title: Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial.
abstract: BACKGROUND
  Anesthetics and neuraxial anesthesia commonly result in vasodilation/hypotension. Norepinephrine counteracts this effect and thus allows for decreased intraoperative hydration. The authors investigated whether this approach could result in reduced postoperative complication rate.
  
  
  METHODS
  In this single-center, double-blind, randomized, superiority trial, 166 patients undergoing radical cystectomy and urinary diversion were equally allocated to receive 1 ml·kg·h of balanced Ringer's solution until the end of cystectomy and then 3 ml·kg·h until the end of surgery combined with preemptive norepinephrine infusion at an initial rate of 2 µg·kg·h (low-volume group; n = 83) or 6 ml·kg·h of balanced Ringer's solution throughout surgery (control group; n = 83). Primary outcome was the in-hospital complication rate. Secondary outcomes were hospitalization time, and 90-day mortality.
  
  
  RESULTS
  In-hospital complications occurred in 43 of 83 patients (52%) in the low-volume group and in 61 of 83 (73%) in the control group (relative risk, 0.70; 95% CI, 0.55-0.88; P = 0.006). The rates of gastrointestinal and cardiac complications were lower in the low-volume group than in the control group (5 [6%] vs. 31 [37%]; relative risk, 0.16; 95% CI, 0.07-0.39; P < 0.0001 and 17 [20%] vs. 39 [48%], relative risk, 0.43; 95% CI, 0.26-0.60; P = 0.0003, respectively). The median hospitalization time was 15 days [range, 11, 27d] in the low-volume group and 17 days [11, 95d] in the control group (P = 0.02). The 90-day mortality was 0% in the low-volume group and 4.8% in the control group (P = 0.12).
  
  
  CONCLUSIONS
  A restrictive-deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy and urinary diversion significantly reduced the postoperative complication rate and hospitalization time.
authors.affiliation: From the Department of Anaesthesiology and Pain Therapy (P.Y.W., F.S.) and Department of Urology (F.C.B., G.N.T., U.E.S.), University Hospital Bern, Bern, Switzerland.
authors.forename: Patrick Y
authors.initials: PY
authors.lastname: Wuethrich
authors.forename: Fiona C
authors.initials: FC
authors.lastname: Burkhard
authors.forename: George N
authors.initials: GN
authors.lastname: Thalmann
authors.forename: Frank
authors.initials: F
authors.lastname: Stueber
authors.forename: Urs E
authors.initials: UE
authors.lastname: Studer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers; D000077324:Crystalloid Solutions; D015653:Cystectomy / Q000379:methods* / Q000401:mortality; D004311:Double-Blind Method; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007262:Infusions, Intravenous; D007552:Isotonic Solutions / Q000627:therapeutic use; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000008:administration & dosage / Q000627:therapeutic use*; D010952:Plasma Substitutes / Q000627:therapeutic use; D011182:Postoperative Care; D011183:Postoperative Complications / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control*; D011446:Prospective Studies; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D015415:Biomarkers; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions; D010952:Plasma Substitutes; D014662:Vasoconstrictor Agents; D009638:Norepinephrine