Highs and lows in high-risk surgery: the controversy of goal-directed haemodynamic management

Jukka Takala

doi:10.1186/cc3929

Abstract

Although various systems have been developed to identify patients at increased risk of peri- and postoperative mortality and morbidity, little effort has been made in developing tools to reduce this risk. In this issue of Critical Care, Pearse et al. publish two reports related to predicting and improving outcome in high-risk surgical patients. Rather than conducting large, multicentre, randomised, controlled trials, the research group at St George's Hospital in London has persistently and systematically tested the concept of goal-directed haemodynamic management in high risk surgery in their single-centre setting. Their results have been impressive, demonstrating that in this setting, various outcome measures can be reduced with goal-directed haemodynamic management. The impressive positive results of the Pearse studies contrast sharply with the negative results of multicentre studies, such as that of Sandham et al. One reason may be that, like several other successful single-centre trials, Pearse et al. used strict treatment protocols rather than guidelines. In addition, single-centre studies utilize their investigators' knowledge of their patients' risk profiles and familiarity with the care processes and infrastructures of their institutions. An understanding of the organisational and case-mix aspects of pre-, peri-and post-operative management is vital for planning multicentre trials of goal-directed management.

Highlights

McKendry et al [13] showed in cardiac surgery patients that haemodynamic management driven by stroke volume postoperatively reduced the length of hospital stay
The present study by Pearse et al [7] demonstrates reduced morbidity and length of hospital stay in high-risk patients undergoing major, predominantly vascular or abdominal surgery when receiving oxygen-delivery-driven goal-directed management based on lithium indicator dilution and pulse power cardiac output
The management of the control group was strictly protocolised, based on central venous pressure-driven fluid challenges. This series of single-centre studies with impressive positive results is in sharp contrast to the negative results of the multicenter study by Sandham et al [14], where patients undergoing major surgery were randomised to receive pulmonary artery catheter with oxygen transport-driven guidelines for peri- and postoperative haemodynamic management versus conventional management

Summary

Introduction

Risk of death and major complications after surgery is impressively low today in the general surgical patient population: less than 1% of all patients undergoing surgery die during the same hospital admission [1]. In patients undergoing major abdominal surgery, the presence of more than one clinical risk factor of surgical complications may increase the postoperative mortality threeto four-fold [2]. What is much more surprising is how little effort has been invested in developing tools to reduce the risk of peri- and postoperative complications in well-defined patient groups at high risk, and how little success has been achieved in this area.

Results

Conclusion