Goal-directed Therapy Protocol Research Articles

Assisted Fluid Management and Sublingual Microvascular Flow During High-Risk Abdominal Surgery: A Randomized Controlled Trial.

Implementation of goal-directed fluid therapy (GDFT) protocols remains low. Protocol compliance among anesthesiologists tends to be suboptimal owing to the high workload and the attention required for implementation. The assisted fluid management (AFM) system is a novel decision support tool designed to help clinicians apply GDFT protocols. This system predicts fluid responsiveness better than anesthesia practitioners do and achieves higher stroke volume (SV) and cardiac index values during surgery. We tested the hypothesis that an AFM-guided GDFT strategy would also be associated with better sublingual microvascular flow compared to a standard GDFT strategy. This bicenter, parallel, 2-arm, prospective, randomized controlled, patient and assessor-blinded, superiority study considered for inclusion all consecutive patients undergoing high-risk abdominal surgery who required an arterial catheter and uncalibrated SV monitoring. Patients having standard GDFT received manual titration of fluid challenges to optimize SV while patients having an AFM-guided GDFT strategy received fluid challenges based on recommendations from the AFM software. In all patients, fluid challenges were standardized and titrated per 250 mL and vasopressors were administered to maintain a mean arterial pressure >70 mm Hg. The primary outcome (average of each patient's intraoperative microvascular flow index (MFI) across 4 intraoperative time points) was analyzed using a Mann-Whitney U test and the treatment effect was estimated with a median difference between groups with a 95% confidence interval estimated using the bootstrap percentile method (with 1000 replications). Secondary outcomes included SV, cardiac index, total amount of fluid, other microcirculatory variables, and postoperative lactate. A total of 86 patients were enrolled over a 7-month period. The primary outcome was significantly higher in patients with AFM (median [Q1-Q3]: 2.89 [2.84-2.94]) versus those having standard GDFT (2.59 [2.38-2.78] points, median difference 0.30; 95% confidence interval [CI], 0.19-0.49; P < .001). Cardiac index and SVI were higher (3.2 ± 0.5 vs 2.7 ± 0.7 l.min-1.m-2; P = .001 and 42 [35-47] vs 36 [32-43] mL.m-2; P = .018) and arterial lactate concentration was lower at the end of the surgery in patients having AFM-guided GDFT (2.1 [1.5-3.1] vs 2.9 [2.1-3.9] mmol.L-1; P = .026) than patients having standard GDFT strategy. Patients having AFM received a higher fluid volume but 3 times less norepinephrine than those receiving standard GDFT (P < .001). Use of an AFM-guided GDFT strategy resulted in higher sublingual microvascular flow during surgery compared to use of a standard GDFT strategy. Future trials are necessary to make conclusive recommendations that will change clinical practice.

Advanced fluid management strategies in burn patients undergoing general surgery: a comprehensive review

Fluid management in burn patients undergoing general surgery poses unique challenges due to the complex pathophysiological changes associated with burn injuries. Effective resuscitation and perioperative fluid therapy are critical in optimizing outcomes and minimizing complications in this vulnerable patient population. This review explores the latest evidence-based approaches to fluid management in burn patients, emphasizing the importance of individualized strategies that consider burn size, depth, patient age, comorbidities, and surgical factors. We examine the role of advanced hemodynamic monitoring, crystalloid versus colloid solutions, and the integration of goal-directed therapy protocols. Additionally, we discuss the implications of burn-related complications such as systemic inflammatory response syndrome (SIRS), sepsis, and multi-organ dysfunction on fluid management strategies. By synthesizing current research and clinical guidelines, this review aims to provide a comprehensive framework for clinicians to enhance perioperative care in burn patients undergoing general surgery.

Fluid therapy and pulmonary complications in abdominal surgeries: randomized controlled trial

BackgroundThere is no consensus on the most effective strategy for Postoperative Pulmonary Complication (PPC) reduction. This study hypothesized that a Goal-Directed Fluid Therapy (GDFT) protocol of infusion of predetermined boluses reduces the occurrence of PPC in patients undergoing elective open abdominal surgeries when compared with Standard of Care (SOC) strategy. MethodsRandomized, prospective, controlled study, conducted from May 2012 to December 2014, with ASA I, II or III patients undergoing open abdominal surgeries, lasting at least 120 min, under general anesthesia, randomized into the SOC and the GDFT group. In the SOC, fluid administration was according to the anesthesiologist's discretion. In the GDFT, the intervention protocol, based on bolus infusion according to blood pressure and delta pulse pressure, was applied. Patients were postoperatively evaluated by an anesthesiologist blinded to the group allocation regarding PPC incidence, mortality, and Length of Hospital Stay (LOHS). ResultsForty-two patients in the SOC group and 43 in the GDFT group. Nineteen patients (45%) in the SOC and 6 in the GDFT (14%) had at least one PPC (p = 0.003). There was no difference in mortality or LOHS between the groups. Among the patients with PPC, four died (25%), compared to two deaths in patients without PPC (3%) (p = 0.001). The LOHS had a median of 14.5 days in the group with PPC and 9 days in the group without PPC (p = 0.001). ConclusionThe GDFT protocol resulted in a lower rate of PPC; however, the LOHS and mortality did not reduce.

The Effect of Implementing the Sepsis Early Goal-Directed Therapy (EGDT) Protocol on Patient Mortality in the Hospital ICU in Cairo, Egypt

Introduction: Sepsis is a life-threatening systemic inflammatory syndrome with a high mortality rate. Early goal-directed therapy (EGDT) is a structured therapy protocol that aims to improve tissue perfusion and oxygenation in sepsis patients.&#x0D; Methods: This retrospective observational study analyzed data on sepsis patients in the ICU of a Cairo hospital, Egypt (2020-2023). Patient mortality was compared before and after the implementation of the EGDT protocol.&#x0D; Results: Of the 220 sepsis patients, 120 were treated before and 100 after EGDT implementation. Patient mortality in the EGDT group was significantly lower (12% vs 25%, p&lt;0.05).&#x0D; Conclusion: Implementation of the EGDT protocol can reduce the mortality of sepsis patients in the hospital ICU in Cairo, Egypt.

Unresponsive Low Mixed Venous Oxygen Saturation During Early Intensive Care Unit Stay is Associated With Increased Risk of Organ Dysfunction After Cardiac Surgery: A Single-Center Retrospective Study

The aim of the study was to determine if unresponsive mixed venous oxygen saturation (SvO2) values during early postoperative hours are associated with postoperative organ dysfunction. A single-center retrospective observational study. A university hospital. A total of 6,282 adult patients requiring cardiac surgery who underwent surgery in a University Hospital from 2007 to 2020. A pulmonary artery catheter was used to gather SvO2 samples after surgery at admission to the intensive care unit (ICU) and 4 hours later. For the analysis, patients were divided into 4 groups according to their SvO2 values. The rate of organ dysfunctions categorized according to the SOFA score was then studied among these subgroups. The crude mortality rate for the cohort at 1 year was 4.3%. Multiple organ dysfunction syndrome (MODS) was present in 33.0% of patients in the early postoperative phase. During the 4-hour initial treatment period, 43% of the 931 patients with low SvO2 on admission responded to goal-directed therapy to increase SvO2 >60%; whereas, in 57% of the 931 patients, the low SvO2 was sustained. According to the adjusted logistic regression analyses, the odds ratio for MODS (4.23 [95% CI 3.41-5.25]), renal- replacement therapy (4.97 [95% CI 3.28-7.52]), time on a ventilator (2.34 [95% CI 2.17-2.52]), and vasoactive-inotropic score >30 (3.62 [95% CI 2.96-4.43]) were the highest in the group with sustained low SvO2. Patients with SvO2 <60% at ICU admission and 4 hours later had the greatest risk of postoperative MODS. Responsiveness to a goal-directed therapy protocol targeting maintaining or increasing SvO2 ≥60% at and after ICU admission may be beneficial.

Impact of fluid and haemodynamic management in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy on postoperative outcomes - A systematic review.

Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive surgery associated with significant fluid shift and blood loss. The haemodynamic management and fluid therapy protocol may impact postoperative outcomes. This systematic review was conducted to find the effect of haemodynamic monitoring and perioperative fluid therapy in CRS-HIPEC on postoperative outcomes. We searched PubMed, Scopus and Google Scholar. All studies published between 2010 and 2022 involving CRS-HIPEC surgeries that compared the effect of fluid therapy and haemodynamic monitoring on postoperative outcomes were included. Keywords for database searches included a combination of Medical Subject Headings terms and plain text related to the CRS-HIPEC procedure. The risk of bias and the certainty assessment were done by Risk of Bias-2 and the methodological index for non-randomised studies. The review included 16 published studies out of 388 articles. The studies were heterogeneous concerning the design type and parameter measures. The studies with goal-directed fluid therapy protocol had a duration of intensive care unit (ICU) stay that varied from 1 to 20 days, while mortality varied from 0% to 9.5%. The choice of fluid, crystalloid versus colloid, remains inconclusive. The studies that compared crystalloids and colloids for perioperative fluid management did not show a difference in clinical outcomes. The interpretation of the available literature is challenging because the definitions of various fluid regimens and haemodynamic goals are not uniform among studies. An individualised approach to perioperative fluid therapy and a justified dynamic index cut-off for haemodynamic monitoring seem reasonable for CRS-HIPEC procedures.

Optimising Intraoperative Fluid Management in Patients Treated with Adolescent Idiopathic Scoliosis-A Novel Strategy for Improving Outcomes.

Scoliosis surgery is a challenge for the entire team in terms of safety, and its accomplishment requires the utilization of advanced monitoring technologies. A prospective, single centre, non-randomised controlled cohort study, was designed to assess the efficacy of protocolised intraoperative haemodynamic monitoring and goal-directed therapy in relation to patient outcomes following posterior fusion surgery for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure management during the surgical procedure, whereas the intervention group (n = 35, mean age: 14 years) underwent minimally invasive haemodynamic monitoring. Arterial pulse contour analysis (APCO) devices were employed, along with goal-directed therapy protocol centered on achieving target mean arterial pressure and stroke volume. This was facilitated through the application of crystalloid boluses, ephedrine, and noradrenaline. The intervention group was subjected to a comprehensive protocol following Enhanced Recovery After Surgery (ERAS) principles. Remarkably, the intervention group exhibited notable advantages (p < 0.05), including reduced hospital stay durations (median 7 days vs. 10), shorter episodes of hypotension (mean arterial pressure < 60 mmHg-median 8 vs. 40 min), lesser declines in postoperative haemoglobin levels (-2.36 g/dl vs. -3.83 g/dl), and quicker extubation times. These compelling findings strongly imply that the integration of targeted interventions during the intraoperative care of AIS patients undergoing posterior fusion enhance a set of treatment outcomes.

Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

Intraoperative hemodynamic optimization using the hypotension prediction index vs. goal-directed hemodynamic therapy during elective major abdominal surgery: the Predict-H multicenter randomized controlled trial

BackgroundIntraoperative hypotension (IOH) is associated with increased morbidity and mortality after major abdominal surgery but remains significant even when using goal-directed hemodynamic therapy (GDHT) protocols. The Hypotension Prediction Index (HPI) is a machine learning-derived parameter that predicts arterial hypotension. We tested the hypothesis that an HPI-based protocol reduces the duration and severity of hypotension compared with a GDHT protocol during major abdominal surgery.MethodsThis is a parallel-arm double-blinded multicenter randomized trial involving adult patients undergoing elective major abdominal surgery at five centers. Patients were optimized according to a previously recommended GDHT protocol (GDHT group) or the HPI value (HPI group). Hemodynamic optimization in both groups started 15 min after the surgical incision. The primary outcome was the intraoperative time-weighted average of mean arterial pressure under 65 mmHg (TWA-MAP &amp;lt; 65 mmHg). Other metrics for IOH and secondary outcomes, including TWA below individual baseline values of intraoperative tissue oxygenation (StO2), postoperative AKIRisk, postoperative complications, length of stay, and 30-day mortality, were explored.ResultsEighty patients were randomized (40 patients in each group). TWA-MAP &amp;lt; 65 mmHg was 0.06 (25th–75th interquartile range: 0–0.27) mmHg in the GDTH group vs. 0 (0–0.04) mmHg in the HPI group (p = 0.015). Total time with MAP &amp;lt; 65 mmHg per patient was 4.6 (0–21) min in the GDHT group and 0 (0–3) min in the HPI group (p = 0.008). The TWA below the baseline StO2 was 0.40% (0.12%–2.41%) in the GDHT group and 0.95% (0.15%–3.20%) in the HPI group (p = 0.353). The AKIRisk values obtained in the GDHT group were 0.30 (0.14–0.53) and 0.34 (0.15–0.67) in the GDHT and HPI groups (p = 0.731), respectively. Both groups had similar postoperative complications, length of stay, and 30-day mortality.ConclusionsAn HPI-based protocol reduced intraoperative hypotension compared with a standard GDHT protocol, with no differences in tissue oxygenation and postoperative AKIRisk.

Prioridades de investigación en términos de fluidoterapia perioperatoria y monitorización hemodinámica: encuesta de consenso Delphi del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia (SHTF) de la Sociedad española de Anestesiología y Reanimación (SEDAR)

BackgroundResearch on perioperative fluid therapy and hemodynamic monitoring is difficult and expensive. The objectives of the present study were to summarize and prioritize these issues, in order of research importance. research importance. MethodsStructured electronic Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Subcommittee on Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Resuscitation. Results77 issues were identified, which were ranked in order of prioritization. The were categorized into crystalloid, colloid, hemodynamic monitoring and others. and others. Thirty-one issues were categorized as of essential research priority, to determine whether intraoperative hemodynamic optimization algorithms based on the index of invasive or noninvasive hypotension prediction index versus other management strategies could reduce the incidence of postoperative reduce the incidence of postoperative complications, as well as whether the use of biomarkers of renal stress in conjunction biomarkers of renal stress in conjunction with a goal-directed fluid therapy protocol could reduce hospital stay and the hospital stay and the incidence of acute renal failure in adult patients undergoing non-cardiac surgery, and whether the non-cardiac surgery, achieving the highest consensus. ConclusionsThe Subcommittee on Fluid Therapy and Hemodynamic Monitoring of the Section of Hemostasis, Transfusion Medicine and Fluid Therapy of the Spanish Society of Anesthesiology and Resuscitation of the Spanish Society of Anesthesiology and Resuscitation will use these results for further research.

Hypotension Prediction Index guided Goal Directed therapy and the amount of Hypotension during Major Gynaecologic Oncologic Surgery: a Randomized Controlled clinical Trial

Intraoperative hypotension (IOH) is associated with increased morbidity and mortality. Hypotension Prediction Index (HPI) is a machine learning derived algorithm that predicts IOH shortly before it occurs. We tested the hypothesis that the application of the HPI in combination with a pre-defined Goal Directed Therapy (GDT) hemodynamic protocol reduces IOH during major gynaecologic oncologic surgery. We enrolled women scheduled for major gynaecologic oncologic surgery under general anesthesia with invasive arterial pressure monitoring. Patients were randomized to a GDT protocol aimed at optimizing stroke volume index (SVI) or hemodynamic management based on HPI guidance in addition to GDT. The primary outcome was the amount of IOH, defined as the timeweighted average (TWA) mean arterial pressure (MAP) < 65 mmHg. Secondary outcome was the TWA-MAP < 65 mmHg during the first 20 min after induction of GA. After exclusion of 10 patients the final analysis included 60 patients (30 in each group). The median (25–75th IQR) TWA-MAP < 65 mmHg was 0.14 (0.04–0.66) mmHg in HPI group versus 0.77 (0.36–1.30) mmHg in Control group, P < 0.001. During the first 20 min after induction of GA, the median TWA-MAP < 65 mmHg was 0.53 (0.06–1.8) mmHg in the HPI group and 2.15 (0.65–4.2) mmHg in the Control group, P = 0.001. Compared to a GDT protocol aimed to SVI optimization, a machine learning-derived algorithm for prediction of IOH combined with a GDT hemodynamic protocol, reduced IOH and hypotension after induction of general anesthesia in patients undergoing major gynaecologic oncologic surgery.Trial registration number: NCT04547491. Date of registration: 10/09/2020.

Goal-directed fluid therapy using uncalibrated pulse contour analysis and balanced crystalloid solutions during hip revision arthroplasty: a quality implementation project

BackgroundTo implement a goal-directed fluid therapy (GDFT) protocol using crystalloids in hip revision arthroplasty surgery within a quality management project at a tertiary hospital using a monocentric, prospective observational study.MethodsAdult patients scheduled for elective hip revision arthroplasty surgery were screened for inclusion in this prospective study. Intraoperatively stroke volume (SV) was optimized within a previously published protocol using uncalibrated pulse contour analysis and balanced crystalloids. Quality of perioperative GDFT was assessed by protocol adherence, SV increase as well as the rate of perioperative complications. Findings were then compared to two different historical groups of a former trial: one receiving GDFT with colloids (prospective colloid group) and one standard fluid therapy (retrospective control group) throughout surgery. Statistical analysis constitutes exploratory data analyses and results are expressed as median with 25th and 75th percentiles, absolute and relative frequencies, and complication rates are further given with 95% confidence intervals for proportions using the normal approximation without continuity correction.ResultsSixty-six patients underwent GDFT using balanced crystalloids and were compared to 130 patients with GDFT using balanced colloids and 130 controls without GDFT fluid resuscitation. There was a comparable increase in SV (crystalloids: 65 (54–74 ml; colloids: 67.5 (60–75.25 ml) and total volume infused (crystalloids: 2575 (2000–4210) ml; colloids: 2435 (1760–3480) ml; and controls: 2210 (1658–3000) ml). Overall perioperative complications rates were similar (42.4% (95%CI 30.3–55.2%) for crystalloids and 49.2% (95%CI 40.4–58.1%) for colloids and lower compared to controls: 66.9% (95%CI 58.1–74.9)). Interestingly, a reduced number of hemorrhagic complications was observed within crystalloids: 30% (95%CI 19.6–42.9); colloids: 43% (95%CI 34.4–52.0); and controls: 62% (95%CI 52.6–69.9). There were no differences in the rate of admission to the post-anesthesia care unit or intensive care unit as well as the length of stay.ConclusionsPerioperative fluid management using a GDFT protocol with crystalloids in hip revision arthroplasty surgery was successfully implemented in daily clinical routine. Perioperative complications rates were reduced compared to a previous management without GDFT and comparable when using colloids.Trial registration: ClinicalTrials.gov identifier: NCT01753050.

Goal-Directed Haemodynamic Therapy Improves Patient Outcomes in Kidney Transplantation.

Introduction: Kidney transplant graft function depends on optimised haemodynamics. However, high fluid volumes risk hypervolaemic complications. The Edwards Lifesciences ClearSight™ device permits fluid titration through markers of preload and beat-to-beat blood pressure monitoring. We evaluated the implementation of a novel goal-directed haemodynamic therapy protocol to determine whether patient outcomes had improved. Design: A retrospective evaluation of standard care versus goal-directed haemodynamic therapy in adults undergoing kidney transplantation was performed in a single centre between April 2016 and October 2019. Twenty-eight standard-of-care patients received intraoperative fixed-rate infusion and 28 patients received goal-directed haemodynamic therapy. The primary outcome was volume of fluid administered intraoperatively. Secondary outcomes included blood product and vasoactive drug exposure, graft and recipient outcomes. Results: Intraoperative fluid administered was significantly reduced in the goal-directed haemodynamic therapy cohort (4325 vs 2751 ml, P < .001). Exposure to vasopressor (67.9% vs 42.9%, P = .060) and blood products (17.9% vs 3.6%, P = .101) was unchanged. Immediate graft function (82.1% vs 75.0%, P = .515), dialysis requirement (14.3% vs 21.4%, P = .729) and creatinine changes post-operatively were unchanged. In the goal-directed haemodynamic therapy cohort, 1 patient had pulmonary oedema (3.6%) versus 21.4% in the standard cohort. Patients in the goal-directed haemodynamic therapy group were more likely to mobilise within 48 hours of surgery (number needed to treat = 3.5, P = .012). Conclusions: Protocolised goal-directed haemodynamic therapy in kidney transplantation was safe and may improve patient, graft, and surgical outcomes. Clinical trials assessing goal-directed approaches are needed.

Association of low mixed venous oxygen saturations during early ICU stay with increased 30-day and 1-year mortality after cardiac surgery: a single-center retrospective study

BackgroundLow postoperative mixed venous oxygen saturation (SvO2) values have been linked to poor outcomes after cardiac surgery. The present study was designed to assess whether SvO2 values of < 60% at intensive care unit (ICU) admission and 4 h after admission are associated with increased mortality after cardiac surgery.MethodsDuring the years 2007–2020, 7046 patients (74.4% male; median age, 68 years [interquartile range, 60–74]) underwent cardiac surgery at an academic medical center in Finland. All patients were monitored with a pulmonary artery catheter. SvO2 values were obtained at ICU admission and 4 h later. Patients were divided into four groups for analyses: SvO2 ≥ 60% at ICU admission and 4 h later; SvO2 ≥ 60% at admission but < 60% at 4 h; SvO2 < 60% at admission but ≥ 60% at 4 h; and SvO2 < 60% at both ICU admission and 4 h later. Kaplan–Meier survival curves, Cox regression models, and receiver operating characteristic curve analysis were used to assess differences among groups in 30-day and 1-year mortality.ResultsIn the overall cohort, 52.9% underwent coronary artery bypass grafting (CABG), 29.1% valvular surgery, 12.1% combined CABG and valvular procedures, 3.5% surgery of the ascending aorta or aortic dissection, and 2.4% other cardiac surgery. The 1-year crude mortality was 4.3%. The best outcomes were associated with SvO2 ≥ 60% at both ICU admission and 4 h later. Hazard ratios for 1-year mortality were highest among patients with SvO2 < 60% at both ICU admission and 4 h later, regardless of surgical subgroup.ConclusionSvO2 values < 60% at ICU admission and 4 h after admission are associated with increased 30-day and 1-year mortality after cardiac surgery. Goal-directed therapy protocols targeting SvO2 ≥ 60% may be beneficial. Prospective studies are needed to confirm these observational findings.

Impact of PCO2 gap protocol application on early postoperative mortality and organ failure in high risk surgical patients undergoing major abdominal surgeries

Background: high risk surgical patients undergoing major abdominal surgeries still have higher rate of mortality and organ failure rates in the early postoperative period. Objective: We aimed to assess PCO2 gap protocol application in the intraoperative and early post-operative (first 12 hours) on postoperative mortality and organ failure in high risk surgical patients undergoing major abdominal surgeries compared to a classical goal directed therapy protocol (GDT) targeting mean arterial blood pressure (MAP), mixed venous oxygen saturation (SvO2), central venous pressure (CVP), Haematocrite value (Hct) and urine output (UOP). Patients and Methods: Guided by Shoemacker et al score 80 high risk surgical patients undergoing major abdominal surgeries were divided into two groups group A PCO2 gap algorithm was applied intraoperative and 12 h postoperative end point PCO2 gap 2-6mm Hg ,group B goal directed therapy protocol targeting MAP &gt; 65mmHg, CVP between 8-12cmH2O , Haematocrite value more than 30, Svo2 &gt;75% and urine output more than &gt;0.5 ml/kg/hr an applied intraoperative and 12 postoperative end point . Postoperative organs dysfuctions were assessed using the Sequential Organ Failure Assessment (SOFA) score recorded daily ICU discharge then every three days till discharge home.

A goal-directed therapy protocol for preventing acute kidney injury after laparoscopic liver resection: a retrospective observational cohort study.

Postoperative acute kidney injury (AKI) remains a serious complication of liver resection with restrictive fluid therapy. However, unlike open hepatectomy, laparoscopic liver resection (LLR) does not have established anesthesia management strategies. We compared our goal-directed therapy (GDT) protocol for LLR with/without carperitide and the conventional restrictive method regarding AKI prevention. The GDT thresholds in this retrospective observational cohort study were as follows: stroke volume variation, ≤ 15%; pulse pressure variation, ≤ 13%; oxygen delivery index, ≥ 600mL/min/m2; and mean arterial pressure (MAP), ≥ 55mmHg. If the thresholds were not achieved, a 250mL infusion fluid bolus was administered. The MAP target was changed to > 65mmHg if the urine output was < 0.3mL/kg/h. Postoperative AKI within 48h and perioperative outcomes within 90days were analyzed. Forty-seven propensity score-matched pairs from 127 patients were investigated. We adjusted for AKI risk factors and surgical difficulty; 46.8% of the GDT group received carperitide. The GDT group had a lower postoperative AKI rate (10.6% vs. 27.7%, P = 0.04) and shorter overall (P = 0.04) and postoperative (P < 0.01) hospital stays than the conventional group. Furthermore, the GDT group received more intraoperative fluid (P = 0.001) and phenylephrine (P = 0.02), without significant increases in blood loss and transfusion volume, than the conventional group. GDT reduced the AKI rates post-LLR.

Goal-directed fluid therapy versus restrictive fluid therapy: A cardiomerty study during one-lung ventilation in patients undergoing thoracic surgery

ABSTRACT Background Fluid management during thoracic anaesthesia is a challenge for the anaesthesiologists. The “safe zone” between volume overload (pulmonary oedema risk) and hypovolemia (renal failure risk) remains to be narrow and hard to determine. Purpose The aim of the present study was to assess goal-directed fluid therapy using cardiometry versus restrictive fluid therapy during one-lung ventilation in patients planned for having thoracic surgery. Methods After receiving the Ethics Committee approval and taking an informed written consent, a prospective randomized study was conducted. Fifty adult patients of both genders were scheduled for thoracic surgery with one lung ventilation. Patients were randomly categorized using closed envelope technique into two equal groups (25 patients each). Group I: a number of 25 patients underwent thoracic surgery and were managed with goal directed fluid therapy using intraoperative cardiometry. Group II: a number of 25 patients underwent thoracic surgery and were managed with intraoperative restrictive fluid therapy. Results There was a significantly increased serum lactate level, serum creatinine with decreased urine output in restrictive therapy group (RT) by the end of the surgery, immediately postoperative and 6 h postoperative (p value of <0.001). The restrictive hypoxic index values were much higher than the goal directed group values, yet, both were of normal range and no patient suffered of lung injury. A significant increase in serum neutrophil gelatinase-associated lipocalin (Ngal) in the restrictive therapy group compared to the goal directed therapy group. (p value of <0.001). Conclusion From these results, we concluded that patients undergoing thoracic surgery are preferably to be maintained over goal directed therapy protocol using electrical cardiometry. Fluid restriction is better to be individualized and aided by new technologies based on beat-to-beat variations.

Effect of goal-directed fluid management guided by non-invasive device on incidence of postoperative complications in neurosurgery

Abstract Introduction: Goal-directed hemodynamic therapy aims to reduce the incidence of postoperative complications in patients undergoing surgical procedures. Optimal preload is mandatory to achieve adequate cardiac output and oxygen supply to organs and tissues. Neurosurgical patients are at risk of inadequate preload, decreased blood flow and reduced oxygen delivery, all of which can lead to organ dysfunction. Current knowledge regarding the effect of fluid management on patient-orientated outcomes in neurosurgery is limited. Therefore, this study aims to compare the safety and feasibility of goal-directed therapy with standard management in patients undergoing neurosurgical procedures. Methods and analysis: Patients undergoing neurosurgical operation will be randomised into two groups. Therapy in the first group of patients will be guided by standard perioperative monitoring. In the second group, perioperative therapy will be guided using non-invasive hemodynamic monitoring in addition to standard monitoring. Administration of fluids and vasoactive drugs will depend on the assessment of stroke volume variation and cardiac index. The safety of goal-directed hemodynamic therapy protocol will be assessed by comparing incidences of adverse events between groups.

Perioperative Individualized Goal Directed Therapy for Cardiac Surgery: A Historical-Prospective, Comparative Effectiveness Study.

Introduction: Cardiac surgery patients are at increased risk for post-operative complications and prolonged length of stay. Perioperative goal directed therapy (GDT) has demonstrated utility for non-cardiac surgery, however, GDT is not common for cardiac surgery. We initiated a quality improvement (QI) project focusing on the implementation of a GDT protocol, which was applied from the immediate post-bypass period into the intensive care unit (ICU). Our hypothesis was that this novel GDT protocol would decrease ICU length of stay and possibly improve postoperative outcomes. Methods: This was a historical prospective, QI study for patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Integral to the QI project was education towards all associated providers on the concepts related to GDT. The protocol involved identifying patient specific targets for cardiac index and mean arterial pressure. These targets were maintained from the post-CPB period to the first 12 h in the ICU. Statistical comparisons were performed between the year after GDT therapy was launched to the last two years prior to protocol implementation. The primary outcome was ICU length of stay. Results: There was a significant decrease in ICU length of stay when comparing the year after the protocol initiation to years prior, from a median of 6.19 days to 4 days (2017 vs. 2019, p < 0.0001), and a median of 5.88 days to 4 days (2018 vs. 2019, p < 0.0001). Secondary outcomes demonstrated a significant reduction in total administered volumes of inotropic medication(milrinone). All other vasopressors demonstrated no differences across years. Hospital length of stay comparisons did not demonstrate a significant reduction. Conclusion: These results suggest that an individualized goal directed therapy for cardiac surgery patients can reduce ICU length of stay and decrease amount of inotropic therapy.

The Impact of Early Goal Directed Therapy and PCO2 Gap Protocol on Outcomes of High-Risk Surgical Patients Admitted to ICU: A Prospective Study

Objectives: High risk surgical patients are prone to experience complicated outcomes that directly lead to longer days on ventilators and consequently longer ICU and hospital stay. PCO2 gap has elicited an increasing interest in directing resuscitation towards optimizing CO2 gap. Thus, we aimed to compare the impact of PCO2 gap targeting protocol to a classical Goal Directed Therapy Protocol (GDT) on ICU stay Ventilator day and length of hospital stay, in high-risk surgical patients admitted to ICU. Design: Blinded prospective randomized clinical trial. Settings: Qena University Hospital. Patients: 80 patients who have high risk surgical criteria adopted from Shoemacker et al score and were admitted to ICU postoperatively, were divided into two groups: in group (A) PCO2 gap algorithm was applied 12 h postoperative with end point PCO2 gap 2-6 mm Hg ,and in group (B) goal directed therapy protocolwas applied 12 postoperative targeting endpoints: MAP >65mmHg, CVP between 8-12 cmH2O, Haematocrite value more than 30, SvO2 >75% and urine output more than >0.5 ml/kg/hr. Measurements and results: Regarding duration of ventilator dependency, ICU stay and hospital stay, all values were lower in group a compared to group B although it was statistically insignificant. Conclusion: In high risk surgical patients in ICU, targeting PCO2 values has no significant difference to early goal directed therapy regarding the decrease in ventilation days, ICU stay or hospital stay.