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Heart, Lung and Circulation

Haemodynamic Monitoring Needs for Goal-Directed Fluid Therapy in Lung Resection

Published:October 12, 2021DOI:https://doi.org/10.1016/j.hlc.2021.08.024
      The implementation of Enhanced Recovery After Surgery (ERAS) pathways is thought to facilitate recovery by diminishing disruption of homeostasis associated with surgery and streamlining perioperative care. The European Society of Thoracic Surgeons has recently put forth guidelines for enhanced recovery after lung surgery in light of emerging evidence of their benefits, such as reductions in pulmonary and cardiac events, fluid overload, length of stay (LOS), opiate use, and hospital costs [
      • Batchelor T.J.P.
      • Rasburn N.J.
      • Abdelnour-Berchtold E.
      • Brunelli A.
      • Cerfolio R.J.
      • Gonzalez M.
      • et al.
      Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons (ESTS).
      ]. Strategies for perioperative fluid management have evolved as appreciation for the deleterious effects of liberal fluid resuscitation has been followed by recognition of complications associated with restrictive fluid regimens [
      • Arslantas M.K.
      • Kara H.V.
      • Tuncer B.B.
      • Yildizeli B.
      • Yuksel M.
      • Bostanci K.
      • et al.
      Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections.
      ,
      • Kim J.A.
      • Ahn H.J.
      • Oh A.R.
      • Choi J.
      Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study.
      ,
      • Licker M.
      • de Perrot M.
      • Spiliopoulos A.
      • Robert J.
      • Diaper J.
      • Chevalley C.
      • et al.
      Risk factors for acute lung injury after thoracic surgery for lung cancer.
      ,
      • Myles P.S.
      • Bellomo R.
      Restrictive or liberal fluid therapy for major abdominal surgery.
      ]. Optimal fluid management for pulmonary resections remains elusive in patient populations at risk for interstitial and alveolar oedema due to multifactorial lung injury from existing pulmonary disease, previous chemoradiotherapy, intraoperative lung manipulation, one-lung ventilation (OLV), and ischaemia-reperfusion injury [
      • Batchelor T.J.P.
      • Rasburn N.J.
      • Abdelnour-Berchtold E.
      • Brunelli A.
      • Cerfolio R.J.
      • Gonzalez M.
      • et al.
      Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons (ESTS).
      ]. When such factors are compounded by fluid overload, there is an increased risk of acute respiratory distress syndrome, atelectasis, pneumonia, empyema and death, though the role of intraoperative versus postoperative fluid administration remains incompletely understood [
      • Arslantas M.K.
      • Kara H.V.
      • Tuncer B.B.
      • Yildizeli B.
      • Yuksel M.
      • Bostanci K.
      • et al.
      Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections.
      ,
      • Licker M.
      • de Perrot M.
      • Spiliopoulos A.
      • Robert J.
      • Diaper J.
      • Chevalley C.
      • et al.
      Risk factors for acute lung injury after thoracic surgery for lung cancer.
      ,
      • Zeldin R.A.
      • Normandin D.
      • Landtwing D.
      • Peters R.M.
      Postpneumonectomy pulmonary edema.
      ,
      • Yang R.
      • Du C.
      • Xu J.
      • Yao L.
      • Zhang S.
      • Wu Y.
      Excessive intravenous crystalloid infusion after video-assisted thoracoscopic surgery lobectomy is associated with postoperative pneumonia.
      ]. The degree of lung injury, which appears to correlate with the extent of lung resection, is highest after pneumonectomy or extensive resection, followed by lobectomy irrespective of tumour laterality; even patients who undergo sublobar wedge resections or segmentectomies have a 4% rate of lung injury [
      • Alam N.
      • Park B.J.
      • Wilton A.
      • Seshan V.E.
      • Bains M.S.
      • Downey R.J.
      • et al.
      Incidence and risk factors for lung injury after lung cancer resection.
      ,
      • Kutlu C.A.
      • Williams E.A.
      • Evans T.W.
      • Pastorino U.
      • Goldstraw P.
      Acute lung injury and acute respiratory distress syndrome after pulmonary resection.
      ,
      • Ruffini E.
      • Parola A.
      • Papalia E.
      • Filosso P.L.
      • Mancuso M.
      • Oliaro A.
      • et al.
      Frequency and mortality of acute lung injury and acute respiratory distress syndrome after pulmonary resection for bronchogenic carcinoma.
      ]. Moderate intraoperative infusion rates during minimally invasive lung resections are associated with significantly lower incidences of postoperative pneumonia (24.1% vs 39–49%) and overall pulmonary complications (25.9% vs 44–51%) relative to more restrictive and liberal infusion rates, which is consistent with open thoracotomies [
      • Kim J.A.
      • Ahn H.J.
      • Oh A.R.
      • Choi J.
      Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study.
      ,
      • Wu Y.
      • Yang R.
      • Xu J.
      • Rusidanmu A.
      • Zhang X.
      • Hu J.
      Effects of intraoperative fluid management on postoperative outcomes after lobectomy.
      ]. While the importance of a judicious fluid regimen is apparent, the merits of the traditional restrictive fluid strategy are debatable in light of concerns for impaired tissue perfusion, organ dysfunction, and acute kidney injury (AKI) secondary to hypovolaemia [
      • Kim J.A.
      • Ahn H.J.
      • Oh A.R.
      • Choi J.
      Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study.
      ,
      • Myles P.S.
      • Bellomo R.
      Restrictive or liberal fluid therapy for major abdominal surgery.
      ,
      • Ahn H.J.
      • Kim J.A.
      • Lee A.R.
      • Yang M.
      • Jung H.J.
      • Heo B.
      The risk of acute kidney injury from fluid restriction and hydroxyethyl starch in thoracic surgery.
      ,
      • Egal M.
      • de Geus H.R.
      • van Bommel J.
      • Groeneveld A.B.
      Targeting oliguria reversal in perioperative restrictive fluid management does not influence the occurrence of renal dysfunction: A systematic review and meta-analysis.
      ,
      • Matot I.
      • Dery E.
      • Bulgov Y.
      • Cohen B.
      • Paz J.
      • Nesher N.
      Fluid management during video-assisted thoracoscopic surgery for lung resection: a randomized, controlled trial of effects on urinary output and postoperative renal function.
      ]. Increased awareness of the adverse sequelae of too little or too much fluid has prompted the search for monitoring devices to guide patient-specific, goal-directed fluid therapy (GDFT) that can help curtail organ-specific morbidity associated with pulmonary resections. We reflect on the clinical utility of select devices and suggest that ultrasound-based technologies, such as oesophageal Doppler and lung ultrasound, show promise as tools to facilitate euvolaemia with dry lungs during lung resection. The capabilities of minimally invasive monitors that utilise pulse wave analysis and transpulmonary thermodilution could also be harnessed during OLV once the threshold values for their application are better understood. In light of limited available evidence to date for the application of haemodynamic monitors in lung resection surgery, we propose the concurrent use of tissue perfusion biomarkers to promote fluid optimisation and oxygen delivery.

      Keywords

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      References

        • Batchelor T.J.P.
        • Rasburn N.J.
        • Abdelnour-Berchtold E.
        • Brunelli A.
        • Cerfolio R.J.
        • Gonzalez M.
        • et al.
        Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS(R)) Society and the European Society of Thoracic Surgeons (ESTS).
        Eur J Cardiothorac Surg. 2019; 55: 91-115
        • Arslantas M.K.
        • Kara H.V.
        • Tuncer B.B.
        • Yildizeli B.
        • Yuksel M.
        • Bostanci K.
        • et al.
        Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections.
        J Thorac Cardiovasc Surg. 2015; 149 (21 e1): 314-320
        • Kim J.A.
        • Ahn H.J.
        • Oh A.R.
        • Choi J.
        Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study.
        Sci Rep. 2020; 10: 8449
        • Licker M.
        • de Perrot M.
        • Spiliopoulos A.
        • Robert J.
        • Diaper J.
        • Chevalley C.
        • et al.
        Risk factors for acute lung injury after thoracic surgery for lung cancer.
        Anesth Analg. 2003; 97: 1558-1565
        • Myles P.S.
        • Bellomo R.
        Restrictive or liberal fluid therapy for major abdominal surgery.
        N Engl J Med. 2018; 379: 1283
        • Zeldin R.A.
        • Normandin D.
        • Landtwing D.
        • Peters R.M.
        Postpneumonectomy pulmonary edema.
        J Thorac Cardiovasc Surg. 1984; 87: 359-365
        • Yang R.
        • Du C.
        • Xu J.
        • Yao L.
        • Zhang S.
        • Wu Y.
        Excessive intravenous crystalloid infusion after video-assisted thoracoscopic surgery lobectomy is associated with postoperative pneumonia.
        J Cardiothorac Surg. 2019; 14: 209
        • Alam N.
        • Park B.J.
        • Wilton A.
        • Seshan V.E.
        • Bains M.S.
        • Downey R.J.
        • et al.
        Incidence and risk factors for lung injury after lung cancer resection.
        Ann Thorac Surg. 2007; 84 (discussion 91): 1085-1091
        • Kutlu C.A.
        • Williams E.A.
        • Evans T.W.
        • Pastorino U.
        • Goldstraw P.
        Acute lung injury and acute respiratory distress syndrome after pulmonary resection.
        Ann Thorac Surg. 2000; 69: 376-380
        • Ruffini E.
        • Parola A.
        • Papalia E.
        • Filosso P.L.
        • Mancuso M.
        • Oliaro A.
        • et al.
        Frequency and mortality of acute lung injury and acute respiratory distress syndrome after pulmonary resection for bronchogenic carcinoma.
        Eur J Cardiothorac Surg. 2001; 20 (discussion 6-7): 30-36
        • Wu Y.
        • Yang R.
        • Xu J.
        • Rusidanmu A.
        • Zhang X.
        • Hu J.
        Effects of intraoperative fluid management on postoperative outcomes after lobectomy.
        Ann Thorac Surg. 2019; 107: 1663-1669
        • Ahn H.J.
        • Kim J.A.
        • Lee A.R.
        • Yang M.
        • Jung H.J.
        • Heo B.
        The risk of acute kidney injury from fluid restriction and hydroxyethyl starch in thoracic surgery.
        Anesth Analg. 2016; 122: 186-193
        • Egal M.
        • de Geus H.R.
        • van Bommel J.
        • Groeneveld A.B.
        Targeting oliguria reversal in perioperative restrictive fluid management does not influence the occurrence of renal dysfunction: A systematic review and meta-analysis.
        Eur J Anaesthesiol. 2016; 33: 425-435
        • Matot I.
        • Dery E.
        • Bulgov Y.
        • Cohen B.
        • Paz J.
        • Nesher N.
        Fluid management during video-assisted thoracoscopic surgery for lung resection: a randomized, controlled trial of effects on urinary output and postoperative renal function.
        J Thorac Cardiovasc Surg. 2013; 146: 461-466
        • Rozental O.
        • Thalappillil R.
        • White R.S.
        • Tam C.W.
        To swan or not to swan: indications, alternatives, and future directions.
        J Cardiothorac Vasc Anesth. 2021; 35: 600-615
        • Deng Q.W.
        • Tan W.C.
        • Zhao B.C.
        • Wen S.H.
        • Shen J.T.
        • Xu M.
        Is goal-directed fluid therapy based on dynamic variables alone sufficient to improve clinical outcomes among patients undergoing surgery? A meta-analysis.
        Crit Care. 2018; 22: 298
        • Hamilton M.A.
        • Cecconi M.
        • Rhodes A.
        A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients.
        Anesth Analg. 2011; 112: 1392-1402
        • Xu H.
        • Shu S.H.
        • Wang D.
        • Chai X.Q.
        • Xie Y.H.
        • Zhou W.D.
        Goal-directed fluid restriction using stroke volume variation and cardiac index during one-lung ventilation: a randomized controlled trial.
        J Thorac Dis. 2017; 9: 2992-3004
        • Zhang J.
        • Chen C.Q.
        • Lei X.Z.
        • Feng Z.Y.
        • Zhu S.M.
        Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study.
        Clinics (Sao Paulo). 2013; 68: 1065-1070
        • Jeong D.M.
        • Ahn H.J.
        • Park H.W.
        • Yang M.
        • Kim J.A.
        • Park J.
        Stroke volume variation and pulse pressure variation are not useful for predicting fluid responsiveness in thoracic surgery.
        Anesth Analg. 2017; 125: 1158-1165
        • Suehiro K.
        • Okutani R.
        Stroke volume variation as a predictor of fluid responsiveness in patients undergoing one-lung ventilation.
        J Cardiothorac Vasc Anesth. 2010; 24: 772-775
        • Haas S.
        • Eichhorn V.
        • Hasbach T.
        • Trepte C.
        • Kutup A.
        • Goetz A.E.
        • et al.
        Goal-directed fluid therapy using stroke volume variation does not result in pulmonary fluid overload in thoracic surgery requiring one-lung ventilation.
        Crit Care Res Pract. 2012; 2012: 687018
        • De Backer D.
        • Bakker J.
        • Cecconi M.
        • Hajjar L.
        • Liu D.W.
        • Lobo S.
        • et al.
        Alternatives to the Swan-Ganz catheter.
        Intensive Care Med. 2018; 44: 730-741
        • Phillips C.R.
        • Chesnutt M.S.
        • Smith S.M.
        Extravascular lung water in sepsis-associated acute respiratory distress syndrome: indexing with predicted body weight improves correlation with severity of illness and survival.
        Crit Care Med. 2008; 36: 69-73
        • Yuanbo Z.
        • Jin W.
        • Fei S.
        • Liangong L.
        • Xunfa L.
        • Shihai X.
        • et al.
        ICU management based on PiCCO parameters reduces duration of mechanical ventilation and ICU length of stay in patients with severe thoracic trauma and acute respiratory distress syndrome.
        Ann Intensive Care. 2016; 6: 113
        • Chung F.T.
        • Lin S.M.
        • Lin S.Y.
        • Lin H.C.
        Impact of extravascular lung water index on outcomes of severe sepsis patients in a medical intensive care unit.
        Respir Med. 2008; 102: 956-961
        • Korom S.
        • Hillinger S.
        • Cardell M.
        • Zhai W.
        • Tan Q.
        • Dutly A.
        • et al.
        Sildenafil extends survival and graft function in a large animal lung transplantation model.
        Eur J Cardiothorac Surg. 2006; 29: 288-293
        • Licker M.
        • Tschopp J.M.
        • Robert J.
        • Frey J.G.
        • Diaper J.
        • Ellenberger C.
        Aerosolized salbutamol accelerates the resolution of pulmonary edema after lung resection.
        Chest. 2008; 133: 845-852
        • Perrin G.
        • Roch A.
        • Michelet P.
        • Reynaud-Gaubert M.
        • Thomas P.
        • Doddoli C.
        • et al.
        Inhaled nitric oxide does not prevent pulmonary edema after lung transplantation measured by lung water content: a randomized clinical study.
        Chest. 2006; 129: 1024-1030
        • Assaad S.
        • Popescu W.M.
        FOCUS in Thoracic Surgery: Does feasibility mean functionality?.
        J Cardiothorac Vasc Anesth. 2018; 32: 853-854
        • Assaad S.
        • Kyriakides T.
        • Tellides G.
        • Kim A.W.
        • Perkal M.
        • Perrino A.
        Extravascular lung water and tissue perfusion biomarkers after lung resection surgery under a normovolemic fluid protocol.
        J Cardiothorac Vasc Anesth. 2015; 29: 977-983
        • Haas S.A.
        • Trepte C.J.
        • Nitzschke R.
        • Jurgens T.P.
        • Goepfert M.S.
        • Goetz A.E.
        • et al.
        An assessment of global end-diastolic volume and extravascular lung water index during one-lung ventilation: is transpulmonary thermodilution usable?.
        Anesth Analg. 2013; 117: 83-90
        • Naidu B.V.
        • Dronavalli V.B.
        • Rajesh P.B.
        Measuring lung water following major lung resection.
        Interact Cardiovasc Thorac Surg. 2009; 8: 503-506
        • Assaad S.
        • Kratzert W.B.
        • Perrino Jr., A.C.
        Extravascular lung water monitoring for thoracic and lung transplant surgeries.
        Curr Opin Anaesthesiol. 2019; 32: 29-38
        • Bjerregaard L.S.
        • Moller-Sorensen H.
        • Hansen K.L.
        • Ravn J.
        • Nilsson J.C.
        Using clinical parameters to guide fluid therapy in high-risk thoracic surgery. A retrospective, observational study.
        BMC Anesthesiol. 2015; 15: 91
        • Volpicelli G.
        • Skurzak S.
        • Boero E.
        • Carpinteri G.
        • Tengattini M.
        • Stefanone V.
        • et al.
        Lung ultrasound predicts well extravascular lung water but is of limited usefulness in the prediction of wedge pressure.
        Anesthesiology. 2014; 121: 320-327
        • Cagini L.
        • Andolfi M.
        • Becattini C.
        • Ranalli M.G.
        • Bartolucci F.
        • Mancuso A.
        • et al.
        Bedside sonography assessment of extravascular lung water increase after major pulmonary resection in non-small cell lung cancer patients.
        J Thorac Dis. 2018; 10: 4077-4084
        • Kaufmann K.B.
        • Stein L.
        • Bogatyreva L.
        • Ulbrich F.
        • Kaifi J.T.
        • Hauschke D.
        • et al.
        Oesophageal Doppler guided goal-directed haemodynamic therapy in thoracic surgery - a single centre randomized parallel-arm trial.
        Br J Anaesth. 2017; 118: 852-861
        • Marik P.E.
        Noninvasive cardiac output monitors: a state-of the-art review.
        J Cardiothorac Vasc Anesth. 2013; 27: 121-134
        • Porter T.R.
        • Shillcutt S.K.
        • Adams M.S.
        • Desjardins G.
        • Glas K.E.
        • Olson J.J.
        • et al.
        Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography.
        J Am Soc Echocardiogr. 2015; 28: 40-56
        • Kim K.K.
        • Krause M.
        • Brandes I.F.
        • Khanna A.K.
        • Bartels K.
        Transesophageal echocardiography for perioperative management in thoracic surgery.
        Curr Opin Anaesthesiol. 2021; 34: 7-12
        • Kratz T.
        • Holz S.
        • Steinfeldt T.
        • Exner M.
        • Campo dell'Orto M.
        • Kratz C.
        • et al.
        Feasibility and impact of focused intraoperative transthoracic echocardiography on management in thoracic surgery patients: an observational study.
        J Cardiothorac Vasc Anesth. 2018; 32: 848-852
        • Hahn R.T.
        • Abraham T.
        • Adams M.S.
        • Bruce C.J.
        • Glas K.E.
        • Lang R.M.
        • et al.
        Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.
        J Am Soc Echocardiogr. 2013; 26: 921-964
        • Harky A.
        • Clarke C.G.
        • Kar A.
        • Bashir M.
        Epidural analgesia versus paravertebral block in video-assisted thoracoscopic surgery.
        Interact Cardiovasc Thorac Surg. 2019; 28: 404-406
        • Kashiwagi Y.
        • Iida T.
        • Kunisawa T.
        • Iwasaki H.
        [Efficacy of Ultrasound-guided Thoracic Paravertebral Block Compared with the Epidural Analgesia in Patients Undergoing Video-assisted Thoracoscopic Surgery].
        Masui. 2015; 64: 1010-1014
        • Kapoor P.M.
        • Magoon R.
        • Rawat R.
        • Mehta Y.
        Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: "A clinical outcome and biomarker-based study".
        Ann Card Anaesth. 2016; 19: 638-682