Clinical and economic impact of goal-directed fluid therapy during elective gastrointestinal surgery

Juying Jin, Su Min, Dan Liu, Ling Liu, Bixiao Lv, Juying Jin, Su Min, Dan Liu, Ling Liu, Bixiao Lv

Abstract

Background: Several randomized controlled trials suggest that goal-directed fluid therapy (GDFT) may result in improved postoperative outcomes. The aim of this study was to assess the clinical and financial impact of the real-life implementation of intraoperative GDFT in patients undergoing elective gastrointestinal surgery in a Chinese tertiary medical center.

Methods: This Quality Improvement Program (QIP) study comprised three phases of 5, 1, and 5 months, respectively. During the first phase, we retrospectively collected perioperative data from patients who received standard intraoperative fluid management from January to May 2016. Then a 1-month training period allowed the clinical staff to become familiar with the GDFT protocol. After the training phase, GDFT was used from July to November 2016. In the GDFT group, stroke volume (SV) was continuously monitored and optimized towards the plateau of the Frank-Starling curve. The primary outcome measure was postoperative morbidity (the proportion of patients with one or more complications within 30 days after surgery). Secondary outcomes were total hospital cost, postoperative length of hospital stay, and 30-day mortality.

Results: Data from 200 patients before (control group) and 201 patients after the implementation of GDFT (GDFT group) were collected and compared. There was no significant difference in demographics and surgical procedures between the two groups. Postoperative morbidity was significantly lower in the GDFT group than in the control group (30.8% vs. 44.0%, p = 0.006). No significant differences were observed for mean total hospital cost (76,793 RMB vs. 74,444 RMB; p = 0.430), median postoperative length of hospital stay (10 days vs. 10 days; p = 0.104), and 30-day mortality (1% vs. 0.5%; p = 0.565).

Conclusion: In patients undergoing gastrointestinal surgery, the implementation of a GDFT protocol was associated with a reduction in postoperative morbidity without increasing costs.

Trial registration: clinicaltrials.gov, NCT02507557. Registered 13 July 2015.

Keywords: Gastrointestinal surgery; Goal-directed fluid therapy; Postoperative complications; Stroke volume.

Conflict of interest statement

This study was approved by the ethics committee of the First Affiliated Hospital of Chongqing Medical University (registration number: 20160301). Written informed consent was obtained from all patients in the GDFT group. The local ethics committee waived the requirement for informed consent in the control group due to the retrospective nature of the analysis.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flowchart of the patients in this study
Fig. 2
Fig. 2
Intraoperative goal-directed algorithm. SV stroke volume, SBP systolic blood pressure, MAP mean artery pressure. Maintained dose of infusion of crystalloid during surgery was 2~ 4 mL/kg/h for open procedure and 1~ 2 mL/kg/h for laparoscopic procedure. After incision for open cases and after pneumoperitoneum for laparoscopic cases, patients received a 200-mL colloid bolus over 5–10 min. If SV increased by > 10%, the bolus was repeated until it increased by  10% below the plateau value. In case of hypotension (SBP  20% from baseline) in fluid non-responders, an infusion of dobutamine was recommended if CI was 2, and ephedrine boluses of 5 to 15 mg or norepinephrine infusion were recommended if CI was > 2.5 L/min/m2. Protocol should not influence blood product administration

References

    1. Bartha E, Davidson T, Hommel A, Thorngren KG, Carlsson P, Kalman S. Cost-effectiveness analysis of goal-directed hemodynamic treatment of elderly hip fracture patients: before clinical research starts. Anesthesiology. 2012;117(3):519–530. doi: 10.1097/ALN.0b013e3182655eb2.
    1. Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006;97(6):755–757. doi: 10.1093/bja/ael290.
    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: results of prospective randomized study. Crit Care. 2010;14(3):R118. doi: 10.1186/cc9070.
    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(2):514–519.
    1. Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SA, Hansen B, Moller DR, Lundbech LB, Andersen N, Berg V, et al. 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;109(2):191–199. doi: 10.1093/bja/aes163.
    1. Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238(5):641–648. doi: 10.1097/01.sla.0000094387.50865.23.
    1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect. 2013;14(1):73–156. doi: 10.1089/sur.2013.9999.
    1. Calvo-Vecino JM, Ripolles-Melchor J, Mythen MG, Casans-Frances R, Balik A, Artacho JP, Martinez-Hurtado E, Serrano Romero A, Fernandez Perez C, Asuero de Lis S, et al. Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial) Br J Anaesth. 2018;120(4):734–744. doi: 10.1016/j.bja.2017.12.018.
    1. Cannesson M, Ramsingh D, Rinehart J, Demirjian A, Vu T, Vakharia S, Imagawa D, Yu Z, Greenfield S, Kain Z. Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study. Crit Care. 2015;19:261. doi: 10.1186/s13054-015-0945-2.
    1. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114(3):640–651. doi: 10.1213/ANE.0b013e318240d6eb.
    1. Doherty M, Buggy DJ. Intraoperative fluids: how much is too much? Br J Anaesth. 2012;109(1):69–79. doi: 10.1093/bja/aes171.
    1. Flynn DN, Speck RM, Mahmoud NN, David G, Fleisher LA. The impact of complications following open colectomy on hospital finances: a retrospective cohort study. Perioper Med (Lond) 2014;3(1):1. doi: 10.1186/2047-0525-3-1.
    1. Futier E, Constantin JM, Petit A, Chanques G, Kwiatkowski F, Flamein R, Slim K, Sapin V, Jaber S, Bazin JE. Conservative vs restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial. Arch Surg. 2010;145(12):1193–1200. doi: 10.1001/archsurg.2010.275.
    1. Grocott MP, 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;111(4):535–548. doi: 10.1093/bja/aet155.
    1. Habicher M, Balzer F, Mezger V, Niclas J, Muller M, Perka C, Kramer M, Sander M. Implementation of goal-directed fluid therapy during hip revision arthroplasty: a matched cohort study. Perioper Med (Lond) 2016;5:31. doi: 10.1186/s13741-016-0056-x.
    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;112(6):1392–1402. doi: 10.1213/ANE.0b013e3181eeaae5.
    1. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth. 2002;89(4):622–632. doi: 10.1093/bja/aef220.
    1. Luo J, Xue J, Liu J, Liu B, Liu L, Chen G. Goal-directed fluid restriction during brain surgery: a prospective randomized controlled trial. Ann Intensive Care. 2017;7(1):16. doi: 10.1186/s13613-017-0239-8.
    1. Michard F. Decision support for hemodynamic management: from graphical displays to closed loop systems. Anesth Analg. 2013;117(4):876–882. doi: 10.1213/ANE.0b013e31827e5002.
    1. Michard F, Giglio MT, Brienza N. Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome. Br J Anaesth. 2017;
    1. Michard F, Mountford WK, Krukas MR, Ernst FR, Fogel SL. Potential return on investment for implementation of perioperative goal-directed fluid therapy in major surgery: a nationwide database study. Perioper Med (Lond) 2015;4:11. doi: 10.1186/s13741-015-0021-0.
    1. Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, Christophi C, Leslie K, McGuinness S, Parke R, et al. Restrictive versus liberal fluid therapy for major abdominal surgery. N Engl J Med. 2018;378(24):2263–2274. doi: 10.1056/NEJMoa1801601.
    1. National Institute for Health and Clinical Excellence. Medical technologies guidance MTG3: CardioQODM oesophageal doppler monitor. 2011. .
    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(1):25–32. doi: 10.1097/00000542-200507000-00008.
    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 [ISRCTN38797445] Crit Care. 2005;9(6):R687–R693. doi: 10.1186/cc3887.
    1. Sadique Z, Harrison DA, Grieve R, Rowan KM, Pearse RM, group Os Cost-effectiveness of a cardiac output-guided haemodynamic therapy algorithm in high-risk patients undergoing major gastrointestinal surgery. Perioper Med (Lond) 2015;4:13. doi: 10.1186/s13741-015-0024-x.
    1. Salzwedel C, Puig J, Carstens A, Bein B, Molnar Z, Kiss K, Hussain A, Belda J, Kirov MY, Sakka SG, et al. 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. Crit Care. 2013;17(5):R191. doi: 10.1186/cc12885.
    1. Saturni S, Bellini F, Braido F, Paggiaro P, Sanduzzi A, Scichilone N, Santus PA, Morandi L, Papi A. Randomized controlled trials and real life studies. Approaches and methodologies: a clinical point of view. Pulm Pharmacol Ther. 2014;27(2):129–138. doi: 10.1016/j.pupt.2014.01.005.
    1. Scheeren TW, Wiesenack C, Gerlach H, Marx G. Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. J Clin Monit Comput. 2013;27(3):225–233. doi: 10.1007/s10877-013-9461-6.
    1. Senagore AJ, Emery T, Luchtefeld M, Kim D, Dujovny N, Hoedema R. Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. Dis Colon Rectum. 2009;52(12):1935–1940. doi: 10.1007/DCR.0b013e3181b4c35e.
    1. Sun Y, Chai F, Pan C, Romeiser JL, Gan TJ. Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery—a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2017;21(1):141. doi: 10.1186/s13054-017-1728-8.
    1. Thom O, Taylor DM, Wolfe RE, Myles P, Krum H, Wolfe R. Pilot study of the prevalence, outcomes and detection of occult hypoperfusion in trauma patients. Emerg Med J. 2010;27(6):470–472. doi: 10.1136/emj.2009.073254.
    1. Veelo DP, van Berge Henegouwen MI, Ouwehand KS, Geerts BF, Anderegg MC, van Dieren S, Preckel B, Binnekade JM, Gisbertz SS, Hollmann MW. Effect of goal-directed therapy on outcome after esophageal surgery: a quality improvement study. PLoS One. 2017;12(3):e0172806. doi: 10.1371/journal.pone.0172806.
    1. Vonlanthen R, Slankamenac K, Breitenstein S, Puhan MA, Muller MK, Hahnloser D, Hauri D, Graf R, Clavien PA. The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg. 2011;254(6):907–913. doi: 10.1097/SLA.0b013e31821d4a43.
    1. Yuan J, Sun Y, Pan C, Li T. Goal-directed fluid therapy for reducing risk of surgical site infections following abdominal surgery—a systematic review and meta-analysis of randomized controlled trials. Int J Surg. 2017;39:74–87. doi: 10.1016/j.ijsu.2017.01.081.
    1. Zakhaleva J, Tam J, Denoya PI, Bishawi M, Bergamaschi R. The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: a randomized controlled trial. Color Dis. 2013;15(7):892–899. doi: 10.1111/codi.12180.
    1. Zhang J, Chen CQ, Lei XZ, Feng ZY, Zhu SM. Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study. Clinics (Sao Paulo) 2013;68(7):1065–1070. doi: 10.6061/clinics/2013(07)27.
    1. Zheng H, Guo H, Ye JR, Chen L, Ma HP. Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. World J Surg. 2013;37(12):2820–2829. doi: 10.1007/s00268-013-2203-6.

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