Algorithm-guided goal-directed haemodynamic therapy does not improve renal function after major abdominal surgery compared to good standard clinical care: a prospective randomised trial.

Sebastian Schmid,Markus Heim,Bettina Jungwirth,Manfred Blobner,Barbara Kapfer,Ralph Bogdanski,Aida Anetsberger

doi:10.1186/s13054-016-1237-1

Abstract

BackgroundAcute kidney injury is a common complication after major surgery. In this study, we investigated whether an algorithm-guided goal-directed haemodynamic therapy (GDT) can improve renal outcome compared to good standard clinical care.MethodsA total of 180 patients undergoing major abdominal surgery were prospectively and randomly assigned to one of two groups: in the GDT group, patients were treated with a GDT algorithm using transpulmonary thermodilution while standard care was applied to the control patients. Change in creatinine was studied as the primary end point, postoperative complications as well as 1-year mortality as secondary outcomes. Haemodynamics in GDT and control patients were compared calculating goal-achievement rates.ResultsPostoperative change in creatinine (18 ± 39 μmol/l (control) vs. 16 ± 42 μmol/l (GDT); mean difference (95 % confidence interval) 1.6 μmol/l (−10 to 13 μmol/l)) was comparable between the GDT and the control group. Postoperative complications and mortality during hospital stay and after 1 year were not influenced by the use of a GDT algorithm. Achievement rates of haemodynamic goals were not higher in the GDT group compared to the already high (>80 %) rates in the control group. Multivariate regression analysis revealed intraoperative hypotension (MAP < 70 mmHg) and postoperative hypovolaemia (GEDI < 640 ml/m2) as risk factors for postoperative renal impairment.ConclusionsIn this study, GDT was not superior to standard clinical care in order to avoid renal failure after major abdominal surgery. The reason for this finding is most likely the high achievement rate of haemodynamic goals in the control group, which cannot be improved by the GDT algorithm.Trial registrationClinicaltrials.gov; NCT01035541; registered 17 December 2009.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1237-1) contains supplementary material, which is available to authorized users.

Highlights

Acute kidney injury is a common complication after major surgery
The aim of this study was to investigate if an intra- and postoperative goal-directed haemodynamic therapy (GDT) algorithm can improve renal outcomes after major abdominal surgery compared to standard clinical care
Thirteen patients were excluded from the analysis, as they did not receive the allocated intervention, that means surgery was terminated due to unexpected findings during the operation

Summary

Introduction

Acute kidney injury is a common complication after major surgery. In this study, we investigated whether an algorithm-guided goal-directed haemodynamic therapy (GDT) can improve renal outcome compared to good standard clinical care. Hypoperfusion and haemodynamic instability resulting in a mismatch of oxygen demand and delivery are discussed in the pathogenesis of postoperative renal impairment, raising the question whether perioperative goal-directed haemodynamic therapy (GDT) might improve postoperative renal outcome [5, 6]. Most of the studies investigated vascular and cardiac surgery patients and used a composite end point of perioperative morbidity in lieu of renal outcome [7] It is not known yet, whether an algorithmguided GDT is superior to a haemodynamic therapy guided by established clinical standard of care in order to avoid renal failure after non-cardiac surgery. As just a few studies have recorded achievement rates of haemodynamic goals in both the algorithm-guided GDT as well as the standard clinical care, the conclusion that the use of a GDT algorithm can effectively improve haemodynamic state cannot be drawn yet

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