Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study

Maxime Cannesson, Davinder Ramsingh, Joseph Rinehart, Aram Demirjian, Trung Vu, Shermeen Vakharia, David Imagawa, Zhaoxia Yu, Sheldon Greenfield, Zeev Kain, Maxime Cannesson, Davinder Ramsingh, Joseph Rinehart, Aram Demirjian, Trung Vu, Shermeen Vakharia, David Imagawa, Zhaoxia Yu, Sheldon Greenfield, Zeev Kain

Abstract

Introduction: Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention.

Methods: This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database).

Results: In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1-13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7-9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6-16) days to 7 (5-11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18% (95% confidence interval 9-27%). The incidence of NSQIP complications decreased from 39% to 25% (p = 0.04).

Conclusion: These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries.

Trial registration: Clinicaltrials.gov NCT02057653. Registered 17 December 2013.

Figures

Fig. 1
Fig. 1
Perioperarive goal-directed algorithm. C.I. cardiac index, IBW ideal body weight, SV stroke volume, SVV stroke volume variation
Fig. 2
Fig. 2
Time series analysis showing length of stay in the hospital (in days) for each patient over the total study period including pre-implementation period (left side of the gray area), training period (gray area), and post-implementation period (right side of the gray area)

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