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Initiation of an Anesthesia Protocol Reduces Intraoperative Crystalloid and Blood Administration During Pancreaticoduodenectomy: a Single Center Retrospective Study
Nathan Bolton*1, William C. Conway1, Shoichiro a. Tanaka1, James B. Hyatt2, Kara L. Roncin2, John S. Bolton1
1Surgery, Ochsner, New Orleans, LA; 2Medical University of the Americas, Nevis, Saint Kitts and Nevis
Introduction: Recent evidence points to improved outcomes after complex GI surgery when fluid and blood administration is minimized, often as part of an enhanced recovery after surgery program (ERAS). Due to the potential for significant fluid shifts and blood loss, pancreaticoduodenectomy (PD) patients can be given excess volume during surgery. Herein we report outcomes after PD when a restrictive protocol is followed.
Methods: Data was collected retrospectively on patients who underwent PD from 01/2008 until 09/2013. Groups were defined based on protocol initiation in October 2010 which dictated conservative crystalloid and blood administration and encouraged low-volume albumin use. Group A was defined as pre-protocol while group B was defined as post-protocol. Demographics, preoperative data, and outcomes were analyzed. Primary outcomes included intraoperative crystalloid (IC), colloid and blood use. Additionally, data was collected on intraoperative hypotension (IH), kidney injury (AKI) and hospital length of stay.
Results: A total of 228 patient who underwent PD were analyzed. 102 underwent PD before protocol initiation (Group A) and 126 after initiation (Group B). Group characteristics were similar in regards to age (A 65.3 vs B 64.1 [p=0.4]), sex (A M:F 54/46% vs B M:F 51/49% [p0.78]), BMI (A 27.4 vs B 27.1 [p=0.68]) and starting Hct (A 36.9 vs B 36.5 [p=0.59]). Pre-operative albumin (A 3.7 vs B 3.2 [p<0.01]) was lower in group B, and more patients in group B underwent neoadjuvant therapies although this difference was non-significant (A 12% vs B 18% [p=0.28]). There was a trend towards more vascular resections in group B (A 20% v B 30% [p=0.08]). IC use (A 7150ml vs B 4814ml [p<0.01]), need for blood transfusion (A 47% vs B 23% [p<0.01]) and volume of blood used (A 1.2 units vs B 0.61 units [p<0.01]) were all significantly decreased in group B with an increase in the use of colloid fluids (A 225ml vs B 612ml [p<0.01]). Despite this significant shift in volume administration, there were no differences between groups in either frequency of intraoperative hypotension (A 63% vs B 68% [p=0.64]) or incidence of post-operative AKI (A 0.06% vs B 0.13% [p=0.15]). Additionally, group B patients had a lower incidence of post-operative pressor use (A 16% vs B 5% [p<0.05]), shorter ICU stay (A 2.23 days vs B 1.5 days [p<0.01]), and shorter overall hospital stay (A 15.6 days vs B 11.9 days [p<0.01]).
Conclusion: A team, protocol-driven approach can minimize fluid and blood administration in PD patients. After initiation of our protocol, crystalloid and blood use were significantly reduced, without an increase in IH or post-operative AKI. Overall outcomes appear to be improved as well, with a reduction in LOS noted after protocol initiation. Fluid and blood management is likely an important component of an ERAS protocol for PD patients.
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