Use Of Goal-directed Fluid Therapy Research Articles

Pulse pressure variation guided goal-direct fluid therapy decreases postoperative complications in elderly patients undergoing laparoscopic radical resection of colorectal cancer: a randomized controlled trial

ObjectiveThe use of goal-directed fluid therapy (GDFT) has been shown to reduce complications and improve prognosis in high-risk abdominal surgery patients. However, the utilization of pulse pressure variation (PPV) guided GDFT in laparoscopic surgery remains a subject of debate. We hypothesized that utilizing PPV guidance for GDFT would optimize short-term prognosis in elderly patients undergoing laparoscopic radical resection for colorectal cancer compared to conventional fluid therapy.MethodsElderly patients undergoing laparoscopic radical resection of colorectal cancer were randomized to receive either PPV guided GDFT or conventional fluid therapy and explore whether PPV guided GDFT can optimize the short-term prognosis of elderly patients undergoing laparoscopic radical resection of colorectal cancer compared with conventional fluid therapy.ResultsThe incidence of complications was significantly lower in the PPV group compared to the control group (32.8% vs. 57.1%, P = .009). Additionally, the PPV group had a lower occurrence of gastrointestinal dysfunction (19.0% vs. 39.3%, P = .017) and postoperative pneumonia (8.6% vs. 23.2%, P = .033) than the control group.ConclusionUtilizing PPV as a monitoring index for GDFT can improve short-term prognosis in elderly patients undergoing laparoscopic radical resection of colorectal cancer.Registration numberChiCTR2300067361; date of registration: January 5, 2023.

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Expert Consensus on the Use of Human Serum Albumin in Adult Cardiac Surgery.

Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience

ObjectivesTo evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes.MethodsThis retrospective...

Optimization of the target strategy of perioperative infusion therapy based on monitoring data of central hemodynamics in order to prevent complications.

Enhanced Recovery After Surgery (ERAS) protocols are increasingly used in the perioperative period around the world. The concept of goal-directed fluid therapy (GDT) is a key element of the ERAS protocols. Inadequate perioperative infusion therapy can lead to a number of complications, including the development of an infectious process, namely surgical site infections, pneumonia, urinary tract infections. Optimal infusion therapy is difficult to achieve with standard parameters (e.g., heart rate, blood pressure, central venous pressure), so there are various methods of monitoring central hemodynamics – from invasive, minimally invasive to non-invasive. The latter are increasingly used in clinical practice. The current evidence base shows that perioperative management, specifically the use of GDT guided by real-time, continuous hemodynamic monitoring, helps clinicians maintain a patient’s optimal fluid balance. The manuscript presents the analytical data, which describe the benefits and basic principles of perioperative targeted infusion therapy based on central hemodynamic parameters to reduce the risk of complications.

Effect of Goal-Directed Intraoperative Fluid Therapy on Duration of Hospital Stay and Postoperative Complications in Patients Undergoing Excision of Large Supratentorial Tumors.

Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors. Forty patients of 18-65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals. The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups. This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores. CTRI/2016/10/007350.

Goal-Directed Fluid Therapy Based on Pulse-Pressure Variation Compared with Standard Fluid Therapy in Patients Undergoing Complex Spine Surgery: A Randomized Controlled Trial.

Study DesignProspective, randomized, controlled study.PurposeTo determine whether the use of goal-directed fluid therapy (GDT) guided by pulse-pressure variation (PPV) and fluid management protocol can reduce intraoperative hypotension, blood transfusion requirements, and postoperative complications in adults undergoing complex spine surgery.Overview of LiteratureComplex spine surgeries involve a significant risk of blood loss and intraoperative hypotension. Previous studies showed that GDT reduces intraoperative hypotension and postoperative complications in these surgery types; however, limited information exists about GDT guided by PPV.MethodsSixty adults (18–70 years) patients undergoing complex spine surgeries at Siriraj Hospital, Mahidol University, Thailand were enrolled. Patients were allocated to two groups (30 patients in each) using computer-generated randomization. Intraoperative fluid and vasopressor were administrated via either GDT or standard care. The GDT algorithm used PPV and fluid protocol as the primary tool to guide hemodynamic management. The incidences and episodes of perioperative hypotension were measured as the outcomes.ResultsFifty-seven patients were analyzed (three patients in the GDT group were excluded). The baseline characteristics and surgical procedures of the two groups did not differ significantly. The prevalence of intraoperative hypotension was 80.0% for the control group and 66.7% for the GDT group (p=0.25). Two episodes (1–3) of intraoperative hypotension occurred in the control group, and one episode (0–3) occurred in the GDT group; the difference was not significantly different (p=0.57). The intraoperative blood transfusion requirements and postoperative complications were similar in both the groups. In the subgroup analysis, patients with intraoperative hypotension exhibited a higher incidence of postoperative bowel dysfunction.ConclusionsPPV-guided GDT and fluid protocol, as compared with standard practice, did not show significant advantages with respect to intraoperative hypotension, blood transfusion, or postoperative complications in patients undergoing complex spine surgery in the prone position.

Application of ERAS protocol in esophagectomy: a national survey among Italian centers performing esophageal surgery.

The application of enhanced recovery after surgery guidelines for esophageal surgery in different units remains unclear. This survey intended to investigate how such protocol is applied among Italian esophageal surgery units. A survey with 40 questions was mailed to Italian centers that performed at least 10 esophagectomies per year. It included questions about the type of hospital and unit and pre-, intra- and post-operative items. Difficulties encountered were investigated. Thirteen (65%) centers answered the survey, and all met the minimal safety requirements, e.g., the presence of intensive care units and 24-h on-call operative endoscopy and radiology facilities. Fifty percent of esophagectomies with a minimally invasive approach were performed in 84.6% of the centers. Regarding pre-operative items, the highest scores were for the application of nutritional support, dysphagia palliation and presence of a multidisciplinary tumor board, whereas the lowest score was for the use of immunonutrition. Regarding intra-operative items, hypothermia prevention and the use of goal-directed fluid therapy and volatile anesthesia were diffusely adopted, whereas the rate of using abdominal drains was high. Regarding post-operative items, nausea prevention, multimodal analgesia and early mobilization were applied frequently, whereas the use of nasogastric tubes and regular transfer to intensive care units was diffused. The primary barriers in enhanced recovery after surgery protocol application were resistance and a lack of paramedic personnel. This survey's results highlight the efforts undertaken by several centers to apply enhanced recovery after surgery philosophy and in this regard, demonstrate a good standing in Italy.

Efficacy of goal-directed fluid therapy monitored by pulse-pressure variation using a continuous noninvasive arterial pressure monitoring system (the CNAPTM system) during parathyroidectomy in patients with end-stage renal failure – a randomised trial

IntroductionThere are no well-recognised guidelines for intraoperative fluid management in patients with end-stage renal failure (ESRF). Goal-directed fluid therapy (GDFT) is a concept of perioperative fluid management that improves patients’ prognosis. In this study, we assessed a GDFT protocol with monitoring of pulse pressure variation (PPV) in patients with ESRF undergoing parathyroidectomy.Material and methodsA total of 102 patients who underwent elective parathyroidectomy were randomised into a control group (restrictive group, n = 51), managed with a restricted fluid regimen, or a PPV group (GDFT group, n = 51), given a normal saline infusion, and they were monitored for changes in PPV. If PPV reached > 13%, 250 ml of normal saline was administered over 15 min. Ephedrine was given to keep the mean arterial pressure > 65 mm Hg. Haemodynamic variables in the perioperative period were recorded. The primary endpoint was the occurrence of postoperative hypotension.ResultsThe occurrence of postoperative hypotension (0 vs. 11.67%, p = 0.027) and complications (35.3% vs. 54.9%, p = 0.047) in the GDFT group was lower than in the restrictive group. The volume of saline infused during the operation was 364 (219–408) ml and 50 (50–50) ml, respectively (p = 0.001). Ephedrine was given to 16/51 (29.4%) patients of the GDFT group and 27/51 (52.9%) patients of the restrictive group (p = 0.027).ConclusionsThe use of GDFT with dynamic PPV monitoring in patients with ESRF undergoing parathyroidectomy could potentially be used to guide the administration of infused fluids, with the possibility of reducing the occurrence of postoperative hypotension.

Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: a single centre retrospective observational study

BackgroundRight hepatectomy is a complex procedure that carries inherent risks of perioperative morbidity. To evaluate outcome differences between a low central venous pressure fluid intervention strategy and a goal directed fluid therapy (GDFT) cardiac output algorithm we performed a retrospective observational study. We hypothesized that a GDFT protocol would result in less intraoperative fluid administration, reduced complications and a shorter length of hospital stay.MethodsPatients undergoing hepatectomy using an established enhanced recovery after surgery (ERAS) programme between 2010 and 2017 were extracted from a prospectively managed electronic hospital database. Inclusion criteria included adult patients, undergoing open right (segments V-VIII) or extended right (segments IV-VIII) hepatectomy. Primary outcome: amount of intraoperative fluid administration used between the two groups. Secondary outcomes: type and amount of vasoactive medications used, the development of predefined postoperative complications, hospital length of stay, and 30-day mortality. Complications were defined by the European Perioperative Clinical Outcome definitions and graded according to Clavien-Dindo classification. The association between GDFT and the amount of fluid and vasoactive medication used was investigated using logistic and linear regression models.ResultsFifty-eight consecutive patients were identified. 26 patients received GDFT and 32 received Usual care. There were no significant differences in baseline patient characteristics. Less intraoperative fluid was used in the GDFT group: median (IQR) 2000 ml (1175 to 2700) vs. 2750 ml (2000 to 4000) in the Usual care group; p = 0.03. There were no significant differences in the use of vasoactive medications. Postoperative complications were similar: 9 patients (35%) in the GDFT group vs. 18 patients (56%) in the Usual care group; p = 0.10, OR: 0.41; (95%CI: 0.14 to 1.20). Median (IQR) length of stay for patients in the GDFT group was 7 days (6:8) vs. 9 days (7:13) in the Usual care group; incident rate ratio 0.72 (95%CI: 0.56 to 0.93); p = 0.012. There was no difference in perioperative mortality.ConclusionsIn patients undergoing open right hepatectomy with an established ERAS programme, use of GDFT was associated with less intraoperative fluid administration and reduced hospital length of stay when compared to Usual care. There were no significant differences in postoperative complications or mortality.Trial registrationAustralian New Zealand Clinical Trials Registry: no12619000558123 on 10/4/19.

Evaluation of the Collaborative Use of an Evidence-Based Care Bundle in Emergency Laparotomy

Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients. To assess whether a collaborative approach to implement a 6-point care bundle is associated with reduction in mortality and length of stay and improvement in the delivery of standards of care across a group of hospitals. The Emergency Laparotomy Collaborative (ELC) was a UK-based prospective quality improvement study of the implementation of a care bundle provided to patients requiring emergency laparotomy between October 1, 2015, and September 30, 2017. Participants were 28 National Health Service hospitals and emergency surgical patients who were treated at these hospitals and whose data were entered into the National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation outcomes were compared with baseline data from July 1, 2014, to September 30, 2015. Data entry and collection were performed through the NELA. A 6-point, evidence-based care bundle was used. The bundle included prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer to the operating room within defined time goals after the decision to operate, use of goal-directed fluid therapy, postoperative admission to an intensive care unit, and multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative care. Change management and leadership coaching were provided to ELC leadership teams. Primary outcomes were in-hospital mortality, both crude and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the changes after implementation of the separate metrics in the care bundle. A total of 28 hospitals participated in the ELC and completed the project. The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of 65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%] and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from 9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year 1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were achieved. A collaborative approach using a quality improvement methodology and a care bundle appeared to be effective in reducing mortality and length of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach to see better patient outcomes and care delivery performance.

Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice

BackgroundThere is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. MethodsA 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. ResultsA 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. ConclusionsThis questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

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Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomized controlled trial. Reisinger KW, Willigers HM, Jansen J, Buurman WA, Von Meyenfeldt MF, Beets GL, Poeze M1. Goal-directed fluid therapy (GDFT) is one of the central components of enhanced recovery after surgery (ERAS) programs. Early studies found a significant reduction in length of stay and also decreased morbidity and mortality associated with the use of GDFT in the setting of traditional care pathways. However, more recent trials have shown no significant benefit, particularly when an ERAS program is fully implemented, reflecting the difficulty in estimating the contribution of each specific component of the bundle of interventions. Moreover, there is also great controversy over the value that the different methodologies used for GDFT, such as Doppler, hemodynamic parameters from an arterial line or noninvasive cardiac output monitoring devices, can provide. In this issue, Reisinger et al. have performed a randomized controlled trial (RCT) with the aim of investigating the effect of Doppler guided GDFT on intestinal damage and gastrointestinal perfusion during colorectal surgery as compared with standard post-operative fluid replacement. It is important to emphasize that unlike previous studies, the authors do not only analyse clinical outcomes but also try to uncover the mechanisms responsible for these results. This RCT shows that Doppler guided GDFT during and after surgery for colorectal cancer increases global gastrointestinal perfusion but no differences were observed in length of stay or postoperative complications. The authors hypothesize that the benefits of fluid optimization might be clinically evident only in high-risk patients. Although the observed changes in gastrointestinal perfusion did not translate into lower morbidity, we must highlight the need for studies such as this in which not only clinical outcomes are investigated but also the mechanisms responsible for them. That is the only way to advance in the knowledge of surgery and provide better care to our patients.

Enhanced recovery after surgery (ERAS®) in gynecologic oncology - Practical considerations for program development.

Enhanced recovery after surgery (ERAS®) in gynecologic oncology - Practical considerations for program development.

Analysis of Variability in Intraoperative Fluid Administration for Colorectal Surgery: An Argument for Goal-Directed Fluid Therapy.

Fluid therapy in the perioperative period varies greatly between anesthesia providers and may have a negative impact on surgical outcomes. We conducted a retrospective analysis of 705 elective colorectal cases consisting of colectomies, ileocolic resections, and low anterior resections at an academic institution from January 1, 2010 to May 29, 2015, collected by our electronic medical record before implementation of Enhanced Recovery After Surgery (ERAS®) pathways. The mean for total crystalloid administration was 2578 mL with a standard deviation (SD) that was approximately 50% of the mean value. A combination of both normal saline and lactated Ringer's solution was used in almost all cases without a clear rationale for fluid choice. Fluid administered to patients was disproportional to measured intraoperative fluid losses (estimated blood loss and urine output) by a factor of 10. The average rate of fluid given was 1050 mL/h with an SD of nearly the same amount (951 mL). There was a variability of over 67% in total crystalloid administered based on both ideal body weight and total body weight. We found that a wide variability in the amount and type of fluid therapy administered existed at our institution before implementation of a colorectal ERAS pathway or routine use of goal-directed fluid therapy (GDFT). ERAS pathways with GDFT protocols could lead to more rational and consistent fluid therapy leading to improved outcomes.

Goal Directed Fluid Therapy Decreases Postoperative Morbidity But Not Mortality in Major Non-cardiac Surgery

(Abstracted from J Anesth, 31:66–81, 2017) The objective of this meta-analysis and systematic review was to determine dynamic goal-directed fluid therapy’s (GDFT’s) effect on postoperative morbidity and mortality in noncardiac surgical patients. The effect of both noninvasive and less invasive dynamic parameter–guided GDFT in noncardiac surgical populations was assessed in this study.

Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials.

Optimum perioperative fluid administration may improve postoperative outcome after major surgery. This meta-analysis and systematic review has been aimed to determine the effect of dynamic goal directed fluid therapy (GDFT) on postoperative morbidity and mortality in non-cardiac surgical patients. Meta-analysis of published prospective randomized controlled trials where GDFT based on non-invasive flow based hemodynamic measurement has been compared with a standard care. Data from 41 prospective randomized trials have been included in this study. Use of GDFT in major surgical patients does not decrease postoperative hospital/30-day mortality (OR 0.70, 95% CI 0.46-1.08, p=0.11) length of post-operative hospital stay (SMD -0.14; 95% CI -0.28, 0.00; p=0.05) and length of ICU stay (SMD -0.12; 95% CI -0.28, 0.04; p=0.14). However, number of patients having at least one postoperative complication is significantly lower with use of GDFT (OR 0.57; 95% CI 0.43, 0.75; p<0.0001). Abdominal complications (p=0.008), wound infection (p=0.002) and postoperative hypotension (p=0.04) are also decreased with used of GDFT as opposed to a standard care. Though patients who received GDFT were infused more colloid (p<0.0001), there is no increased risk of heart failure or pulmonary edema and renal failure. GDFT in major non- cardiac surgical patients has questionable benefit over a standard care in terms of postoperative mortality, length of hospital stay and length of ICU stay. However, incidence of all complications including wound infection, abdominal complications and postoperative hypotension is reduced.

When is enough enough? Individualized goal-directed fluid therapy for surgery

In the current issue of JCMC, Scheeren et al. [1] support the circulation during surgery according to the so-called individualized goal-directed fluid therapy (GDT) concept. It is self evident that it is not desirable to provide patients with too much volume and, on the other hand, hypovolemic shock should be avoided. Hypovolemic shock is life threading and it is, maybe therefore common to provide the surgical patient with a volume surplus. Yet, it would seem ideal if the volume administered to patients during surgery, as to patients in general, reflects what is in need so that a ‘‘normal’’ blood volume is maintained at all times. The word ‘‘normovolemia’’ should be introduced to represent balance between hypovolemia and hypervolemia. A hypovolemic shock develops with a significant (30 %) reduction of the central blood volume, even with maintained total blood volume. The central blood volume is reduced during, e.g. head up tilt and cardiac stroke volume (SV) and output (CO), as venous oxygen saturation (SvO2) decrease [2]. Conversely, the central blood volume is expanded during head-down tilt, but such expanded central blood volume does not affect SV, CO, or SvO2 [3]. In other words, the heart is on the ascending part of the Frank-Starling curve during head up tilt, while for supine humans the heart is operating on the upper flat part of the curve. The clinical correlate to these experimental findings is that for supine humans the intravascular volume is normalized when flow-related variables (stroke volume variation, SV, CO and SvO2) do not respond to volume administration, i.e. it is secured that the patient is not ‘‘volume responsive’’ to the administration of, e.g. 200 ml colloid [5] as also used by Scheeren et al. [1]. As a rule of the thumb, SvO2 is reduced by 1 % for a 100 ml blood deficit while blood pressure decreases only following a 30 % reduction of the blood volume, i.e. with a blood loss of approximately 1–1.5 l. With a reduction of the central blood volume as during haemorrhage, blood pressure is maintained by recruitment of fluid to the circulation and, ultimately by peripheral vasoconstriction meaning that organ perfusion becomes compromised. With the high accuracy of GDT (100–200 ml) compared to a volume strategy directed by heart rate and blood pressure, the common finding is that GDT reduces postoperative complications [5] likely because GDT maintains organ flow. Scheeren et al. [1] find a lower number of wound infections with the use of GDT to 26 patients undergoing high risk surgery and other expressions of outcome (number of patients with least one complication, number of complications per patient, and ‘‘SOFA’’ and ‘‘TISS’’ scores) also tended to improve (vs. 26 control patients). Taken together, GDT offers a rational basis for volume administration compared to the large variation among the different fixed volume regimes, both ‘‘liberal’’ and ‘‘restrictive’’, applied to surgical patients [4]. To establish GDT for wide use to surgical patients requires, however, not only that relevant apparatus is available but also that the concept is exposed to large and ideally multicenter trials for which the work by Scheeren et al. [1] is intended to define the number of patients in need. Yet, not all trials find enhanced outcome following GDT (e.g. [6]), indicating that the fixed volume regime chosen for comparison was reasonable and that for various procedures, GDT can This is the commentary to Thomas W.L. Scheeren et al. (doi: 10.1007/s10877-013-9461-6).

Goal-directed fluid therapy- a survey of anaesthetists in the UK, USA, Australia and New Zealand

BackgroundGoal-directed fluid therapy (GDFT) has been shown to reduce complications and hospital length of stay following major surgery. However, there has been no assessment regarding its use in clinical practice.MethodsAn electronic survey was administered to randomly selected anaesthetists from the United Kingdom (UK, n = 2000) and the United States of America (USA, n = 2000), and 500 anaesthetists from Australia/New Zealand (AUS/NZ). Preferences, clinical use and attitudes towards GDFT were investigated. Results were collated to examine regional differences.ResultsThe response rates from the UK (n = 708) and AUS/NZ (n = 180) were 35%, and 36% respectively. The response rate from the USA was very low (n = 178; 9%). GDFT use was significantly more common in the UK than in AUS/NZ (p < 0.01). The Oesophageal Doppler Monitor was the most preferred instrument in the UK (n = 362; h76%) with no clear preferences in other regions. GDFT was most commonly utilised in major abdominal surgery and for patients with significant comorbidities. The commonest reasons stated for not using GDFT were either lack of availability of monitoring tools (AUS/NZ: 57 (70%); UK: 94 (64%)) or a lack of experience with instruments (AUS/NZ: 43 (53%); UK: 51 (35%)). A subset of respondents (AUS/NZ: 22(27%); UK: 45 (30%)) felt GDFT provided no perceived benefit. Enthusiasm towards the use of GDFT in the absence of existing barriers was high.ConclusionSeveral hypotheses were generated regarding important differences in the use of GDFT between anaesthetists from the UK and AUS/NZ. There is significant interest in utilising GDFT in clinical practice and existing barriers should be addressed.

Dopexamine Has No Additional Benefit in High-Risk Patients Receiving Goal-Directed Fluid Therapy Undergoing Major Abdominal Surgery

Dopexamine has been shown to reduce both mortality and morbidity in major surgery when it is used as part of a protocol to increase oxygen delivery in the perioperative period. A European multicenter study has examined the use of dopexamine in patients undergoing major abdominal surgery, showing a trend toward improved survival and reduced complications in high-risk patients when receiving low-dose dopexamine (0.5 μg · kg(-1) · min(-1)). A reduced oxygen uptake at the anaerobic threshold (AT) has been shown to confer a significant risk of mortality in patients undergoing major abdominal surgery and allows objective identification of a high-risk operative group. In this study, we assessed the effects of low-dose dopexamine on morbidity after major abdominal surgery in patients who were at increased risk by virtue of a reduced AT. Patients undergoing elective major colorectal or urological surgery who had an AT of <11 mL · kg(-1) · min(-1) or an AT of 11 to 14 mL · kg(-1) · min(-1) with a history of ischemic heart disease were recruited. Before surgery, a radial arterial cannula was placed and attached to an Edwards Lifesciences FloTrac/Vigileo system for measuring cardiac output. Patients were given a 250-mL bolus of Voluven (6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride) until the stroke volume no longer increased by 10%, then received either dopexamine (0.5 μg · kg(-1) · min(-1)) or saline 0.9% for 24 hours. During surgery, fluid boluses of Voluven were given if the stroke volume variation was >10%. No crystalloid was given during surgery. A standardized postoperative fluid regime with Hartmann solution was prescribed at 1.5 mL · kg(-1) · h(-1) for 24 hours. The primary outcome measure was postoperative morbidity measured by the Postoperative Morbidity Survey. One hundred twenty-four patients were recruited over a 23-month period. The incidence of morbidity as measured by the Postoperative Morbidity Survey on day 5 was 55% in the control group versus 47% in the dopexamine group (P = 0.14). There was no significant reduction in morbidity on any measured postoperative day. Complication rates, mortality, and hospital length of stay were similar between the 2 groups; however, administration of dopexamine was associated with earlier return of tolerating an enteral diet. With the effective use of goal-directed fluid therapy in elective surgical patients, the routine use of dopexamine does not confer an additional clinical benefit.