 19 patients and no significant changes in any of the individual scoring components including IVC diameter and collapsibility, hepatic venous Doppler flow pattern, and portal vein pulsatility. There was also no significant change in biventricular function.

Notable limitations to our study include data collection at a single center, small sample size, and lack of randomization. As an observational study, we could only generate hypotheses to conduct further studies but cannot implement changes in care based on these findings alone. We cannot say our GDHT protocol provided an adequate or the ideal amount of fluid resuscitation, we can only say it did not lead to over-resuscitation to the point of venous congestion.

Conclusions

Our study investigated the impact of a GDHT protocol on elective colorectal surgery patients, focusing on SV optimization using PLR and assessed outcomes through POCUS with the VExUS grading system. Results suggest that patients treated with this GDHT protocol do not show signs of venous congestion. The study emphasizes the nuanced approach of maintaining recruitable SV rather than maximizing SV and highlights the potential benefits of incorporating ultrasound techniques for fluid management. However, limitations such as a single-center setting and small sample size necessitate further randomized studies to validate these findings.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://ls.amegroups.com/article/view/10.21037/ls-24-12/rc

Data Sharing Statement: Available at https://ls.amegroups.com/article/view/10.21037/ls-24-12/dss

Peer Review File: Available at https://ls.amegroups.com/article/view/10.21037/ls-24-12/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-24-12/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any parts of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Virginia Commonwealth University Health System’s Institutional Review Board (IRB) approved the study protocol (French + Shah; IRB #HM20019227, The Effect of Enhanced Recovery After Surgery Pathways on Postoperative Patient Outcomes) and informed patient consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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