Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

Michel E van Genderen, Jorden Paauwe, Jeroen de Jonge, Ralf J P van der Valk, Alexandre Lima, Jan Bakker, Jasper van Bommel, Michel E van Genderen, Jorden Paauwe, Jeroen de Jonge, Ralf J P van der Valk, Alexandre Lima, Jan Bakker, Jasper van Bommel

Abstract

Introduction: Altered peripheral perfusion is strongly associated with poor outcome in critically ill patients. We wanted to determine whether repeated assessments of peripheral perfusion during the days following surgery could help to early identify patients that are more likely to develop postoperative complications.

Methods: Haemodynamic measurements and peripheral perfusion parameters were collected one day prior to surgery, directly after surgery (D0) and on the first (D1), second (D2) and third (D3) postoperative days. Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient (T(skin-diff)). Generalized linear mixed models were used to predict severe complications within ten days after surgery based on Clavien-Dindo classification.

Results: We prospectively followed 137 consecutive patients, from among whom 111 were included in the analysis. Severe complications were observed in 19 patients (17.0%). Postoperatively, peripheral perfusion parameters were significantly altered in patients who subsequently developed severe complications compared to those who did not, and these parameters persisted over time. CRT was altered at D0, and PPI and T(skin-diff) were altered on D1 and D2, respectively. Among the different peripheral perfusion parameters, the diagnostic accuracy in predicting severe postoperative complications was highest for CRT on D2 (area under the receiver operating characteristic curve = 0.91 (95% confidence interval (CI) = 0.83 to 0.92)) with a sensitivity of 0.79 (95% CI = 0.54 to 0.94) and a specificity of 0.93 (95% CI = 0.86 to 0.97). Generalized mixed-model analysis demonstrated that abnormal peripheral perfusion on D2 and D3 was an independent predictor of severe postoperative complications (D2 odds ratio (OR) = 8.4, 95% CI = 2.7 to 25.9; D2 OR = 6.4, 95% CI = 2.1 to 19.6).

Conclusions: In a group of patients assessed following major abdominal surgery, peripheral perfusion alterations were associated with the development of severe complications independently of systemic haemodynamics. Further research is needed to confirm these findings and to explore in more detail the effects of peripheral perfusion-targeted resuscitation following major abdominal surgery.

Figures

Figure 1
Figure 1
Flowchart of patient inclusion in the study.
Figure 2
Figure 2
Receiver operating characteristic curves of peripheral perfusion parameters for prediction of severe complications. Receiver operating characteristic curves for capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient (Tskin-diff) to predict severe complications on the first postoperative day (D1) (a) and the second postoperative day (D2) (b). Full details, including sensitivity and specificity values of the curves, are given in Table 5.

References

    1. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368–1375. doi: 10.1056/NEJMsa0903048.
    1. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2009;103:637–646. doi: 10.1093/bja/aep279.
    1. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Participants in the VA National Surgical Quality Improvement Program. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326–343.
    1. Gheorghe A, Calvert M, Pinkney TD, Fletcher BR, Bartlett DC, Hawkins WJ, Mak T, Youssef H, Wilson S. Systematic review of the clinical effectiveness of wound-edge protection devices in reducing surgical site infection in patients undergoing open abdominal surgery. Ann Surg. 2012;255:1017–1029. doi: 10.1097/SLA.0b013e31823e7411.
    1. Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281:1310–1317. doi: 10.1001/jama.281.14.1310.
    1. Braga M, Capretti G, Pecorelli N, Balzano G, Doglioni C, Ariotti R, Di Carlo V. A prognostic score to predict major complications after pancreaticoduodenectomy. Ann Surg. 2011;254:702–708. doi: 10.1097/SLA.0b013e31823598fb.
    1. Moonesinghe SR, Mythen MG, Das P, Rowan KM, Grocott MPW. Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery: qualitative systematic review. Anesthesiology. 2013;119:959–981. doi: 10.1097/ALN.0b013e3182a4e94d.
    1. Ives CL, Harrison DK, Stansby GS. Tissue oxygen saturation, measured by near-infrared spectroscopy, and its relationship to surgical-site infections. Br J Surg. 2007;94:87–91. doi: 10.1002/bjs.5533.
    1. Jhanji S, Lee C, Watson D, Hinds C, Pearse RM. Microvascular flow and tissue oxygenation after major abdominal surgery: association with post-operative complications. Intensive Care Med. 2009;35:671–677. doi: 10.1007/s00134-008-1325-z.
    1. Kern JW, Shoemaker WC. Meta-analysis of hemodynamic optimization in high-risk patients. Crit Care Med. 2002;30:1686–1692. doi: 10.1097/00003246-200208000-00002.
    1. Goepfert MS, Richter HP, Eulenburg CZ, Gruetzmacher J, Rafflenbeul E, Roeher K, von Sandersleben A, Diedrichs S, Reichenspurner H, Goetz AE, Reuter DA. Individually Optimized Hemodynamic Therapy Reduces Complications and Length of Stay in the Intensive Care Unit: A Prospective, Randomized Controlled Trial. Anesthesiology. 2013;119:824–836. doi: 10.1097/ALN.0b013e31829bd770.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–642. doi: 10.1093/bja/aei223.
    1. Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, Willemsen SP, Bakker J. for the LACTATE study group. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182:752–761. doi: 10.1164/rccm.200912-1918OC.
    1. Meregalli A, Oliveira RP, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care. 2004;8:R60–R65. doi: 10.1186/cc2423.
    1. Lima A, Jansen TC, van Bommel J, Ince C, Bakker J. The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients. Crit Care Med. 2009;37:934–938. doi: 10.1097/CCM.0b013e31819869db.
    1. van Genderen ME, Lima A, Akkerhuis M, Bakker J, van Bommel J. Persistent peripheral and microcirculatory perfusion alterations after out-of-hospital cardiac arrest are associated with poor survival. Crit Care Med. 2012;40:2287–2294. doi: 10.1097/CCM.0b013e31825333b2.
    1. Ait-Oufella H, Lemoinne S, Boelle PY, Galbois A, Baudel JL, Lemant J, Joffre J, Margetis D, Guidet B, Maury E, Offenstadt G. Mottling score predicts survival in septic shock. Intensive Care Med. 2011;37:801–807. doi: 10.1007/s00134-011-2163-y.
    1. van Genderen ME, van Bommel J, Lima A. Monitoring peripheral perfusion in critically ill patients at the bedside. Curr Opin Crit Care. 2012;18:273–279. doi: 10.1097/MCC.0b013e3283533924.
    1. Knaus WA. APACHE 1978–2001: the development of a quality assurance system based on prognosis: milestones and personal reflections. Arch Surg. 2002;137:37–41.
    1. Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Crit Care Med. 1998;26:1793–1800. doi: 10.1097/00003246-199811000-00016.
    1. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Br J Surg. 1998;85:1217–1220. doi: 10.1046/j.1365-2168.1998.00840.x.
    1. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–196. doi: 10.1097/SLA.0b013e3181b13ca2.
    1. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. doi: 10.1097/.
    1. Breitenstein S, DeOliveira ML, Raptis DA, Slankamenac K, Kambakamba P, Nerl J, Clavien PA. Novel and simple preoperative score predicting complications after liver resection in noncirrhotic patients. Ann Surg. 2010;252:726–734. doi: 10.1097/SLA.0b013e3181fb8c1a.
    1. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. 1992. Chest. 2009;136:e28. doi: 10.1378/chest.09-2267.
    1. Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med. 2002;30:1210–1213. doi: 10.1097/00003246-200206000-00006.
    1. Lima A, van Bommel J, Sikorska K, van Genderen M, Klijn E, Lesaffre E, Ince C, Bakker J. The relation of near-infrared spectroscopy with changes in peripheral circulation in critically ill patients. Crit Care Med. 2011;39:1649–1654. doi: 10.1097/CCM.0b013e3182186675.
    1. Tekkis PP, Prytherch DR, Kocher HM, Senapati A, Poloniecki JD, Stamatakis JD, Windsor AC. Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM) Br J Surg. 2004;91:1174–1182. doi: 10.1002/bjs.4430.
    1. Steyerberg EW, Neville BA, Koppert LB, Lemmens VEPP, Tilanus HW, Coebergh JWW, Weeks JC, Earle CC. Surgical mortality in patients with esophageal cancer: development and validation of a simple risk score. J Clin Oncol. 2006;24:4277–4284. doi: 10.1200/JCO.2005.05.0658.
    1. Markus PM, Martell J, Leister I, Horstmann O, Brinker J, Becker H. Predicting postoperative morbidity by clinical assessment. Br J Surg. 2005;92:101–106. doi: 10.1002/bjs.4608.
    1. Guzman JA, Dikin MS, Kruse JA. Lingual, splanchnic, and systemic hemodynamic and carbon dioxide tension changes during endotoxic shock and resuscitation. J Appl Physiol (1985) 2005;98:108–113.
    1. Biffl WL, Moore EE, Moore FA, Peterson VM. Interleukin-6 in the injured patient: marker of injury or mediator of inflammation? Ann Surg. 1996;224:647–664. doi: 10.1097/00000658-199611000-00009.
    1. Sato N, Koeda K, Ikeda K, Kimura Y, Aoki K, Iwaya T, Akiyama Y, Ishida K, Saito K, Endo S. Randomized study of the benefits of preoperative corticosteroid administration on the postoperative morbidity and cytokine response in patients undergoing surgery for esophageal cancer. Ann Surg. 2002;236:184–190. doi: 10.1097/00000658-200208000-00006.
    1. Boerma EC, van der Voort PH, Spronk PE, Ince C. Relationship between sublingual and intestinal microcirculatory perfusion in patients with abdominal sepsis. Crit Care Med. 2007;35:1055–1060. doi: 10.1097/01.CCM.0000259527.89927.F9.
    1. Hiltebrand LB, Koepfli E, Kimberger O, Sigurdsson GH, Brandt S. Hypotension during fluid-restricted abdominal surgery: effects of norepinephrine treatment on regional and microcirculatory blood flow in the intestinal tract. Anesthesiology. 2011;114:557–564. doi: 10.1097/ALN.0b013e31820bfc81.
    1. Brugger LE, Beldi G, Beck M, Porta F, Bracht H, Candinas D, Takala J, Jakob SM. Splanchnic vasoregulation after major abdominal surgery in pigs. World J Surg. 2010;34:2057–2063. doi: 10.1007/s00268-010-0560-y.
    1. Pol HW, Sibma E, Zeebregts CJ, Pierik EG, Meerwaldt R. Increased skin autofluorescence after colorectal operation reflects surgical stress and postoperative outcome. Am J Surg. 2011;202:583–589. doi: 10.1016/j.amjsurg.2010.10.019.
    1. Dimopoulou I, Armaganidis A, Douka E, Mavrou I, Augustatou C, Kopterides P, Lyberopoulos P, Tzanela M, Orfanos SE, Pelekanou E, Kostopanagiotou G, Macheras A, Giamarellos-Bourboulis EJ. Tumour necrosis factor-α (TNFα) and interleukin-10 are crucial mediators in post-operative systemic inflammatory response and determine the occurrence of complications after major abdominal surgery. Cytokine. 2007;37:55–61. doi: 10.1016/j.cyto.2007.02.023.
    1. Pölönen P, Ruokonen E, Hippeläinen M, Pöyhönen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg. 2000;90:1052–1059. doi: 10.1097/00000539-200005000-00010.
    1. Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH, Gramkow CS, Okholm M, Blemmer T, Svendsen PE, Rottensten HH, Thage B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641–648. doi: 10.1097/01.sla.0000094387.50865.23.
    1. Morelli A, Donati A, Ertmer C, Rehberg S, Lange M, Orecchioni A, Cecchini V, Landoni G, Pelaia P, Pietropaoli P, Van Aken H, Teboul JL, Ince C, Westphal M. Levosimendan for resuscitating the microcirculation in patients with septic shock: a randomized controlled study. Crit Care. 2010;14:R232. doi: 10.1186/cc9387.
    1. De Backer D, Creteur J, Dubois MJ, Sakr Y, Koch M, Verdant C, Vincent JL. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med. 2006;34:403–408. doi: 10.1097/01.CCM.0000198107.61493.5A.
    1. Hiltebrand LB, Pestel G, Hager H, Ratnaraj J, Sigurdsson GH, Kurz A. Perioperative fluid management: comparison of high, medium and low fluid volume on tissue oxygen pressure in the small bowel and colon. Eur J Anaesthesiol. 2007;24:927–933. doi: 10.1017/S0265021507000816.
    1. Dünser MW, Takala J, Brunauer A, Bakker J. Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach. Crit Care. 2013;17:326. doi: 10.1186/cc12727.
    1. Vincent JL, Ince C, Bakker J. Clinical review: Circulatory shock–an update: a tribute to Professor Max Harry Weil. Crit Care. 2012;16:239. doi: 10.1186/cc10846.
    1. Trzeciak S, McCoy JV, Dellinger RP, Arnold RC, Rizzuto M, Abate NL, Shapiro NI, Parrillo JE, Hollenberg SM. Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis. Intensive Care Med. 2008;34:2210–2217. doi: 10.1007/s00134-008-1193-6.
    1. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth. 2002;89:622–632. doi: 10.1093/bja/aef220.
    1. van Genderen ME, Lima A, de Geus H, Klijn E, Wijnhoven B, Gommers D, van Bommel J. Serum C-reactive protein as a predictor of morbidity and mortality in intensive care unit patients after esophagectomy. Ann Thorac Surg. 2011;91:1775–1779. doi: 10.1016/j.athoracsur.2011.02.042.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する