Figure - uploaded by Laurence Weinberg
Content may be subject to copyright.
Source publication
Background
Routine fluid prescription is common practice amongst anesthesiologists caring for patients undergoing colonoscopy. However there is limited information about routine procedural fluid prescription practices of anesthesiologists in this setting. Routine fluid administration may also have important pharmaco-economic implications for the he...
Context in source publication
Context 1
... dian patient age was 48 years (range 18-83 years); 174 (60%) were female. One-hundred and eighty one patients (63%) received a cannula size 22 gauge (internal diam- eter 0.41 mm) or smaller; and 108 patients (37%) re- ceived a 20 gauge cannula (internal diameter 0.60 mm) or larger (Figure 1). All patients had their IV cannulae inserted in the procedure room before the colonoscopy procedure commenced. ...Citations
... Gastrointestinal endoscopy is a commonly performed procedure with over a million cases performed annually in Australia. 1 The combined effect of fasting and bowel preparation has the potential to contribute to patients being intravascularly volume depleted, with weight loss, postural hypotension and elevations in serum creatinine. 2 Anaesthesiologists administer fluid in 64% of these cases with large variability in the volume given, despite there being no high quality data to support or refute this practice. 3,4 Neither high (20 ml/kg) nor low (2 ml/kg) volume crystalloid infusion reliably reduced the incidence of hypotension, which occurred in almost 60% of patients. 1 Similarly, high or low volume crystalloid administration does not clearly reduce more subjective symptoms such as nausea, vomiting, headache and light-headedness. ...
Intravenous fluids are commonly administered for patients having colonoscopy despite relatively little data to support this practice. It is unclear what, if any, effect crystalloid administration has on stroke volume and cardiac output in patients who are fasting and have had bowel preparation agents. We aimed to assess the physiological effect of 10 ml/kg of crystalloid administration in colonoscopy patients on haemodynamic parameters including stroke volume, stroke volume variation and cardiac output, as measured with transthoracic echocardiography. Our secondary aims were to determine whether stroke volume variation predicted fluid responsiveness in gastrointestinal endoscopy patients and whether these haemodynamic measures are different in fasting patients with bowel preparation (colonoscopy patients) compared to fasting patients alone (gastroscopy patients). We recruited 54 patients having elective gastrointestinal endoscopy (25 colonoscopy, 29 gastroscopy). All patients had stroke volume, cardiac output and stroke volume variation measured with transthoracic echocardiography at baseline. In colonoscopy patients, stroke volume, cardiac output and stroke volume variation were remeasured after 10 ml/kg of intravenous crystalloid. Administration of 10 ml/kg of crystalloid increases stroke volume by 19.6 ml (p < 0.00005) and cardiac output by 0.81 l/min (p < 0.001). Stroke volume variation reduced from 23% to 14% after fluid administration (p < 0.0011). The optimum threshold of stroke volume variation to predict fluid responsiveness was 21% with a sensitivity of 77.8% and specificity of 62.5%. Administration of 10 ml/kg of crystalloid increases stroke volume and cardiac output, and reduces stroke volume variation in fasting elective colonoscopy patients.
... [1,13,[22][23][24] Where does evidence stand? It has been noted that routine fluid prescription among anesthesiologists varies largely according to the individual habit [25,26] as well as other independent factors such as differences in surgical types, trauma, preoperative hydration, anesthetic technique, comorbidity, gender, and age. Currently, there is no a clear consensus on the definition of liberal versus restrictive fluid therapy (i.e., how less is too less?). ...
Currently, there is no consensus about the optimum intraoperative fluid therapy strategy. There is growing body of evidence supports the beneficial effects of adopting “Goal-directed therapy” over either the “liberal” or “restrictive” fluid therapy strategies. In this narrative review, we have presented the evidence to support the optimum strategy for intraoperative therapy. In conclusion, whatever the intravenous fluid replacement strategy used, the anesthesiologist must be prepared to adjust the composition and rate of the fluids administered to provide sufficient intravascular fluid volume for adequate perfusion of vital organs without overwhelming the glycocalyx function with fluid overloads.
... Vasopressor drug used and postoperative complications such as postoperative hypotension, nausea, vomiting, dizziness were similar in both groups. These results were consistent with the finding of previous studies, comparing 2 ml/kg and 20 ml/kg of Plasmalyte ® preloading (6,7) . Another study which compared 1.5 ml/ kg and 15 ml/kg of Hartmann's solution infused before elective colonoscopy showed that incidence of hypotension during sedation were not different between groups (5) . ...
Objective: Colonoscopy is a common procedure for diagnostic, therapeutic or surveillance purposes. Pre-procedural fasting and bowel preparation to facilitate the procedure may result in dehydration, which could lead to hypotension during colonoscopy under sedation. The goal of this study is to test the hypothesis that pre-procedural intravenous lactated Ringer's solution (LRS) preloading decreases the incidence of intra-procedural hypotension during sedation for elective colonoscopy. Material and Method: Sixty ASA 1 to 2 Patients, aged 18 to 60 years presenting for elective colonoscopy were randomized into 2 groups, control (C group) or preloading group (L group). Before procedure, C group received intravenous LRS of 1 hour maintenance while L group received intravenous LRS 200 ml preloading in 15 minutes prior to colonoscopy. Sedation was achieved by intravenous fentanyl 25 mcg and propofol infusion using target-control infusor (TCI) with preset target of propofol blood level 3.5 to 6 mcg/ml. Primary outcome was the incidence of hypotension, defined as >25% decrease in systolic blood pressure from baseline during sedation. Secondary outcome were vasopressor use and post-procedural complications (nausea, vomiting and dizziness). Results: Fifty-three patients, 28 in C group and 25 in L group, completed the study. The incidence of hypotension were 39.3% in C group and 40.0% in L group (p = 0.958). Vasopressor use and post-procedural complications were either not significantly different between groups. Conclusion: Pre-procedural intravenous LRS 200 ml preloading cannot prevent hypotension during sedation for elective colonoscopy in ASA 1 to 2 patients.
... 2 In an attempt to ameliorate these symptoms and signs, many anesthesiologists commonly administer prophylactic intravenous fluids during sedation for colonoscopy. 3,4 Nevertheless, this practice is not supported by the currently available evidence 1,5 and may increase the cost of care. ...
... 1 Patients in our two studies were similar in terms of baseline characteristics, bowel preparation, and fasting, but the patients in our current study had longer procedures, received more propofol per minute, and had a higher incidence of hypotension than patients in our previous study. Our results are also consistent with Weinberg et al.'s observational study, 5 although the median volume of fluid infused in that study was only 325 (range 0-1,000) mL. There are a number of potential explanations for our results. ...
Purpose
The purpose of this study was to compare the incidence of hypotension during sedation in adults presenting for elective colonoscopy and randomized to intravenous Plasma-Lyte 148® at either 2 mL·kg−1 (low volume) or 20 mL·kg−1 (high volume).
Methods
Patients aged ≥ 18 yr presenting for elective colonoscopy, with or without gastroscopy, after oral bowel preparation were randomized to receive the intervention immediately before the start of the procedure. Hypotension was defined as a ≥ 25% decrease in systolic blood pressure (SBP) from baseline during the procedure. Secondary outcomes included SBP < 90 mmHg, lowest SBP during sedation, duration of hypotension, use of vasopressors, postoperative outcomes, and cost.
Results
Seventy-five patients were randomly allocated to either the low-volume or high-volume group, respectively (total n = 150). The incidence of hypotension was similar in the two groups (59% vs 56%, respectively; odds ratio, 0.90; 95% confidence interval, 0.47 to 1.71; P = 0.74). The incidence of SBP < 90 mmHg, the lowest SBP during sedation, the duration of hypotension, the use of vasopressors, and postoperative outcomes were also similar in the two groups.
Conclusions
This study does not support the routine use of 20 mL·kg−1 of intravenous Plasma-Lyte 148 to prevent hypotension and other complications during sedation for elective colonoscopy in adult patients. Clinical Trials Registry (ANZCTR 12615001288516).
... Although these factors largely represent nonmodifiable factors at the patient level, recent evidence has demonstrated that other factors pertaining to structures and processes can be targeted as potential avenues to implement standardized fluid resuscitation therapies and therefore improve clinical outcomes. For example, in their study assessing variations in fluid practices, Weinberg et al. 23 demonstrated significant differences in fluid practices among anesthesiologists. Furthermore, and perhaps more interestingly, the authors noted that these differences in fluid volume did not correlate with symptoms of hypotension/shock, operative time, or the occurrence of adverse perioperative events. ...
... Furthermore, and perhaps more interestingly, the authors noted that these differences in fluid volume did not correlate with symptoms of hypotension/shock, operative time, or the occurrence of adverse perioperative events. 23 Although differences in the practices k i m e t a l v a r i a t i o n i n c r y s t a l l o i d a d m i n i s t r a t i o n of providers accounted for a relatively smaller proportion of variation in fluid administration (10% of the explained variation), results of the present study reiterate the need for goal-directed strategies and evidence-based guidelines. Although traditional fluid strategies promote a liberal administration of crystalloid to the surgical patient, more recent evidence-based studies have suggested a more restrictive, goal-directed approach to fluid resuscitation. ...
Background:
Large variations exist regarding the type and volume of fluid to be administered to patients. This study aimed to quantitate variations in the administration of crystalloid fluids at the level of the patient, provider, and procedure at a large, tertiary care center.
Method:
Patients who underwent major cardiac, thoracic, or abdominal procedures between 2011 and 2014 were identified. Variations in crystalloid administration were compared by procedure and provider using a coefficient of variation (CV). Multivariable hierarchical linear modeling was performed to identify factors predictive of fluid administration and quantitate variation at the level of the patient and provider.
Results:
Among 6248 patients who met inclusion criteria, the average crystalloid volume was 25.8 mL kg(-1) m(2) h(-1), corresponding to a CV of 55%. Patients who underwent pancreatectomy received the highest corrected crystalloid volume (32.7 mL kg(-1) m(2) h(-1)), whereas those who underwent coronary artery bypass grafting received the lowest corrected crystalloid volume (14.7 mL kg(-1) m(2) h(-1)). Variations in fluid practices were noted between providers (corrected CV; 14.7%-97.1%) and within the practices of the same provider (corrected CV range; 24.1%-87.9%). On multivariable analysis, age and changes in hemoglobin concentration were associated with a higher crystalloid volume (both P < 0.05). Although over 90% of the variation was attributed to patient-level factors, approximately 10% was due to factors at level of the provider (surgeon: 5.8% versus anesthesiologist: 3.4%).
Conclusions:
Wide variations were noted in crystalloid administration between procedures, providers, and within providers. Evidence-based practices and goal-directed therapies should be incorporated to avoid unwanted variations.
Background
Retrospective studies have questioned the benefits of intravenous (IV) fluids during routine colonoscopies given they are performed on well patients who experience limited fluid loss, consume clear fluids up until 2 h prior and low IV volumes typically infused. This trial aims to assess the impact of IV fluid on hypotension and electrolyte changes amongst patients undergoing colonoscopy.
Methods
Participants undergoing colonoscopies were randomized (single blinded) to IV fluid or no IV fluid. Primary outcomes were equivalence of intraoperative hypotensive episodes (>20% drop in systolic blood pressure (SBP)) and changes in serum electrolytes post procedure. Secondary outcomes included patient reported outcome measures (PROMs).
Results
Of the 470 participants enrolled, 84/235 (35.7%) from the IV fluids group and 88/230 (38.3%) from the no IV fluids group experienced a hypotensive event (difference in prevalence −2.5, 95% CI −11.3, 6.3). Fourteen participants in each group required clinical intervention to provide haemodynamic support (difference in prevalence −0.1, 95% CI −4.4, 4.2). Postoperative electrolytes changes and PROMs were similar for both groups.
Conclusion
Whilst definitive recommendations for IV fluid use during routine colonoscopy are not possible as this trial was underpowered to show equivalence between the groups for hypotensive events, there was no clinically meaningful difference between the groups. These findings provide important data for meta-synthesis and for planning future work.
Background: Colonoscopy is a valuable diagnostic method that patients are not willing to undergo because of the fear of its complications. The purpose of this study was to determine the effect of intravenous fluid therapy prior to colonoscopy on blood circulation parameters and pain in patients and duration of Colonoscopy.
