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

Cornelie Salzwedel, Jaume Puig, Arne Carstens, Berthold Bein, Zsolt Molnar, Krisztian Kiss, Ayyaz Hussain, Javier Belda, Mikhail Y Kirov, Samir G Sakka, Daniel A Reuter, Cornelie Salzwedel, Jaume Puig, Arne Carstens, Berthold Bein, Zsolt Molnar, Krisztian Kiss, Ayyaz Hussain, Javier Belda, Mikhail Y Kirov, Samir G Sakka, Daniel A Reuter

Abstract

Introduction: Several 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).

Methods: 160 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.

Results: The 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).

Conclusions: This 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 registration: ClinicalTrial.gov, NCT01401283.

Figures

Figure 1
Figure 1
Hemodynamic treatment algorithms: a) Algorithm for initial assessment and treatment. b) Algorithm for further intraoperative optimization.
Figure 2
Figure 2
Mean arterial pressure intraoperatively. * Significantly different between control group and study group (P < 0.05).
Figure 3
Figure 3
Postoperative complications. a) number of complications. b) number of patients with complications. * Significantly different between control group and study group (P < 0.05).
Figure 4
Figure 4
Number of patients with complications: bowel versus no bowel surgery. * Significantly different between control group and study group (P < 0.05).

References

    1. Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, Vallet B, Vincent JL, Hoeft A, Rhodes A. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;17:1059–1065. doi: 10.1016/S0140-6736(12)61148-9.
    1. Strunden MS, Heckel K, Goetz AE, Reuter DA. Perioperative fluid and volume management: physiological basis, tools and strategies. Ann Intensive Care. 2011;17:2. doi: 10.1186/2110-5820-1-2.
    1. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using esophageal Doppler monitoring during bowel surgery. Anesthesia. 2002;17:845–849.
    1. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;17:1069–1076. doi: 10.1002/bjs.5454.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative esophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;17:634–642. doi: 10.1093/bja/aei223.
    1. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomized controlled trial. BMJ. 1997;17:909–912. doi: 10.1136/bmj.315.7113.909.
    1. Bartha E, Arfwedson, Imnell A, Fernlund ME, Andersson LE, Kalman S. Randomized controlled trial of goal-directed hemodynamic treatment in patients with proximal femoral fracture. Br J Anaesth. 2013;17:545–553. doi: 10.1093/bja/aes468.
    1. Cecconi M, Fasano N, Langiano N, Divella M, Costa MG, Rhodes A, Della Rocca G. Goal-directed hemodynamic therapy during elective total hip arthroplasty under regional anesthesia. Crit Care. 2011;17:R132. doi: 10.1186/cc10246.
    1. Zhang Z, Xu X, Ni H. Small studies may overestimate the effect sizes in critical care meta-analyses: a meta-epidemiological study. Crit Care. 2013;17:R2. doi: 10.1186/cc11919.
    1. Mythen MG, Webb AR. Intraoperative gut mucosal hypoperfusion is associated with increased post-operative complications and cost. Intensive Care Med. 1994;17:99–104. doi: 10.1007/BF01707662.
    1. Pierrakos C, Velissaris D, Scolletta S, Heenen S, De Backer D, Vincent J-L. Can changes in arterial pressure be used to detect changes in cardiac index during fluid challenge in patients with septic shock? Intensive Care Med. 2012;17:422–428. doi: 10.1007/s00134-011-2457-0.
    1. Breukers RM, Sepehrkhouy S, Spiegelenberg SR, Groeneveld AB. Cardiac output measured by a new arterial pressure waveform analysis method without calibration compared with thermodilution after cardiac surgery. J Cardiothorac Vasc Anesth. 2007;17:632–635. doi: 10.1053/j.jvca.2007.01.001.
    1. Button D, Weibel L, Reuthebuch O, Genoni M, Zollinger A, Hofer CK. Clinical evaluation of the FloTrac/Vigileo™ system and two established continuous cardiac output monitoring devices in patients undergoing cardiac surgery. Br J Anaesth. 2007;17:329–936. doi: 10.1093/bja/aem188.
    1. Krejci V, Vannucci A, Abbas A, Chapman W, Kangrga IM. Comparison of calibrated and uncalibrated arterial pressure-based cardiac output monitors during orthotopic liver transplantation. Liver Transpl. 2010;17:773–782.
    1. Slagt C, Beute J, Hoeksema M, Malagon I, Mulder JW, Groeneveld JA. Cardiac output derived from arterial pressure waveform analysis without calibration vs. thermodilution in septic shock: evolving accuracy of software versions. Eur J Anaesthesiol. 2010;17:550–554.
    1. Petzoldt M, Riedel C, Braeunig J, Haas S, Goepfert MS, Treede H, Baldus S, Goetz AE, Reuter DA. Stroke volume determination using transcardiopulmonary thermodilution and arterial pulse contour analysis in severe aortic valve disease. Intensive Care Med. 2013;17:601–611. doi: 10.1007/s00134-012-2786-7.
    1. Biasis M, Bernard O, Ha JC, Degryse C, Sztark F. Abilities of pulse pressure variations and stroke volume variations to predict fluid responsiveness in prone position during scoliosis surgery. Br J Anaesth. 2010;17:407–413. doi: 10.1093/bja/aeq031.
    1. Derichard A, Robin E, Tavernier B, Costecalde M, Fleyfel M, Onimus J, Lebuffe G, Chambon JP, Vallet B. Automated pulse pressure and stroke volume variations from radial artery: evaluation during major abdominal surgery. Br J Anaesth. 2009;17:678–684. doi: 10.1093/bja/aep267.
    1. Gouvea G, Diaz R, Auler L, Toledo R, Martinho JM. Evaluation of the pulse pressure variation index as a predictor of fluid responsiveness during orthotopic liver transplantation. Br J Anaesth. 2009;17:238–243. doi: 10.1093/bja/aep123.
    1. Hadian M, Severyn DA, Pinsky MR. The effects of vasoactive drugs on pulse pressure and stroke volume variation in postoperative ventilated patients. J Crit Care. 2011;17:328.e1–8. doi: 10.1016/j.jcrc.2010.08.018.
    1. Reuter DA, Felbinger TW, Kilger E, Schmidt C, Lamm P, Goetz AE. Optimizing fluid therapy in mechanically ventilated patients after cardiac surgery by on-line monitoring of left ventricular stroke volume variations. Comparison with aortic systolic pressure variations. Br J Anaesth. 2002;17:124–126. doi: 10.1093/bja/88.1.124.
    1. Reuter DA, Goresch T, Goepfert MS, Wildhirt SM, Kilger E, Goetz AE. Effects of mid-line thoracotomy on the interaction between mechanical ventilation and cardiac filling during cardiac surgery. Br J Anaesth. 2004;17:808–813. doi: 10.1093/bja/aeh151.
    1. Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, Pradl R, Stepan M. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients. Crit Care. 2010;17:R118. doi: 10.1186/cc9070.
    1. Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F. Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care. 2007;17:R100. doi: 10.1186/cc6117.
    1. Saklad M. Grading of patients for surgical procedures. Anesthesiology. 1941;17:281–284. doi: 10.1097/00000542-194105000-00004.
    1. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;17:356–360.
    1. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;17:326–341.
    1. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomized, controlled trial [ISRCTN38797445] Crit Care. 2005;17:R687. doi: 10.1186/cc3887.
    1. Corcoran T, Rhodes JE, Clarke SS, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;17:640–651. doi: 10.1213/ANE.0b013e318240d6eb.
    1. Gurgel ST, do Nascimento P. Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg. 2011;17:1384–1391. doi: 10.1213/ANE.0b013e3182055384.
    1. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. 2011;17:1392–1402. doi: 10.1213/ANE.0b013e3181eeaae5.
    1. Grocott MPW, Dushianthan A, Hamilton MA, Mythen MG, Harrison D, Rowan K. Optimisation Systematic Review Steering Group. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. Br J Anaesth. 2013;17:535–548. doi: 10.1093/bja/aet155.
    1. Dalfino L, Giglio MT, Puntillo F, Marucci M, Brienza N. Hemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care. 2011;17:R154. doi: 10.1186/cc10284.
    1. Challand C, Struthers R, Sneyd JR, Erasmus PD, Mellor N, Hosie KB, Minto G. Randomized controlled trial of intraoperative goal-directed fluid therapy in aerobically fit and unfit patients having major colorectal surgery. Br J Anaesth. 2012;17:53–62. doi: 10.1093/bja/aer273.
    1. Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SA, Hansen B, Moller DR, Lundbech LB, Andersen N, Berg V, Thomassen N, Andersen ST, Simonsen L. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth. 2012;17:191–199. doi: 10.1093/bja/aes163.
    1. Arulkumaran N, Corredor C, Hamilton M, Grounds M, Ball J, Rhodes A, Cecconi M. Treatment-related cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Crit Care. 2013;17:P195. doi: 10.1186/cc12133.
    1. Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gonorek B, Hennerici MG, Iung B, Kelm M, Kjeldsen KP, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OF, Sicari R, Van den Berghe G, Vermassen F, Hoeks SE, Vanhoerbeek I, Vahanian A, Auricchio A, Bax JJ, Ceconi C, Dean V, Filippatos G. et al.Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anesthesiology (ESA) Eur J Anaesthesiol. 2010;17:92–137.
    1. De Backer D, Marx G, Tan A, Junker C, Van Nuffelen M, Hüter L, Ching W, Michard F, Vincent JL. Arterial pressure-based cardiac output monitoring: a multicenter validation of the third-generation software in septic patients. Intensive Care Med. 2011;17:233–240. doi: 10.1007/s00134-010-2098-8.

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