Abstract
IntroductionGoal-directed therapy (GDT) has been shown in numerous studies to decrease perioperative morbidity and mortality. The mechanism of benefit of GDT, however, has not been clearly elucidated. Targeted resuscitation of the vascular endothelium with GDT might alter the postoperative inflammatory response and be responsible for the decreased complications with this therapy.MethodsThis trial was registered at ClinicalTrials.gov as NCT01681251. Forty patients undergoing elective open repair of their abdominal aortic aneurysm, 18 years of age and older, were randomized to an interventional arm with GDT targeting stroke volume variation with an arterial pulse contour cardiac output monitor, or control, where fluid therapy was administered at the discretion of the attending anesthesiologist. We measured levels of several inflammatory cytokines (C-reactive protein, Pentraxin 3, suppressor of tumorgenicity--2, interleukin-1 receptor antagonist, and tumor necrosis factor receptor-III) preoperatively and at several postoperative time points to determine if there was a difference in inflammatory response. We also assessed each group for a composite of postoperative complications.ResultsTwenty patients were randomized to GDT and twenty were randomized to control. Length of stay was not different between groups. Intervention patients received less crystalloid and more colloid. At the end of the study, intervention patients had a higher cardiac index (3.4 ± 0.5 vs. 2.5 ± 0.7 l/minute per m2, p < 0.01) and stroke volume index (50.1 ± 7.4 vs. 38.1 ± 9.8 ml/m2, p < 0.01) than controls. There were significantly fewer complications in the intervention than control group (28 vs. 12, p = 0.02). The length of hospital and ICU stay did not differ between groups. There was no difference in the levels of inflammatory cytokines between groups.ConclusionsDespite being associated with fewer complications and improved hemodynamics, there was no difference in the inflammatory response of patients treated with GDT. This suggests that the clinical benefit of GDT occurs in spite of a similar inflammatory burden. Further work needs to be performed to delineate the mechanism of benefit of GDT.Trial registrationClinicalTrials.gov Identifier: NCT01681251. Registered 18 May 2011.
Highlights
Goal-directed therapy (GDT) has been shown in numerous studies to decrease perioperative morbidity and mortality
The goal-directed therapy (GDT) method of fluid administration relies on the utilization of minimally invasive cardiac output monitoring to tailor fluid administration to a maximal cardiac output or other reliable markers of preload such as stroke volume variation (SVV) or pulse pressure variation (PPV) [5]
This increase in cardiac index (CI) was due to an increase in the amount of colloid administered in the intervention group
Summary
Goal-directed therapy (GDT) has been shown in numerous studies to decrease perioperative morbidity and mortality. Targeted resuscitation of the vascular endothelium with GDT might alter the postoperative inflammatory response and be responsible for the decreased complications with this therapy. The studies performed to date, predominantly in patients undergoing gastrointestinal surgery, have demonstrated that the utilization of GDT decreases morbidity, mortality and both hospital and ICU length of stay [6,7,8,9,10,11]. The benefit of GDT in vascular surgery patients has been less robust, presumably due to the higher rate of cardiovascular complications in this patient population [12, 13]. There has been a suggestion by some that GDT reduces gut mucosal hypoperfusion and this may result in a less robust inflammatory response to surgery [17, 18]
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