Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial

Laurence Weinberg, Damian Ianno, Leonid Churilov, Ian Chao, Nick Scurrah, Clive Rachbuch, Jonathan Banting, Vijaragavan Muralidharan, David Story, Rinaldo Bellomo, Chris Christophi, Mehrdad Nikfarjam, Laurence Weinberg, Damian Ianno, Leonid Churilov, Ian Chao, Nick Scurrah, Clive Rachbuch, Jonathan Banting, Vijaragavan Muralidharan, David Story, Rinaldo Bellomo, Chris Christophi, Mehrdad Nikfarjam

Abstract

We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. "precision" fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.

Conflict of interest statement

Competing Interests: LW, RB have received Department research funding from Baxter Healthcare and Edwards Lifesciences. LW and RB have received honoraria from Baxter Healthcare. LW has received honoraria from Baxter Healthcare and Edwards Lifesciences. MN is the founder of Pancare Foundation, which is an Australian not-for-profit pancreatic cancer organisation. Pancare Foundation has received education funding from Edwards Lifesciences. All other authors have read the journal's policy and have declared that they have no competing interests. This is an investigator initiated and lead multi centre RCT. No industry, company or external organisations have been involved in any aspect of the study, including conception, design, methodology, analyses and manuscript preparation. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Surgery-specific cardiac output algorithm.
Fig 1. Surgery-specific cardiac output algorithm.
Fig 2. Consort diagram.
Fig 2. Consort diagram.
Fig 3. Modified Rankin scale showing the…
Fig 3. Modified Rankin scale showing the proportion of participants in the usual care and goal directed therapy (GDT) groups with complications.

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