Goal-directed fluid therapy in renal failure patients undergoing parathyroidectomy: a randomized, single-center, controlled trial

DOI: https://doi.org/10.21203/rs.3.rs-2266085/v1

Abstract

Purpose: Parathyroidectomy, recommended when secondary hyperparathyroidism develops in renal failure patients on long-term renal dialysis, has high cardiovascular risks due to chronic fluid depletion. Stroke volume variation (SVV) is suitable for real-time liquid therapy titration under general anesthesia. We aimed to evaluate the Goal-directed fluid therapy by SVV for parathyroidectomy in renal failure patients.

Materials and Methods: This randomized controlled trial enrolled renal failure patients (N = 121) scheduled for parathyroidectomy under general anesthesia. The Goal-directed fluid therapy (GDT) group monitor was infused with saline until SVV was under 10%; the controls received standard restricted fluid therapy (SRT). Vasoactive agents were also available to maintain systolic blood pressure (SBP)≥90mmHg, mean blood pressure (MAP)≥65mmHg, or cardiac index 2.5–4.5 (L/min/m2). Data were presented as mean or median. The primary outcome was the perioperative hemodynamic changes. The secondary outcomes were blood gas analysis, fluid supplementation, vasoactive drug dosage, operation time, dialysis parameters, postoperative complications, postoperative lactate levels, and total days of hospitalization.

Results: Compared with SRT, GDT-Group patients needed more fluid, and their ephedrine use was reduced; they achieved stable blood flow changes during the perioperative period, who had lower serum lactic acid (cLAC) levels and postoperative complications.

Conclusion: This is the first study to propose that goal-directed fluid therapy by SVV in renal failure patients undergoing short-term surgery under general anesthesia could correct volume depletion, optimize tissue perfusion, and reduce blood pressure fluctuations and postoperative complications, with no long-term adverse effects.

Trial registration: Research Ethics Committee of Clinical Research Ethics Committee of China-Japan Friendship Hospital, Beijing, China (2018-125-K91-1). The study protocol was registered in Chinese Clinical Trial Register Network (ChiCTR1800019009, 21/10/2018).

Introduction

Patients with end-stage renal disease (ESRD) and long-term renal dialysis commonly develop secondary hyperparathyroidism (SHPT) [1] characterized by persistently elevated levels of the parathyroid hormone (PTH) and parathyroid hyperplasia due to hyperphosphatemia, hypocalcemia, and 1,25(OH)2D deficiency due to a decline in kidney function [2]. Severe SHPT potentially affects ESRD patient outcomes, and several national and international clinical practice guidelines recommend maintaining PTH levels within specific ranges [3],[4]. Parathyroidectomy (PTx) is the ultimate option when medical treatment fails or is not tolerated because of adverse effects in patients with severe SHPT [5], [6]. However, PTx for SHPT is associated with a high risk of cardiovascular events due to chronic fluid depletion. Long-term systemic vessel constriction, aggressive water intake restriction, impaired vascular and left ventricular compliance, removal of water during dialysis before surgery, and preoperative fasting could all contribute to vascular collapse and ischemic events during general anesthesia [7]. Contrastingly, fluid overload can aggravate cardiac insufficiency, hypertension, and extravascular edema. Furthermore, surgery-related events, such as vagal reflex, hyperkalemia, and hypocalcemia, increase cardiovascular risk in PTx patients [8]. PTx for SHPT has an extremely narrow therapeutic window for fluid therapy and thus requires liquid titration. However, the ideal fluid response parameter for patients with kidney failure undergoing general anesthesia is yet to be clarified.

Stroke volume variation (SVV) is an indicator of volumetric response and calculated through changes in the area under the arterial blood pressure waveform. SVV is influenced by the respiratory cycle, reflecting the interference of intra-thoracic pressure with the venous return [9]. Several studies have proved that SVV is a dynamic, easily obtained, and reliable predictor of fluid responsiveness in various clinical settings and is suitable for real-time liquid therapy titration in mechanically ventilated patients under general anesthesia [10]. A randomized controlled study by Benes et al. [11] found that the Vigileo/FloTrac system’s use to maintain SVV under 10% using colloid boluses of 3 ml/kg to guide fluid therapy in patients undergoing elective intraabdominal surgery is associated with good intraoperative hemodynamic stability, decreased serum lactate at the end of the surgery, and few postoperative organ complications. Furthermore, SVV can be used to guide intraoperative fluid therapy in patients with ESRD undergoing hemodialysis [12],[13].

The purpose of our study was to investigate the effect of SVV-directed fluid therapy, its influence on hemodynamic function and prognosis in patients with renal failure undergoing general anesthesia, and compare it with standard restrictive fluid therapy.

Methods

Study design

This trial was a randomized, single-center, assessor-blinded trial comparing goal-directed fluid therapy with standard restrictive intravenous-fluid regimen in patients with renal failure undergoing parathyroidectomy which was approved by the Clinical Research Ethics Committee of China-Japan Friendship Hospital, Beijing, China (2018-125-K91-1). This study was registered on the Chinese Clinical Trial Register Network (http://www.chictr.org/; registration number, ChiCTR1800019009, 21/10/2018). The treatment plans of both study groups were clearly explained to each patient, and they have given informed consent.

Participants

There were 154 SHPT patients underwent elective PTx surgery in China-Japan Friendship Hospital from May 2018 to April 2019. Patients with SHPT scheduled for PTx were screened to determine their eligibility. Patients were enrolled if they: (1) met the ESRD diagnostic criteria and a surgery for SHPT was indicated, (2) received hemodialysis treatment within 24 hours before surgery, (3) were under 65 years of age, and (4) signed an informed consent form and were willing to participate in the trial. Patients with the following characteristics were ineligible for this trial: (1) irregular heart rhythm, (2) severe hyperkalemia (K+>5.5mmol/L), (3) left ventricular diastolic dysfunction, (4) ejection fraction (EF) < 50%, (5) abnormal liver function, (6) pulmonary hypertension (pulmonary systolic blood pressure [SBP] > 40 mmHg) or right heart function insufficiency, (7) aortic regurgitation, (8) abnormal ventricular wall motion in stages, (9) body weight ≤ 45 kg or ≥ 140 kg as it affects the accuracy of FloTrac/Vigileo monitoring values, and (10) patients with fistulas in both arms. According to the inclusion and exclusion criteria, we enrolled 131 patients (American Society of Anesthesiologists grade of all patients were III). (Figure.1)

Randomization and blinding

All included SHPT patients were randomly divided into a goal-directed liquid therapy (GDT) group and standard restricted fluid therapy (SRT) group using the SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA) A fixed value (2000000) was used to generate random numbers at a 1:1 ratio. Patients were randomized into one of two groups using the concealed envelope method. The GDT group received the SVV-directed intraoperative fluid therapy, and the SRT group received routine fluid therapy during the operation. It was not possible to blind the fluid therapy given to the groups [14]. The patients participating in the experiment and the anesthesiologists were blinded to the treatment allocation. The assessment of the outcome was blinded as follows: the patient data were blinded for identity, randomisation, and all information on the provided fluid therapy. The data were analyzed by an independent group of personnel, breaking the blindness during the data analysis stage.

Procedures

Preoperative preparation.

After entering the operating room, the two groups of patients underwent electrocardiogram (ECG) monitoring. Before induction, the diameter of the inferior vena cava (IVC) was measured during spontaneous breathing using transthoracic ultrasound (LOGIQ E portable color Doppler ultrasound, GE Company, Tampa, FL, USA). A doctor trained on transthoracic echocardiography performed the measurement. The measurement was performed at a distance of 1–2 cm between the junction of the IVC and the right atrium or at the junction of the inferior hepatic vena cava. The measurement line was perpendicular to the long axis of the IVC [15]. The diameter of the IVC was measured at the end of both expiration and inspiration in one breathing cycle, and the average of measurements during three consecutive breathing cycles was calculated. The IVC collapse rate (ΔIVC = [(IVCmax – IVCmin)/IVCmax] × 100%) of more than 50% indicated volume responsiveness. (IVCmax = end-expiratory diameter of inferior vena cava; IVCmin = end-inspiratory diameter of inferior vena cava). A 20G or 22G arterial catheter was used to puncture the radial artery in the non-ostomy arm, continuously monitor the invasive blood pressure, and draw arterial blood for blood gas analysis.

Induction and anesthesia maintenance program.

General anesthesia induction gives fentanyl 2-4ug/kg or sufentanil 0.2-0.4ug/kg, cis-atracurium 0.2-0.3mg/kg, propofol 1-2mg/ kg or etomidate 0.2-0.6mg/kg; anesthesia maintenance with 0–1% sevoflurane inhalation, remifentanil 0.1-03ug/kg/min, propofol 4-12mg/kg/h continuous pumping. During the operation, BIS was used to monitor the depth of anesthesia, maintained between 40–60. The cis-atracurium intermittently pushed to maintain muscle relaxation. The tracheal tube was made of steel wire tracheal tube, which was lubricated by lidocaine glue, and the muscle relaxation was completely relieved. After effect, use direct laryngoscopy for endotracheal intubation. For those with sinus tachycardia before intubation, add esmolol 0.5mg/kg. Mechanical ventilation is performed after intubation, tidal volume is 8-10ml/kg, inhaled oxygen concentration is 60%, inhalation-expiration ratio is 1:2, respiration rate is 10–12 times/min, end-tidal CO2 is maintained at 35-45mmHg, pulse oxygen is saturated Degree > 95%.

Fluid therapy and circulatory maintenance program (Fig. 2).

All patients received normal saline 0.9% NaCl infusion during the operation. In the GDT group, SVV was used to guide fluid therapy during the operation, and the FloTracTM cardiac output sensor was used to connect with the VigileoTM monitor (version 1.10 [second generation], Edwards Life Sciences, Irvine, CA, USA), adjust the zero, and record the cardiac index (CI) and SVV. The CI was maintained at 2.5–4.5 L/min/m2, SVV < 10%, and SBP ≥ 90 mmHg or mean arterial pressure, MAP ≥ 65 mmHg; if SVV was ≥ 10%, it was observed for 5 minutes, and if it was still ≥ 10%, rehydration speed was opened under the premise of ensuring clinical safety, and 3 ml/kg of 0.9% NaCl was infused within 5 minutes to bring the SVV under 10%. When SBP was less than 90 mmHg or MAP was less than 65 mmHg, in addition to the physiological saline infusion, intermittent intravenous bolus injection of ephedrine or norepinephrine bolus injection or pump injection was used to maintain SBP ≥ 90 mmHg or MAP ≥ 65 mmHg. When the CI was still at a low cardiac output (CO) level (CI < 2.5 L/min/m2) after proper fluid replacement, vasoactive drugs were used to maintain the CI at 2.5–4.5 L/min/m2.

In the SRT group, parameters related to cardiac function could not be directly monitored during the operation. Therefore, the CO value was estimated using the Liljestrand-Zander formula: CO = [(SBP – diastolic blood pressure {DBP}/(SBP + DBP)] × heart rate; The CO value was multiplied by a constant k to obtain the corrected value COADJ; k was derived from the GDT group through FloTrac™/VigileoTM monitor. The ratio of the measured COVigileo to CO was calculated according to the formula: k = COVigileo/CO; Also, CI = CO/body surface area, where: body surface area = (0.0061 × height [in cm]) + (0.0128 × weight [in kg]) − 0.1529. To obtain the CIADJ values before and after the SRT group. The magnitude of blood pressure variability (BPV or blood pressure fluctuation) was measured by calculating the coefficient of variation (CV) as follows: CV = SDMAP/MAP × 100%.

Post-induction hypotension events and intraoperative hypotension events were recorded. Intraoperative hypotension was defined as SBP [or MAP] < 30% of the preoperative baseline or MAP ≤ 50 mmHg. Conventional restrictive fluid therapy was administered during the operation in the SRT group. Vasoactive drugs were also used to maintain SBP ≥ 90 mmHg or MAP ≥ 65 mmHg. We also recorded hypotensive events after induction and intraoperative hypotension.

Postoperative monitoring

After the operation, the patient was extubated, and blood was drawn again for blood gas analysis and ΔIVC measurement. The patient was then sent to the post-anesthesia care unit (PACU) to continue monitoring and treatment and record blood pressure, heart rate, and rehydration volume. After the patient returned to the ward, the ECG, blood pressure, and oxygen saturation were monitored continuously for 12h. The patient underwent dialysis on the second day after the operation, and the blood pressure before and after dialysis and the ultrafiltration volume of dialysis were recorded. Telephone follow-ups were carried out 7 and 30 days after the operation, and complications were recorded.

Outcomes

The primary outcome was the perioperative hemodynamic changes. The secondary outcomes were blood gas analysis, fluid supplementation, vasoactive drug dosage, operation time, dialysis parameters, postoperative complications, postoperative lactate levels, and total days of hospitalization. The preoperative, intraoperative, and postoperative outcomes were measured.

Statistical analysis

A total of 18 patients (nine in each group) were included in the pre-experiment. According to the pre-experiment results, we expected the GDT group’s postoperative lactic acid level to reduce by more than 0.2 mmol/L compared with the SRT group. Using the PASS software (version 11.0), type I error, α = 0.05, and power, 1 - β = 0.8, the estimated sample size was 49 cases (Fig. 2). Considering that 20% of patients may be lost to follow-up, 60 cases were required per group, with 120 cases in the two groups. Statistical analyses were performed using the SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, USA). Continuous data were represented as mean ± standard deviation or median and interquartile range, categorical data were represented as counts and percentages, and differences between conditions were compared using independent sample t-test, chi-squared test, or a non-parametric test. Statistical significance was set at p < 0.05.

Results

In 131 patients, one patient was switched to local anesthesia during the operation, three cases of elective surgery were temporarily canceled due to patient reasons, and six refused to sign the informed consent. The total number of patients included in the study was 121 (GDT group, 60 patients; SRT group, 61 patients; Figure 1). The characteristics of all participants were described in Table 1. 

Perioperative hemodynamic changes 

There was no significant difference between the intraoperative or perioperative blood pressure changes between the GDT and SRT groups (p > 0.05, Figure 3). The ephedrine dosage and the frequency of vasoactive drug use were significantly lower in the GDT group than in the SRT group (p < 0.05); the postoperative serum lactic acid level was also lower [0.97 ± 0.40 mmol/L vs. 1.30 ± 0.52 mmol/L; p < 0.001] (Table 3). The GDT group’s postoperative CI was higher than that of the SRT group (4.29 [3.21, 4.99] L/min/m2 vs. 3.18 [2.41, 4.48] L/min/m2; p < 0.05). There were no statistically significant differences in the BPV between the two groups before the operation to the outpatient period (p > 0.05) or from the postoperative period to the dialysis period (p > 0.05) (Table 4). However, the BPV between the two groups from preoperative to 6, 12, and 24 h after surgery were significantly different; the BPV in the GDT group was smaller than that in controls (Figure 3; Table 4). Also, the amount of dialysis ultrafiltration after surgery (p > 0.05) was not significantly different between the two groups.

Other perioperative outcome indicators

The demographic data, underlying diseases, surgical methods, and preoperative variables, such as vital signs, iPTH levels, ΔIVC, and blood gas analysis, were not statistically different between the two groups. Also, the intraoperative hypotensive events, anesthesia time, operation time, PACU recovery time, and estimated blood loss were not statistically different. In terms of volume status and volume response, intraoperative fluid supplementation was significantly higher in the GDT group than in controls (500 [385, 720] ml vs. 320 [230, 430] ml; p < 0.01). Also, more patients in the GDT group had a postoperative ΔIVC < 50% than controls (28% vs. 15%; p < 0.05) (Table 2).

Prognosis

Postoperative complications in the GDT and SRT groups included hypocalcemia (20 vs. 24 cases), hyperkalemia (eight cases in each group), postoperative hypertension (four vs. three cases), hypotension during dialysis (8 vs. 11 cases), and postoperative wound bleeding or hematoma (one vs. two cases), respiratory infection (one vs. four cases), arrhythmia (one vs. three cases), heart failure (one case in each group). Additionally, the GDT group had three infection cases and one angina pectoris case, whereas the SRT group had a cerebral infarction case. 

The incidence of complications in the GDT group was reduced within 7 days after surgery compared to the controls (33% vs. 53%; p < 0.05). However, there were no significant differences in the number of hospitalization days, rehospitalization rates, and incidence of complications within 30 days after surgery (Table 3).

Discussion

PTx is an effective and final choice for treating ESRD and long-term renal dialysis in SHPT patients. The SVV can be used to guide intraoperative rehydration in patients undergoing surgery. In this study, compared with the CON group, the SVV-group patients had a larger intraoperative rehydration volume, a higher postoperative heart index, and reduced intraoperative vasoactive drug dosage and frequency of use. Moreover, the BPV in the SVV group was smaller, indicating that the SVV-group patient’s hemodynamics were relatively more stable preoperatively than 24 h after surgery.

Hemodynamic management of ESRD patients involves achieving appropriate preload and afterload and maintaining blood pressure. Excessive or insufficient intraoperative fluid replacement in ESRD patients greatly impairs cardiac and renal functions. Therefore, perioperative volume management with PTx is challenging for anesthesiologists. The application of central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP) to assess vascular volume status is limited because these measurements have a poor correlation with the patient’s fluid reactivity [16],[17]. Inserting an invasive pulmonary artery catheter does not improve the prognosis of critically ill patients [18]. Furthermore, the operation time of PTx is short; thus, the use of pulmonary artery catheters for perioperative hemodynamic monitoring in ESRD patients is not recommended. Compared with standard management programs, goal-directed therapy based on dynamic monitoring of changes in SBP, pulse pressure, and SVV improved the prognosis of high-risk patients [19],[20]. A study in ESRD patients showed that after infusion of 500 ml of liquid SVV decreased left ventricular end-diastolic volume; however, three-dimensional ultrasound did not show measurement changes due to post-infusion diastolic dysfunction [12]. Kanda et al. suggested that SVV is a useful indicator of hypovolemia or fluid responsiveness in ESRD patients. They recommended inserting an arterial catheter before anesthesia for real-time monitoring of blood pressure, SVV, CO, and CI [7].

The SVV threshold in this study was based on a study by Benes et al. [11]. They used SVV < 10% as the goal to guide perioperative fluid treatment in open surgery. When SVV was more than 10%, the fluid supplement volume per time was 3 ml/kg. The results showed that the lactic acid level in the SVV-guided fluid supplement group was significantly reduced, and the length of hospital stay was shortened. Therefore, we believe that using SVV < 10% as the goal for perioperative fluid therapy can provide patients with a good prognosis.

Although there was no difference in the length of hospital stay between our two study groups, a randomized controlled trial by Jochen Mayer et al. reported that the average length of hospital stay in the SVV-guided fluid supplement group was significantly reduced by 4 days [21]. However, this difference could be due to differences in surgeries, although the population in both studies comprised high-risk surgery patients. Mayer et al.’s study participants underwent long and more traumatic abdominal surgeries, including colon resection, pancreatectomy, and hepatectomy. Contrastingly, the patients in our study underwent cervical parathyroidectomy, a short operation with quick recovery, and there was no difference in the duration of hospital stay between the two groups.

The lower incidence of complications within 7 days after surgery in the intervention group than the controls in our study is consistent with previously conducted similar studies [22],[23],[24],[25]. However, there was no difference in the incidence of complications 30 days after surgery. Due to the short duration of anesthesia and surgery, the average procedure duration is approximately 1.5 h. Therefore, SVV-guided fluid supplementation can only improve the short-term volume status of SHPT patients, which is beneficial for patients in the long term. Other factors that affect the prognosis, such as patients' combined chronic diseases, PTH level changes, and preoperative cardiac function status were not different between the two groups; however, it was expected after surgery because the patients had renal failure. Factors such as the dialysis method and the dialysis ultrafiltration amount may affect a patient’s effective blood volume status.

Few studies exist on SVV to guide renal failure patients receiving PTx. More such research studies are needed in the future. We will continue to explore the use of SVV to guide intraoperative fluid rehydration in patients with cardiac insufficiency.

Conclusions

For patients with renal failure undergoing PTx, a minor surgery under general anesthesia, the SVV-guided fluid therapy using the FloTrac/VigileoTM system could correct volume depletion, maintain stable perioperative blood pressure (that is, few fluctuations), reduce lactic acid levels, optimize tissue oxygenation and organ perfusion, and reduce postoperative complications with no long-term adverse effects.

Abbreviations

BPV, blood pressure variability; CI, cardiac index; cLAC, serum lactic acid; CO, cardiac output; CV, coefficient of variation; DBP, diastolic blood pressure; ECG, electrocardiogram; ESRD, end-stage renal disease; GDT, goal-directed fluid therapy; IVC, inferior vena cava; MAP, mean arterial pressure; PACU, post-anesthesia care unit; PTH, parathyroid hormone; PTx, parathyroidectomy; SBP, systolic blood pressure; SHPT, secondary hyperparathyroidism; SRT, standard restricted fluid therapy; SVV,  stroke volume variation; ΔIVC, inferior vena cava collapse rate.

Declarations

Acknowledgments: Not applicable

Authors’ contributions: Quanyong Yang and Tegeleqi Bu completed the trial. Kaili Yu and Ying Ma wrote the main manuscript text and Xiaobei Zhang prepared figures 1-3. Lifang Wang prepared tables 1-4. Yiqing Yin is responsible for coming up with project ideas and participating in the whole process. All authors reviewed the manuscript.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of data and materials: The dataset used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations 

Ethics approval and consent to participate: We obtained written informed consent from the patients or their legal representatives. Research Ethics Committee of Clinical Research Ethics Committee of China-Japan Friendship Hospital, Beijing, China (2018-125-K91-1). The study protocol was registered in Chinese Clinical Trial Register Network (ChiCTR1800019009, October 21, 2018). All procedures in the study involving human participants were performed in accordance with the ethics standards of the institutional and national research committee and with the Helsinki Declaration and its later amendments or comparable ethics standards.

Consent for publication: Not applicable.

Competing interests: None declared

Declaration of interest: All authors declare no competing interests. No other disclosures were reported.

Authors' information

Quanyong Yang, E-mail: [email protected] Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China;Tianjin’s Clinical Research Center for Cancer, Tianjin, China;Key laboratory of Cancer Prevention and Therapy, Tianjin, China

Tegeleqi Bu, E-mail: [email protected] Department of Anesthesiology, Peking University Hospital, Beijing, China.

Kaili Yu, E-mail: [email protected] Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China;Tianjin’s Clinical Research Center for Cancer, Tianjin, China;Key laboratory of Cancer Prevention and Therapy, Tianjin, China

Ying Ma, E-mail: [email protected] Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China;Tianjin’s Clinical Research Center for Cancer, Tianjin, China;Key laboratory of Cancer Prevention and Therapy, Tianjin, China

Lifang Wang, E-mail: [email protected] Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China.

Xiaobei Zhang, E-mail: [email protected] Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China;Tianjin’s Clinical Research Center for Cancer, Tianjin, China;Key laboratory of Cancer Prevention and Therapy, Tianjin, China

Yiqing Yin, E-mail: [email protected] Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China;Tianjin’s Clinical Research Center for Cancer, Tianjin, China;Key laboratory of Cancer Prevention and Therapy, Tianjin, China

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Tables

Table 1. Baseline characteristics of the GDT group and SRT group

 

GDT group

(N=60)

SRT group (N=61)

P-value

Sex ratio (M: F)

32/28

37/24

0.418

Age (years)

47.8±10.8

47.0±11.0

0.706

Height (cm)

165.0±8.4

166.6±8.6

0.315

Weight (kg)

59.6±12.1

63.6±14.6

0.109

BMI

21.8±3.4

22.7±3.9

0.166

Basic disease

 

 

 

 Hypertension [cases, (%)]

58(96.7%)

57(93.4%)

0.416

  Coronary heart disease [cases, (%)]

5(8.3%)

7(11.4%)

0.565

  Diabetes [cases, (%)]

3(5.0%)

4(6.5%)

0.715

Surgical approach

 

 

 

 Total parathyroidectomy [cases, (%)]

46(76.7%)

50(82.0%)

0.473

 Total parathyroidectomy +autologous  

 transplantation [cases, (%)]

14(23.3%)

11(18.0%)

0.508

Before operation IVC%

40±14

44±15

0.155

Basic vital signs

 

 

 

  MAP (mmHg)

114±18

115±19

0.796

  HR (bpm)

85±13

81±12

0.059

  COADJ/CO (L/min)

8.07(7.03,9.49)

7.45(5.91,8.82)

0.162

  CIADJ/CI (L/min/m2)

5.01(4.13,6.27)

4.51(3.47,5.73)

0.222

  SVV (%)

12±6

N/A

 

Blood/gas analysis

 

                                 

 

  pH (mmol/L)

7.38±0.06

7.38±0.05

0.91

  Na2+ (mmol/L)

140±3

140±5

0.453

  K(mmol/L)

4.7±0.7

4.6±0.6

0.147

  CI(mmol/L)

103±3

103±3

0.918

  Ca2+ (mmol/L)

1.25±0.07

1.23±0.13

0.263

  HCO3(mmol/L)

22.2±3.0

22.1±2.8

0.853

  BE (mmol/L)

-2.2±3.2

-2.2±3.0

0.974

  cLac (mmol/L)

1.37±0.60

1.09±0.47

0.063

  Hemoglobin (g/dL)

11.1±2.2

11.3±2.2

0.701

  iPTH (pg/mL)

1830±970

1988±829

0.384

The measurement data is expressed as the mean ± standard deviation (cases), the count data is expressed as the quantity (%), and BMI: body mass index.

Table 2: Intraoperative data.

 

SVV group

(N=60)

CON group (N=61)

P-value

Intraoperative hypotension events

14(23%)

20(33%)

0.313

Rehydration volume

 

 

 

     Intraoperative (mL)

485(300,650)

250(180,350)

<0.001**

     PACU (mL)

50(20,100)

50(15,100)

0.275

     Total (mL)

500(385,720)

320(230,430)

<0.001**

Use ephedrine

10(17%)

22(36%)

0.016* 

     Dosage (mg)

2.00(0, 5.37)

4.43(0, 7.28)

0.012*

Use norepinephrine

20(33%)

33(54%)

0.386

     Dosage (ug)

22.18±68.24

27.70±69.34

0.533

Use vasoactive drugs

24(40%)

41(67%)

0.004*

Time

 

 

 

     Anesthesia time (min)

90±29

98±34

0.142

     Operation time (min)

63±25

71±31

0.11

     PACU recovery time (min)

50±20.31

46±18

0.345

Blood loss (mL)

15±8

13±9

0.332

Postoperative vital signs

 

 

 

MAP (mmHg)

103.56±18.14

99.01±20.18

0.195

     HR (bpm)

80.24±13.72

77.10±12.19

0.231

COADJ/CO (L/min)

6.86(5.14,7.98)

5.09(3.86,7.16)

0.001**

CIADJ/CI (L/min/m2)

4.29(3.21,4.99)

3.18(2.41,4.48)

0.009**

     SVV (%)

9±4 (P=0.034*, vs preoperative)

N/A

 

Blood/gas analysis in PACU

 

 

 

     PH (mmol/L)

7.37±0.05

7.35±0.06

0.137

     Na2+ (mmol/L)

140±3

139±3

0.541

     K(mmol/L)

4.8±0.8

4.7±0.7

0.163

CI(mmol/L)

105±3

103±3

0.021*

     Ca2+ (mmol/L)

1.22±0.11

1.21±0.11

0.535

HCO3(mmol/L)

21.0±2.7

20.9±4.5

0.914

BE (mmol/L)

-3.8±2.9

-2.9±3.3

0.124

     cLac (mmol/L)

0.97±0.40

1.30±0.52

<0.001**

     Hemoglobin (g/dL)

10.8±1.9

11.0±2.1

0.535

iPTH (pg/mL) in PACU

73±195

91±235

0.683

Postoperative IVC<50%

28%

15%

0.016*

Measurement data are expressed as mean ± standard deviation (cases) or median (25%, 75%) and count data are expressed as quantity (%). SBP: systolic blood pressure; DBP: diastolic blood pressure; MAP: mean arterial pressure; cLac: Serum Lactic Acid; CI: Heart Index; HR: Heart Rate; SVV: Stroke Volume Variation. *p<0.05, **p<0.01.

Table 3: Postoperative data.

 

SVV group

(N=60)

CON group (N=61)

P-value

Postoperative dialysis

 

 

 

  MAP at the start of hemofiltration(mmHg)

99±19

99±21

0.916

  MAP at the end of hemofiltration(mmHg)

97±19

97±20

0.849

  Ultrafiltration capacity (L)

2.1±1.0

1.9±0.9

0.596

  Ultrafiltration flow (mL/min)

237±27

243±28

0.363

Hospitalization days (days)

4.2±1.5

4.9±1.6

0.059

Types of postoperative complications

 

 

 

  Wound bleeding/wound hematoma (case)

1

2

 

  Recurrent laryngeal nerve injury (case)

0

0

 

  Hypertension (case)

4

3

 

  Hypotension (case)

8

11

 

  Hypocalcemia (case)

20

24

 

  Hyperkalemia (case)

8

8

 

  Infection

 

 

 

    Wound infection (case)

0

0

 

    Respiratory tract infection (case)

3

4

 

Cardiovascular and cerebrovascular events

 

 

 

    Angina pectoris (case)

1

0

 

    Myocardial infarction (case)

0

0

 

    Arrhythmia (case)

1

3

 

Heart failure (case)

1

0

 

Cerebral infarction (case)

0

1

 

Complication rate within 7 days after operation

33%

53%

0.046*

Complication rate within 30 days after surgery

53%

59%

0.335

Rehospitalization rate

20%

26%

0.475

Lost to follow-up rate

12%

8%

0.525

Measurement data are expressed as mean ± standard deviation (cases) or median (25%, 75%) and count data are expressed as quantity (%). SBP: systolic blood pressure; DBP: diastolic blood pressure; MAP: mean arterial pressure; cLac: Serum Lactic Acid; CI: Heart Index; HR: Heart Rate; SVV: Stroke Volume Variation. *p<0.05, **p<0.01.

Table 4: Perioperative blood pressure variability (BPV)

Blood pressure variability (BPV)

SVV group (N=60)

CON group (N=61)

p value

CV preoperative-out of the room

19.85(18.00,19.85)

20.91(19.53,22.07)

0.134

CV before-6h after operation

10.44(7.31,12.62)

11.99(9.71,15.84)

0.029*

CV before-12h after operation

9.80(6.70,12.66)

12.93(8.58,21.03)

<0.001**

CV before-24h after operation

9.77(7.01,12.21)

14.28(9.03,20.42)

<0.001**

CV postoperative-dialysis

3.24(1.53,7.04)

3.77(1.44,8.04)

0.665

Measurement data are expressed as median (25%, 75%), CV: coefficient of variation, CV=SDMAP/MAP×100%, *p<0.05, **p<0.01.