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Pulse Pressure Variation Guided Fluid Therapy During Kidney Transplantation

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Pulse Pressure Variation Guided Fluid Therapy During Kidney Transplantation Rev Bras Anestesiol. 2020;70(3):194---201 SCIENTIFIC ARTICLE Pulse pressure variation guided fluid therapy during ଝ kidney transplantation: a randomized controlled trial a,∗ a a a Alessandro De Cassai , Ottavia Bond , Silvia Marini , Giulio Panciera , b b a b a Lucrezia Furian , Flavia Neri , Giulio Andreatta , Paolo Rigotti , Paolo Feltracco a University of Padova, Department of Medicine --- DIMED, Section of Anesthesiology and Intensive Care, Padova, Italy b Padua University Hospital, Department of Surgery, Oncology and Gastroenterology, Kidney and Pancreas Transplant Unit, Padua, Italy Received 12 November 2019; accepted 15 February 2020 Available online 17 May 2020 KEYWORDS Abstract Kidney Purpose: Kidney transplantation is the gold-standard treatment for end stage renal disease. transplantation; Although different hemodynamic variables, like central venous pressure and mean arterial pres- sure, have been used to guide volume replacement during surgery, the best strategy still ought Fluid therapy; Creatinine; to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good Urea; predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room Urine settings. The aim of this study was to investigate whether a PPV guided fluid management strat- egy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. Methods: We conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients random- ized in the ‘‘PPV’’ group received fluids whenever PPV was higher than 12%, patients in the ‘‘free fluid’’ group received fluids following our institutional standard care protocol for kidney -1 -1 transplantations (10 mL.kg . h ). Results: Urinary output was similar at every time-point between the two groups, urea was sta- tistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second post- operative day. Urea, creatinine and urine output were not different at the hospital discharge. Conclusion: PPV guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery. © 2020 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). ଝ Congresses: Partial results have have already been presented at Euroanesthesia 2019 ( 1 --- 3 June 2019). ∗ Corresponding author. E-mail: [email protected] (A. De Cassai). https://doi.org/10.1016/j.bjane.2020.04.022 © 2020 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Pulse pressure variation guided fluid therapy during kidney transplantation: a randomized controlled trial 195 PALAVRAS-CHAVE Reposic¸ão de volume orientada pela variac¸ão da pressão de pulso durante Transplante renal; transplante renal: estudo randomizado controlado Fluido terapia; Creatinina; Resumo Ureia; Objetivo: Transplante renal é o tratamento padrão-ouro na doenc¸a renal em estágio terminal. Urina Embora diferentes variáveis hemodinâmicas, tais como pressão venosa central e pressão arterial média, tem sido usadas para orientar a estratégia de reposic¸ão volêmica durante a cirurgia, a melhor estratégia ainda não foi determinada. A Variac¸ão da Pressão de Pulso (VPP) durante o ciclo respiratório é reconhecida como um bom preditor da resposta à infusão de volume para otimizac¸ão hemodinâmica perioperatória no centro cirúrgico. O objetivo do estudo foi estudar se a estratégia de reposic¸ão de volume orientada por VPP é melhor do que a estratégia liberal de reposic¸ão de volume durante cirurgia de transplante renal.O principal objetivo do estudo foi identificar diferenc¸a no débito urinário na primeira hora do pós-operatório. Método: Realizamos estudo prospectivo, uni-cego, randomizado, controlado. Incluímos 40 pacientes submetidos a transplante renal de doador cadáver. Pacientes randomizados para o grupo ‘‘VPP’’ receberam volume quando a VPP estava acima de 12%, e os pacientes no grupo ‘‘reposic¸ão liberal’’ receberam volume de acordo com o nosso protocolo institucional padrão -1 -1 de assistência para transplante renal (10 mL.kg . h ). Resultados: O débito urinário foi semelhante em todos os tempos nos dois grupos, a ureia foi estatisticamente diferente a partir do terceiro dia do pós-operatório com pico no quarto dia do pós-operatório e a creatinina apresentou tendência semelhante, tornando-se estatisticamente diferente a partir do segundo dia do pós-operatório. Ureia, creatinina e débito urinário não estavam diferentes na alta hospitalar. Conclusões: A terapia orientada por VPP durante transplante renal melhorou de forma signifi- cante os níveis de ureia e creatinina na primeira semana pós-transplante renal. © 2020 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http://creativecommons.org/licenses/by- nc-nd/4.0/). Background and objective We hypothesized that a PPV-based fluid management dur- ing KT may be as effective as a liberal fluid strategy during KT, ensuring adequate postoperative urine output and being Kidney transplantation (KT) is the gold-standard treatment able, at the same time, to avoid fluid overload. to End Stage Renal Disease (ESRD). Patients with ESRD 1 Differences in Urine Output (UO) in the first postopera- receiving KT have a higher survival rate and a lesser health- 2,3 tive hour was the main outcome of this study. care expenditure than patients undergoing dialysis. Secondary outcomes were differences in UO, urea and Recent studies pointed out that an optimized fluid creatinine levels in the first postoperative week, differences therapy during transplant surgeries is associated with in the need of haemodialysis and differences in cardiopul- better graft function, possibly by maintaining optimal monary complications rate among the two groups. blood volumes and providing adequate oxygen delivery to 4 --- 6 tissues: inadequate volume infusions during KT could result in acute respiratory failure and prolonged mechan- Methods 1 ical ventilation, whereas fluid overload is considered to be detrimental for graft perfusion, microcirculation Design 4 and tissue oxygen delivery. Fluid management during KT is, therefore, a challenge for the anesthesiologist We conducted a prospective, single blind; non inferiority with little to no evidence supporting the proper prac- randomized controlled trial with a parallel design and a 1:1 tice. allocation ratio. The study protocol was approved by the In the past few years, different hemodynamic varia- Institutional Review Board of Padova (4423/AO/18) and reg- bles like Central Venous Pressure (CVP) or Mean Arterial istered on Clinicaltrials.gov (NCT03446196). The study was Pressure (MAP) were proposed as targets for adequate in accordance with the 1964 Helsinki declaration and its perioperative fluid infusion; however, a recent study later amendments or comparable ethical standards. Every demonstrated their poor performance in predicting graft patient enrolled in the trial provided written informed con- function.7 sent to participate. Respiratory arterial Pulse Pressure Variation (PPV) is con- sidered to be a good predictor of fluid responsiveness for 8---11 Subjects and setting hemodynamic optimization in the perioperative setting. No study has yet examined a PPV guided hemodynamic opti- Informed consent to participate to the trial was requested to mization during KT. all individual patients who met inclusion/exclusion criteria. 196 A. De Cassai et al. ≥ We included every patient with age 18 undergoing kidney than 12%; patients in the ‘‘free fluid’’ group received normal transplantation from cadaver. Exclusion criteria were double saline according to our institutional standard care protocol -1 -1 kidney transplantation, combined kidney-pancreas trans- (10 mL.kg . h plus and following a fluid replacement for plantation, combined liver-kidney transplantation and/or bleeding with saline at 1:1 ratio). history of heart disease and/or cardiac arrhythmias. Dynamic variables based on interaction between pul- monary and cardiac cycle, such as PPV, are considered better predictors of fluid responsiveness in patients during general Randomization 10 anesthesia and mechanical ventilation when compared to CVP or other static parameters.PPV values higher than 9% Twenty ‘‘Free fluid’’ and 20 ‘‘PPV’’ cardstocks were pre- and lower than 13% are less reliable than more extreme val- pared by a member of the research team not involved in the ues in predicting response to crystalloid infusion: in order to clinical setting (GP). He then inserted each cardstock in a avoid this ‘‘gray area’’, we chose PPV of ≥ 12% as a trigger different envelope and sealed the envelopes, proceeding to to increase saline infusion. shuffle the sealed envelopes. Although all patients were connected to the MostCareUP At the day of the surgery, after obtaining written monitor, attending anesthesiologists were blinded to Most- informed consent, the patients were randomly assigned by CareUP
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