Abstract
IntroductionPerioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention.MethodsThis is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database).ResultsIn the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1–13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7–9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6–16) days to 7 (5–11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18 % (95 % confidence interval 9–27 %). The incidence of NSQIP complications decreased from 39 % to 25 % (p = 0.04).ConclusionThese results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries.Trial registrationClinicaltrials.gov NCT02057653. Registered 17 December 2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0945-2) contains supplementary material, which is available to authorized users.
Highlights
Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow
Under the conditions of this quality improvement project we found that implementation of standardized PGDT strategies reduced length of stay in the hospital (LOS) and the incidence of postoperative complications in patients undergoing high-risk abdominal and pelvic surgeries
Another potential improvement for the future will be related to techniques/strategies aimed at increasing the compliance to the protocol
Summary
Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. Perioperative goal-directed therapy (PGDT) strategies based on cardiac output and/or oxygen delivery optimization have been shown to improve postoperative outcome in patients undergoing high-risk surgery [1,2,3,4,5,6]. This has been reported in both single center trials [5, 7], and quality improvement-based studies [3], and confirmed in published meta-analyses [2, 8]. The effectiveness of this approach in real life settings is not clearly understood
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