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Kaufmann KB, Stein L, Bogatyreva L, Ulbrich F, Kaifi JT, Hauschke D, Loop T, Goebel U. Oesophageal Doppler guided goal-directed haemodynamic therapy in thoracic surgery - a single centre randomized parallel-arm trial. Br J Anaesth 2018; 118:852-861. [PMID: 28575331 DOI: 10.1093/bja/aew447] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2016] [Indexed: 01/22/2023] Open
Abstract
Background Postoperative pulmonary and renal complications are frequent in patients undergoing lung surgery. Hyper- and hypovolaemia may contribute to these complications. We hypothesized that goal-directed haemodynamic management based on oesophageal Doppler monitoring would reduce postoperative pulmonary complications in a randomized clinical parallel-arm trial. Methods One hundred patients scheduled for thoracic surgery were randomly assigned to either standard haemodynamic management (control group) or goal-directed therapy (GDT group) guided by an oesophageal Doppler monitoring-based algorithm. The primary endpoint was postoperative pulmonary complications, including spirometry. Secondary endpoints included haemodynamic variables, renal, cardiac, and neurological complications, and length of hospital stay. The investigator assessing outcomes was blinded to group assignment. Results Forty-eight subjects of each group were analysed. Compared to the control group, fewer subjects in the GDT group developed postoperative pulmonary complications (6 vs. 15 patients; P = 0.047), while spirometry did not differ between groups. Compared to the control group, patients of the GDT group showed higher cardiac index (2.9 vs. 2.1 [l min - 1 m - 2 ]; P < 0.001) and stroke volume index (43 vs. 34 [ml m 2 ]; P < 0.001) during surgery. Renal, cardiac and neurological complications did not differ between groups. Length of hospital stay was shorter in the GDT compared to the control group (9 vs. 11 days; P = 0.005). Conclusions Compared to standard haemodynamic management, oesophageal Doppler monitor-guided GDT was associated with fewer postoperative pulmonary complications and a shorter hospital stay. Clinical trial registration. The study was registered in the German Clinical Trials Register (DRKS 00006961). https://drks-neu.uniklinik-freiburg.de/drks_web/.
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Affiliation(s)
| | - L Stein
- Department of Anaesthesiology and Critical Care
| | - L Bogatyreva
- IMBI, Institute of Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - F Ulbrich
- Department of Anaesthesiology and Critical Care
| | - J T Kaifi
- Department of Thoracic Surgery, Medical Centre - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - D Hauschke
- IMBI, Institute of Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - T Loop
- Department of Anaesthesiology and Critical Care
| | - U Goebel
- Department of Anaesthesiology and Critical Care
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2
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Kaufmann KB, Baar W, Rexer J, Loeffler T, Heinrich S, Konstantinidis L, Buerkle H, Goebel U. Evaluation of hemodynamic goal-directed therapy to reduce the incidence of bone cement implantation syndrome in patients undergoing cemented hip arthroplasty - a randomized parallel-arm trial. BMC Anesthesiol 2018; 18:63. [PMID: 29875024 PMCID: PMC5991443 DOI: 10.1186/s12871-018-0526-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/25/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The bone cement implantation syndrome (BCIS) is a frequent and potentially disastrous intraoperative complication in patients undergoing cemented hip arthroplasty. Several risk factors have been identified, however randomized controlled trials to reduce the incidence of BCIS are still pending. We hypothesized that goal-directed hemodynamic therapy guided by esophageal Doppler monitoring (EDM) may reduce the incidence of BCIS in a randomized, controlled parallel-arm trial. METHODS After approval of the local ethics committee, 90 patients scheduled for cemented hip arthroplasty at the Medical Center - University of Freiburg were randomly assigned to either standard hemodynamic management or goal-directed therapy (GDT) guided by an esophageal Doppler monitoring-based algorithm. The primary endpoint was the incidence of overall BCIS including grade 1-3 after cementation of the femoral stem. Secondary endpoints included cardiac function, length of hospital stay and postoperative complications. RESULTS Ninety patients were finally analyzed. With regards to the primary endpoint, the overall incidence of BCIS showed no difference between the GDT and control group. Compared to the control group, patients of the GDT group showed a higher cardiac index before and after bone cement implantation (2.7 vs. 2.2 [l●min- 1●m- 2]; 2.8 vs. 2.4 [l●min- 1●m- 2]; P = 0.003, P = 0.042), whereas intraoperative amount of fluids and mean arterial pressure did not differ. CONCLUSIONS The implementation of a specific hemodynamic goal-directed therapy did not reduce the overall incidence of BCIS in patients undergoing cemented hip arthroplasty. TRIAL REGISTRATION This randomized clinical two-arm parallel study was approved by the local Ethics Committee, Freiburg, Germany [EK 160/15, PI: U. Goebel] and registered in the German Clinical Trials Register ( DRKS No. 00008778 , 16th of June, 2015).
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Affiliation(s)
- Kai B Kaufmann
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany. .,Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Wolfgang Baar
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Judith Rexer
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Loeffler
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Heinrich
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Konstantinidis
- Department of Orthopaedic and Trauma Surgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hartmut Buerkle
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Goebel
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany. .,Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Laher AE, Watermeyer MJ, Buchanan SK, Dippenaar N, Simo NCT, Motara F, Moolla M. A review of hemodynamic monitoring techniques, methods and devices for the emergency physician. Am J Emerg Med 2017; 35:1335-1347. [PMID: 28366285 DOI: 10.1016/j.ajem.2017.03.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 02/07/2023] Open
Abstract
The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end-organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini-fluid challenge, the end-expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.
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Affiliation(s)
- Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
| | - Matthew J Watermeyer
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Sean K Buchanan
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Nicole Dippenaar
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | | | - Feroza Motara
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Muhammed Moolla
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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Abstract
This article provides a critical discussion examining why adult patients continue to unnecessarily deteriorate and die despite repeated healthcare policy initiatives. After considering the policy background and reviewing current trends in the data, it proposes some solutions that, if enacted, would, the authors believe, have a direct impact on survival rates. Health professionals working in hospitals are failing to recognise signs of physiological deterioration. As a result, adult patients are dying unnecessarily, estimated to be in the region of 1000 a month. This is despite international healthcare policy requiring practitioners to be appropriately trained to recognise the deteriorating adult patient and to intervene. A literature review centred on health policy for England from 1999 to 2015 was undertaken, with reference to international policy and practice. This article also draws on the authors' combined clinical experience, which is underpinned by relevant research and theory. The implications for nursing could be significant. Change is urgently required otherwise people will continue to die unnecessarily. Health professionals, healthcare organisations and international governments working together can prevent unnecessary deaths from happening within acute hospitals.
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Affiliation(s)
- James Waldie
- Critical Care Nurse, Guy's and St Thomas' NHS Foundation Trust, London
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Licker M, Triponez F, Ellenberger C, Karenovics W. Fluid Therapy in Thoracic Surgery: A Zero-Balance Target is Always Best! Turk J Anaesthesiol Reanim 2016; 44:227-229. [PMID: 27909600 DOI: 10.5152/tjar.2016.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Switzerland
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospital of Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Switzerland
| | - Wolfram Karenovics
- Department of Thoracic and Endocrine Surgery, University Hospital of Geneva, Switzerland
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Ahmad T, Beilstein CM, Aldecoa C, Moreno RP, Molnár Z, Novak-Jankovic V, Hofer CK, Sander M, Rhodes A, Pearse RM. Variation in haemodynamic monitoring for major surgery in European nations: secondary analysis of the EuSOS dataset. Perioper Med (Lond) 2015; 4:8. [PMID: 26405521 PMCID: PMC4581514 DOI: 10.1186/s13741-015-0018-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 09/16/2015] [Indexed: 11/20/2022] Open
Abstract
Background The use of cardiac output monitoring may improve patient outcomes after major surgery. However, little is known about the use of this technology across nations. Methods This is a secondary analysis of a previously published observational study. Patients aged 16 years and over undergoing major non-cardiac surgery in a 7-day period in April 2011 were included into this analysis. The objective is to describe prevalence and type of cardiac output monitoring used in major surgery in Europe. Results Included in the analysis were 12,170 patients from the surgical services of 426 hospitals in 28 European nations. One thousand four hundred and sixteen patients (11.6 %) were exposed to cardiac output monitoring, and 2343 patients (19.3 %) received a central venous catheter. Patients with higher American Society of Anesthesiologists (ASA) scores were more frequently exposed to cardiac output monitoring (ASA I and II, 643 patients [8.6 %]; ASA III–V, 768 patients [16.2 %]; p < 0.01) and central venous catheter (ASA I and II, 874 patients [11.8 %]; ASA III–V, 1463 patients [30.9 %]; p < 0.01). In elective surgery, 990 patients (10.8 %) were exposed to cardiac output monitoring, in urgent surgery 252 patients (11.7 %) and in emergency surgery 173 patients (19.8 %). A central venous catheter was used in 1514 patients (16.6 %) undergoing elective, in 480 patients (22.2 %) undergoing urgent and in 349 patients (39.9 %) undergoing emergency surgery. Nine hundred sixty patients (7.9 %) were monitored using arterial waveform analysis, 238 patients (2.0 %) using oesophageal Doppler ultrasound, 55 patients (0.5 %) using a pulmonary artery catheter and 44 patients (2.0 %) using other technologies. Across nations, cardiac output monitoring use varied from 0.0 % (0/249 patients) to 27.5 % (19/69 patients), whilst central venous catheter use varied from 5.6 % (7/125 patients) to 43.2 % (16/37 patients). Conclusions One in ten patients undergoing major surgery is exposed to cardiac output monitoring whilst one in five receives a central venous catheter. The use of both technologies varies widely across Europe. Trial registration ClinicalTrials.gov Identifier: NCT01203605. Date of registration: 15.09.2010. Electronic supplementary material The online version of this article (doi:10.1186/s13741-015-0018-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tahania Ahmad
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Christian M Beilstein
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Cesar Aldecoa
- Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Rui P Moreno
- Unidade de Cuidados Intensivos Neurocríticos, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | | | | | | | | | | | - Rupert M Pearse
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, Royal London Hospital, London, E1 1BB UK
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Laight NS, Levin AI. Transcardiopulmonary Thermodilution-Calibrated Arterial Waveform Analysis: A Primer for Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2015; 29:1051-64. [PMID: 26279223 DOI: 10.1053/j.jvca.2015.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Nicola S Laight
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
| | - Andrew I Levin
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa.
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