How are hemodynamic changes managed in patients undergoing total gastrectomy?

Management of Hemodynamic Changes in Total Gastrectomy

Hemodynamic management in total gastrectomy requires careful fluid balance, vasopressor support when needed, and vigilant monitoring to prevent complications from both fluid deficit and overload. 1

Preoperative Hemodynamic Optimization

• Goal-directed hemodynamic preoptimization should be considered for high-risk patients undergoing total gastrectomy 1
• Preoperative assessment should include:
  • Cardiac risk stratification
  • Evaluation of baseline fluid status
  • Thromboembolic risk assessment with appropriate prophylaxis 1

Intraoperative Hemodynamic Management

Fluid Management

• Aim for near-zero fluid balance to reduce complications by 59% and hospital stay by 3.4 days 1
• Avoid excess 0.9% saline which can cause:
  • Hyperosmolar states
  • Hyperchloremic acidosis
  • Decreased renal blood flow and glomerular filtration
  • Reduced gastric blood flow and decreased gastric intramucosal pH 1

Vasopressor Support

• For hypotensive patients receiving epidural analgesia, use vasopressors rather than indiscriminate fluid boluses 1
• This approach maintains hemodynamic stability while avoiding fluid overload complications

Monitoring Parameters

• Key parameters to monitor:
  • Heart rate
  • Arterial pressure
  • Central venous pressure
  • Stroke volume/cardiac output
  • Pulse pressure variation 2

Postoperative Hemodynamic Changes and Management

Expected Hemodynamic Changes

• Cardiac output and cardiac index typically increase significantly until POD 3 3
• Blood volume decreases significantly on POD 1 compared to preoperative levels 3
• Total gastrectomy patients show greater hemodynamic changes than those with distal gastrectomy 4

Fluid Management

• Intravenous fluid therapy usually unnecessary beyond day of operation except for upper GI procedures 1
• When IV fluids are required:
  • Provide maintenance fluids at 25-30 ml/kg/day
  • Limit sodium to 70-100 mmol/day
  • Add potassium supplements up to 1 mmol/kg/day 1
• Replace ongoing losses (vomiting, high stoma output) on a like-for-like basis 1

Nutritional Support

• Begin oral diet on morning after surgery when possible 1
• For malnourished patients, consider nutritional support for 10-14 days 1
• TPN should be initiated once hemodynamic stability is achieved (typically 7-10 days after surgery) 1
• Provide 25-30 kcal/kg/day and 1.0-1.5 g/kg/day of protein 1

Managing Hemodynamic Complications

Bleeding Management

• For hemodynamically stable patients with GI bleeding:
  • Endoscopy is first-line diagnostic and therapeutic approach 1
  • Consider angio-CT and embolization if endoscopy fails 1
• For hemodynamically unstable patients:
  • Immediate surgical exploration without delay 1, 5
  • Do not delay surgery for additional imaging in unstable patients 5

Thromboembolic Prophylaxis

• Administer low-molecular-weight heparin as soon as possible 1
• Adjust dose based on patient weight, thrombotic risk, and creatinine clearance 1
• Continue prophylaxis for at least 4 weeks after discharge 1
• Consider anti-Xa level monitoring for patients with BMI ≥35 kg/m² 1

Pitfalls to Avoid

• Fluid overload: Can cause splanchnic edema, increased abdominal pressure, decreased mesenteric blood flow, ileus, and anastomotic dehiscence 1
• Fluid deficit: Can lead to decreased venous return, cardiac output, tissue perfusion, and oxygen delivery 1
• Delayed intervention: For unstable patients with ongoing bleeding, surgical exploration should not be delayed 5
• Inadequate VTE prophylaxis: Patients with gastrointestinal malignancy are at high risk for thromboembolism 1

By carefully managing hemodynamics during total gastrectomy, monitoring for expected changes, and promptly addressing complications, outcomes can be optimized for these complex surgical patients.