ENT Surgery Clinical Trial
Official title:
Einfluss Der Intermittierenden Pneumatischen Kompression Der Unteren Extremitäten Auf Den Intraoperativen Flüssigkeitsbedarf
Fluid restriction has become of great interest in perioperative care. There is, however, a conflict of interest between fluid restriction and hemodynamic stability. The investigators hypothesized that intermittent pneumatic compression may recruit blood from venous capacity vessels of the lower limbs and thus enable fluid restriction without compromising hemodynamic stability.
Induction of general anesthesia has a variety of effects on the cardiovascular system, all
resulting in impaired hemodynamics. Besides reduced sympathetic tone (Sellgren et al.;Ebert,
Kanitz, and Kampine) and direct negative inotropic effect of anesthetic agents(Gare et al.),
reduction of cardiac preload (Dahlgren et al.;von Spiegel et al.) plays a major role.
Therefore administration of large amounts of i.v. fluid is a common method to counter
adverse hemodynamic effects. In addition, substitution for fluid loss during preoperative
fasting has been recommended for decades. However, preoperative fasting may lead to less
fluid loss than assumed so far(Jacob et al.), and there is increasing evidence that i.v.
fluid has many adverse effects. Perioperative weight gain due to fluid overload is an
independent predictor of mortality (Lowell et al.). Besides a detrimental effect on
gastrointestinal (Nisanevich et al.;Gan et al.;Noblett et al.;Wakeling et al.;Lobo et al.),
i.v. fluid may harm the endothelial barrier (Bruegger et al.), possibly leading to a vicious
circle of impaired barrier function and increased demand for i.v. fluids (Chappell et al.).
In order to restore cardiac preload, timing, volume, and composition of the fluid are
important. Free water (e.g. glucose 5%) or "physiologic saline" have very high volumes of
distribution, while colloid application is associated with various adverse effects (Schramko
et al.;Dart et al.). This has led to increased interest in intraoperative volume restriction
(de Aguilar-Nascimento et al.;McArdle et al.;Muller et al.;Walsh et al.). The ideal i.v.
fluid remains to be found, yet it exists already if autotransfusion is considered as fluid
therapy. The recruitable amount of blood that is contained in capacity vessels of the legs
has not been precisely determined, but estimates range from 100 to 300 ml in each leg
(citations). The easiest way to recover the blood that is sequestered from systemic
circulation is passive leg raising or Trendelenburg positioning, two methods that have
entered intensive care routine to assess volume responsiveness. However in many clinical
situations passive leg raising or Trendelenburg position is not feasible, e.g. ear, nose,
and throat (ENT) or neurosurgical procedures. Intermittent pneumatic compression (IPC) is an
established therapeutic intervention for several indications such as lymphedema, post
thrombotic ulcers and arterial claudication (Wienert et al.)and has been recommended for
intraoperative prevention of thrombembolism. (Geerts et al.). When used during laparoscopy
it can effectively reduce hemodynamic adverse effects of pneumoperitoneum (Alishahi et
al.;Bickel et al.;Bickel et al.;Bickel et al.;Kurukahvecioglu et al.). So far its use in a
general surgical population to promote volume restriction has not been assessed. We compared
fluid demand in patients undergoing minor ENT surgery with or without IPC under a
standardized, goal-directed fluid management protocol.
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Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Investigator), Primary Purpose: Treatment
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