Goal-directed Hemodynamic Therapy Research Articles

Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia

IntroductionTotal hip replacement is one of the most commonly performed major orthopaedic operations. Goal-directed therapy (GDT) using haemodynamic monitoring has previously demonstrated outcome benefits in high-risk surgical patients under general anaesthesia. GDT has never been formally assessed during regional anaesthesia.MethodsPatients undergoing total hip replacement while under regional anaesthesia were randomised to either the control group (CTRL) or the protocol group (GDT). Patients in the GDT group, in addition to standard monitoring, were connected to the FloTrac sensor/Vigileo monitor haemodynamic monitoring system, and a GDT protocol was used to maximise the stroke volume and target the oxygen delivery index to > 600 mL/minute/m2.ResultsPatients randomised to the GDT group were given a greater volume of intravenous fluids during the intraoperative period (means ± standard deviation (SD): 6,032 ± 1,388 mL vs. 2,635 ± 346 mL; P < 0.0001), and more of the GDT patients received dobutamine (0 of 20 CTRL patients vs. 11 of 20 GDT patients; P < 0.0003). The GDT patients also received more blood transfused during the intraoperative period (means ± SD: 595 ± 316 mL vs. 0 ± 0 mL; P < 0.0001), although the CTRL group received greater volumes of blood replacement postoperatively (CTRL patients 658 ± 68 mL vs. GDT patients 198 ± 292 mL; P < 0.001). Overall blood consumption (intraoperatively and postoperatively) was not different between the two groups. There were an increased number of complications in the CTRL group (20 of 20 CTRL patients (100%) vs. 16 of 20 GDT patients (80%); P = 0.05). These outcomes were predominantly due to a difference in minor complications (20 of 20 CTRL patients (100%) vs. 15 of 20 GDT patients (75%); P = 0.047).ConclusionsGDT applied during regional anaesthesia in patients undergoing elective total hip replacement changes intraoperative fluid management and may improve patient outcomes by decreasing postoperative complications. Larger trials are required to confirm our findings.Trial registrationSRCTN11616985

Goal-directed haemodynamic therapy in cardiac surgery

The concept of goal-directed haemodynamic optimisation was developed in the late 70s and early 80s of the last century by the surgeon W C Shoemaker. 1 Observational studies showed that high-risk surgical patients that did not survive after major non-cardiac surgery were characterised by the inability to adapt oxygen delivery to the perioperatively increased oxygen demand. 2,3 He suggested improving patients’ outcomes by optimising the cardiac index and oxygen delivery to the haemodynamic levels observed in survivors. Stimulated by Shoemaker’s ideas, he and various other researchers performed prospective studies that clearly supported this concept. 4,5,6,7

Haemodynamic goal-directed therapy and postoperative infections: earlier is better. a systematic review and meta-analysis

IntroductionInfectious complications are the main causes of postoperative morbidity. The early timing of their promoting factors is the rationale for perioperative strategies attempting to reduce them. Our aim was to determine the effects of perioperative haemodynamic goal-directed therapy on postoperative infection rates.MethodsWe performed a systematic review and meta-analysis. MEDLINE, EMBASE, The Cochrane Library and the DARE databases were searched up to March 2011. Randomised, controlled trials of major surgery in adult patients managed with perioperative goal-directed therapy or according to routine haemodynamic practice were included. Primary outcome measure was specific type of infection.ResultsTwenty-six randomised, controlled trials with a combined total of 4,188 participants met our inclusion criteria. Perioperative goal-directed therapy significantly reduced surgical site infections (pooled OR 0.58, 95% CI 0.46 to 0.74; P < 0.0001), pneumonia (pooled OR 0.71, 95% CI 0.55 to 0.92; P = 0.009), and urinary tract infections (pooled OR 0.44, 95% CI 0.22 to 0.84; P = 0.02). A significant benefit was found regarding total infectious episodes (OR 0.40, 95% CI 0.28 to 0.58; P < 0.00001).ConclusionsFlow-directed haemodynamic therapy designed to optimise oxygen delivery protects surgical patients against postoperative hospital-acquired infections and must be strongly encouraged, particularly in the high-risk surgical population.

Peri-operative hemodynamic therapy: only large clinical trials can resolve our uncertainty

In this issue of Critical Care, Cecconi and colleagues report the findings of a small trial of goal-directed hemodynamic therapy (GDT) in patients undergoing major orthopedic surgery under regional anesthesia. This is an interesting trial and the first of which we are aware to test the efficacy of GDT in this patient group. The findings suggest that this intervention is associated with improved adverse event rates after surgery. However, in this trial, as in all small trials of GDT, the potential for bias leaves some uncertainty regarding how widely the findings should be implemented. Such limitations may be impossible to completely eliminate from trials of complex interventions, but large multicenter trials may allow us to substantially decrease bias and improve the generalizability of the findings.

A Simple Physiologic Algorithm for Managing Hemodynamics Using Stroke Volume and Stroke Volume Variation: Physiologic Optimization Program

Intravascular volume status and volume responsiveness continue to be important questions for the management of critically ill or injured patients. Goal-directed hemodynamic therapy has been shown to be of benefit to patients with severe sepsis and septic shock, acute lung injury and adult respiratory distress syndrome, and for surgical patients in the operating room. Static measures of fluid status, central venous pressure (CVP), and pulmonary artery occlusion pressure (PAOP) are not useful in predicting volume responsiveness. Stroke volume variation and pulse pressure variation related to changes in stroke volume during positive pressure ventilation predict fluid responsiveness and represent an evolving practice for volume management in the intensive care unit (ICU) or operating room. Adoption of dynamic parameters for volume management has been inconsistent. This manuscript reviews some of the basic physiology regarding the use of stroke volume variation to predict fluid responsiveness in the ICU and operating room. A management algorithm using this physiology is proposed for the critically ill or injured in various settings.

The use of early intervention to prevent postoperative complications

The incidence of complications following major surgery is surprisingly high. Patients who develop complications suffer a reduction in long-term survival. This review aims to explore recent advances in the management of surgical patients aimed at preventing postoperative complications. Identifying patients prior to surgery who are at risk of a poor outcome remains challenging. There are a number of scoring systems to assist clinical risk assessment. Recent work has investigated the use of plasma biomarkers for perioperative risk prediction. Therapies aimed at reducing complication rates by attempting to improve tissue oxygen delivery include goal-directed haemodynamic therapy and postoperative noninvasive ventilation. The role of perioperative beta-adrenoceptor antagonists remains unclear. Other important measures include the use of a surgical safety checklist and thromboprophylaxis. Current systems for the identification and treatment of high-risk surgical patients are inadequate. Further research is required to establish the optimal approach to the identification and management of the high-risk surgical patient.

Performance of Bedside Transpulmonary Thermodilution Monitoring for Goal-Directed Hemodynamic Management After Subarachnoid Hemorrhage

Early goal-directed hemodynamic therapy is of particular importance for adequate cerebral circulation of patients with vasospasm after subarachnoid hemorrhage but is often precluded by the invasiveness of established cardiac output determination using a pulmonary artery catheter. This study was undertaken to validate the usefulness of less invasive goal-directed hemodynamic monitoring by transpulmonary thermodilution technique in patients after subarachnoid hemorrhage. One hundred sixteen patients with subarachnoid hemorrhage who underwent surgical clipping within 24 hours of ictus were investigated. Validation of transpulmonary thermodilution-derived intermittent/continuous cardiac output and cardiac preload (global end diastolic volume) were compared with pulmonary artery catheter-derived reference cardiac output and pulmonary capillary wedge pressure or central venous pressure in 16 patients diagnosed with vasospasm. In a subsequent trial of 100 consecutive cases, clinical results between the new and standard management paradigms were compared. Transpulmonary thermodilution-derived intermittent cardiac output and transpulmonary thermodilution-derived continuous cardiac output showed close agreement to catheter-derived reference cardiac output with high correlation (r=0.85 and 0.77) and low percentage error (13.5% and 18.0%). Fluid responsiveness to defined volume loading was predicted better with global end diastolic volume than with pulmonary capillary wedge pressure and central venous pressure for larger receiver operating characteristic curve area. Patients receiving early goal-directed management by transpulmonary thermodilution experienced reduced frequencies of vasospasm and cardiopulmonary complications compared with those managed with standard therapy (P<0.05), whereas their functional outcomes at 3 months were not different (P=0.06). Goal-directed hemodynamic management guided by transpulmonary thermodilution appears to have a therapeutic advantage for optimizing the prognosis of patients with subarachnoid hemorrhage with vasospasm over conventional methods.

Peri-operative Goal-directed Haemodynamic Therapy – Why Are We Where We Are Now, and What Is Needed to Move Forward?

Peri-operative Goal-directed Haemodynamic Therapy – Why Are We Where We Are Now, and What Is Needed to Move Forward?

Perioperative goal directed haemodynamic therapy – do it, bin it, or finally investigate it properly?

The literature concerning the use of goal directed haemodynamic therapy (GDHT) in high risk surgical patients has been importantly increased by the study of Lopes and colleagues. Using a minimally invasive assessment of fluid status and pulse pressure variation monitoring during mechanical ventilation, improvements were seen in post-operative complications, duration of mechanical ventilation, and length of hospital and intensive care unit (ICU) stay. Many small studies have shown improved outcome using various GDHT techniques but widespread implementation has not occurred. Those caring for perioperative patients need to accept the published evidence base or undertake a larger, multi-centre study.

The classical Guyton view that mean systemic pressure, right atrial pressure, and venous resistance govern venous return is/is not correct

The classical Guyton view that mean systemic pressure, right atrial pressure, and venous resistance govern venous return is/is not correct

Minimally invasive hemodynamic monitoring and goal-directed therapy

To the extent possible, hemodynamic monitoring should be non-invasive, continuous and reflect metabolic qualities, such as tissue blood flow and oxygen delivery. Recent advances in technologies have created new opportunities to switch from more invasive and risky monitoring to less invasive eons. However, degradation of signal quality and understanding of the relation between these newer minimally invasive and non-invasive measures with more traditional invasive ones is central to their effective use. Finally, since no monitoring device improves patient outcome unless coupled to a treatment that improves patient outcome, finding common pathways to integrate these newer monitoring devices into proven treatment algorithms will be an essential part of their integration into clinical practice.

Clinical review: How to optimize management of high-risk surgical patients

For many patients optimal perioperative care may require little or no additional medical management beyond that given by the anaesthetist and surgeon. However, the continued existence of a group of surgical patients at high risk for morbidity and mortality indicates an ongoing need to identify such patients and deliver optimal care throughout the perioperative period. A group of patients exists in whom the risk for death and serious complications after major surgery is in excess of 20%. The risk is related mainly to the patient's preoperative physiological condition and, in particular, the cardiovascular and respiratory reserves. Cardiovascular management of the high-risk surgical patient is of particular importance. Once the medical management of underlying disease has been optimized, two principal areas remain: the use of haemodynamic goals to guide fluid and inotropic therapy, and perioperative β blockade. A number of studies have shown that the use of goal-directed haemodynamic therapy during the perioperative period can result in large reductions in morbidity and mortality. Some patients may also benefit from perioperative β blockade, which in selected patients has also been shown to result in significant mortality reductions. In this review a pragmatic approach to perioperative management is described, giving guidance on the identification of the high-risk patient and on the use of goal-directed haemodynamic therapy and β blockade.

Recently published papers: of head injuries, high frequencies and haemodynamic optimization.

Recently published papers: of head injuries, high frequencies and haemodynamic optimization.

A trial of goal-directed hemodynamic therapy incritically Ill patients

A trial of goal-directed hemodynamic therapy incritically Ill patients

Measurement of cardiac output by thermal dilution in man.

Measurement of cardiac output by thermal dilution in man.