Preoperative Optimization of Cardiovascular Hemodynamics Improves Outcome in Peripheral Vascular Surgery

Abstract

The hypothesis that optimizing hemodynamics using pulmonary artery (PA) catheter (preoperative 'tune-up') would improve outcome in patients undergoing limb-salvage arterial surgery was tested. Eighty-nine patients were randomized to preoperative tune-up either in the surgical intensive care unit (SICU) (group 1) or the preinduction room (group 2) or to control (group 3). The tune-up consisted of fluid loading, afterload reduction, and/or inotropic support to achieve predetermined endpoints. Patients with a PA catheter had significantly fewer adverse intraoperative events (p less than 0.05), less postoperative cardiac morbidity (p less than 0.05), and less early graft thrombosis (p less than 0.05) than the control group. The overall study mortality rate was 3.4%, with a mortality rate of 9.5% in the control group and 1.5% in the PA catheter groups. There were no differences in ICU length of stay (LOS), hospital LOS, or total hospital costs, although the percentage of cost from complications was higher in group 3 (p greater than 0.05). In this group of patients, preoperative cardiac assessment and optimization is associated with improved outcome.

Revisão sistemática dos marcadores de otiminização da perfusão tecidual em ensaios clínicos aleatórios de cirurgias de alto risco

“…Study or Subgroup Bishop, 1995Boldt, 1998Chytra, 2007Fleming, 1992Lobo, 2000Lobo, 2006Lopes, 2007Shoemaker, 1988Shultz, 1985 Total (95% CI) Total events Heterogeneity: Chi² = 3.01, df = 6 (P = 0.81); I² = 0% Test for overall effect: Z = 4.92 (P < 0.00001) Bender, 1997Berlauk, 1991Bishop, 1995Boldt, 1998Bonazzi, 2002Boyd, 1993Fleming, 1992Lobo, 2000Lobo, 2006Polonen, 2000Sandham, 2003Shoemaker, 1988Shultz, 1985Takala, 2000Ueno, 1998Valentine, 1997Velmahos, 2000Wilson, 1999 Ziegler, 1997…”

“…Uma revisão recente com 21 estudos sobre otimização hemodinâmica em pacientes de alto risco demonstrou um benefício apenas quando foi realizada antes do desenvolvimento de disfunções orgânicas e naqueles estudos com taxa de mortalidade do grupo controle acima de 20% (Kern and Shoemaker 2002 UENO et al, 199811,11% VELMAHOS et al, 200011,43% BOLDT et al, 199813,33% PEARSE et al, 200515,00% TAKALA et al, 200015,71% WILSON et al 199917,39% CHYTRA et al, 2007 21,95% BOYD et al, 199322,22% LOBO et al, 200628,00% SCHULTZ et al, 198528,57% LOPES et al, 2007 31,25% SHOEMACKER et al, 198833,33% BISHOP et al, 199536,92% FLEMING et al, 1992 44,12% LOBO et al, 2000 50,00% Bender, 1997Berlauk, 1991Boldt, 1998Conway, 2002Fleming, 1992Kapoor, 2008Lopes, 2007Mythen, 1995Polonen, 2000Shoemaker, 1988Shultz, 1985Sinclair, 1997Ueno, 1998Ziegler, 1997 Total (95% CI) Interpretação: Gráfico em funil enviesado.…”

“…Bender, 1997 Berlauk, 1991Boldt, 1998Conway, 2002Fleming, 1992Kapoor, 2008Lopes, 2007Mythen, 1995Polonen, 2000Shoemaker, 1988Shultz, 1985Sinclair, 1997Ueno, 1998 Ziegler, 1997…”

“…Bender, 1997 Berlauk, 1991Bishop, 1995Boldt, 1998Bonazzi, 2002Boyd, 1993Chytra, 2007Conway, 2002Donati, 2007Fleming, 1992Gan, 2002Kapoor, 2008Lobo, 2000Lobo, 2006Lopes, 2007Mythen, 1995Pearse, 2005Polonen, 2000Sandham, 2003Shoemaker, 1988Shultz, 1985Sinclair, 1997Stone, 2003Takala, 2000Ueno, 1998Valentine, 1997Velmahos, 2000Venn, 2002Wakeling, 2005Wilson, 1999 Ziegler, 1997…”

“…Total events Heterogeneity: Chi² = 36.08, df = 17 (P = 0.004); I² = 53% Test for overall effect: Z = 3.01 (P = 0.003) Bender, 1997Berlauk, 1991Bishop, 1995Boldt, 1998Bonazzi, 2002Boyd, 1993Fleming, 1992Kapoor, 2008Lobo, 2000Lobo, 2006Pearse, 2005Sandham, 2003Shoemaker, 1988Takala, 2000Ueno, 1998Valentine, 1997Velmahos, 2000Wilson, 1999 Total (95% CI) Total events Heterogeneity: Chi² = 29.12, df = 15 (P = 0.02); I² = 48% Test for overall effect: Z = 2.54 (P = 0.01) Heyland (1996), talvez a primeira revisão sistemática sobre estudos clínicos aleatórios designados para atingir valores supranormais de IC, IDO2 e IVO2 em pacientes críticos, atribuiu um rigor metodológico e selecionou apenas sete artigos de 64 identificados e concluiu que existe uma tendência não estatisticamente significativa de diminuição da taxa de mortalidade, risco Assim, há a necessidade de constante atualização científica para esse assunto tão complexo e contraditório, motivando esta revisão sistemática e todas as outras que ainda virão, na tentativa de elucidar, baseada na melhor evidência possível, todas as questões pertinentes (Cook and Guyatt 1994).…”