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Most of these techniques require trained staff, are costly, and involve a lengthy set
up. In order to be cost- effective, they should not be routinely employed, but indicated on a case by case basis [51].
NIRS measures the oxygenation of the cerebral cortex as it correlates to cerebral
oxygenation. The cerebral oxygen supply can be added to regional blood ow and
using other patient factors such as intraoperative surgical eld events, hemoglobin
values, pulse oximeter, mean arterial pressure, one can estimate cerebral oxygenation capacity [52].
R. Madhani et al.
Invasive Arterial Pressure
Common reasons to use an arterial line encompass induced hypotension, anticipated hypotension, hemodynamic instability, and precise beat-to-beat monitoring in
patients with end organ disease. Other indications involve monitoring arterial waveforms for abnormal patterns, analyzing arterial pressure waveform to help predict
uid responsiveness, and obtaining arterial blood samples [53].
Contraindications list thrombus, infection, thrombocytopenia (<30,000 per
microliter of blood) or distorted anatomy (aneurysm, congenital malformation, arteriovenous stula, stent, vascular graft) at the puncture site. Concern for lack of collateral blood ow or vascular insufciency (peripheral artery disease or Raynaud
disease) deserves mention as well [54].
Complications include local or systemic infection, bruising, edema, vasospasm, bleeding, hematoma, thromboembolism, pseudoaneurysm of arteriovenous stula formation at the site, air embolism, or damage to surrounding
structures [53]. The shape of the arterial waveform is dened by the degree of
upstroke which represents contractility, and the degree of downstroke which represents peripheral vascular resistance [53]. The shape of the waveform can provide insight into different hemodynamic variables and can be altered by different
pathologies involving the heart, valves, surrounding vasculature and pericardium.
The mean arterial pressure (MAP) is measured in every surgery to help ensure
adequate organ perfusion.
Arterial pressure waveforms measured at the periphery have higher systolic
blood pressures, steeper systolic upstroke, lower diastolic blood pressure, wider
pulse pressures, and lower and later dicrotic notches [55]. The level of the pressure transducer position is critical. In most cases, the transducer should be placed
even with the heart, which is either 5cm behind the sternum or at the mid axillary
line in a supine patient. If patient positioning is changed, the position of the transducer should be adjusted to make sure it continues level with the heart [56].
Arterial pressure waveform analysis can be used to assess various indices such as
pulse pressure variation (PPV), systolic blood pressure variation (SPV) and stroke
volume variation (SVV), to help determine uid responsiveness [57].
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Central Venous Pressure
Central Venous Pressure (CVP) is dened as the pressure that blood exerts on the
walls of the inferior vena cava (IVC) near the entry to the right atrium. It reects the
amount of blood returning to the heart, and is used to estimate preload to the heart.
The normal range for CVP is dened as 8–12mmHg and can uctuate with changes
in intravascular volume or venous compliance [58]. Recent studies reveal that CVP
is an unreliable predictor of uid responsiveness [58, whereas arterial pulse pressure variation (PPV) evident in mechanically ventilated patients is a sensitive and
specic marker of uid responsiveness [59], yielding decreased postoperative complications and lengths of hospital stay [60]. Right atrial pressure and jugular venous
pulse pressure could be alternative markers for poor systolic heart function and
volume overload.
Systolic Pressure Variation (SPV)/Pulse Pressure
Variation (PPV)
These are often documented variables in critically ill patients, and are endowed with
prognostic value. Nevertheless, there are many pitfalls in their interpretation and
bedside use [61, 62]. In mechanically ventilated patients, the degree of respiratory
variation on stroke volume (SVV) can accurately predict uid responsiveness [63].
PPV is most effective in patients on mechanical ventilation receiving a tidal volume of 6-8mL/kg and who are not triggering spontaneous breaths, although spontaneous breathing activity might not interfere as much as previously thought [64]
Also, the patients must be in sinus rhythm as arrhythmias can affect contractility
and thus pulse pressure [65].
PPV has been shown to be more effective when compared to CVP [63].
Monitoring pulse pressure variation and minimizing the change in pulse pressure
through uid administration during high-risk surgical procedures has been found to
improve postoperative outcomes and decrease hospital length of stay [66].
Stroke Volume Variation
Stroke Volume variation (SVV) is classied under the same physiological principles
as PPV.It is usually measured through an arterial catheter that analyzes atrial compliance and systemic vascular resistance to create the arterial pressure waveform. SVV
can be calculated from this waveform, as well as from devices that measure aortic
blood ow velocity such as esophageal Doppler, bioimpedance, and bioreactance.
Numerous studies have found that a SVV>10% indicates uid responsiveness [67].
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R. Madhani et al.
SVV has the same limitations as PPV, plus some additional inuential factors,
such as patient position. One study showed that stroke volume (SV) is decreased in
patients in prone and 30 degree head-up positions. This decrease in SV leads to an
increase in SVV [68]. PPV may be preferred also because the transducer used to
measure SVV is more expensive and may not always be available [69].
SVV 100 (SVmax -SVmin)SVmean
/
Pulmonary Capillary Wedge Pressure
Pulmonary capillary wedge pressure (PCWP) is often used to assess left atrial pressure. It is also related to left ventricle lling pressure, left ventricle end diastolic
pressure (LVEDP) and mitral valve function. During heart relaxation in a patient
without mitral stenosis, the left ventricle, left atrium, and pulmonary veins are in a
continuous circuit therefore PCWP is indicative of LVEDP [70]. A normal pulmonary capillary wedge pressure is considered between 4-12mmHg. Mitral stenosis
and left ventricular failure can cause elevated PCWPs [71].
PCWP is useful in circumstances of mitral stenosis, as well as for diagnosing pulmonary hypertension. This last condition triggers increased perioperative morbidity and
mortality. PCWP can be used to differentiate between cardiogenic and noncardiogenic
pulmonary edema. Findings greater than 18mmHg usually indicate increased cardiac
pressures which back up through the pulmonary circulation causing elevated pulmonary
capillary pressures and increase capillary permeability causing edema [72]. Given the
invasiveness of pulmonary artery catheter (PAC) placement, its adoption is diminishing
and other devices are preferred to assess hemodynamic status [72–74].
Mixed Venous Oxygen Saturation
Mixed venous oxygen saturation (SvO2) is believed to be endowed with prognostic
abilities in seriously ill patients, as abnormal values are generally associated with
tissue hypoxia and higher mortality [75]. Nevertheless precision and trending ability are low and only blood collected with a distally placed pulmonary artery catheter
(ScvO2) permits reliable estimations [75–80].
Echocardiography
Transthoracic (TTE) and transesophageal (TEE) echocardiography (gehealthcare.
com, philips.com and others) are valuable tools for bedside evaluation of a
patient’s cardiopulmonary conditions. Indications for TTE in a perioperative
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61
setting should generally be reserved for assessment of hemodynamic changes that
are unresolving with standard care such as volume shifts, cardiac function, or
pulmonary pathology, without the use of other imaging techniques that would
require patient transportation. This includes invasive surgeries such as high risk
cardiac and cardiothoracic procedures, certain liver resections, and major transplantations. The indication should be based on the patient’s past medical conditions as well as on ongoing alterations in cardiac structure and function. TEE is
much more invasive compared to the TTE with risk of esophageal injury, and
requires a competent physician for interpretation. At the same time it provides a
larger array of information including cardiac output, stroke volume and intra
luminal pressures. It allows for evaluation and diagnosis of structural diseases
relating to the heart chambers, valves or surrounding vessels. TEE can create
three dimensional views of the heart, enabling diagnosis of structural diseases
relating to the heart chambers, valves or surrounding vessels. Nevertheless TEE
should be reserved to teams familiar with the technique, notably for operative
decisions dependent on ndings of TEE [81].
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Part II
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Lifestyle Interventions
Chapter 5
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Prehabilitation forGastrointestinal Cancer
Surgery
JoelLambert, DarenSubar, andChristopherGaffney
Abbreviations
COPD Chronic Obstructive Pulmonary Disease
COVID-19 Coronavirus disease 2019
CPET Cardiopulmonary Exercise Test
ECG Electrocardiography
ERAS Enhanced Recovery After Surgery
ESPEN European Society for Clinical Nutrition and Metabolism
GI Gastrointestinal
MDT Multi-Disciplinary Team
MUST Malnutrition Universal Screening Tool
NHS National Health Service
NIHR National Institute of Health Research
RCT Randomised Controlled Trial
SPECS Standard care versus Prehabilitation in patients undergoing Elective
hepatopancreatobiliary and colorectal Cancer Surgery
WHO World Health Organisation
J. Lambert · D. Subar
Lancaster Medical School, Lancaster University, Lancaster, UK
East Lancashire Hospitals NHS Trust, Blackburn, UK
BRIDGES Research Group, Department of General Surgery, Royal Blackburn Teaching
Hospitals NHS Trust, Blackburn, UK
e-mail: j.lambert1@lancaster.ac.uk; Daren.Subar@elht.nhs.uk
C. Gaffney (
Lancaster Medical School, Lancaster University, Lancaster, UK
e-mail: c.gaffney@lancaster.ac.uk
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_5
*)
69© The Author(s), under exclusive license to Springer Nature
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