Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study

Abstract

IntroductionStroke volume variation (SVV) is a good and easily obtainable predictor of fluid responsiveness, which can be used to guide fluid therapy in mechanically ventilated patients. During major abdominal surgery, inappropriate fluid management may result in occult organ hypoperfusion or fluid overload in patients with compromised cardiovascular reserves and thus increase postoperative morbidity. The aim of our study was to evaluate the influence of SVV guided fluid optimization on organ functions and postoperative morbidity in high risk patients undergoing major abdominal surgery.MethodsPatients undergoing elective intraabdominal surgery were randomly assigned to a Control group (n = 60) with routine intraoperative care and a Vigileo group (n = 60), where fluid management was guided by SVV (Vigileo/FloTrac system). The aim was to maintain the SVV below 10% using colloid boluses of 3 ml/kg. The laboratory parameters of organ hypoperfusion in perioperative period, the number of infectious and organ complications on day 30 after the operation, and the hospital and ICU length of stay and mortality were evaluated. The local ethics committee approved the study.ResultsThe patients in the Vigileo group received more colloid (1425 ml [1000-1500] vs. 1000 ml [540-1250]; P = 0.0028) intraoperatively and a lower number of hypotensive events were observed (2[1-2] Vigileo vs. 3.5[2-6] in Control; P = 0.0001). Lactate levels at the end of surgery were lower in Vigileo (1.78 ± 0.83 mmol/l vs. 2.25 ± 1.12 mmol/l; P = 0.0252). Fewer Vigileo patients developed complications (18 (30%) vs. 35 (58.3%) patients; P = 0.0033) and the overall number of complications was also reduced (34 vs. 77 complications in Vigileo and Control respectively; P = 0.0066). A difference in hospital length of stay was found only in per protocol analysis of patients receiving optimization (9 [8-12] vs. 10 [8-19] days; P = 0.0421). No difference in mortality (1 (1.7%) vs. 2 (3.3%); P = 1.0) and ICU length of stay (3 [2-5] vs. 3 [0.5-5]; P = 0.789) was found.ConclusionsIn this study, fluid optimization guided by SVV during major abdominal surgery is associated with better intraoperative hemodynamic stability, decrease in serum lactate at the end of surgery and lower incidence of postoperative organ complications.Trial registrationCurrent Controlled Trials ISRCTN95085011.

CVP vs. dynamic hemodynamic parameters as preload indicators in hemodynamically unstable patients after major surgery

“…(18,19,20) The values of the blood lactates were also different between the two groups which has a considerable predictive value for postoperative patients hospitalized in the ICU, which is in agreement with other studies (21). Our study had some limitations, primarily the relatively low number of patients in the sample.…”

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

“…This should be given rapidly over five to ten minutes, 23 and although there is no consensus on the type of fluid given, most trials in the operating room showing an improved outcome were performed with a colloid. [24][25][26][27][28][29][30][31][32] Importantly, hemodynamic instability does not equate with volume responsiveness; indeed, only 50% of hemodynamically unstable patients in the operating room are ''volume responders''. 33 Moreover, volume responsiveness does not always mean that a fluid bolus is needed.…”

“…46 Dynamic parameters can also alert the anesthesia provider to episodes of hypovolemia before there is any change in HR, BP, or SV. 28,47 Nevertheless, it is important to reiterate that, while the dynamic parameters are robust indicators of volume responsiveness, this does not necessarily mean that the patient needs volume. Like all measured variables, they should not be used in isolation, trends and the fluid and hemodynamic priorities of the patient should always be considered.…”

State-of-the-art fluid management in the operating room

“…Benes et al randomized 120 patients undergoing major abdominal surgery with expected blood loss >1000 ml to either GDFT with the Flotrac/Vigileo or routine intraoperative care [32]. The aim of the GDFT group was to maintain SVV <10% using colloid boluses of 3 ml/kg.…”