Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study

Abstract

IntroductionSeveral single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients. We hypothesized that using a treatment algorithm based on pulse pressure variation, cardiac index trending by radial artery pulse contour analysis, and mean arterial pressure in a study group (SG), would result in reduced complications, reduced length of hospital stay and quicker return of bowel movement postoperatively in abdominal surgical patients, when compared to a control group (CG).Methods160 patients undergoing elective major abdominal surgery were randomized to the SG (79 patients) or to the CG (81 patients). In the SG hemodynamic therapy was guided by pulse pressure variation, cardiac index trending and mean arterial pressure. In the CG hemodynamic therapy was performed at the discretion of the treating anesthesiologist. Outcome data were recorded up to 28 days postoperatively.ResultsThe total number of complications was significantly lower in the SG (72 vs. 52 complications, p = 0.038). In particular, infection complications were significantly reduced (SG: 13 vs. CG: 26 complications, p = 0.023). There were no significant differences between the two groups for return of bowel movement (SG: 3 vs. CG: 2 days postoperatively, p = 0.316), duration of post anesthesia care unit stay (SG: 180 vs. CG: 180 minutes, p = 0.516) or length of hospital stay (SG: 11 vs. CG: 10 days, p = 0.929).ConclusionsThis multi-center study demonstrates that hemodynamic goal-directed therapy using pulse pressure variation, cardiac index trending and mean arterial pressure as the key parameters leads to a decrease in postoperative complications in patients undergoing major abdominal surgery.Trial registrationClinicalTrial.gov, NCT01401283.

Multimodal individualized concept of hemodynamic monitoring

“…Target DO 2 was based on the preoperatively determined individual DO 2 values. In the treatment group after the first hour of optimization, 40% of patients received dobutamine as compared with none in the controls, a very similar result to that of the previous trial [23]. Their main finding was that achievement of preoperative DO 2 soon after major surgery was associated with a reduction in early postoperative morbidity, yet this occurred irrespective of additional postoperative hemodynamic management.…”

“…In a recent large multicenter-randomized study, PPV, MAP and CI-trending-based approach reduced postoperative complications in high-risk surgical patients undergoing major abdominal surgery by almost 50% [23]. A subgroup of patients undergoing bowel surgery benefited the most from this intervention.…”

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“…Recent studies show that the application of haemodynamic monitoring can improve outcomes [54,55]. As explained above, CO monitoring with TPTD combined with pulse contour analysis obtained with the PiCCO system provides information on fluid status, fluid responsiveness, CO, contractility of the myocardium and severity of the pulmonary oedema.…”

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“…Table 2 provides a more detailed comparison. [44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59] Clinical application of technology is based on knowledge and experience in obtaining and applying the information received. If a care provider targets the wrong hemodynamic end points or interprets a poor waveform as an accurate tracing, benefits may be limited.…”