Effect of Intraoperative Goal-Directed Fluid Management on Tissue Oxygen Tension in Obese Patients: a Randomized Controlled Trial

Abstract

Background Perioperative subcutaneous tissue oxygen tension (PsqO2) is substantially reduced in obese surgical patients. Goal-directed fluid therapy optimizes cardiac performance and thus tissue perfusion and oxygen delivery. We therefore tested the hypothesis that intra- and postoperative PsqO2 is significantly reduced in obese patients undergoing standard fluid management compared to goal-directed fluid administration. Methods We randomly assigned 60 obese patients (BMI ≥ 30 kg/m2) undergoing laparoscopic bariatric surgery to receive either esophageal Doppler-guided goal-directed fluid management or conventional fluid treatment. Our primary outcome parameter was intra- and postoperative PsqO2 measured with a polarographic electrode in the subcutaneous tissue of the upper arm. A random effects linear regression model was used to analyze the effect of intervention. Results Overall, mean (± SD) PsqO2 was significantly higher in obese patients receiving goal-directed therapy compared to conventional fluid therapy (65.8 ± 28.0 mmHg vs. 53.7 ± 21.7, respectively; repeated measures design adjusted difference: 13.0 mmHg [95% CI 2.3 to 23.7; p = 0.017]). No effect was seen intraoperatively (69.6 ± 27.9 mmHg vs. 61.4 ± 28.8, difference: 9.7 mmHg [95% CI -3.8 to 23.2; p = 0.160]); however, goal-directed fluid management improved PsqO2 in the early postoperative phase (63.1 ± 27.9 mmHg vs. 48.4 ± 12.5, difference: 14.5 mmHg [95% CI 4.1 to 24.9; p = 0.006]). Intraoperative fluid requirements did not differ between the two groups. Conclusions Goal-directed fluid therapy improved subcutaneous tissue oxygenation in obese patients. This effect was more pronounced in the early postoperative period. Clinical Trial Number and Registry The study was registered at ClinicalTrials.gov (NCT 01052519).

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

“…In a RCT of 60 patients undergoing laparoscopic bariatric surgery, GDFT was associated with improved tissue oxygenation in the early postoperative period [ 108 ] . Additionally, GDFT guided by stroke volume optimization according to arterial pressure waveform analysis or by Pleth Variability Index (PVI) can decrease the incidence of postoperative nausea and vomiting and shorten hospital LOS [ 109 ].…”

Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis

“…Our search resulted in 5485 records from five databases (PUBMED ® , Embase ® , CENTRAL, Web of Science, and SCOPUS ® ). Finally, 15 RCTs were included in the qualitative synthesis [ 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ], and in one RCT (Cho and colleagues), two types of GDFT protocols were implemented [ 46 ]. According to our selection criteria, it was not possible to decide which group should be included in the quantitative synthesis, and therefore we decided to include this study only in the qualitative synthesis.…”

“…According to our selection criteria, it was not possible to decide which group should be included in the quantitative synthesis, and therefore we decided to include this study only in the qualitative synthesis. Eleven studies were included in the quantitative synthesis [ 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 56 , 57 , 58 ].…”

Goal-Directed Intraoperative Fluid Therapy Benefits Patients Undergoing Major Gynecologic Oncology Surgery: A Controlled Before-and-After Study

“…In this study, patients in the GDFT group received significantly less fluid infusion than the control group (15.8 vs. 17.9 ml/kg/h, P = 0.013), while fluid loss was similar between the two groups (6.9 vs. 7.1 ml/kg/h, P = 0.691). A larger amount of fluid was infused in our group of patients compared with the other types of surgery including laparoscopic gastric bypass surgery ( 7 ), colorectal surgery ( 8 ), and esophageal surgery ( 9 ). Even compared with patients undergoing other open abdominal surgeries (including visceral, vascular, and urology surgeries) receiving goal-directed fluid therapy ( 10 ), patients in our study received more fluids intraoperatively (15.8 vs. 10.8 ml/kg/h).…”