Respiratory induced dynamic variations of stroke volume and its surrogates are very sensitive and specific predictors of fluid responsiveness, but their use as targets for volume management can be limited. In a recent study, limiting factors were present in 53 % of surgical patients with inserted arterial line. In the intensive care unit (ICU) population the frequency is presumably higher, but the real prevalence is unknown. Our goal was to study the feasibility of dynamic variations guided initial volume resuscitation in specific critical states. We have performed a 5 year retrospective evaluation of patients admitted with diagnosis sepsis, polytrauma, after high risk surgery or cardiac arrest. Occurrence of major (sedation, mandatory ventilation and tidal volume, open chest and arrhythmias) and minor limiting factors (PEEP level, use of vasopressors and presence of arterial catheter) was screened within the first 24 h after admission. In the study period 1296 patients were hospitalized in our ICU with severe sepsis (n = 242), polytrauma (n = 561), after high risk surgery (n = 351) or cardiac arrest (n = 141). From these patients 549 (42.4 %) fulfilled all major criteria for applicability of dynamic variations. In our evaluation only limited number of patients admitted for polytrauma (51 %), sepsis (37 %), after cardiac arrest (39 %) or surgical procedure (33 %) fulfil all the major criteria for use of dynamic variations at the ICU admission. The prevalence was similar in patients with shock. Occurrence of minor factors can pose further bias in evaluation of these patients. General use of dynamic variations guided protocols for initial resuscitations seems not universally applicable.

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BackgroundPerioperative goal directed therapy (GDT) can substantially improve the outcomes of high risk surgical patients as shown by many clinical studies. However, the approach needs initial investment and can increase the already very high staff workload. These economic imperatives may be at least partly responsible for weak adherence to the GDT concept. A few models are available for the evaluation of GDT cost-effectiveness, but studies of real economic data based on a recent clinical trial are lacking. In order to address this we have performed a retrospective analysis of the data from the “Intraoperative fluid optimization using stroke volume variation in high risk surgical patients” trial (ISRCTN95085011).MethodsThe health-care payers perspective was used in order to evaluate the perioperative hemodynamic optimization costs. Hospital invoices from all patients included in the trial were extracted. A direct comparison between the study (GDT, N = 60) and control (N = 60) groups was performed. A cost tree was constructed and major cost drivers evaluated.ResultsThe trial showed a significant improvement in clinical outcomes for GDT treated patients. The mean cost per patient were lower in the GDT group 2877 ± 2336€ vs. 3371 ± 3238€ in controls, but without reaching a statistical significance (p = 0.596). The mean cost of all items except for intraoperative monitoring and infusions were lower for GDT than control but due to the high variability they all failed to reach statistical significance. Those costs associated with clinical care (68 ± 177€ vs. 212 ± 593€; p = 0.023) and ward stay costs (213 ± 108€ vs. 349 ± 467€; p = 0.082) were the most important differences in favour of the GDT group.ConclusionsIntraoperative fluid optimization with the use of stroke volume variation and Vigileo/FloTrac system showed not only a substantial improvement of morbidity, but was associated with an economic benefit. The cost-savings observed in the overall costs of postoperative care trend to offset the investment needed to run the GDT strategy and intraoperative monitoring.Trial registrationISRCTN95085011

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