Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial

Marcel R Lopes, Marcos A Oliveira, Vanessa Oliveira S Pereira, Ivaneide Paula B Lemos, Jose Otavio C Auler Jr, Frédéric Michard, Marcel R Lopes, Marcos A Oliveira, Vanessa Oliveira S Pereira, Ivaneide Paula B Lemos, Jose Otavio C Auler Jr, Frédéric Michard

Abstract

Introduction: Several studies have shown that maximizing stroke volume (or increasing it until a plateau is reached) by volume loading during high-risk surgery may improve post-operative outcome. This goal could be achieved simply by minimizing the variation in arterial pulse pressure (deltaPP) induced by mechanical ventilation. We tested this hypothesis in a prospective, randomized, single-centre study. The primary endpoint was the length of postoperative stay in hospital.

Methods: Thirty-three patients undergoing high-risk surgery were randomized either to a control group (group C, n = 16) or to an intervention group (group I, n = 17). In group I, deltaPP was continuously monitored during surgery by a multiparameter bedside monitor and minimized to 10% or less by volume loading.

Results: Both groups were comparable in terms of demographic data, American Society of Anesthesiology score, type, and duration of surgery. During surgery, group I received more fluid than group C (4,618 +/- 1,557 versus 1,694 +/- 705 ml (mean +/- SD), P < 0.0001), and deltaPP decreased from 22 +/- 75 to 9 +/- 1% (P < 0.05) in group I. The median duration of postoperative stay in hospital (7 versus 17 days, P < 0.01) was lower in group I than in group C. The number of postoperative complications per patient (1.4 +/- 2.1 versus 3.9 +/- 2.8, P < 0.05), as well as the median duration of mechanical ventilation (1 versus 5 days, P < 0.05) and stay in the intensive care unit (3 versus 9 days, P < 0.01) was also lower in group I.

Conclusion: Monitoring and minimizing deltaPP by volume loading during high-risk surgery improves postoperative outcome and decreases the length of stay in hospital.

Trial registration: NCT00479011.

Figures

Figure 1
Figure 1
Automatic calculation of variation in arterial pulse pressure (ΔPP) from the recordings of arterial pressure and capnographic signals on a regular bedside monitor.
Figure 2
Figure 2
Trial profile.
Figure 3
Figure 3
Numbers of patients with postoperative complications in the control and intervention groups.
Figure 4
Figure 4
Box-and-whiskers representation of the duration (days) of mechanical ventilation (MV), stay in the intensive care unit (ICU), and stay in hospital in the control and intervention groups. The line inside a box denotes the median, the limits of the box denote the 75th centile of the data, and the whiskers represent the 90th centile of the data.

References

    1. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130:423–429.
    1. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: a randomised controlled trial. BMJ. 1997;315:909–912.
    1. Gan TJ, Soppitt A, Maroof M, El-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PSA. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–826. doi: 10.1097/00000542-200210000-00012.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WGA, Miles WFA, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–642. doi: 10.1093/bja/aei223.
    1. Lefrant JY, Bruelle P, Aya AG, Saissi G, Dauzat M, de La Coussaye JE, Eledjam JJ. Training is required to improve the reliability of esophageal Doppler to measure cardiac output in critically ill patients. Intensive Care Med. 1998;24:347–352. doi: 10.1007/s001340050578.
    1. Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005;103:419–428. doi: 10.1097/00000542-200508000-00026.
    1. Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, Richard C, Pinsky MR, Teboul JL. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134–138.
    1. Bendjelid K, Suter PM, Romand JA. The respiratory change in preejection period: a new method to predict fluid responsiveness. J Appl Physiol. 2004;96:337–342. doi: 10.1152/japplphysiol.00435.2003.
    1. Kramer A, Zygun D, Hawes H, Easton P, Ferland A. Pulse pressure variation predicts fluid responsiveness following coronary artery bypass surgery. Chest. 2004;126:1563–1568. doi: 10.1378/chest.126.5.1563.
    1. De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent JL. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med. 2005;31:517–523. doi: 10.1007/s00134-005-2586-4.
    1. Solus-Biguenet H, Fleyfel M, Tavernier B, Kipnis E, Onimus J, Robin E, Lebuffe G, Decoene C, Pruvot FR, Vallet B. Non-invasive prediction of fluid responsivenss during major hepatic surgery. Br J Anaesth. 2006;97:808–816. doi: 10.1093/bja/ael250.
    1. Michard F, Lopes MR, Auler JOC., Jr Pulse pressure variation: beyond the fluid management of patients with shock. Crit Care. 2007;11:131. doi: 10.1186/cc5905.
    1. Michard F, Chemla D, Richard C, Wysocki M, Pinsky MR, Lecarpentier Y, Teboul JL. Clinical use of respiratory changes in arterial pulse pressure to monitor the hemodynamic effects of PEEP. Am J Respir Crit Care Med. 1999;159:935–939.
    1. Bennett-Guerrero E, Welsby I, Dunn TJ, Young LR, Wahl TA, Diers TL, Phillips-Bute BG, Newman MF, Mythen MG. The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg. 1999;89:514–519. doi: 10.1097/00000539-199908000-00050.
    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 randomised, controlled trial. Crit Care. 2005;9:R687–R693. doi: 10.1186/cc3887.
    1. Schulz KF, Grimes DA. Sample size calculations in randomised trials: mandatory and mystical. Lancet. 2005;365:1348–1353. doi: 10.1016/S0140-6736(05)61034-3.
    1. Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis Colon Rectum. 2004;47:1397–1402. doi: 10.1007/s10350-004-0592-1.
    1. Junghans T, Neuss H, Strohauer M, Raue W, Haase O, Schink T, Schwenk W. Hypovolemia after traditional preoperative care in patients undergoing colonic surgery is underrepresented in conventional hemodynamic monitoring. Int J Colorectal Dis. 2006;21:693–697. doi: 10.1007/s00384-005-0065-6.
    1. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94:1176–1186. doi: 10.1378/chest.94.6.1176.
    1. Boyd O, Grounds M, Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA. 1993;270:2699–2707. doi: 10.1001/jama.270.22.2699.
    1. Lobo SMA, Salgado PF, Castillo VG, Borim AA, Polachini CA, Palchetti JC, Brienzi SLA, de Oliveira GG. Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med. 2000;28:3396–3404. doi: 10.1097/00003246-200010000-00003.
    1. Kern JW, Shoemaker WC. Meta-analysis of hemodynamic optimization in high-risk patients. Crit Care Med. 2002;30:1686–1692. doi: 10.1097/00003246-200208000-00002.
    1. Spahn DR, Chassot PG. CON: fluid restriction for cardiac patients during major noncardiac surgery should be replaced by goal-directed intravascular fluid administration. Anesth Analg. 2006;102:344–346. doi: 10.1213/01.ane.0000196511.48033.0b.
    1. Buhre W, Rossaint R. Perioperative management and monitoring in anaesthesia. Lancet. 2003;362:1839–1846. doi: 10.1016/S0140-6736(03)14905-7.
    1. Joshi GP. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg. 2005;101:601–605. doi: 10.1213/01.ANE.0000159171.26521.31.
    1. Boldt J. Fluid management of patients undergoing abdominal surgery – more questions than answers. Eur J Anaesth. 2006;23:631–640. doi: 10.1017/S026502150600069X.
    1. Kita T, Mammoto T, Kishi Y. Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma. J Clin Anesth. 2002;14:252–256. doi: 10.1016/S0952-8180(02)00352-5.
    1. Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, the Danish Study Group on Perioperative Fluid Therapy Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens. Ann Surg. 2003;238:641–648. doi: 10.1097/01.sla.0000094387.50865.23.
    1. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology. 2005;103:25–32. doi: 10.1097/00000542-200507000-00008.
    1. Lobo SM, Lobo FR, Polachini CA, Patini DS, Yamamoto AE, de Oliveira NE, Serrano P, Sanches HS, Spegiorin MA, Queiroz MM, et al. Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients. Crit Care. 2006;10:R72. doi: 10.1186/cc4913.
    1. Michard F. Volume management using dynamic parameters: the good, the bad, and the ugly. Chest. 2005;128:1902–1903. doi: 10.1378/chest.128.4.1902.

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