Effect of Intraoperative Goal-Directed Fluid Management on Tissue Oxygen Tension in Obese Patients: a Randomized Controlled Trial

Abstract Background Perioperative subcutaneous tissue oxygen tension (PsqO2) is substantially reduced in obese surgical patients. Goal-directed fluid therapy optimizes cardiac performance and thus tissue perfusion and oxygen delivery. We therefore tested the hypothesis that intra- and postoperative PsqO2 is significantly reduced in obese patients undergoing standard fluid management compared to goal-directed fluid administration. Methods We randomly assigned 60 obese patients (BMI ≥ 30 kg/m2) undergoing laparoscopic bariatric surgery to receive either esophageal Doppler-guided goal-directed fluid management or conventional fluid treatment. Our primary outcome parameter was intra- and postoperative PsqO2 measured with a polarographic electrode in the subcutaneous tissue of the upper arm. A random effects linear regression model was used to analyze the effect of intervention. Results Overall, mean (± SD) PsqO2 was significantly higher in obese patients receiving goal-directed therapy compared to conventional fluid therapy (65.8 ± 28.0 mmHg vs. 53.7 ± 21.7, respectively; repeated measures design adjusted difference: 13.0 mmHg [95% CI 2.3 to 23.7; p = 0.017]). No effect was seen intraoperatively (69.6 ± 27.9 mmHg vs. 61.4 ± 28.8, difference: 9.7 mmHg [95% CI -3.8 to 23.2; p = 0.160]); however, goal-directed fluid management improved PsqO2 in the early postoperative phase (63.1 ± 27.9 mmHg vs. 48.4 ± 12.5, difference: 14.5 mmHg [95% CI 4.1 to 24.9; p = 0.006]). Intraoperative fluid requirements did not differ between the two groups. Conclusions Goal-directed fluid therapy improved subcutaneous tissue oxygenation in obese patients. This effect was more pronounced in the early postoperative period. Clinical Trial Number and Registry The study was registered at ClinicalTrials.gov (NCT 01052519).

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Obesity Decreases Perioperative Tissue Oxygenation

Anesthesiology ◽

10.1097/00000542-200402000-00015 ◽

2004 ◽

Vol 100 (2) ◽

pp. 274-280 ◽

Cited By ~ 229

Author(s):

Barbara Kabon ◽

Angelika Nagele ◽

Dayakar Reddy ◽

Chris Eagon ◽

James W. Fleshman ◽

...

Keyword(s):

Body Mass Index ◽

Oxygen Tension ◽

Tissue Oxygenation ◽

Subcutaneous Tissue ◽

Supplemental Oxygen ◽

Tissue Oxygen Tension ◽

Obese Patients ◽

Tissue Oxygen ◽

Upper Arm ◽

Oxygen Administration

Background Obesity is an important risk factor for surgical site infections. The incidence of surgical wound infections is directly related to tissue perfusion and oxygenation. Fat tissue mass expands without a concomitant increase in blood flow per cell, which might result in a relative hypoperfusion with decreased tissue oxygenation. Consequently, the authors tested the hypotheses that perioperative tissue oxygen tension is reduced in obese surgical patients. Furthermore, they compared the effect of supplemental oxygen administration on tissue oxygenation in obese and nonobese patients. Methods Forty-six patients undergoing major abdominal surgery were assigned to one of two groups according to their body mass index: body mass index less than 30 kg/m2 (nonobese) or 30 kg/m2 or greater (obese). Intraoperative oxygen administration was adjusted to arterial oxygen tensions of approximately 150 mmHg and approximately 300 mmHg in random order. Anesthesia technique and perioperative fluid management were standardized. Subcutaneous tissue oxygen tension was measured with a polarographic electrode positioned within a subcutaneous tonometer in the lateral upper arm during surgery, in the recovery room, and on the first postoperative day. Postoperative tissue oxygen was also measured adjacent to the wound. Data were compared with unpaired two-tailed t tests and Wilcoxon rank sum test; P < 0.05 was considered statistically significant. Results Intraoperative subcutaneous tissue oxygen tension was significantly less in the obese patients at baseline (36 vs. 57 mmHg; P = 0.002) and with supplemental oxygen administration (47 vs. 76 mmHg; P = 0.014). Immediate postoperative tissue oxygen tension was also significantly less in subcutaneous tissue of the upper arm (43 vs. 54 mmHg; P = 0.011) as well as near the incision (42 vs. 62 mmHg; P = 0.012) in obese patients. In contrast, tissue oxygen tension was comparable in each group on the first postoperative morning. Conclusion Wound and tissue hypoxia were common in obese patients in the perioperative period and most pronounced during surgery. Even with supplemental oxygen tissue, oxygen tension in obese patients was reduced to levels that are associated with a substantial increase in infection risk.

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Continuous intraoperative opioid administration increases subcutaneous tissue oxygen tension

European Journal of Anaesthesiology ◽

10.1097/00003643-200606001-00207 ◽

2006 ◽

Vol 23 (Supplement 37) ◽

pp. 58

Author(s):

B. Kabon ◽

A. Kugener ◽

E. Fleischmann ◽

A. Kurz

Keyword(s):

Oxygen Tension ◽

Subcutaneous Tissue ◽

Tissue Oxygen Tension ◽

Tissue Oxygen ◽

Opioid Administration

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SUBCUTANEOUS TISSUE OXYGEN TENSION IN ???WELL-RESUSCITATED??? TRAUMA PATIENTS

Critical Care Medicine ◽

10.1097/00003246-199401000-00109 ◽

1994 ◽

Vol 22 (1) ◽

pp. A61 ◽

Cited By ~ 6

Author(s):

Harriet Williams Hopf ◽

L Glass-Heidenreich ◽

J Silva ◽

F Pearce ◽

M G Ochsner ◽

...

Keyword(s):

Oxygen Tension ◽

Subcutaneous Tissue ◽

Tissue Oxygen Tension ◽

Trauma Patients ◽

Tissue Oxygen

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DECREASED INCIDENCE OF LOW SUBCUTANEOUS TISSUE OXYGEN TENSION IN "WELL-RESUSCITATED" TRAUMA PATIENTS

Critical Care Medicine ◽

10.1097/00003246-199901001-00530 ◽

1999 ◽

Vol 27 (Supplement) ◽

pp. 176A

Author(s):

H Hopf ◽

M Knudson ◽

N Szaflarski ◽

D Morabito ◽

J West ◽

...

Keyword(s):

Oxygen Tension ◽

Subcutaneous Tissue ◽

Tissue Oxygen Tension ◽

Trauma Patients ◽

Tissue Oxygen

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Effects of continuous remifentanil administration on intra-operative subcutaneous tissue oxygen tension

Anaesthesia ◽

10.1111/j.1365-2044.2007.05228.x ◽

2007 ◽

Vol 62 (11) ◽

pp. 1101-1109 ◽

Cited By ~ 6

Author(s):

B. Kabon ◽

A. Kugener ◽

T. Gruenberger ◽

M. Niedermayr ◽

E. Fleischmann ◽

...

Keyword(s):

Oxygen Tension ◽

Subcutaneous Tissue ◽

Tissue Oxygen Tension ◽

Tissue Oxygen

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EFFECT OF INSPIRED OXYGEN ON TRANSMURAL GUT AND SUBCUTANEOUS TISSUE OXYGEN TENSION

Critical Care Medicine ◽

10.1097/00003246-199501001-00287 ◽

1995 ◽

Vol 23 (Supplement) ◽

pp. A167

Author(s):

David Zabel ◽

Harriet Hopf ◽

Kari Kramer ◽

Thomas Hunt

Keyword(s):

Oxygen Tension ◽

Subcutaneous Tissue ◽

Tissue Oxygen Tension ◽

Tissue Oxygen ◽

Inspired Oxygen

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Perflubron emulsion increases subcutaneous tissue oxygen tension in rats

Wound Repair and Regeneration ◽

10.1111/j.1524-475x.2005.00088.x ◽

2006 ◽

Vol 14 (1) ◽

pp. 55-60 ◽

Cited By ~ 3

Author(s):

Noah A. Rosen ◽

Harriet W. Hopf ◽

Thomas K. Hunt

Keyword(s):

Oxygen Tension ◽

Subcutaneous Tissue ◽

Tissue Oxygen Tension ◽

Tissue Oxygen

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Hypercapnia Improves Tissue Oxygenation

Anesthesiology ◽

10.1097/00000542-200210000-00009 ◽

2002 ◽

Vol 97 (4) ◽

pp. 801-806 ◽

Cited By ~ 80

Author(s):

Ozan Akça ◽

Anthony G. Doufas ◽

Nobutada Morioka ◽

Steve Iscoe ◽

Joseph Fisher ◽

...

Keyword(s):

Cardiac Output ◽

Oxygen Tension ◽

Tissue Oxygenation ◽

Subcutaneous Tissue ◽

Peripheral Tissue ◽

Tissue Oxygen Tension ◽

Wound Infections ◽

Tissue Oxygen ◽

Healthy Human ◽

Surgical Infection

Background Wound infections are common, serious, surgical complications. Oxidative killing by neutrophils is the primary defense against surgical pathogens and increasing intraoperative tissue oxygen tension markedly reduces the risk of such infections. Since hypercapnia improves cardiac output and peripheral tissue perfusion, we tested the hypothesis that peripheral tissue oxygenation increases as a function of arterial carbon dioxide tension (PaCO(2)) in anesthetized humans. Methods General anesthesia was induced with propofol and maintained with sevoflurane in 30% oxygen in 10 healthy volunteers. Subcutaneous tissue oxygen tension (PsqO(2)) was recorded from a subcutaneous tonometer. An oximeter probe on the upper arm measured muscle oxygen saturation. Cardiac output was monitored noninvasively. PaCO(2) was adjusted to 20, 30, 40, 50, or 60 mmHg in random order with each concentration being maintained for 45 min.(2) (2) Results Increasing PaCO(2) linearly increased cardiac index and PsqO(2) : PsqO(2) = 35.42 + 0.77 (PaCO(2)), < 0.001. Conclusions The observed difference in PsqO(2) is clinically important because previous work suggests that comparable increases in tissue oxygenation reduced the risk of surgical infection from -8% to 2 to 3%. We conclude that mild intraoperative hypercapnia increased peripheral tissue oxygenation in healthy human subjects, which may improve resistance to surgical wound infections.

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