A Randomized Clinical Trial of the Effect of Deliberate Perioperative Increase of Oxygen Delivery on Mortality in High-Risk Surgical Patients

Boyd, Owen; Grounds, R. M.; Bennett, E. D.

doi:10.1001/jama.1993.03510220055034

Cited by 848 publications

(357 citation statements)

References 46 publications

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“…Many of these patients are elderly and suffer comorbid medical conditions as well as the local and systemic effects of colorectal disease. Studies of similar patient groups having major surgery have used fluid, inotrope and oxygen therapy to optimise cardiac output and oxygen delivery; these studies demonstrated reductions in mortality and length of hospital stay [3][4][5]. The method of cardiac output measurement in these reports, pulmonary artery catheterisation, is not commonly used for bowel surgery.…”

Section: Discussionmentioning

confidence: 99%

“…The gut is thought to play a critical role in initiating this process [17]. Previous studies have emphasised the importance of optimal fluid provision to improve oxygen delivery and reduce complications [3][4][5]9]. Oesophageal Doppler provides an instantaneous representation of beat-to-beat haemodynamic function and so allows rapid correction of hypovolaemia and oxygen debt.…”

Section: Discussionmentioning

confidence: 99%

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Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery*

et al. 2002

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SummaryOesophageal Doppler monitoring allows non-invasive estimation of stroke volume and cardiac output. We studied the impact of Doppler guided fluid optimisation on haemodynamic parameters, peri-operative morbidity and hospital stay in patients undergoing major bowel surgery. Fifty-seven patients were randomly assigned to Doppler (D) or control (C) groups. All patients received intraoperative fluid therapy at the discretion of the non-investigating anaesthetist. In addition, Group D were given fluid challenges (3 ml.kg Surgical patients undergoing major bowel resection are at high risk of peri-operative complications and death. Centres in the UK report mortality rates in this group of between 4 and 9% [1, 2]. Many of these patients are elderly and suffer comorbid medical conditions as well as the local and systemic effects of colorectal disease. Studies of similar patient groups having major surgery have used fluid, inotrope and oxygen therapy to optimise cardiac output and oxygen delivery; these studies demonstrated reductions in mortality and length of hospital stay [3][4][5]. The method of cardiac output measurement in these reports, pulmonary artery catheterisation, is not commonly used for bowel surgery. Pulmonary artery catheter insertion can be time consuming and has been implicated with complications and excess mortality [6]. Furthermore some trials involving pulmonary artery catheter optimisation of oxygen delivery required pre-operative admission to intensive care which is currently not practical for colorectal resection.The minimally invasive oesophageal Doppler monitor permits real time assessment of cardiac output [7]. Haemodynamic parameters estimated by this device can be used to guide fluid therapy during surgery [8]. A study of patients undergoing repair of femoral neck fracture demonstrated a reduction in length of hospital stay when oesophageal Doppler was used to guide fluid therapy [9].The aim of this study was to examine the effect of oesophageal Doppler guided fluid administration during colorectal resection on haemodynamic performance, hospital stay and postoperative complications.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery*

et al. 2002

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“…Several studies have shown that decreased intra-operative oxygen delivery results in an increased incidence of postoperative complications [22,23]. In a study of 36 cardiac surgical patients, Routsi et al [24] observed a correlation between oxygen consumption and oxygen delivery, with the oxygen extraction ratio remaining largely constant.…”

Section: Discussionmentioning

confidence: 99%

The effect of a pre‐operative infusion of Ringer's solution on splanchnic perfusion in patients undergoing coronary artery bypass grafting

Klein¹,

Osmer

Müller

et al. 2002

Anaesthesia

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SummarySurgical patients develop a fluid deficit during pre-operative starvation. This study examines the effects of pre-operative fluid administration on haemodynamic variables, oxygenation and splanchnic perfusion in patients undergoing elective coronary artery bypass grafting. Forty-eight patients were randomised to receive either a pre-operative crystalloid infusion (crystalloid group, n ¼ 24) or no infusion (control group, n ¼ 24). Patients in the crystalloid group received a continuous infusion of Ringer's solution at 1.5 ml.kg )1 .h )1 from 22:00 h until induction of anaesthesia the next morning. Immediately before induction of anaesthesia, all patients were given a colloid infusion to increase pulmonary capillary wedge pressure and central venous pressure to similar levels in both groups. Haemodynamic and oxygenation parameters were measured using invasive cardiovascular monitoring, and splanchnic perfusion was assessed by indocyanine green clearance. Patients in the crystalloid group received a mean (SD) of 1008 (140) ml of Ringer's solution overnight. Patients in the crystalloid group had a higher splanchnic blood flow than the control group before induction of anaesthesia [mean (SD) ¼ 1782 (573) ml.min )1 vs. 1391 (333) ml.min )1 , p < 0.05]. There were no significant differences in systemic haemodynamic data and global oxygenation parameters between the two groups. Pre-operative infusion of crystalloid appears to result in an improvement in pre-operative splanchnic perfusion.

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“…This would be in keeping with previous studies that formally tested specific protocols. Manipulation of haemodynamics to supranormal goals in high-risk surgery has reduced mortality 15 whereas similar techniques in sepsis have resulted in increased mortality 16 .…”

Section: The Pulmonary Artery Catheter Controversymentioning

confidence: 99%

The pulmonary artery catheter

2002

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The pulmonary artery catheter directly measures cardiac output, pulmonary artery pressures and the oxygen saturations of blood through the heart and in the pulmonary arteriesThe mixed venous oxygen saturation enables an estimate of the oxygen supply/demand balance to be madeThe use of the pulmonary artery catheter in critically ill patients leads to a better understanding of the cardiovascular state of the patient Data obtained from the pulmonary artery catheter are often misunderstood Key Points

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A Randomized Clinical Trial of the Effect of Deliberate Perioperative Increase of Oxygen Delivery on Mortality in High-Risk Surgical Patients

Cited by 848 publications

References 46 publications

Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery*

Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery*

The effect of a pre‐operative infusion of Ringer's solution on splanchnic perfusion in patients undergoing coronary artery bypass grafting

The pulmonary artery catheter

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