Hemodynamics of mesenteric traction syndrome measured by FloTrac sensor

Journal of Clinical Anesthesia (2016) 30, 46–50

Original contribution

Hemodynamics of mesenteric traction syndrome measured by FloTrac sensor☆ Hidemasa Takahashi MD a,⁎, Dai Shida MD b , Kyoko Tagawa MD a , Takeo Suzuki MD a a

Department of Anesthesiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15, Koto-bashi, Sumida-ku, Tokyo 130-8575, Japan Colorectal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan

b

Received 5 March 2013; revised 25 September 2015; accepted 21 December 2015

Keywords: Stroke volume variation; Flurbiprofen axetil; Fluid loading

Abstract Background: Mesenteric traction syndrome (MTS) develops in the early phase of laparotomy, which is triggered by pulling of the mesentery. We attempted to analyze the circulatory dynamics of MTS by using the FloTrac sensor. Methods: Prospective randomized control study, the MTS trial, was conducted with or without prophylactic administration of flurbiprofen axetil in order to control MTS development in 57 elective open colorectal surgeries. None of the Flurbipurofen group patients (n = 23) develop MTS and were allocated to the nonMTS group. Among the non-flurbiprofen group, 28 patients (82%) developed MTS and were categorized into the MTS group. For these patients, in addition to blood pressure, stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured by FloTrac sensor. Results: The lowest blood pressure was noted within 30 minutes from the beginning of the intra-abdominal examination; in the non-MTS group, the mean blood pressure decreased by 16.7%, and in the MTS group, it decreased by 34.2% (P b .01). SVV of the 28 MTS patients was as follows: b 9% in 10 patients (35.7%), N 9% and b 13% in 8 patients (28.6%), and N 13% in 10 patients (35.7%). SVRI rose in the non-MTS group by 5.1%, whereas it fell in the MTS group by 15.1% (P b .01), indicating the close relationship between MTS and SVRI. Conclusions: The SVV results indicate that fluid loading is not that optimal treatment against hypotension of MTS and that it is also important to consider the use of a vasoconstrictor. FloTrac is therefore useful for making an appropriate decision on the treatment strategy for MTS. © 2016 Elsevier Inc. All rights reserved.

1. Introduction One of the factors leading to hypotension in the early phase of laparotomy is mesenteric traction syndrome (MTS). It occurs when the mesentery is pulled during the ☆

Disclosures: None of the authors have any conflicts of interest to declare. ⁎ Corresponding author at: Department of Anesthesiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15, Koto-bashi, Sumida-ku, Tokyo 130-8575, Japan. Tel.: + 81 3 3633 6151; fax: +81 3 3633 6173. E-mail address: [email protected] (H. Takahashi). http://dx.doi.org/10.1016/j.jclinane.2015.12.001 0952-8180/© 2016 Elsevier Inc. All rights reserved.

procedure [1–3]. Its incidence rate is 30% to 85% and reportedly increases with remifentanyl use [4,5]. It is believed that pulling of the mesentery results in prostacyclin release, and the patients exhibit symptoms of hemodynamic changes such as hypotension, tachycardia, and a flushed face. Recently, our group as well as another research group demonstrated that inhibiting the synthesis of prostacyclin by using nonsteroidal anti-inflammatory drugs, such as flurbipurofen axetil, could prevent MTS [5,6]. Thus, MTS seems to be prevented by administration of nonsteroidal anti-inflammatory drugs; however, its hemodynamics has not been revealed yet.

Hemodynamics of MTS measured by FloTrac

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Intraoperative hypotension lasting for more than 10 minutes in longer-than-2-hour operations results in longer postoperative hospital stay and higher morbidity [7]. In order to minimize the risk of complications, hypotension must be immediately taken care of in MTS patients. However, treatment of hypotension caused by MTS has not been sufficiently examined. Although fluid resuscitation has been recommended as the treatment of MTS, it is difficult to judge whether it is appropriate, because the hemodynamic changes that occur during MTS have not been clarified yet. Recently, the FloTrac sensor with the Vigileo monitoring system has become clinically available for examining hemodynamic changes; it is based on arterial pulse contour analysis conducted using an arterial line indwelled in a radial artery (Edwards Lifesciences, Irvine, CA). Stroke volume (SV) and SV variation (SVV) can be continuously monitored with this system. SVV is the percentage change in SV caused by respiratory changes in arterial pulse pressure, and it functions as a parameter for fluid responsiveness. When it is higher than 13%, in arrhythmia-free patients under mechanical ventilation, it is highly likely that cardiac output (CO) will increase in response to fluid administration [8–10]. Although FloTrac is often used in major abdominal surgery, probable cases of MTS, no study has so far reported the hemodynamic changes during MTS, as observed using FloTrac. Our objectives were to analyze the circulatory dynamics, such as SVV, SV index (SVI), and systemic vascular resistance index (SVRI), during MTS and to determine the usefulness of FloTrac for deciding the best treatment strategy for MTS.

2. Materials and methods This study was approved by the institutional review board (IRB) of Tokyo Metropolitan Bokutoh Hospital (IRB code:

15-Heisei23). Written informed consent was obtained from all patients who participated. This study was registered in UMIN-CTR (UMIN0000091111). After obtaining IRB approval and written informed consent, patients who received elective surgery of colorectal cancer at our hospital were enrolled in this prospective, randomized clinical trial, named the MTS trial. A prospective randomized control study was conducted at our hospital. Patients younger than 20 years and those who had renal dysfunction, hepatic failure, peptic ulcer, aspirin-induced asthma, or arrhythmia were excluded. The course of the surgical procedure included peritoneal incision, opening of the abdomen, liver palpation (abdominal examination), and unfolding of the colon; the same surgical team performed all the operations. In our study, a total of 57 patients were randomly divided into 2 groups (Fig. 1): one group of patients was pretreated with flurbiprofen axetil (1 mg/kg; maximum, 50 mg; flurbiprofen group, n = 23), and the other group of patients was not given flurbiprofen pretreatment (non-flurbiprofen group, n = 34). As none of the 23 flurbipurofen group patients developed MTS, all of them (100%) were allocated to the non-MTS group in our study. Among the 34 non-flurbiprofen patients, 28 (82%) developed MTS and they were categorized into the MTS group. Six patients who did not develop MTS in non-flurbiprofen group were excluded from our study. All patients in both groups received general anesthesia in combination with epidural anesthesia. After admission into the operating room, an epidural catheter was inserted. Anesthesia was induced with propofol (1.5-2 mg · kg−1), rocuronium (0.6 mg · kg−1), sevoflurane (1%-3%), remifentanyl (0.25-0.5 μg · kg−1 · min−1), and ephedrine and dopamine when needed. After intubation, anesthesia was maintained with oxygen, air, sevoflurane (1.%2-1.4%), and remifentanil (0.1-0.25 μg · kg−1 · min−1). Then the radial artery was cannulated for continuous measurement of arterial pulse

MTS trial open abdominal colectomy n = 57

Flurbiprofen axetil

Flurbiprofen axetil not administered

administered Flurbiprofen group n = 23

non-Flurbiprofen group n = 34

not developed MTS

developed MTS

non-MTS group n=23

MTS group n = 28

Analyzed SVV, SVI,SVRI at the lowest blood pressure

Fig. 1

not developed MTS Excluded n = 6

non-MTS: n = 23 MTS: n = 28

Flowchart depicting the study population and subgroup distribution.

48 pressure. Following administration of 0.375% ropivacaine (4-6 mL) through the epidural catheter, the surgery was started. When hypotension requiring treatment were observed, ephedrine, phenylephrine, or fluid (crystalloid solution or colloid solution), or all 3 were used at the discretion of the anesthesiologist in charge. The tidal volume setting of the mechanical ventilator was 8 to 10 mL/kg. The time of abdominal opening was defined as the time at which the peritoneum was incised and abdominal cavity was opened. The time of abdominal examination was defined as the time when liver palpation was started prior to unfolding the colon. If a decrease in blood pressure from the baseline at abdominal examination, accompanied by facial flush, was observed within 30 minutes after the abdominal examination, it was considered to indicate MTS. The FloTrac sensor was connected to the arterial line to monitor SVV and, thus, determine SVI. With central venous pressure (CVP) input externally, systemic vascular resistance (SVR) was to be calculated, but in this study, because we did not use central venous catheters, 0 mm Hg CVP was adopted for SVR calculation which are recommended by Edwards Lifesciences Co and as the study reported previously (http://www. asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid= E8A92DD1839638D9C65FFB37766B4A61?year= 2012&index=4&absnum=4323). Data obtained were extracted using a computer software (Edwards Lifesciences Multi-Data Logger ver. 4.0; Edwards Lifesciences). Throughout the perioperative care, all patients were treated by our enhanced recovery after surgery protocols [11]. No preoperative and postoperative fasting (provision of oral nutrition) as well as intensive preadmission counseling, avoidance of sodium/fluid overload, intraoperative warm-air body heating, enforced postoperative mobilization, and multimodal team care were among the main changes brought about by the introduction of enhanced recovery after surgery protocols [11]. The results are presented as mean ± SD. The statistical methods used for comparison between the groups were Fisher exact test for frequency date and unpaired t-test for continuous variables. If the P value was b .05, the result was considered to be statistical significant.

3. Results The patient backgrounds of both groups are shown in Table 1. No massive emergent bleeding within 30 minutes after the abdominal examination was observed throughout this study. The mean time of all patients from the beginning of the operation to the abdominal examination was 8 minutes 38 seconds (non-MTS group, 9 minutes 52 seconds; MTS group, 8 minutes 11 seconds). In the MTS group, the mean time from the abdominal examination to the development of facial flush was 6 minutes 29 seconds, and it was 9 minutes 22 seconds until blood pressure decreased to the lowest level. In the non-MTS group, the mean time from the abdominal examination to the decrease in blood pressure to the lowest level was 15 minutes 7 seconds.

H. Takahashi et al. Table 1

Patient characteristics. MTS group Non-MTS group

No. of cases Age (y) Sex ratio (male/female) Height (cm) Weight (kg) Types of surgery Right hemicolectomy Left hemicolectomy Sigmoidectomy Transverse colectomy Low anterior resection Abdominoperineal resection Subtotal colectomy Use of epidural anesthesia Use of dopamine

28 69.4 ± 9.0 19:9 160.3 ± 9.6 56.8 ± 13.5

23 70.0 ± 11.3 18:5 159.2 ± 9.7 56.5 ± 9.9

6 2 4 0 9 6 1 28 (100%) 27 (96%)

5 0 1 2 14 2 0 23 (100%) 23 (100%)

MTS = mesenteric traction syndrome.

The mean arterial pressure (Table 2) during abdominal examination was 78.4 ± 14.5 mm Hg in the non-MTS group and 83.9 ± 16.5 mm Hg in the MTS group. The lowest blood pressure was 64.3 ± 8.4 mm Hg in the non-MTS group and 54.6 ± 9.7 mm Hg in the MTS group. The rate of decrease in blood pressure was significantly greater in the MTS group compared with the non-MTS group (34.2% ± 8.0% vs 16.7% ± 10.3%; P b .01). SVV values (Table 3) of the 28 MTS patients corresponding to the lowest blood pressure were quite varied. They were b 9% in 10 of the 28 patients (35.7%), N 9% and b 13% in 8 (28.6%), and N 13% in 10 (35.7%). It means that only half of patients are fluid responsiveness and require fluid administration. SVI (Table 2) during abdominal examination was 45.3 ± 10.1 mL · beat− 1 · m− 2 in the non-MTS group and 47.0 ± 12.1 mL · beat− 1 · m− 2 in the MTS group, and it decreased at the time of the lowest blood pressure to as low as 37.9 ± 6.3 mL · beat− 1 · m− 2 in the non-MTS group and 33.4 ± 6.8 mL · beat− 1 · m− 2 in the MTS group. The rate of decrease was significantly greater in the MTS group compared with the non-MTS group (27.2% ± 11.3% vs 14.9% ± 11.0%; P b .01). SVRI (Fig. 2) decreased in 25 of the 28 MTS patients. During abdominal examination, SVRI was 2174 ± 433 dyne-s · cm−5 · m2 in the non-MTS group and 2265 ± 590 dyne-s · cm−5 · m2, but at the lowest blood pressure, SVRI of the MTS group considerably decreased to 1889 ± 491 dyne-s · cm−5 · m2, whereas it was 2270 ± 434 dyne-s · cm−5 · m2 in the non-MTS group; that is, the decrease in SVRI was significantly higher in the MTS group compared with the non-MTS group (15.1% ± 16.0% vs − 5.1% ± 11.5%; P b .01).

4. Discussion In this study, by using the FloTrac sensor, we analyzed the circulatory dynamics during MTS seen in the early phase of laparotomy. Recently, SVV has been drawing attention as

Hemodynamics of MTS measured by FloTrac Table 2

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Comparison of the lowest blood pressure value and circulatory dynamics during abdominal examination. Non-MTS group

MTS group

During abdominal At the lowest Variation examination blood pressure

During abdominal At the lowest Variation examination blood pressure

Mean blood pressure (mm Hg) 78.4 ± 14.5 45.3 ± 10.1 SVI (mL · beat− 1 · m− 2) SVRI (dyne · s/cm5 · m2) 2174 ± 433

64.3 ± 8.4 37.9 ± 6.3 2270 ± 434

− 16.7% ± 10.3% 83.9 ± 16.5 − 14.9% ± 11.0% 47.0 ± 12.1 5.1% ± 11.5% 2265 ± 590

54.6 ± 9.7 33.4 ± 6.8 1889 ± 491

− 34.2% ± 8.0% ⁎ −27.2% ± 11.3% ⁎ −15.1% ± 16.0% ⁎

MTS = mesenteric traction syndrome; SVI = stroke volume index; SVRI = systemic vascular resistance index. Data are represented as mean ± SD. ⁎ P b .01 (compared with the non-MTS group).

one of the dynamic parameters for fluid management, for indicating whether fluid loading will increase CO; thus, SVV may be a better alternative to CVP for fluid management, as a predictor of fluid responsiveness [8–10]. When SVV is N 13% under controlled ventilation, patients are to be considered fluid responsive, which is an indication for fluid administration. However, in this study, only 10 of the 28 patients (35.7%) fell into this category (SVV is N 13%). As shown in Table 3, in this study, SVV values of the 28 MTS patients corresponding to the lowest blood pressure were quite varied, suggesting that only half of patients are fluid responsiveness and require fluid administration. The reason why only half of patients are fluid responsiveness during MTS is unknown and needs further investigation. In a study reported by Cannesson et al [9] with 413 patients, the authors described that among patients with PPV b 9%, only 11% were actually fluid responsive. This means that a PPV that is b 9% does not indicate fluid responsiveness, and for such patients, fluid loading may not be the appropriate treatment of hypotension. PPV is not the same as SVV. However, PPV is also one of the dynamic indexes. In our study, 10 of 28 patients (35.7%) showed an SVV of b 9%, when MTS occurred. For these patients, fluid administration would have resulted in fluid overloading. Perioperative fluid excess can result in tissue edema and increased complications [12]. SVV thus seems to be a useful parameter for determining whether fluid is to be administered for the treatment of hypotension during MTS. At the lowest blood pressure, SVR of the MTS patients was significantly lower compared with the non-MTS patients. This is consistent with the results of a precedent study by Hudson et al [13] in which a significant SVR decrease in MTS patients within 5 minutes after peritoneal incision was reported. Hypotension during MTS is considered to be associated with SVR decrease caused by the vasodilatory effects of prostacyclin Table 3

Distribution of SVV values at the lowest blood.

SVV

No. of case

%

b 9% N 9% and b 13% N 13%

10 8 10

35.7 28.6 35.7

SVV = stroke volume variation.

[1–3]. Thus, for the treatment of hypotension by MTS, using a vasopressor is important, in addition to fluid loading, especially one like phenylephrine. None of the patients who received prophylactic premedication with flurbiprofen axetil in our study developed MTS. This result is consistent with the report by Fujimoto et al [5], who concluded that prophylactic administration of flurbiprofen axetil could prevent MTS development. However, flurbiprofen axetil is contraindicated in certain cases, for example, for patients with renal dysfunction; therefore, MTS use in all cases with flurbiprofen axeril is impossible. In such cases, the hemodynamic state should be observed with FloTrac, and the optimal treatment should be chosen depending on each patient's condition as indicated by the SVV value: if the patient is fluid responsive, fluid loading should be performed, and if not, vasopressor treatment should be used. Moreover, the type of vasopressor to be used should be chosen based on the SVRI values. In this study, the blood pressure of patients in the MTS group decreased by 34.2%. In the report by Tassoudis et al [7], hypotension was defined as mean blood pressure b 60 or b 70 mm Hg, with a decrease rate of 30% or more from the baseline. Moreover, they reported that intraoperative hypotension lasting more than 10 minutes in longer-than-2-hour operations resulted in longer postoperative hospital stay and higher morbidity. Thus, in order to minimize the risk of complications, hypotension must be immediately taken care of in MTS patients. By choosing an appropriate treatment of MTS using FloTrac, the risk of perioperative complications can be minimized. There are 2 main limitations of this study. First, FloTrac cannot be used for arrhythmic patients. In such cases, without SVV, SVRI, or SVI, the treatment choice is based on the anesthesiologist’s experiences. For such cases, the end-expiratory occlusion test recommended by Monnet [14] can be useful. In this method, the airways are occluded at end-expiration to check the extent of CO change under constant low intrathoracic pressure. It is a useful dynamic parameter to predict fluid responsiveness, and the values are reliable in arrhythmic patients. This method can thus work as a substitute for FloTrac in the case of arrhythmic patients. Second, in this study, CVP was not actually measured. We calculated SVR under the assumption that CVP was 0 mm Hg as the previous study (written in the Materials and Methods

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H. Takahashi et al. 3000 during abdominal examination During low BP

2500

2000

1500

1000

500

0 non-MTS group

Fig. 2

MST group

Comparison of systemic vascular resistance index between non-MTS group and MTS group. MTS = mesenteric traction syndrome.

section); therefore, the absolute values of SVRI could be slightly erroneous. Nevertheless, the results are consistent with the results of a precedent study by Hudson et al, where the SVRI of the MTS group significantly decreased compared with the non-MTS group. Thus, we believe that the percentage change in SVRI is a reliable reference. Despite these limitations, one of the benefits of FloTrac is that it has a low degree of invasiveness.

5. Conclusion We were able to better understand the circulatory dynamics occurring during MTS with the help of FloTrac. We were able to determine the SVV and SVRI values of MTS patients using FloTrac and accordingly determine whether fluid loading or vasoconstrictor administration was the appropriate treatment. Our study results suggest that FloTrac is a useful device for monitoring patients undergoing laparotomy and determining the treatment strategy for MTS.

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