Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study

Abstract

Perioperative hemodynamic optimisation improves postoperative outcome for patients undergoing high-risk surgery (HRS). In this prospective randomized multicentre study we studied the effects of an individualized, goal-directed fluid management based on continuous stroke volume variation (SVV) and stroke volume (SV) monitoring on postoperative outcomes. 64 patients undergoing HRS were randomized either to a control group (CON, n = 32) or a goal-directed group (GDT, n = 32). In GDT, SVV and SV were continuously monitored (FloTrac/Vigileo) and patients were brought to and maintained on the plateau of the Frank-Starling curve (SVV <10 % and SV increase <10 % in response to fluid loading). Organ dysfunction was assessed using the SOFA score and resource utilization using the TISS score. Patients were followed up to 28 days for postoperative complications. Main outcome measures were the number of complications (infectious, cardiac, respiratory, renal, hematologic and abdominal post-operative complications), maximum SOFA score and cumulative TISS score during ICU stay, duration of mechanical ventilation, length of ICU stay, and time until fit for discharge. 12 patients had to be excluded from final analysis (6 in each group). During surgery, GDT received more colloids than CON (1,589 vs. 927 ml, P < 0.05) and SVV decreased in GDT (from 9.0 to 8.0 %, P < 0.05) but not in CON. The number of postoperative wound infections was lower in GDT (0 vs. 7, P < 0.01). Although not statistically significant, the proportion of patients with at least one complication (46 vs. 62 %), the number of postoperative complications per patient (0.65 vs. 1.40), the maximum sofa score (5.9 vs. 7.2), and the cumulative TISS score (69 vs. 83) tended to be lower. This multicentre study shows that fluid management based on a SVV and SV optimisation protocol is feasible and decreases postoperative wound infections. Our findings also suggest that a goal-directed strategy might decrease postoperative organ dysfunction.

Simplified Intraoperative Goal-Directed Therapy Using the FloTrac/Vigileo System: An Analysis of Its Usefulness and Safety

“…Moreover, comparable effects of GDT using solely the FloTrac/Vigileo system to its effects using other hemodynamic monitors have been demonstrated, and this therapy has been reported as simple and safe [10] [11]. We also previously reported in a small series (before the present study) that GDT contributes to the standardization of fluid management [13] and a reduction in surgical costs [14].…”

Effects of goal-directed fluid therapy with different lactated Ringer’s: hydroxyethyl starch ratios in hemorrhagic shock dogs

“…A goal-directed fluid therapy, which aims to achieve maximal cardiac output and stroke volume while avoiding fluid overload, is associated with reductions in mortality, postoperative complications, and length of hospital stay compared with fluid management guided with traditional physiologic targets [heart rate (HR), blood pressure (BP), central venous pressure, urinary output, arterial oxygenation, and pH] (Pearse et al, 2005;Scheeren et al, 2013).…”

Influence of early goal-directed therapy using arterial waveform analysis on major complications after high-risk abdominal surgery: study protocol for a multicenter randomized controlled superiority trial

“…Since the start of the trial in May 2012, a number of interesting studies have been published which partially addressed the shortcomings mentioned above [5, 21–23]. Two studies demonstrated that the implementation of a goal-directed strategy was cost-effective [21, 22].…”

“…Two studies demonstrated that the implementation of a goal-directed strategy was cost-effective [21, 22]. In addition, two multicenter studies were performed in which a reduction in complications was shown [5, 23]. However, minor complications were included, and the number of patients was rather small in these studies.…”