Effect of Goal-directed Haemodynamic Therapy Guided by Non-invasive Monitoring on Perioperative Complications in Elderly Hip Fracture Patients Within an Enhanced Recovery Pathway.

Abstract

Background: Goal-Directed Hemodynamic Therapy (GDHT) has been shown to reduce morbidity and mortality in high-risk surgical patients. However, there is little evidence of its efficacy in patients undergoing hip fracture surgery. This study aims to evaluate the effect of GDHT guided by non-invasive haemodynamic monitoring on perioperative complications in patients undergoing hip fracture surgery.Methods: Patients > 64 years undergoing hip fracture surgery within an Enhanced Recovery Pathway were enrolled in this single-center, non-randomized, intervention study with a historical control group and 12-months follow-up. Exclusion criteria were patients with pathological fractures, traffic-related fractures and refractures. Control group patients received the standard care given at our hospital. Intervention group patients received an individualized management strategy aimed at achieving an optimal stroke volume by fluid administration, in addition to a systolic blood pressure > 90 mmHg and an optimal cardiac index according to the patient's age and baseline metabolic equivalents. No changes were made between groups in the enhanced recovery protocols, nor in the composition of the multidisciplinary team during the study period. Primary combined outcome was perioperative complications. Intraoperatively: haemodynamic instability, sustained cardiac arrhythmias. Postoperative complications: cardiovascular, respiratory, infectious and renal complications. Secondary outcomes were administered fluids, vasopressor requirements, perioperative transfusion, length of hospital stay, readmission and one-year survival.Results: 551 patients (Control group=272; Intervention group=279). Intraoperative haemodynamic instability was lower in the intervention group (37.5% vs 28.0%; p=0.017). GDHT patients had fewer postoperative cardiovascular (18.8% vs 7.2%; p < 0.001), respiratory (15.1% vs 3.6%; p<0.001) and infectious complications (21% vs 3.9%; p<0.001) but not renal (12.1% vs 33.7%; p<0.001). Intervention group patients had less vasopressors requirements (p<0.001) and received less fluids (p=0.001) than control group. Fewer patients required transfusion in GDHT group (p<0.001). For intervention group patients, median length of hospital stay was shorter (p < 0.001) and one-year survival higher (p<0.003).Conclusions: The use of GDHT decreases intraoperative complications and postoperative cardiovascular, respiratory and infectious but not postoperative renal complications. This strategy was associated with a shorter hospital stay and increased one-year survival.Trial registration: Clinicaltrials.gov: NCT02479321