Abstract
BackgroundIntraoperative fluid therapy guided by mechanical ventilation-induced pulse-pressure variation (PPV) may improve outcomes after major surgery. We tested this hypothesis in a multi-center study.MethodsThe patients were included in two periods: a first control period (control group; n = 147) in which intraoperative fluids were given according to clinical judgment. After a training period, intraoperative fluid management was titrated to maintain PPV < 10% in 109 surgical patients (PPV group). We performed 1:1 propensity score matching to ensure the groups were comparable with regard to age, weight, duration of surgery, and type of operation. The primary endpoint was postoperative hospital length of stay.ResultsAfter matching, 84 patients remained in each group. Baseline characteristics, surgical procedure duration and physiological parameters evaluated at the start of surgery were similar between the groups. The volume of crystalloids (4500 mL [3200-6500 mL] versus 5000 mL [3750-8862 mL]; P = 0.01), the number of blood units infused during the surgery (1.7 U [0.9-2.0 U] versus 2.0 U [1.7-2.6 U]; P = 0.01), the fraction of patients transfused (13.1% versus 32.1%; P = 0.003) and the number of patients receiving mechanical ventilation at 24 h (3.2% versus 9.7%; P = 0.027) were smaller postoperatively in PPV group. Intraoperative PPV-based improved the composite outcome of postoperative complications OR 0.59 [95% CI 0.35-0.99] and reduced the postoperative hospital length of stay (8 days [6-14 days] versus 11 days [7-18 days]; P = 0.01).ConclusionsIn high-risk surgeries, PPV-directed volume loading improved postoperative outcomes and decreased the postoperative hospital length of stay.Trial RegistrationClinicalTrials.gov Identifier; retrospectively registered- NCT03128190
Highlights
Intraoperative fluid therapy guided by mechanical ventilation-induced pulse-pressure variation (PPV) may improve outcomes after major surgery
It was observed that the incidence of non-dialytic renal failure, the white cell count, mean arterial pressure (MAP) and duration of surgery were significantly greater than in the PPV group, while the incidence of cirrhosis, tidal
Postoperative outcomes in the propensity matched cohort Upon Intensive care unit (ICU) admission and 24 h later, the MAP and Heart rate (HR) were similar in both groups (Table 3)
Summary
Intraoperative fluid therapy guided by mechanical ventilation-induced pulse-pressure variation (PPV) may improve outcomes after major surgery. We tested this hypothesis in a multi-center study. Intraoperative hemodynamic strategies aiming to maintain adequate oxygen delivery have been shown to reduce morbidity, mortality, and postoperative length of hospital stay in several publications [4,5,6,7]. Despite the evidence favoring intraoperative hemodynamic optimization in high-risk patients, [8] the role of each intervention in increasing oxygen delivery remains unclear. Excessive fluid administration may aggravate pulmonary dysfunction, prolong the need for mechanical ventilation, extend the hospital length of stay and increase postoperative mortality [9]
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