Goal-directed fluid therapy vs. low central venous pressure during major open liver resections (GALILEO): a surgeon- and patient-blinded randomized controlled trial

Markus W Hollmann,Bart F Geerts,Marc G Besselink,Martin V.H Rutten,Rogier V Immink,Thomas M Van Gulik,Zühre Uz,Timothy H Mungroop,Iris M Jongerius,Denise P Veelo

doi:10.1016/j.hpb.2021.03.013

Markus W Hollmann, Bart F Geerts + Show 8 more

Open Access

https://doi.org/10.1016/j.hpb.2021.03.013

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Journal: HPB	Publication Date: Apr 12, 2021
Citations: 11	License type: cc-by

Affiliation: Amsterdam University Medical Centers

Abstract

BackgroundLow central venous pressure (low-CVP) is the clinical standard for fluid therapy during major liver surgery. Although goal-directed fluid therapy (GDFT) has been associated with reduced morbidity and mortality in major abdominal surgery, concerns remain on blood loss when applying GDFT in liver surgery. This randomized trial compared outcomes of low-CVP and GDFT during major liver resections. MethodsIn this surgeon- and patient-blinded RCT, patients undergoing major open liver resections (≥3 segments) were randomized between low-CVP (n = 20) or GDFT (n = 20). Primary outcome was intraoperative blood loss. Secondary outcomes included the quality of the surgical field (VAS scale 0 (worst)-100 (best)) and major morbidity (≥grade 3 Clavien-Dindo). ResultsDuring surgery, CVP was 3 ± 2 mmHg in the low-CVP group vs. 7 ± 3 mmHg in the GDFT group (P < 0.001). Blood loss (1425 vs. 1275 mL; P = 0.640) and the rate of major morbidity (40% vs. 50%, P = 0.751), did not differ between low-CVP and GDFT, respectively. The quality of the surgical field was comparable between groups (low-CVP 83% vs. GDFT 80%, P = 0.955). ConclusionIn major open liver resections, GDFT was not associated with differences in intraoperative blood loss, major morbidity or quality of the surgical field, compared to low-CVP. Larger RCTs are needed to confirm this finding. Registration number: NTR5821 (www.trialregister.nl).

Highlights

In contrast to a commonly held belief, this small randomized trial found that goal-directed fluid therapy (GDFT) did not lead to an increase in blood loss or reduced quality of the surgical field compared to Low central venous pressure (low-central venous pressure (CVP)) during major open liver resections
Since no significant disadvantages of GDFT were observed, and mean blood loss was 125 mL less with GDFT, the study suggests that GDFT can be used safely in major liver surgery and routine application of low-CVP in liver surgery might be unnecessary
Since GDFT was started directly after induction of anaesthesia, optimal tissue perfusion throughout the entire procedure and postoperative process is pursued. This was the first trial that examined the commonly used rationale for low-CVP by liver surgeons, i.e., that low-CVP improves the quality of the surgical field and a higher CVP could worsen it

Summary

Introduction

Intraoperative blood loss during major liver resection is associated with increased perioperative morbidity and mortality. Techniques to reduce intraoperative blood loss during transection of the liver include vascular inflow occlusion and reduction of the central venous pressure (CVP) using nitro-glycerine (NTG) infusion, head-up positioning and restrictive fluid management.3 – 6Low-CVP is believed to lower the venous pressure in the hepatic vascular bed and decrease venous backflow, resulting in reduced blood loss while transecting the liver. A majority of liver surgeons worldwide (77%) prefer low-CVP during major liver resections. risks of perioperative fluid restriction and ensuing organ hypo-perfusion seem to be insignificant in small RCT’s assessing low-CVP during liver surgery, larger trials incorporating all types of non-cardiac surgery reported an association between intraoperative fluid restriction and impaired postoperative outcome. In addition, intraoperative hypotension has been associated with adverse events e.g., acute kidney injury and an increase in 30-day mortality.. Intraoperative blood loss during major liver resection is associated with increased perioperative morbidity and mortality.. Goal-directed fluid therapy (GDFT) has been associated with reduced morbidity and mortality in major abdominal surgery, concerns remain on blood loss when applying GDFT in liver surgery. This randomized trial compared outcomes of low-CVP and GDFT during major liver resections. Methods: In this surgeon- and patient-blinded RCT, patients undergoing major open liver resections (3 segments) were randomized between low-CVP (n = 20) or GDFT (n = 20). Conclusion: In major open liver resections, GDFT was not associated with differences in intraoperative blood loss, major morbidity or quality of the surgical field, compared to low-CVP.

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