Goal-directed fluid management based on stroke volume variation and stroke volume optimization during high-risk surgery: a pilot multicentre randomized controlled trial

Introduction: Perioperative hemodynamic optimization has been shown to be useful to improve the postoperative outcome of patients undergoing major surgery. We designed a pilot study in patients undergoing major abdominal, urologic or vascular surgery to investigate the effects of a goal-directed (GD) fluid management based on continuous stroke volume variation (SVV) and stroke volume (SV) monitoring on postoperative outcomes. Methods: Fifty-two high-risk-surgical patients (ASA 3 or 4, arterial and central venous catheter in place, postoperative admission in ICU) were randomized either to a control group (Group C, n = 26) or to a goal-directed group (Group G, n = 26). Patients with cardiac arrhythmia or ventilated with a tidal volume <7 ml/kg were excluded. In Group G, SVV and SV were continuously monitored with the FloTrac™/Vigileo™ system (Edwards Lifesciences, USA) and patients were brought to and maintained on the plateau of the Frank-Starling curve (SVV <10% and SV increase <10% in response to fluid loading). During the ICU stay, organ dysfunction was assessed using the SOFA score and resource utilization using the TISS score. Patients were followed up to 28 days after surgery for infectious, cardiac, respiratory, renal, hematologic and abdominal complications. Results: Group G and Group C were comparable for ASA score, comorbidities, type and duration of surgery (275 vs. 280 minutes), heart rate, MAP and CVP at the start of surgery. However, Group G was younger than Group C (68 vs. 73 years, P < 0.05). During surgery, Group G received more colloids than Group C (1,589 vs. 927 ml, P < 0.05) and SVV decreased in Group G (from 9.0 to 8.0%, P < 0.05) but not in Group C. The number of postoperative wound infections was lower in Group G (0 vs. 7, P < 0.01). Although not statistically significant, the proportion of patients with at least one complication (46 vs. 62%), the number of postoperative complications per patient (0.65 vs. 1.40), the maximum ICU SOFA score (5.9 vs. 7.2), and the cumulative ICU TISS score (69 vs. 83) were also lower in Group G. ICU and hospital length of stay were similar in both groups. Conclusion: Although the two groups were not perfectly matched, this pilot shows that fluid management based on SVV and SV optimization decreases wound infections. It also suggests that such a GD strategy may decrease postoperative organ dysfunction and resource utilization. However, this remains to be confirmed by a larger study

Evaluation of a new arterial pressure-based cardiac output device requiring no external calibration

<p>Abstract</p> <p>Background</p> <p>Several techniques have been discussed as alternatives to the intermittent bolus thermodilution cardiac output (CO_PAC) measurement by the pulmonary artery catheter (PAC). However, these techniques usually require a central venous line, an additional catheter, or a special calibration procedure. A new arterial pressure-based cardiac output (CO_AP) device (FloTrac™, Vigileo™; Edwards Lifesciences, Irvine, CA, USA) only requires access to the radial or femoral artery using a standard arterial catheter and does not need an external calibration. We validated this technique in critically ill patients in the intensive care unit (ICU) using CO_PACas the method of reference.</p> <p>Methods</p> <p>We studied 20 critically ill patients, aged 16 to 74 years (mean, 55.5 ± 18.8 years), who required both arterial and pulmonary artery pressure monitoring. CO_PACmeasurements were performed at least every 4 hours and calculated as the average of 3 measurements, while CO_APvalues were taken immediately at the end of bolus determinations. Accuracy of measurements was assessed by calculating the bias and limits of agreement using the method described by Bland and Altman.</p> <p>Results</p> <p>A total of 164 coupled measurements were obtained. Absolute values of CO_PACranged from 2.80 to 10.80 l/min (mean 5.93 ± 1.55 l/min). The bias and limits of agreement between CO_PACand CO_APfor unequal numbers of replicates was 0.02 ± 2.92 l/min. The percentage error between CO_PACand CO_APwas 49.3%. The bias between percentage changes in CO_PAC(ΔCO_PAC) and percentage changes in CO_AP(ΔCO_AP) for consecutive measurements was -0.70% ± 32.28%. CO_PACand CO_APshowed a Pearson correlation coefficient of 0.58 (<it>p </it>< 0.01), while the correlation coefficient between ΔCO_PACand ΔCO_APwas 0.46 (<it>p </it>< 0.01).</p> <p>Conclusion</p> <p>Although the CO_APalgorithm shows a minimal bias with CO_PACover a wide range of values in an inhomogeneous group of critically ill patients, the scattering of the data remains relative wide. Therefore, the used algorithm (V 1.03) failed to demonstrate an acceptable accuracy in comparison to the clinical standard of cardiac output determination.</p

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment

Emergency coronary artery bypass grafting using minimized versus standard extracorporeal circulation--a propensity score analysis

BACKGROUND: The impact of minimized extracorporeal circulation (MECC) for emergency revascularization remains controversial. METHODS: A total of 348 patients underwent emergency CABG with MECC (n=146) or conventional extracorporeal circulation (CECC; n=175) between January 2005 and December 2010. Using propensity score matching after binary logistic regression, 100 patients, who underwent CABG with MECC could be matched with 100 patients, who underwent CABG with CECC. Primary outcome was 30-day mortality. RESULTS: Unadjusted 30-day mortality was 14.8% in patients with CECC and 6.9% in those with MECC (mean difference -7.9%; p=0.03). The adjusted mean difference (average treatment effect of the treated, ATT) after matching was -1.0% (95% CI -8.6 to 7.6; p=1.0). Intensive care unit stay (adjusted mean difference 1.0; 95% CI -0.2 to 3.2; p=0.70) and hospital stay (adjusted mean difference 1.0; 95% CI -2.0 to 3.6; p=0.40) did not show significant differences between both groups. The adjusted mean difference for postoperative low cardiac output syndrome was -1.1% (95% CI -7.3 to 7.1; p=0.83) without significant differences between CECC and MECC. Postoperative mechanical ventilation time, drain loss, postoperative rethoracotomy, postoperative neurological events, new onset renal replacement therapy and respiratory failure also had insignificant average treatment effects of the treated. In addition, all average treatment effects (ATEs) did not significantly differ between both groups. CONCLUSION: Using propensity score estimation and matching, we did not observe significant differences in terms of survival and further outcomes in patients who undergo emergency CABG with CECC or MECC, but our results call for further analysis