Intraoperative hemodynamic management during pancreatoduodenectomy - an analysis of 525 patients.

IF 2.1 3区 医学 Q2 SURGERY
Maximilian Dietrich, Tobias Hölle, Mattia Piredda, Manuel Feißt, Patrick Rehn, Maik von der Forst, Dania Fischer, Thilo Hackert, Jan Larmann, Christoph W Michalski, Markus A Weigand, Martin Loos, Felix C F Schmitt
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Abstract

Importance: Optimization of perioperative hemodynamic management during major pancreatic surgery can reduce postoperative complications.

Objective: In this study, we aimed to investigate the effect of intraoperative hemodynamic management, in consideration of both anesthesiologic and surgery-related aspects on major short-term complications following partial pancreatoduodenectomy (PD).

Design, setting and participants: Data of 525 patients undergoing PD between January 2017 and December 2018 at the Heidelberg University Hospital were retrospectively analyzed.

Main outcomes and measures: Primary outcome was a composite of 90-day mortality, pancreatic fistula and completion pancreatectomy. Logistic regression was performed to estimate the impact of anesthesiologic and surgical factors. Furthermore, patients were stratified by the amount of fluid administered intraoperatively and the maximum catecholamine dose to examine the impact on the primary endpoint.

Results: Using logistic regression analysis we demonstrated that epidural anesthesia was associated with a reduction in the occurrence of the combined endpoint (OR 0.568; CI 0.331-0.973), this effect was primarily driven by a lower rate of completion pancreatectomy. The intraoperative administration of fresh frozen plasma (FFP) doubled the odds of the occurrence of the primary endpoint (OR 2.238; CI 1.290-3.882). The comparison of patients with and without FFP transfusion showed that all components of the primary endpoint were more frequent in the FFP group. Complication rates in the stratified fluid groups showed a U-shaped curve with the least amount of complications in patients who received 6.5 to 8 ml/kg/h of intraoperative fluid. The comparison of maximum norepinephrine doses revealed the same pattern with the least complication rate in the low-intermediate dose range (0.05-0.08 µg/kg/min and 0.08-0.11 µg/kg/min).

Conclusions and relevance: Epidural anesthesia had a beneficial effect on the rate of major surgical complications following PD, whereas intraoperative FFP transfusion showed a negative association. Intraoperative hemodynamic management appears to have a major impact on perioperative mortality and morbidity with a U-shaped relation for both fluid and vasopressor dose.

胰十二指肠切除术中的术中血流动力学管理--对 525 例患者的分析。
重要性:优化胰腺大手术围术期血流动力学管理可减少术后并发症。目的:在本研究中,我们旨在探讨术中血流动力学管理在麻醉和手术相关方面对胰十二指肠部分切除术(PD)后主要短期并发症的影响。设计、环境和参与者:回顾性分析2017年1月至2018年12月在海德堡大学医院接受PD治疗的525例患者的数据。主要结局和措施:主要结局是90天死亡率、胰瘘和完全胰切除术的综合结果。采用Logistic回归估计麻醉和手术因素的影响。此外,根据术中给药的液体量和最大儿茶酚胺剂量对患者进行分层,以检查对主要终点的影响。结果:通过logistic回归分析,我们证明硬膜外麻醉与联合终点发生率的降低相关(OR 0.568;CI 0.331-0.973),这种影响主要是由较低的胰腺切除术完成率驱动的。术中给予新鲜冷冻血浆(FFP)使主要终点发生的几率增加了一倍(OR 2.238;可信区间1.290 - -3.882)。输注FFP和未输注FFP患者的比较显示,FFP组主要终点的所有组成部分都更频繁。分层输液组的并发症发生率呈u型曲线,术中输液6.5 ~ 8ml /kg/h的患者并发症最少。低-中剂量范围(0.05 ~ 0.08µg/kg/min和0.08 ~ 0.11µg/kg/min)的最大去甲肾上腺素剂量比较,并发症发生率最低。结论及意义:硬膜外麻醉对PD术后主要手术并发症的发生率有有利影响,而术中输注FFP则呈负相关。术中血流动力学管理似乎对围手术期死亡率和发病率有重要影响,与液体和血管加压剂剂量呈u型关系。
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来源期刊
CiteScore
3.30
自引率
8.70%
发文量
342
审稿时长
4-8 weeks
期刊介绍: Langenbeck''s Archives of Surgery aims to publish the best results in the field of clinical surgery and basic surgical research. The main focus is on providing the highest level of clinical research and clinically relevant basic research. The journal, published exclusively in English, will provide an international discussion forum for the controlled results of clinical surgery. The majority of published contributions will be original articles reporting on clinical data from general and visceral surgery, while endocrine surgery will also be covered. Papers on basic surgical principles from the fields of traumatology, vascular and thoracic surgery are also welcome. Evidence-based medicine is an important criterion for the acceptance of papers.
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