Outcomes of implementation of enhanced goal directed therapy in high-risk patients undergoing abdominal surgery

Abstract

Background and Aims:Advanced monitoring targeting haemodynamic and oxygenation variables can improve outcomes of surgery in high-risk patients. We aimed to assess the impact of goal directed therapy (GDT) targeting cardiac index (CI) and oxygen extraction ratio (O2ER) on outcomes of high-risk patients undergoing abdominal surgery.Methods:In a prospective randomised trial, forty patients (American Society of Anaesthesiologists II and III) undergoing major abdominal surgeries were randomised into two groups. In-Group A mean arterial pressure ≥ 65 mmHg, central venous pressure ≥ 8–10 mmHg, urine output ≥ 0.5 mL/kg/h and central venous oxygen saturation ≥ 70% were targeted intra-operatively and 12 h postoperatively. In-Group-B (enhanced GDT), in addition to the monitoring in-Group-A, CI ≥ 2.5 L/min/m2 and O2ER ≤ 27% were targeted. The end-points were lactate levels and base deficit during and after surgery. The secondary end points were length of Intensive Care Unit (ICU) and hospital stay and postoperative complications. Wilcoxon Mann Whitney and Chi-square tests were used for statistical assessment.Results:Lactate levels postoperatively at 4 and 8 h were lower in-Group-B (P < 0.05). The mean base deficit at 3, 4, 5 and 6 h intra-operatively and postoperatively after 4, 8 and 12 h were lower in-Group-B (P < 0.05). There were no significant differences in ICU stay (2.10 ± 1.52 vs. 2.90 ± 2.51 days) or hospital stay (10.85 + 4.39 vs. 13.35 + 6.77 days) between Group A and B.Conclusions:Implementation of enhanced GDT targeting CI and OER was associated with improved tissue oxygenation.

Effects of perioperative goal-directed fluid therapy combined with the application of alpha-1 adrenergic agonists on postoperative outcomes: a systematic review and meta-analysis

“…Seventeen trials [ 28 , 29 , 31 – 33 , 35 , 36 , 39 , 41 , 43 , 45 – 51 ] included patients who were less than 65 years old, and 14 trials [ 3 , 9 , 24 – 27 , 30 , 34 , 37 , 38 , 40 , 42 , 44 , 52 ] included patients who were more than 65 years old. As for the type of alpha-1 adrenergic agonists used in studies, 17 studies [ 3 , 25 , 27 – 30 , 34 – 38 , 40 , 44 , 45 , 49 – 52 ] selected norepinephrine, 11 studies [ 24 , 26 , 31 – 33 , 39 , 41 , 42 , 50 , 52 ] considered phenylephrine, 2 studies [ 43 , 46 ] used norepinephrine and phenylephrine, and 1 study [ 9 ] used metaraminol.…”

“…As for the type of alpha-1 adrenergic agonists used in studies, 17 studies [ 3 , 25 , 27 – 30 , 34 – 38 , 40 , 44 , 45 , 49 – 52 ] selected norepinephrine, 11 studies [ 24 , 26 , 31 – 33 , 39 , 41 , 42 , 50 , 52 ] considered phenylephrine, 2 studies [ 43 , 46 ] used norepinephrine and phenylephrine, and 1 study [ 9 ] used metaraminol. Additionally, 18 trials [ 3 , 27 – 29 , 31 , 32 , 35 , 37 , 38 , 40 – 45 , 47 , 48 , 52 ] involved abdominal surgery. Four trials [ 34 , 46 , 50 , 51 ] were related to thoracic surgery.…”

“…The subgroup analyses revealed that GDFT combined with alpha-1 adrenergic agonists significantly reduced LOS associated with abdominal surgery (WMD − 1.20 days; 95% CI –2.12 to − 0.28; P = 0.01; I 2 = 71%; n = 16 [ 3 , 27 – 29 , 31 , 32 , 35 , 38 , 40 – 45 , 48 , 52 ]), norepinephrine as interventions (WMD − 1.46 days; 95% CI –2.29 to − 0.64; P = 0.0005; I 2 = 62%; n = 16 [ 3 , 25 , 27 – 30 , 34 – 36 , 38 , 40 , 44 , 45 , 48 , 50 , 52 ]) (Fig. 5 ) and low risk of bias (WMD − 0.98 days; 95% CI –1.58 to − 0.38; P = 0.001; I 2 = 56%; n = 16 [ 25 , 26 , 28 – 30 , 32 , 34 , 36 , 38 , 40 , 42 , 45 , 48 – 50 , 52 ]) (Additional file 7 ).…”

Metabolic profile in right lobe living donor hepatectomy: Comparison of lactated Ringer′s solution and normal saline versus acetate based balanced salt solution - a pilot study

“…Liberal fluid administration by goal-directed therapy has been shown to reduce lactate levels in high-risk patients undergoing abdominal surgery. [ 20 ] However, our fluid strategy for hepatectomy did not affect lactates, and there were no differences in the volume of fluids or need for inotropes between both groups. The blood losses were minimal, and transfusion was administered to two patients in group L following blood loss due to clamp slippage.…”

Impact of perioperative hemodynamic optimization therapies in surgical patients: economic study and meta-analysis

“…Kumar et al, 2015 [38] Randomized study evaluating the impact of GDT on the cardiac index and O2 extraction rate in patients undergoing abdominal surgery.…”