Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial

András Mikor, Domonkos Trásy, Márton F Németh, Angelika Osztroluczki, Szilvia Kocsi, Ildikó Kovács, Gábor Demeter, Zsolt Molnár, András Mikor, Domonkos Trásy, Márton F Németh, Angelika Osztroluczki, Szilvia Kocsi, Ildikó Kovács, Gábor Demeter, Zsolt Molnár

Abstract

Background: Major abdominal surgery is associated with significant risk of morbidity and mortality in the perioperative period. Optimising intraoperative fluid administration may result in improved outcomes. Our aim was to compare the effects of central venous pressure (CVP), and central venous oxygen saturation (ScvO2)-assisted fluid therapy on postoperative complications in patients undergoing high risk surgery.

Methods: Patients undergoing elective major abdominal surgery were randomised into control and ScvO2 groups. The target level of mean arterial pressure (MAP) was ≥ 60 mmHg in both groups. In cases of MAP < 60 mmHg patients received either a fluid or vasopressor bolus according to the CVP < 8 mmHg in the control group. In the ScvO2 group, in addition to the MAP, an ScvO2 of <75% or a >3% decrease indicated need for intervention, regardless of the actual MAP. Data are presented as mean ± standard deviation or median (interquartile range).

Results: We observed a lower number of patients with complications in the ScvO2 group compared to the control group, however it did not reach statistical significance (ScvO2 group: 10 vs.

Control group: 19; p = 0.07). Patients in the ScvO2 group (n = 38) received more colloids compared to the control group (n = 41) [279(161) vs. 107(250) ml/h; p < 0.001]. Both groups received similar amounts of crystalloid (1126 ± 471 vs. 1049 ± 431 ml/h; p = 0.46) and norepinephrine [37(107) vs. 18(73) mcg/h; p = 0.84]. Despite similar blood loss in both groups, the ScvO2 group received more blood transfusions (63% vs. 37%; p = 0.018). More patients in the control group had a postoperative PaO2/FiO2 < 200 mmHg (23 vs. 10, p < 0.01). Twenty eight day survival was significantly higher in the ScvO2 group (37/38 vs. 33/41 p = 0.018).

Conclusion: ScvO2-assisted intraoperative haemodynamic support provided some benefits, including significantly better postoperative oxygenation and 28 day survival rate, compared to CVP-assisted therapy without a significant effect on postoperative complications during major abdominal surgery.

Trial registration: ClinicalTrials.gov NCT02337010.

Figures

Fig. 1
Fig. 1
Flowchart of the study design. MAP: mean arterial pressure, CVP: central venous pressure, ScvO2: central venous oxygen saturation, HES: hydroxyethyl starch, NE: norepinephrine
Fig. 2
Fig. 2
CONSORT flow diagram of the study
Fig. 3
Fig. 3
Changes in central venous saturation (ScvO2) during the operation. Data are shown as mean and standard deviation
Fig. 4
Fig. 4
Changes in mean arterial pressure (MAP) during the operation. Data are shown as mean and standard deviation
Fig. 5
Fig. 5
Changes in central venous pressure (CVP) during the operation. Data are shown as mean and standard deviation
Fig. 6
Fig. 6
Changes in lactate level during the operation. Data are shown as mean and standard deviation

References

    1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372:139–144. doi: 10.1016/S0140-6736(08)60878-8.
    1. Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care. 2002;14:269–276. doi: 10.1093/intqhc/14.4.269.
    1. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126:66–75. doi: 10.1067/msy.1999.98664.
    1. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth. 2002;89:622–632. doi: 10.1093/bja/aef220.
    1. Lowell JA, Schifferdecker C, Driscoll DF, Benotti PN, Bistrian BR. Postoperative fluid overload: not a benign problem. Crit Care Med. 1990;18:728–733. doi: 10.1097/00003246-199007000-00010.
    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. 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;145:1193–2000. doi: 10.1001/archsurg.2010.275.
    1. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134:172–178. doi: 10.1378/chest.07-2331.
    1. Linton RAF, Linton NWF, Kelly F. Is clinical assessment of the circulation reliable in postoperative cardiac surgical patients? J Cardiothorac Vasc Anesth. 2002;16:4–7. doi: 10.1053/jcan.2002.29631.
    1. Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, Teboul JL. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;5:64–68. doi: 10.1097/01.CCM.0000249851.94101.4F.
    1. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57:845–849. doi: 10.1046/j.1365-2044.2002.02708.x.
    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. 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. doi: 10.1164/ajrccm.162.1.9903035.
    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. Cannesson M, Pestel G, Ricks C, Hoeft A, Perel A. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care. 2011;15:R197. doi: 10.1186/cc10364.
    1. Molnar Z, Umgelter A, Toth I, Livingstone D, Weyland A, Sakka SG, Meier-Hellmann A. Continuous monitoring of ScvO2 by a new fibre-optic technology compared with blood gas oximetry in critically ill patients: a multicentre study. Intensive Care Med. 2007;33:1767–1770. doi: 10.1007/s00134-007-0743-7.
    1. Pearse RM, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Changes in central venous saturation after major surgery, and association with outcome. Crit Care. 2005;9:R694–699. doi: 10.1186/cc3888.
    1. Collaborative Study Group on Perioperative ScvO2 Monitoring Multicentre study on peri- and postoperative central venous oxygen saturation in high-risk surgical patients. Crit Care. 2006;10:R158. doi: 10.1186/cc5094.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829. doi: 10.1097/00003246-198510000-00009.
    1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377. doi: 10.1056/NEJMoa010307.
    1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R, The Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165–228. doi: 10.1007/s00134-012-2769-8.
    1. Mayer J, Boldt J, Mengistu A, Röhm KD, Suttner S. Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Crit Care. 2010;14:R18. doi: 10.1186/cc8875.
    1. Ferguson ND, Fan E, Camporota L. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38:1573–1582. doi: 10.1007/s00134-012-2682-1.
    1. KDIGO Clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:8–12. doi: 10.1038/kisup.2012.7.
    1. Reinhart K, Kuhn HJ, Hartog C, Bredle DL. Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill. Intensive Care Med. 2004;30:1572–1578. doi: 10.1007/s00134-004-2337-y.
    1. Antonelli M, Levy M, Andrews PJ, Chastre J, Hudson LD, Manthous C, Meduri GU, Moreno RP, Putensen C, Stewart T, Torres A. Hemodynamic monitoring in shock and implications for management: International Consensus Conference, Paris, France, 27–28 April 2006. Intensive Care Med. 2007;33:575–590. doi: 10.1007/s00134-007-0531-4.
    1. Donati A, Loggi S, Preiser JC, Orsetti G, Münch C, Gabbanelli V, Pelaia P, Pietropaoli P. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132:1817–1824. doi: 10.1378/chest.07-0621.
    1. Silva JM, Jr, Oliveira AM, de Morais SZ, de Araújo LS, Victoria LG, Marubayashi LY. Influence of central venous oxygen saturation on in-hospital mortality of surgical patients. Rev Bras Anestesiol. 2010;60:593–602. doi: 10.1016/S0034-7094(10)70074-X.
    1. Tanczos K, Mikor A, Leiner T, Toth I, Molnar Z. Goal directed intrapoerative fluid management: Central venous pressure (CVP) vs central venous saturation (ScvO2) [abstract] Intensive Care Med. 2008;34(Suppl 1):0251.
    1. Kocsi S, Demeter G, Fogas J, Erces D, Kaszaki J, Molnar Z. Central venous oxygen saturation is a good indicator of altered oxygen balance in isovolemic anemia. Acta Anaesth Scand. 2012;56:291–297. doi: 10.1111/j.1399-6576.2011.02622.x.
    1. Goepfert MS, Richter HP, Zu Eulenburg C, Gruetzmacher J, Rafflenbeul E, Roeher K, von Sandersleben A, Diedrichs S, Reichenspurner H, Goetz AE, Reuter DA. Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: a prospective, randomized controlled trial. Anesthesiology. 2013;119:824–836. doi: 10.1097/ALN.0b013e31829bd770.
    1. Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH, Gramkow CS, Okholm M, Blemmer T, Svendsen PE, Rottensten HH, Thage B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F, The Danish Study Group on Perioperative Fluid Therapy Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens – a randomized assessor-blinded multicenter trial. 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. Kirov MY, Kuzkov VV, Molnar Z. Perioperative haemodynamic therapy. Curr Opin Crit Care. 2010;16:384–392. doi: 10.1097/MCC.0b013e32833ab81e.
    1. Salzwedel C, Puig J, Carstens A, Bein B, Molnar Z, Kiss K, Hussain A, Belda J, Kirov MY, Sakka SG, Reuter DA. 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:R191. doi: 10.1186/cc12885.
    1. Pearse RM, Harrison DA, MacDonald N, Gillies MA, Blunt M, Ackland G, Grocott MP, Ahern A, Griggs K, Scott R, Hinds C, Rowan K, OPTIMISE Study Group Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014;311:2181–2190. doi: 10.1001/jama.2014.5305.
    1. Szakmany T, Toth I, Kovacs Z, Leiner T, Mikor A, Koszegi T, Molnar Z. Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial. Intensive Care Med. 2005;31:656–663. doi: 10.1007/s00134-005-2606-4.
    1. Marik PE, Cavallazzi R. Does the Central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41:1774–1781. doi: 10.1097/CCM.0b013e31828a25fd.
    1. van Beest P, Wietasch G, Scheeren T, Spronk P, Kuiper M. Clinical review: use of venous oxygen saturations as a goal - a yet unfinished puzzle. Crit Care. 2011;15:232. doi: 10.1186/cc10351.
    1. Perz S, Uhlig T, Kohl M, Bredle DL, Reinhart K, Bauer M, Kortgen A. Low and ‘supranormal’ central venous oxygen saturation and markers of tissue hypoxia in cardiac surgery patients: a prospective observational study. Intensive Care Med. 2011;37:52–59. doi: 10.1007/s00134-010-1980-8.
    1. De Backer D, Ospina-Tascon G, Salgado D, Favory R, Creteur J, Vincent JL. Monitoring the microcirculation in the critically ill patient: current methods and future approaches. Intensive Care Med. 2010;36:1813–1825. doi: 10.1007/s00134-010-2005-3.

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다