Abstract
BackgroundSeveral randomized controlled trials (RCTs) have demonstrated that intraoperative goal-directed fluid therapy (GDFT) can decrease postsurgical complications in patients undergoing major abdominal surgery. However, very few studies have demonstrated the value of goal-directed therapy (GDT) in patients undergoing orthopaedic surgery and confirmed it is as useful in real-life conditions. Therefore, we initiated a GDFT implementation programme in patients undergoing hip revision arthroplasty in order to assess its effects on postoperative complications (e.g. infection, cardiac, neurological, renal) (primary outcome) and hospital and intensive care unit (ICU) length of stay (secondary outcomes).MethodsWe developed a GDFT protocol for the haemodynamic management of patients undergoing hip revision arthroplasty. The GDFT protocol was based on continuous monitoring and optimization of stroke volume during the surgical procedure. From December 2012 and for a period of 17 months, 130 patients were treated according to the GDFT protocol (GDFT group). The pre-, intra-, and postoperative characteristics of patients from the GDFT group were compared to those of 130 historical matched patients (control group) who had the same surgery between January 2011 and August 2012.ResultsPatients from the GDFT and from the control group were comparable in terms of age, comorbidities, and P-POSSUM score. Duration of anaesthesia and surgery were also comparable. The GDFT group had a significantly lower morbidity rate (49.2 vs. 66.9%; p = 0.006) and a shorter median hospital length of stay (11 days (9–15) vs. 9 days (8–12); p = 0.003) than the control group. Patients from the control group post-anaesthesia care unit (PACU)/ICU stayed significantly longer at PACU/ICU than patients from the GDFT group (control group vs. GDFT group, 960 min (360–1210) vs. 400 min (207–825); p < 0.001) Patients from the GDFT group received less crystalloids but more colloids during surgery. They also received more often inotropic therapy.ConclusionsIn patients undergoing hip revision arthroplasty, the implementation of GDT as a new standard operating procedure was successful and associated with reduced postsurgical complications, most importantly a reduction in postoperative bleeding as well as hospital and ICU stay.Trial registrationClinicalTrials.gov, NCT01753050 Electronic supplementary materialThe online version of this article (doi:10.1186/s13741-016-0056-x) contains supplementary material, which is available to authorized users.
Highlights
Several randomized controlled trials (RCTs) have demonstrated that intraoperative goal-directed fluid therapy (GDFT) can decrease postsurgical complications in patients undergoing major abdominal surgery
Pearse et al demonstrated in their randomized trial of high-risk patients undergoing major gastrointestinal surgery that the use of a cardiac output-guided haemodynamic therapy algorithm when compared did not significantly reduce postoperative complications and 30-day mortality (Pearse et al 2014); (2) RCTs are done in highly selected patients with extra human and financial resources, such that the extrapolation of their results to the real world may be questioned (Vincent 2009); and (3) only a few studies have been done in orthopaedic patients and none in patients undergoing hip revision arthroplasty
Patients from the GDFT group were compared to 130 historical matched control patients who underwent the same surgical procedure from January 1, 2011, to August 30, 2012, before we developed the algorithm for the prospective group
Summary
Several randomized controlled trials (RCTs) have demonstrated that intraoperative goal-directed fluid therapy (GDFT) can decrease postsurgical complications in patients undergoing major abdominal surgery. Many randomized controlled trials (RCTs) and metaanalysis suggest that perioperative goal-directed fluid therapy (GDFT) decreases postsurgical complications and length of hospital stay in patients undergoing major abdominal procedures (Benes et al 2010; Gan et al 2002; Grocott et al 2012; Hamilton et al 2011; Lopes et al 2007). Pearse et al demonstrated in their randomized trial of high-risk patients undergoing major gastrointestinal surgery that the use of a cardiac output-guided haemodynamic therapy algorithm when compared did not significantly reduce postoperative complications and 30-day mortality (Pearse et al 2014); (2) RCTs are done in highly selected patients with extra human and financial resources, such that the extrapolation of their results to the real world may be questioned (Vincent 2009); and (3) only a few studies have been done in orthopaedic patients and none in patients undergoing hip revision arthroplasty. Patients undergoing revision hip surgery are usually old and often have comorbidities, increasing their risk of complications after surgery
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