Outcome impact of hemodynamic and depth of anesthesia monitoring during major cancer surgery: a before–after study

Abstract

Hemodynamic and depth of anesthesia (DOA) monitoring are used in many high-risk surgical patients without well-defined indications and objectives. We implemented monitoring guidelines to rationalize hemodynamic and anesthesia management during major cancer surgery. In early 2014, we developed guidelines with specific targets (Mean arterial pressure > 65 mmHg, stroke volume variation < 12%, cardiac index > 2.5 l min m, central venous oxygen saturation > 70%, 40 < bispectral index < 60) for open abdominal cancer surgeries > 2 h. Pre-, intra-, and post-operative data were collected from our electronic medical record database and compared before (March-August 2013) and after (March-August 2014) guideline implementation. A total of 596 patients were studied, 313 before (Before group) and 283 after (After group) guideline implementation. The two groups were comparable for age, ASA score, physiological P-POSSUM score, and surgery duration, but the operative P-POSSUM score was higher in the after group (20 vs. 18, p = 0.009). The use of cardiac output, central venous oxygen saturation and DOA monitoring increased from 40 to 61%, 20 to 29%, and 60 to 88%, respectively (all p-values < 0.05). Intraoperative fluid volumes decreased (16.0 vs. 14.5 ml kg h, p = 0.002), whereas the use of inotropes increased (6 vs. 11%, p = 0.022). Postoperative delirium (16 vs. 8%, p = 0.005), urinary tract infections (6 vs. 2%, p = 0.012) and median hospital length of stay (9.6 vs. 8.8 days, p = 0.032) decreased. In patients undergoing major open abdominal surgery for cancer, despite an increase in surgical risk, the implementation of guidelines with predefined targets for hemodynamic and DOA monitoring was associated with a significant improvement in postoperative outcome.

Journal of Clinical Monitoring and Computing end of year summary 2019: hemodynamic monitoring and management

“…Besides hemodynamic monitoring, which is an integral component of pGDT, also depth-of-anesthesia (DoA) monitoring might contribute to the outcome of high-risk surgical patients. In a before-after study setup, Lima et al [32] studied the effect of implementing guidelines for hemodynamic and DoA monitoring in their hospital on intraoperative drug and fluid consumption and postoperative complications. They retrospectively included a large number of patients (n = 596) undergoing abdominal cancer surgery, 313 of which were included before (before group) and 283 after protocol implementation (after group) after having instructed their caregivers on the hemodynamic and DoA targets of their guidelines.…”

Perioperative goal-directed therapy: what’s the best study design to investigate its impact on patient outcome?

“…Lima et al [6] need to be commended for their study investigating the effects of implementing a multimodal "hemodynamic and depth of anesthesia treatment protocol" on patient outcome after major open abdominal cancer surgery [6]. The authors demonstrated that in patients treated after the implementation of the treatment protocol (which included mean arterial pressure, stroke volume variation, cardiac index, central venous oxygen saturation, and bispectral index as targets) the incidence of postoperative delirium was significantly lower and the median hospital length of stay was significantly shorter compared to patients having the same kind of surgery prior to protocol implementation [6].…”

“…The authors demonstrated that in patients treated after the implementation of the treatment protocol (which included mean arterial pressure, stroke volume variation, cardiac index, central venous oxygen saturation, and bispectral index as targets) the incidence of postoperative delirium was significantly lower and the median hospital length of stay was significantly shorter compared to patients having the same kind of surgery prior to protocol implementation [6].…”

“…Instead of performing a randomized controlled trial, Lima et al [6] chose an uncontrolled before-and-after study design [14] (Fig. 1) comparing two periods, the one before (March to August 2013) and that after (March to August 2014) implementation of their treatment protocol.…”

“…In summary, before-and-after studies are used in anesthesiology to evaluate the effectiveness of perioperative goal-directed therapy on patient outcome [6,[15][16][17][18][19]. A before-and-after study can give valuable insights into the feasibility and effectiveness of an intervention under real-life clinical conditions and, therefore, can complement evidence from randomized controlled trials.…”