Effect of goal-directed haemodynamic therapy guided by non-invasive monitoring on perioperative complications in elderly hip fracture patients within an enhanced recovery pathway

Juan V Lorente, Francesca Reguant, Anna Arnau, Marcelo Borderas, Juan C Prieto, Jordi Torrallardona, Laura Carrasco, Patricia Solano, Isabel Pérez, Carla Farré, Ignacio Jiménez, Javier Ripollés-Melchor, Manuel I Monge, Joan Bosch, Juan V Lorente, Francesca Reguant, Anna Arnau, Marcelo Borderas, Juan C Prieto, Jordi Torrallardona, Laura Carrasco, Patricia Solano, Isabel Pérez, Carla Farré, Ignacio Jiménez, Javier Ripollés-Melchor, Manuel I Monge, Joan Bosch

Abstract

Background: Goal-directed haemodynamic therapy (GDHT) has been shown to reduce morbidity and mortality in high-risk surgical patients. However, there is little evidence of its efficacy in patients undergoing hip fracture surgery. This study aims to evaluate the effect of GDHT guided by non-invasive haemodynamic monitoring on perioperative complications in patients undergoing hip fracture surgery.

Methods: Patients > 64 years undergoing hip fracture surgery within an enhanced recovery pathway (ERP) were enrolled in this single-centre, non-randomized, intervention study with a historical control group and 12-month follow-up. Exclusion criteria were patients with pathological fractures, traffic-related fractures and refractures. Control group (CG) patients received standard care treatment. Intervention group (IG) patients received a GDHT protocol based on achieving an optimal stroke volume, in addition to a systolic blood pressure > 90 mmHg and an individualized cardiac index. No changes were made between groups in the ERP during the study period. Primary outcome was percentage of patients who developed intraoperative haemodynamic instability. Secondary outcomes were intraoperative arrhythmias, postoperative complications (cardiovascular, respiratory, infectious and renal complications), administered fluids, vasopressor requirements, perioperative transfusion, length of hospital stay, readmission and 1-year survival.

Results: In total, 551 patients (CG=272; IG=279) were included. Intraoperative haemodynamic instability was lower in the IG (37.5% vs 28.0%; p=0.017). GDHT patients had fewer postoperative cardiovascular (18.8% vs 7.2%; p < 0.001), respiratory (15.1% vs 3.6%; p<0.001) and infectious complications (21% vs 3.9%; p<0.001) but not renal (12.1% vs 33.7%; p<0.001). IG patients had less vasopressor requirements (25.5% vs 39.7%; p<0.001) and received less fluids [2.600 ml (IQR 1700 to 2700) vs 850 ml (IQR 750 to 1050); p=0.001] than control group. Fewer patients required transfusion in GDHT group (73.5% vs 44.4%; p<0.001). For IG patients, median length of hospital stay was shorter [11 days (IQR 8 to 16) vs 8 days; (IQR 6 to 11) p < 0.001] and 1-year survival higher [73.4% (95%CI 67.7 to 78.3 vs 83.8% (95%CI 78.8 to 87.7) p<0.003].

Conclusions: The use of GDHT decreases intraoperative complications and postoperative cardiovascular, respiratory and infectious but not postoperative renal complications. This strategy was associated with a shorter hospital stay and increased 1-year survival.

Trial registration: ClinicalTrials.gov NCT02479321 .

Keywords: Enhanced recovery after surgery; Enhanced recovery pathway; Fluid therapy; Goal-directed haemodynamic therapy; Hip fracture; Intraoperative complications; Mortality; postoperative complications.

Conflict of interest statement

Dr Lorente, Dr Jiménez, Dr Ripollés-Melchor and Dr Monge have received conference fees from Edwards Lifesciences.

Dr Lorente & Dr Ripollés-Melchor have received conference fees from Fresenius Kabi and bioMérieux.

Dr Ripollés-Melchor & Dr Monge have received conference fees from Dextera Medical.

Dr Lorente has received conference fees from Vifor Pharma, Grifols and financial support for research obtained through Edwards Lifesciences Grant Portal. Economic research support from bioMérieux.

Dr Ripollés-Melchor has received conference fees from MSD.

The rest of the authors declare that they have competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Algorithms for goal-directed haemodynamic therapy phases
Fig. 2
Fig. 2
Flow chart of patients during recruitment and 12-month follow-up
Fig. 3
Fig. 3
Kaplan–Meier survival curves according to group allocation. Crude hazard ratio for 1-year survival

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