Extending the role of lactate measurement into the prehospital environment

Early identification of haemodynamic shock is widely acknowledged as a vital step towards improving survival. A report in the previous issue of Critical Care describes the relationship between lactate concentrations in blood samples analysed in the prehospital environment and subsequent hospital mortality. These preliminary data indicate a promising avenue of research into the treatment of haemodynamic shock. Larger observational and interventional trials are needed to confirm the clinical value of serum lactate measurement in the prehospital environment

Peri-operative hemodynamic therapy: only large clinical trials can resolve our uncertainty

In this issue of Critical Care, Cecconi and colleagues report the findings of a small trial of goal-directed hemodynamic therapy (GDT) in patients undergoing major orthopedic surgery under regional anesthesia. This is an interesting trial and the first of which we are aware to test the efficacy of GDT in this patient group. The findings suggest that this intervention is associated with improved adverse event rates after surgery. However, in this trial, as in all small trials of GDT, the potential for bias leaves some uncertainty regarding how widely the findings should be implemented. Such limitations may be impossible to completely eliminate from trials of complex interventions, but large multicenter trials may allow us to substantially decrease bias and improve the generalizability of the findings

Should we use central venous saturation to guide management in high-risk surgical patients?

Measurements of central venous oxygen saturation (ScvO(2)) have been successfully used to guide haemodynamic therapy in critical care. The efficacy of this approach in the treatment of severe sepsis and septic shock has stimulated interest in the use of ScvO(2 )to guide management in patients undergoing major surgery. The physiological basis of ScvO(2 )measurement is complex. A number of outstanding issues will need to be resolved before incorporating ScvO(2 )measurement into routine practice. First, it is not yet clear which value of ScvO(2 )should be targeted. Second, there is some uncertainty as to which interventions are the most effective for achieving the desired value of ScvO(2 )or how long this value should be maintained. The study by The Collaborative Study Group on Perioperative ScvO(2) Monitoring published in this edition of Critical Care may help provide answers to some of these questions. Our understanding of ScvO(2 )measurement remains limited, however, and the routine use of peri-operative ScvO(2)-guided goal-directed therapy cannot be recommended until a large randomised trial has confirmed the value of this approach

Clinical review: How to optimize management of high-risk surgical patients

For many patients optimal perioperative care may require little or no additional medical management beyond that given by the anaesthetist and surgeon. However, the continued existence of a group of surgical patients at high risk for morbidity and mortality indicates an ongoing need to identify such patients and deliver optimal care throughout the perioperative period. A group of patients exists in whom the risk for death and serious complications after major surgery is in excess of 20%. The risk is related mainly to the patient's preoperative physiological condition and, in particular, the cardiovascular and respiratory reserves. Cardiovascular management of the high-risk surgical patient is of particular importance. Once the medical management of underlying disease has been optimized, two principal areas remain: the use of haemodynamic goals to guide fluid and inotropic therapy, and perioperative β blockade. A number of studies have shown that the use of goal-directed haemodynamic therapy during the perioperative period can result in large reductions in morbidity and mortality. Some patients may also benefit from perioperative β blockade, which in selected patients has also been shown to result in significant mortality reductions. In this review a pragmatic approach to perioperative management is described, giving guidance on the identification of the high-risk patient and on the use of goal-directed haemodynamic therapy and β blockade

Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]

INTRODUCTION: Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery. METHODS: This was a randomised controlled trial with concealed allocation. High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 ml min(-1 )m(-2 )or to conventional management. Cardiac output was measured by lithium indicator dilution and pulse power analysis. Patients were followed up for 60 days. RESULTS: Sixty-two patients were randomised to GDT and 60 patients to control treatment. The GDT group received more intravenous colloid (1,907 SD ± 878 ml versus 1,204 SD ± 898 ml; p < 0.0001) and dopexamine (55 patients (89%) versus 1 patient (2%); p < 0.0001). Fewer GDT patients developed complications (27 patients (44%) versus 41 patients (68%); p = 0.003, relative risk 0.63; 95% confidence intervals 0.46 to 0.87). The number of complications per patient was also reduced (0.7 SD ± 0.9 per patient versus 1.5 SD ± 1.5 per patient; p = 0.002). The median duration of hospital stay in the GDT group was significantly reduced (11 days (IQR 7 to 15) versus 14 days (IQR 11 to 27); p = 0.001). There was no significant difference in mortality (seven patients (11.3%) versus nine patients (15%); p = 0.59). CONCLUSION: Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission

Changes in central venous saturation after major surgery, and association with outcome

INTRODUCTION: Despite recent interest in measurement of central venous oxygen saturation (ScvO(2)), there are no published data describing the pattern of ScvO(2 )changes after major general surgery or any relationship with outcome. METHODS: ScvO(2 )and other biochemical, physiological and demographic data were prospectively measured for 8 hours after major surgery. Complications and deaths occurring within 28 days of enrolment were included in the data analysis. Independent predictors of complications were identified with the use of logistic regression analysis. Optimum cutoffs for ScvO(2 )were identified by receiver operator characteristic analysis. RESULTS: Data from 118 patients was analysed; 123 morbidity episodes occurred in 64 these patients. There were 12 deaths (10.2%). The mean ± SD age was 66.8 ± 11.4 years. Twenty patients (17%) underwent emergency surgery and 77 patients (66%) were male. The mean ± SD P-POSSUM (Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity) score was 38.6 ± 7.7, with a predicted mortality of 16.7 ± 17.6%. After multivariate analysis, the lowest cardiac index value (odds ratio (OR) 0.58 (95% confidence intervals 0.37 to 0.9); p = 0.018), lowest ScvO(2 )value (OR 0.94 (0.89 to 0.98); p = 0.007) and P-POSSUM score (OR 1.09 (1.02 to 1.15); p = 0.008) were independently associated with post-operative complications. The optimal ScvO(2 )cutoff value for morbidity prediction was 64.4%. In the first hour after surgery, significant reductions in ScvO(2 )were observed, but there were no significant changes in CI or oxygen delivery index during the same period. CONCLUSION: Significant fluctuations in ScvO(2 )occur in the immediate post-operative period. These fluctuations are not always associated with changes in oxygen delivery, suggesting that oxygen consumption is also an important determinant of ScvO(2). Reductions in ScvO(2 )are independently associated with post-operative complications

Comparison of three methods of extravascular lung water volume measurement in patients after cardiac surgery

This research was supported by an Intensive Care Society (UK) Young Investigator Award and unrestricted research grants from Barts and The London NHS Trust and LiDCO, Lt

Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study

Background: Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery. Methods: This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery. Results: Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory. Conclusions: Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment