Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]

Rupert Pearse, Deborah Dawson, Jayne Fawcett, Andrew Rhodes, R Michael Grounds, E David Bennett, Rupert Pearse, Deborah Dawson, Jayne Fawcett, Andrew Rhodes, R Michael Grounds, E David Bennett

Abstract

Introduction: Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery.

Methods: This was a randomised controlled trial with concealed allocation. High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 ml min(-1) m(-2) or to conventional management. Cardiac output was measured by lithium indicator dilution and pulse power analysis. Patients were followed up for 60 days.

Results: Sixty-two patients were randomised to GDT and 60 patients to control treatment. The GDT group received more intravenous colloid (1,907 SD +/- 878 ml versus 1,204 SD +/- 898 ml; p < 0.0001) and dopexamine (55 patients (89%) versus 1 patient (2%); p < 0.0001). Fewer GDT patients developed complications (27 patients (44%) versus 41 patients (68%); p = 0.003, relative risk 0.63; 95% confidence intervals 0.46 to 0.87). The number of complications per patient was also reduced (0.7 SD +/- 0.9 per patient versus 1.5 SD +/- 1.5 per patient; p = 0.002). The median duration of hospital stay in the GDT group was significantly reduced (11 days (IQR 7 to 15) versus 14 days (IQR 11 to 27); p = 0.001). There was no significant difference in mortality (seven patients (11.3%) versus nine patients (15%); p = 0.59).

Conclusion: Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission.

Figures

Figure 1
Figure 1
Flow of participants through the trial.
Figure 2
Figure 2
Cardiovascular treatment protocols for goal-directed therapy (GDT) and control groups. DO2I, oxygen delivery index; Hb, haemoglobin; SaO2, arterial oxygen saturation.
Figure 3
Figure 3
Oxygen delivery index for goal-directed therapy and control groups during the 8-hour study period. Results are means ± SEM. DO2I, oxygen delivery index; GDT, goal-directed therapy.

References

    1. Boyd O, Grounds RM, 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. 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.
    1. Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ. 1999;318:1099–1103.
    1. Cullinane M, Gray AJ, Hargraves CM, Lansdown M, Martin IC, Schubert M. The 2003 Report of the National Confidential Enquiry into Peri-Operative Deaths. London: NCEPOD; 2003.
    1. Campling EA, Devlin HB, Lunn JN. Report of the National Confidential Enquiry into Peri-Operative Deaths. London: NCEPOD; 1990.
    1. Soni N. Swan song for the Swan-Ganz catheter? BMJ. 1996;313:763–764.
    1. Polonen P, Ruokonen E, Hippelainen M, Poyhonen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg. 2000;90:1052–1059.
    1. McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329:258. doi: 10.1136/bmj.38156.767118.7C.
    1. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. 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. 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: randomised controlled trial. BMJ. 1997;315:909–912.
    1. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88:65–71. doi: 10.1093/bja/88.1.65.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, 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. Pearse RM, Ikram K, Barry J. Equipment review: an appraisal of the LiDCO plus method of measuring cardiac output. Crit Care. 2004;8:190–195. doi: 10.1186/cc2852.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829.
    1. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg. 1998;85:1217–1220. doi: 10.1046/j.1365-2168.1998.00840.x.
    1. Thompson SG, Barber JA. How should cost data in pragmatic randomised trials be analysed? BMJ. 2000;320:1197–1200. doi: 10.1136/bmj.320.7243.1197.
    1. Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5–14. doi: 10.1056/NEJMoa021108.
    1. De Backer D, Creteur J, Vincent JL. Perioperative optimization and right heart catheterization: what technique in which patient? Crit Care. 2003;7:201–202. doi: 10.1186/cc2177.
    1. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361. doi: 10.1056/NEJMoa041895.
    1. Devereaux PJ, Yusuf S, Yang H, Choi PT, Guyatt GH. Are the recommendations to use perioperative beta-blocker therapy in patients undergoing noncardiac surgery based on reliable evidence? CMAJ. 2004;171:245–247.
    1. Arkilic CF, Taguchi A, Sharma N, Ratnaraj J, Sessler DI, Read TE, Fleshman JW, Kurz A. Supplemental perioperative fluid administration increases tissue oxygen pressure. Surgery. 2003;133:49–55. doi: 10.1067/msy.2003.80.
    1. Kusano C, Baba M, Takao S, Sane S, Shimada M, Shirao K, Natsugoe S, Fukumoto T, Aikou T. Oxygen delivery as a factor in the development of fatal postoperative complications after oesophagectomy. Br J Surg. 1997;84:252–257. doi: 10.1046/j.1365-2168.1997.02542.x.
    1. Sheridan WG, Lowndes RH, Young HL. Tissue oxygen tension as a predictor of colonic anastomotic healing. Dis Colon Rectum. 1987;30:867–871.
    1. Guest JF, Boyd O, Hart WM, Grounds RM, Bennett ED. A cost analysis of a treatment policy of a deliberate perioperative increase in oxygen delivery in high risk surgical patients. Intensive Care Med. 1997;23:85–90. doi: 10.1007/s001340050295.
    1. Fenwick E, Wilson J, Sculpher M, Claxton K. Pre-operative optimisation employing dopexamine or adrenaline for patients undergoing major elective surgery: a cost-effectiveness analysis. Intensive Care Med. 2002;28:599–608. doi: 10.1007/s00134-002-1257-y.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する