Current opinion in critical care
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Curr Opin Crit Care · Aug 2013
ReviewReducing perioperative cardiac morbidity and mortality: is this the right goal?
One million people die annually following noncardiac surgery and 4% of patients suffer an adverse cardiac event after surgery. As the number of people having surgery grows, our ability to risk stratify patients becomes more important, particularly in the setting of perioperative myocardial ischemia/necrosis. ⋯ The presence of troponin elevations following noncardiac surgery, particularly in at-risk patients, may enable practitioners to better identify high-risk patients in the postoperative setting. After recognizing those patients at increased risk for poor outcomes, practitioners can then make interventions, which may decrease the patients' in-hospital, 30-day and potentially long-term mortality.
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The review is focused on the challenge of managing airway and ventilation in the intraoperative and postoperative period. ⋯ The combination of planning extubation of predicted and unpredicted difficult airway, both intraoperative low tidal volume and low FiO2 with LRM and PEEP at different points of surgery and postoperative noninvasive ventilation should be considered in patients undergoing surgery to decrease the rate of postoperative pulmonary complications and major fatal complications such as brain damage and death.
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We discuss the formulation of a prescription for intravenous (i.v.) fluid therapy (a 'volume prescription') for critically ill patients: pros/cons of different fluid types; accurate dosing; and qualitative and quantitative toxicities. Updated physiologic concepts are invoked and results of recent major clinical trials on i.v. fluid therapy in the acutely ill are interpreted. ⋯ Similar to any drug used in acutely ill patients, clinicians ordering a volume prescription must recognize that context is crucial. Physiologically balanced crystalloids may be the 'default' fluid for acutely ill patients, and the role for colloids is unclear. Optimal dosing involves assessment of volume responsiveness.
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Using perioperative goal-directed therapy (GDT) or peroperative hemodynamic optimization significantly reduces postoperative complications and risk of death in patients undergoing noncardiac major surgeries. In this review, we discuss the main changes in the field of perioperative optimization over the last few years. ⋯ GDT is safe and more likely to tailor the amount of fluids given to the amount of fluids actually needed. This approach includes assessment of fluid responsiveness and, if necessary, the use of inotropes; moreover, this approach can be coupled with a restrictive strategy for maintenance fluids. These strategies have been increasingly incorporated into protocols for perioperative hemodynamic optimization in high-risk patients undergoing major surgery, resulting in more appropriate use of fluids, vasopressors, and inotropes.
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There is significant controversy for perioperative fluid management. This review discusses the evidence from clinical studies, basic research, and systematic reviews to provide a summary of the current best practice in this area. ⋯ Although potentially life-saving, evidence points to significant hazards associated with various types and use-strategies for intravenous fluids. Like other drugs, intravenous fluids should be used with caution for specific indications, in specific amounts, and with careful attention to potential adverse effects associated with various products. An individualized approach to perioperative fluid therapy is recommended.