Abstract
IntroductionSeveral single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients. We hypothesized that using a treatment algorithm based on pulse pressure variation, cardiac index trending by radial artery pulse contour analysis, and mean arterial pressure in a study group (SG), would result in reduced complications, reduced length of hospital stay and quicker return of bowel movement postoperatively in abdominal surgical patients, when compared to a control group (CG).Methods160 patients undergoing elective major abdominal surgery were randomized to the SG (79 patients) or to the CG (81 patients). In the SG hemodynamic therapy was guided by pulse pressure variation, cardiac index trending and mean arterial pressure. In the CG hemodynamic therapy was performed at the discretion of the treating anesthesiologist. Outcome data were recorded up to 28 days postoperatively.ResultsThe total number of complications was significantly lower in the SG (72 vs. 52 complications, p = 0.038). In particular, infection complications were significantly reduced (SG: 13 vs. CG: 26 complications, p = 0.023). There were no significant differences between the two groups for return of bowel movement (SG: 3 vs. CG: 2 days postoperatively, p = 0.316), duration of post anesthesia care unit stay (SG: 180 vs. CG: 180 minutes, p = 0.516) or length of hospital stay (SG: 11 vs. CG: 10 days, p = 0.929).ConclusionsThis multi-center study demonstrates that hemodynamic goal-directed therapy using pulse pressure variation, cardiac index trending and mean arterial pressure as the key parameters leads to a decrease in postoperative complications in patients undergoing major abdominal surgery.Trial registrationClinicalTrial.gov, NCT01401283.
Highlights
Several single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients
Inclusion criteria were an anticipated duration of surgery of more than 120 minutes or an estimated blood loss of more than 20% of blood volume, American Society of Anesthesiology (ASA) classification 2 or 3, and an indication for an arterial line and central venous catheter
There were no significant differences in the duration of stay in the post-anesthetic care unit (PACU) (SG: 180 (127.5) minutes versus control group (CG): 180 (114) minutes, P = 0.516) or length of hospital stay (SG: 11 (8) days versus CG: 10 (11.8) days, P = 0.929) in the two groups. This is the first randomized multi-center study in patients undergoing major abdominal surgery demonstrating that perioperative hemodynamic goal-directed hemodynamic therapy (GDT) using pulse pressure variation (PPV), radial artery pulse contour cardiac index (CI) and mean arterial pressure (MAP) as its key parameters leads to a reduction in postoperative complications
Summary
Several single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients. Multiple single-center studies have shown that perioperative GDT may significantly improve outcome, in patients undergoing abdominal surgery [3,4,5], and in trauma [6,7] and orthopedic surgery [8]. Oxygen debt can be avoided or, if it occurs due to rapid surgical changes such as sudden blood loss, it can be corrected quickly Routine hemodynamic measurements, such as heart rate and mean arterial pressure (MAP) remain relatively unchanged despite reduced blood flow and are, considered insensitive indicators of hypovolemia [10] or changes in cardiac index (CI) [11]. GDT is targeted to detect hypovolemia and hypoperfusion early in order to make a quick response possible
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