1
|
Alves MRD, Saturnino SF, Zen AB, de Albuquerque DGS, Diegoli H. Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis. CRITICAL CARE SCIENCE 2024; 36:e20240196en. [PMID: 38775544 PMCID: PMC11098079 DOI: 10.62675/2965-2774.20240196-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/08/2023] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE. RESULTS We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%). CONCLUSION Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.
Collapse
Affiliation(s)
| | - Saulo Fernandes Saturnino
- Universidade Federal de Minas GeraisBelo HorizonteMGBrazilUniversidade Federal de Minas Gerais - Belo Horizonte (MG), Brazil.
| | - Ana Beatriz Zen
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
| | | | - Henrique Diegoli
- Academia VBHC Educação e ConsultoriaSão PauloSPBrazilAcademia VBHC Educação e Consultoria - São Paulo (SP), Brazil.
| |
Collapse
|
2
|
Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
Collapse
Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| |
Collapse
|
3
|
Pratomo BY, Sudadi S, Setianto BY, Novenanto TT, Raksawardana YK, Rayhan A, Kurniawaty J. Intraoperative Goal-Directed Perfusion in Cardiac Surgery with Cardiopulmonary Bypass: The Roles of Delivery Oxygen Index and Cardiac Index. Ann Thorac Cardiovasc Surg 2024; 30:23-00189. [PMID: 38684395 PMCID: PMC11082497 DOI: 10.5761/atcs.ra.23-00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/01/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE Goal-directed perfusion (GDP) refers to individualized goal-directed therapy using comprehensive monitoring and optimizing the delivery of oxygen during cardiopulmonary bypass (CPB). This study aims to determine whether the intraoperative GDP protocol method has better outcomes compared to conventional methods. METHODS We searched the PubMed, Central, and Scopus databases up to October 12, 2023. We primarily examined the GDP protocol in adult cardiac surgery, using CPB with oxygen delivery index (DO2I) and cardiac index (CI) as the main parameters. RESULTS In all, 1128 participants from seven studies were included in our analysis. The results showed significant differences in the duration of intensive care unit (ICU) stays (p = 0.01), with a mean difference of -0.33 (-0.59 to 0.07), and hospital length of stay (LOS) (p = 0.0002), with a mean difference of -0.84 (-1.29 to -0.39). There was also a notable reduction in postoperative complications (p <0.00001), odds ratio (OR) of 0.43 (0.32-0.60). However, there was no significant decrease in mortality rate (p = 0.54), OR of 0.77 (0.34-1.77). CONCLUSION Postoperative acute kidney injury and ICU and hospital LOS are significantly reduced when GDP protocols with indicators of flow management, oxygen delivery index, and CI are used in intraoperative cardiac surgery using CPB.
Collapse
Affiliation(s)
- Bhirowo Yudo Pratomo
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Sudadi Sudadi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Budi Yuli Setianto
- Department of Cardiology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Tandean Tommy Novenanto
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | | | - Amar Rayhan
- Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Juni Kurniawaty
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| |
Collapse
|
4
|
Reddy VS, Stout DM, Fletcher R, Barksdale A, Parikshak M, Johns C, Gerdisch M. Advanced artificial intelligence-guided hemodynamic management within cardiac enhanced recovery after surgery pathways: A multi-institution review. JTCVS OPEN 2023; 16:480-489. [PMID: 38204636 PMCID: PMC10774974 DOI: 10.1016/j.xjon.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 01/12/2024]
Abstract
Objective The study objective was to report early outcomes of integrating Hypotension Prediction Index-guided hemodynamic management within a cardiac enhanced recovery pathway on total initial ventilation hours and length of stay in the intensive care unit. Methods A multicenter, historical control, observational analysis of implementation of a hemodynamic management tool within enhanced recovery pathways was conducted by identifying cardiac surgery cases from 3 sites during 2 time periods, August 1 to December 31, 2019 (preprogram), and April 1 to August 31, 2021 (program). Reoperations, emergency (salvage), or cases requiring mechanical assist were excluded. Data were extracted from electronic medical records and chart reviews. Two primary outcome variables were length of stay in the intensive care unit (using Society of Thoracic Surgeons definitions) and acute kidney injury (using modified Kidney Disease Improving Global Outcomes criteria). One secondary outcome variable, total initial ventilation hours, used Society of Thoracic Surgeons definitions. Differences in length of stay in the intensive care unit and total ventilation time were analyzed using Kruskal-Wallis and stepwise multiple linear regression. Acute kidney injury stage used chi-square and stepwise cumulative logistic regression. Results A total of 1404 cases (795 preprogram; 609 program) were identified. Overall reductions of 6.8 and 4.4 hours in intensive care unit length of stay (P = .08) and ventilation time (P = .03) were found, respectively. No significant association between proportion of patients identified with acute kidney injury by stage and period was found. Conclusions Adding artificial intelligence-guided hemodynamic management to cardiac enhanced recovery pathways resulted in associated reduced time in the intensive care unit for patients undergoing nonemergency cardiac surgery across institutions in a real-world setting.
Collapse
Affiliation(s)
- V. Seenu Reddy
- Cardiothoracic Surgery, TriStar Centennial Medical Center, Nashville, Tenn
| | - David M. Stout
- Cardiovascular Anesthesiology, Swedish Heart and Vascular Institute, Seattle, Wash
| | - Robert Fletcher
- Biostatistics, Swedish Heart and Vascular Institute, Seattle, Wash
| | - Andrew Barksdale
- Cardiothoracic Surgery, Franciscan Health Indianapolis, Indianapolis, Ind
| | - Manesh Parikshak
- Cardiothoracic Surgery, Franciscan Health Indianapolis, Indianapolis, Ind
| | - Chanice Johns
- Cardiothoracic Surgery, Franciscan Health Indianapolis, Indianapolis, Ind
| | - Marc Gerdisch
- Cardiothoracic Surgery, Franciscan Health Indianapolis, Indianapolis, Ind
| |
Collapse
|
5
|
Thy SA, Johansen AO, Thy A, Sørensen HH, Mølgaard J, Foss NB, Toft P, Meyhoff CS, Aasvang EK. Associations between clinical interventions and transcutaneous blood gas values in postoperative patients. J Clin Monit Comput 2023; 37:1255-1264. [PMID: 36808596 DOI: 10.1007/s10877-023-00982-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/29/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Postoperative monitoring of circulation and respiration is pivotal to guide intervention strategies and ensure patient outcomes. Transcutaneous blood gas monitoring (TCM) may allow for noninvasive assessment of changes in cardiopulmonary function after surgery, including a more direct assessment of local micro-perfusion and metabolism. To form the basis for studies assessing the clinical impact of TCM complication detection and goal-directed-therapy, we examined the association between clinical interventions in the postoperative period and changes in transcutaneous blood gasses. METHODS Two-hundred adult patients who have had major surgery were enrolled prospectively and monitored with transcutaneous blood gas measurements (oxygen (TcPO2) and carbon dioxide (TcPCO2)) for 2 h in the post anaesthesia care unit, with recording of all clinical interventions. The primary outcome was changes in TcPO2, secondarily TcPCO2, from 5 min before a clinical intervention versus 5 min after, analysed with paired t-test. RESULTS Data from 190 patients with 686 interventions were analysed. During clinical interventions, a mean change in TcPO2 of 0.99 mmHg (95% CI-1.79-0.2, p = 0.015) and TcPCO2 of-0.67 mmHg (95% CI 0.36-0.98, p < 0.001) was detected. CONCLUSION Clinical interventions resulted in significant changes in transcutaneous oxygen and carbon dioxide. These findings suggest future studies to assess the clinical value of changes in transcutaneous PO2 and PCO2 in a postoperative setting. TRIAL REGISTRY Clinical trial number: NCT04735380. CLINICAL TRIAL REGISTRY https://clinicaltrials.gov/ct2/show/NCT04735380.
Collapse
Affiliation(s)
- Sandra A Thy
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Anesthesiology, Odense University Hospital and Faculty of Health Science, University of Southern Denmark, Odense, Denmark.
| | - Andreas O Johansen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - André Thy
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Henrik H Sørensen
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Mølgaard
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital-Amager and Hvidovre, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Palle Toft
- Department of Anesthesiology, Odense University Hospital and Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
6
|
Kotani Y, Kataoka Y, Izawa J, Fujioka S, Yoshida T, Kumasawa J, Kwong JS. High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass. Cochrane Database Syst Rev 2022; 11:CD013494. [PMID: 36448514 PMCID: PMC9709767 DOI: 10.1002/14651858.cd013494.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB. OBJECTIVES To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence. MAIN RESULTS We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB. AUTHORS' CONCLUSIONS A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.
Collapse
Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Junichi Izawa
- Division of Critical Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
- Department of Preventive Services, Kyoto University Graduate School of Public Health, Kyoto, Japan
| | - Shoko Fujioka
- Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Jikei University Kashiwa Hospital, Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
| |
Collapse
|
7
|
Buschmann K, Wiltink J, Ghazy A, Bremerich D, Emrich AL, Beutel ME, Treede H. Does Mental Distress Predict Cardiac Surgical Outcome? Thorac Cardiovasc Surg 2022. [PMID: 36446621 DOI: 10.1055/s-0042-1758824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Mental distress is suspected to influence the morbidity of cardiac patients. Evaluating mental distress in cardiac patients is rare and the impact on surgical outcome is still not certified. METHODS In 94 cardiac surgical patients, mental distress was assessed by the Patient Health Questionnaire-4 (PHQ-4). We defined length of stay in hospital and on intensive care unit as well as time of mechanical ventilation as outcomes on surgery. Age, physical activity, diabetes, overweight, PHQ-4, and an inflammation marker were tested for their predictive value on outcomes. RESULTS Reportedly prevalence of generalized anxiety was 16.0% and depression rate was 13.8%. Length of stay in hospital was 13 ± 8 days, time of mechanical ventilation was 10 (0-1,207) hours, and length of stay on intensive care unit was 3 ± 6 days. Length of stay in hospital was significantly predicted by age (p = 0.048), low physical activity (p = 0.029), and high C-reactive protein (CRP; p = 0.031). Furthermore, CRP was the only significant predictor of time of mechanical ventilation and length of stay on intensive care unit. CONCLUSION Outcome was not predicted by mental distress. However, inflammation marker CRP was predictive for outcome, potentially caused by higher cardiovascular risk profile. Additionally, depression was referred to be associated with inflammation. Probably, the small sample and the timing of assessment were responsible for the missing relation between mental distress and outcome. We presume a relation with low physical activity and depression. Nevertheless, further randomized studies are needed to pay more attention on patients' distress to intervene preoperatively to improve postoperative outcome.
Collapse
Affiliation(s)
- Katja Buschmann
- Department of Cardiovascular Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Jörg Wiltink
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Ahmed Ghazy
- Department of Cardiovascular Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rheinland-Pfalz, Germany
| | | | - Anna Lena Emrich
- Department of Cardiovascular Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Manfred E Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Hendrik Treede
- Department of Cardiovascular Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rheinland-Pfalz, Germany
| |
Collapse
|
8
|
Su YQ, Yu YY, Shen B, Yang F, Nie YX. Management of acute kidney injury in gastrointestinal tumor: An overview. World J Clin Cases 2021; 9:10746-10764. [PMID: 35047588 PMCID: PMC8678862 DOI: 10.12998/wjcc.v9.i35.10746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/08/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal tumors remain a global health problem. Acute kidney injury (AKI) is a common complication during the treatment of gastrointestinal tumors. AKI can cause a decrease in the remission rate and an increase in mortality. In this review, we analyzed the causes and risk factors for AKI in gastrointestinal tumor patients. The possible mechanisms of AKI were divided into three groups: pretreatment, intrafraction and post-treatment causes. Treatment and prevention measures were proposed according to various factors to provide guidance to clinicians and oncologists that can reduce the incidence of AKI and improve the quality of life and survival rate of gastrointestinal tumor patients.
Collapse
Affiliation(s)
- Yi-Qi Su
- Department of Nephrology, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, Fujian Province, China
| | - Yi-Yi Yu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Bo Shen
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yu-Xin Nie
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| |
Collapse
|
9
|
Rozental O, Thalappillil R, White RS, Tam CW. Haemodynamic Monitoring Needs for Goal-Directed Fluid Therapy in Lung Resection. Heart Lung Circ 2021; 31:158-161. [PMID: 34654647 DOI: 10.1016/j.hlc.2021.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/22/2021] [Accepted: 08/30/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY, USA.
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
10
|
Wehrle CJ, Walker M, Worthey A, Jones CE, Lewis F, Arora TK. Barriers to Accurate Fluid Measurement in Perioperative Patients: A Mixed Methods Approach. J Surg Res 2020; 260:95-103. [PMID: 33333385 DOI: 10.1016/j.jss.2020.11.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/07/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgeons depend on fluid intake and output (I/O) measurements for assessment of resuscitation and fluid balance during the perioperative period. Frequently, these measurements are taken by Registered Nurses (RNs) and/or Patient Care Technicians (PCTs). There is variability in the accuracy and consistency of these measurements across nursing units. The goal of this study is to establish what barriers exist in obtaining accurate fluid measurements and potential solutions. MATERIALS AND METHODS A mixed-method, sequential study design was utilized. First, a survey was conducted at a tertiary care institution of 8 nonintensive care nursing units assessing the perceptions of RNs (n = 85) and PCTs (n = 38) regarding fluid intake and output measurements for surgical patients. Four focus groups were then conducted to expand upon the results of the survey. Fourteen participants (10 RNs and 4 PCTs) were interviewed, and transcripts were analyzed by three reviewers. Qualitative data were manually coded by reviewers using a hierarchical methodology. RESULTS Survey response rate was 40.6%. The strongest barriers in the survey were patient load and staff time limitations. About half (49%) of the respondents acknowledged that fluid measurements were inaccurate half of the time. PCTs spend more time collecting and charting I/Os and have higher patient loads (P < 0.001) than RNs. PCTs noted more difficulty with complex patients (P = 0.017) and devices for outputs (P = 0.004). PCT's (94%) handwrite data prior to electronic entry. One-third of nurses reported direct electronic entry (P < 0.001). Overall, 71% would prefer to chart in patient's rooms. Most (80%) of respondents received <5 h of fluids-related training at the time they were hired. Cronbach's alpha for three focus group reviewers was 0.84 (95% CI 0.693-0.923). Themes included understaffing, lack of training, a high percentage of traveling nurses, and poor communication regarding new orders. Recommended solutions to improve I/Os included in-room kiosks for electronic entry and relief of staffing burdens. CONCLUSIONS Fluid I/O measurement accuracy and efficiency may be improved by increased staffing, educational programs, and computer access, streamlining of order sets, simplicity of EMR data entry, and a standardized process for measuring, recording, and charting I/Os.
Collapse
Affiliation(s)
- Chase J Wehrle
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia.
| | - Morgan Walker
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Ayana Worthey
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Caitlin E Jones
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Frank Lewis
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Tania K Arora
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| |
Collapse
|
11
|
Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis. Eur J Anaesthesiol 2019; 35:469-483. [PMID: 29369117 DOI: 10.1097/eja.0000000000000778] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Much uncertainty exists as to whether peri-operative goal-directed therapy is of benefit. OBJECTIVES To discover if peri-operative goal-directed therapy decreases mortality and morbidity in adult surgical patients. DESIGN An updated systematic review and random effects meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase and the Cochrane Library were searched up to 31 December 2016. ELIGIBILITY CRITERIA Randomised controlled trials enrolling adult surgical patients allocated to receive goal-directed therapy or standard care were eligible for inclusion. Trauma patients and parturients were excluded. Goal-directed therapy was defined as fluid and/or vasopressor therapy titrated to haemodynamic goals [e.g. cardiac output (CO)]. Outcomes included mortality, morbidity and hospital length of stay. Risk of bias was assessed using Cochrane methodology. RESULTS Ninety-five randomised trials (11 659 patients) were included. Only four studies were at low risk of bias. Modern goal-directed therapy reduced mortality compared with standard care [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.50 to 0.87; number needed to treat = 59; N = 52; I = 0.0%]. In subgroup analysis, there was no mortality benefit for fluid-only goal-directed therapy, cardiac surgery patients or nonelective surgery. Contemporary goal-directed therapy also reduced pneumonia (OR 0.69; 95% CI, 0.51 to 0. 92; number needed to treat = 38), acute kidney injury (OR 0. 73; 95% CI, 0.58 to 0.92; number needed to treat = 29), wound infection (OR 0.48; 95% CI, 0.37 to 0.63; number needed to treat = 19) and hospital length of stay (days) (-0.90; 95% CI, -1.32 to -0.48; I = 81. 2%). No important differences in outcomes were found for the pulmonary artery catheter studies, after accounting for advances in the standard of care. CONCLUSION Peri-operative modern goal-directed therapy reduces morbidity and mortality. Importantly, the quality of evidence was low to very low (e.g. Grading of Recommendations, Assessment, Development and Evaluation scoring), and there was much clinical heterogeneity among the goal-directed therapy devices and protocols. Additional well designed and adequately powered trials on peri-operative goal-directed therapy are necessary.
Collapse
|
12
|
Kapoor PM, Karanjkar A, Magoon R, Taneja S, Das S, Malik V, Chowdhury UK, Ravi V. Effect of goal-directed therapy on post-operative neutrophil gelatinase-associated lipocalin profile in patients undergoing on-pump coronary artery surgery. Indian J Thorac Cardiovasc Surg 2019; 35:445-452. [PMID: 33061029 DOI: 10.1007/s12055-018-0758-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/08/2018] [Accepted: 10/09/2018] [Indexed: 01/22/2023] Open
Abstract
Purpose Neutrophil gelatinase-associated lipocalin (NGAL) is an early biomarker of acute kidney injury (AKI). Goal-directed therapy (GDT) in on-pump coronary artery bypass grafting (CABG) has been associated with lower post-operative NGAL levels in recent studies. The present study aimed at comparing plasma (P) and urinary (U)-NGAL levels following the use of GDT versus conventional haemodynamic therapy (CT) in patients undergoing on-pump CABG. Methods A prospective randomised controlled study conducted in a single university hospital. A total of 54 patients in the GDT group and 56 patients in CT group after exclusions. Results U-NGAL was significantly lower immediately post-surgery (T 1) in GDT group (25.11 ± 1.5 versus 27.80 ± 1.7 μg/L; p < 0.001) and at 4 h (T 2) (38.19 ± 23.6 versus 52.30 ± 28.3 μg/L; p = 0.006) and at 24 h post-operatively (T 3) (34.85 ± 14 versus 39.7 ± 11.1 μg/L; p = 0.047). P-NGAL was comparable between groups at T 1 but lower in the GDT group at T 2 (92.81 ± 4.8 versus 94.77 ± 4.5 μg/L; p = 0.03) and T 3 (67.44 ± 3.7 versus 75.96 ± 5.3 μg/L; p < 0.001). U-NGAL levels correlated well with the peak post-operative creatinine as compared to P-NGAL. On-pump patients manifest neutrophil activation, accounting for comparable levels of P-NGAL in the two groups at T 1. GDT-based haemodynamic management resulted in lower U-NGAL levels at T 1, T 2 and T 3 and lower P-NGAL levels at T 2 and T 3. Conclusions Haemodynamic optimisation with GDT prevents further renal insult initiated with the inflammatory activation with cardiopulmonary bypass (CPB), as evidenced by lower post-operative U-NGAL levels.
Collapse
Affiliation(s)
- Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Room No. 8, 7th Floor, Cardiothoracic Centre, Cardiothoracic Centre, Ansari Nagar, New Delhi, 110029 India
| | - Ameya Karanjkar
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Room No. 8, 7th Floor, Cardiothoracic Centre, Cardiothoracic Centre, Ansari Nagar, New Delhi, 110029 India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Room No. 8, 7th Floor, Cardiothoracic Centre, Cardiothoracic Centre, Ansari Nagar, New Delhi, 110029 India
| | - Sameer Taneja
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Room No. 8, 7th Floor, Cardiothoracic Centre, Cardiothoracic Centre, Ansari Nagar, New Delhi, 110029 India
| | - Sambhunath Das
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Room No. 8, 7th Floor, Cardiothoracic Centre, Cardiothoracic Centre, Ansari Nagar, New Delhi, 110029 India
| | - Vishwas Malik
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Room No. 8, 7th Floor, Cardiothoracic Centre, Cardiothoracic Centre, Ansari Nagar, New Delhi, 110029 India
| | - Ujjwal Kumar Chowdhury
- Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Cardiothoracic Centre, CNC, Ansari Nagar, New Delhi, 110029 India
| | - Vajala Ravi
- Lady Shri Ram College, University of Delhi, New Delhi, 110024 India
| |
Collapse
|
13
|
Zante B, Reichenspurner H, Kubik M, Schefold JC, Kluge S. Increased admission central venous-arterial CO 2 difference predicts ICU-mortality in adult cardiac surgery patients. Heart Lung 2019; 48:421-427. [PMID: 31200923 DOI: 10.1016/j.hrtlng.2019.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Invasive procedures such as cardiac surgery are associated with perioperative dysfunction of macrocirculation and/or microcirculation and organ failures. Maintenance or resuscitation of an adequate macrocirculation and/or microcirculation is thus crucial in patients after cardiac surgery. We investigated the prognostic power of early central venous-arterial carbon dioxide pressure difference (delta-pCO2) after cardiac surgery. METHODS Retrospective analysis of data from 1,019 cardiac surgery patients treated in the ICU of a tertiary medical care academic center. Clinical outcomes and laboratory measures including metabolic indices and calculated delta-pCO2 were assessed. Receiver operating characteristic (ROC) curves were generated and sensitivity / specificity analysis was performed. Univariate and multivariate regression models were analyzed. RESULTS The area under the ROC curve for delta-pCO2 to predict ICU mortality was 0.72 (sensitivity 65% / specificity 76%) with an optimal delta-pCO2 cut-off value of 8.6 mmHg. In multivariate regression, delta-pCO2 was associated with increased ICU mortality (HR 3.72, 95%-CI 1.3-10.66, p = 0.02). After adjustment for typical confounders, delta-pCO2 remained as independent predictor of ICU mortality after cardiac surgery. CONCLUSIONS In a retrospective data analysis in a large sample of adult post cardiac surgery patients treated in the ICU, we observed that admission central venous-arterial delta-pCO2 independently predicts ICU mortality. Delta-pCO2 might thus contribute risk stratification in ICU patients after cardiac surgery.
Collapse
Affiliation(s)
- Bjoern Zante
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Mathias Kubik
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Kluge
- Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| |
Collapse
|
14
|
Goldthwaite Z, Firstenberg MS, Botsch A. Hemodynamic early goal-directed therapy: Explaining the fine print. Int J Crit Illn Inj Sci 2019; 9:54-56. [PMID: 31334045 PMCID: PMC6625333 DOI: 10.4103/ijciis.ijciis_38_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The management of patients after cardiothoracic surgery can be very complex. Variabilities exist in hemodynamic status after cardiac surgery and the use of cardiopulmonary bypass – all of which can have a significant impact on myocardial Frank–Starling curves. Typically, invasive monitoring with pulmonary artery catheters is used to assess the complex physiology that these patients experience in the perioperative setting. However, the use of invasive monitoring is not without risk, and the broader benefits are poorly defined. Furthermore, there is growing evidence to support the use of hemodynamic early goal-directed therapy to optimize outcomes in critically ill patients. The purpose of this editorial statement is the review of some of the current literature with regards to the utility of goal-directed therapy as applied to the postoperative cardiac surgical patient.
Collapse
Affiliation(s)
- Zoe Goldthwaite
- Department of Cardiothoracic and Vascular Surgery, The Medical Center of Aurora, Aurora, CO, USA
| | - Michael S Firstenberg
- Department of Cardiothoracic and Vascular Surgery, The Medical Center of Aurora, Aurora, CO, USA
| | - Alex Botsch
- Department of Critical Care Medicine, Summa Akron City Hospital, Akron, OH, USA
| |
Collapse
|
15
|
Deng QW, Tan WC, Zhao BC, Wen SH, Shen JT, Xu M. Is goal-directed fluid therapy based on dynamic variables alone sufficient to improve clinical outcomes among patients undergoing surgery? A meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:298. [PMID: 30428928 PMCID: PMC6237035 DOI: 10.1186/s13054-018-2251-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/29/2018] [Indexed: 12/31/2022]
Abstract
Background Whether goal-directed fluid therapy based on dynamic predictors of fluid responsiveness (GDFTdyn) alone improves clinical outcomes in comparison with standard fluid therapy among patients undergoing surgery remains unclear. Methods PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov were searched for relevant studies. Studies comparing the effects of GDFTdyn with that of standard fluid therapy on clinical outcomes among adult patients undergoing surgery were considered eligible. Two analyses were performed separately: GDFTdyn alone versus standard fluid therapy and GDFTdyn with other optimization goals versus standard fluid therapy. The primary outcomes were short-term mortality and overall morbidity, while the secondary outcomes were serum lactate concentration, organ-specific morbidity, and length of stay in the intensive care unit (ICU) and in hospital. Results We included 37 studies with 2910 patients. Although GDFTdyn alone lowered serum lactate concentration (mean difference (MD) − 0.21 mmol/L, 95% confidence interval (CI) (− 0.39, − 0.03), P = 0.02), no significant difference was found between groups in short-term mortality (odds ratio (OR) 0.85, 95% CI (0.32, 2.24), P = 0.74), overall morbidity (OR 1.03, 95% CI (0.31, 3.37), P = 0.97), organ-specific morbidity, or length of stay in the ICU and in hospital. Analysis of trials involving the combination of GDFTdyn and other optimization goals (mainly cardiac output (CO) or cardiac index (CIx)) showed a significant reduction in short-term mortality (OR 0.45, 95% CI (0.24, 0.85), P = 0.01), overall morbidity (OR 0.41, 95% CI (0.28, 0.58), P < 0.00001), serum lactate concentration (MD − 0.60 mmol/L, 95% CI (− 1.04, − 0.15), P = 0.009), cardiopulmonary complications (cardiac arrhythmia (OR 0.58, 95% CI (0.37, 0.92), P = 0.02), myocardial infarction (OR 0.35, 95% CI (0.16, 0.76), P = 0.008), heart failure/cardiovascular dysfunction (OR 0.31, 95% CI (0.14, 0.67), P = 0.003), acute lung injury/acute respiratory distress syndrome (OR 0.13, 95% CI (0.02, 0.74), P = 0.02), pneumonia (OR 0.4, 95% CI (0.24, 0.65), P = 0.0002)), length of stay in the ICU (MD − 0.77 days, 95% CI (− 1.07, − 0.46), P < 0.00001) and in hospital (MD − 1.18 days, 95% CI (− 1.90, − 0.46), P = 0.001). Conclusions It was not the optimization of fluid responsiveness by GDFTdyn alone but rather the optimization of tissue and organ perfusion by GDFTdyn and other optimization goals that benefited patients undergoing surgery. Patients managed with the combination of GDFTdyn and CO/CI goals might derive most benefit. Electronic supplementary material The online version of this article (10.1186/s13054-018-2251-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Qi-Wen Deng
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Wen-Cheng Tan
- Department of Endoscopy, Sun Yat-sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, China
| | - Bing-Cheng Zhao
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, No. 1838, Guangzhou Avenue North, Guangzhou, 510515, China
| | - Shi-Hong Wen
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Jian-Tong Shen
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Miao Xu
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou, 510080, China.
| |
Collapse
|
16
|
Kaufmann T, Clement RP, Scheeren TWL, Saugel B, Keus F, Horst ICC. Perioperative goal-directed therapy: A systematic review without meta-analysis. Acta Anaesthesiol Scand 2018; 62:1340-1355. [PMID: 29978454 DOI: 10.1111/aas.13212] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/03/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Perioperative goal-directed therapy aims to optimise haemodynamics by titrating fluids, vasopressors and/or inotropes to predefined haemodynamic targets. Perioperative goal-directed therapy is a complex intervention composed of several independent component interventions. Trials on perioperative goal-directed therapy show conflicting results. We aimed to conduct a systematic review and meta-analysis to investigate the benefits and harms of perioperative goal-directed therapy. METHODS PubMED, EMBASE, Web of Science and Cochrane Library were searched. Trials were included if they had a perioperative goal-directed therapy protocol. The primary outcome was all-cause mortality. The first secondary outcome was serious adverse events excluding mortality. Risk of bias was assessed, and GRADE was used to evaluate quality of evidence. RESULTS One hundred and twelve randomised trials were included of which one trial (1%) had low risk of bias. Included trials varied in patients: types of surgery which was expected due to inclusion criteria; in intervention and comparison: timing of intervention, monitoring devices, haemodynamic variables, target values, use of fluids, vasopressors and/or inotropes as well as combinations of these within protocols; and in outcome: mortality was reported in 87 trials (78%). Due to substantial clinical heterogeneity also within the various types of surgery a meta-analysis of data, including subgroup analyses, as defined in our protocol was considered inappropriate. CONCLUSION Clinical heterogeneity in patients, interventions and outcomes in perioperative goal-directed therapy trials is too large to perform meta-analysis on all trials. Future trials and meta-analyses highly depend on universally agreed definitions on aspects beyond type of surgery of the complex intervention and its evaluation.
Collapse
Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Ramon P. Clement
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Thomas W. L. Scheeren
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Bernd Saugel
- Department of Anesthesiology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Frederik Keus
- Department of Critical Care University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Iwan C. C. Horst
- Department of Critical Care University Medical Center Groningen University of Groningen Groningen The Netherlands
| |
Collapse
|
17
|
Zhang L, Dai F, Brackett A, Ai Y, Meng L. Association of conflicts of interest with the results and conclusions of goal-directed hemodynamic therapy research: a systematic review with meta-analysis. Intensive Care Med 2018; 44:1638-1656. [PMID: 30105599 DOI: 10.1007/s00134-018-5345-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE The association between conflicts of interest (COI) and study results or article conclusions in goal-directed hemodynamic therapy (GDHT) research is unknown. METHODS Randomized controlled trials comparing GDHT with usual care were identified. COI were classified as industry sponsorship, author conflict, device loaner, none, or not reported. The association between COI and study results (complications and mortality) was assessed using both stratified meta-analysis and mixed effects meta-regression. The association between COI and an article's conclusion (graded as GDHT-favorable, neutral, or unfavorable) was investigated using logistic regression. RESULTS Of the 82 eligible articles, 43 (53%) had self-reported COI, and 50 (61%) favored GDHT. GDHT significantly reduced complications on the basis of the meta-analysis of studies with any type of COI, studies declaring no COI, industry-sponsored studies, and studies with author conflict but not on studies with a device loaner. However, no significant relationship between COI and the relative risk (GDHT vs. usual care) of developing complications was found on the basis of meta-regression (p = 0.25). No significant effect of GDHT was found on mortality. COI had a significant overall effect (p = 0.016) on the odds of having a GDHT-favorable vs. neutral conclusion based on 81 studies. Eighty-four percent of the industry-sponsored studies had a GDHT-favorable conclusion, while only 27% of the studies with a device loaner had the same conclusion grade. CONCLUSIONS The available evidence does not suggest a close relationship between COI and study results in GDHT research. However, a potential association may exist between COI and an article's conclusion in GDHT research.
Collapse
Affiliation(s)
- Lina Zhang
- Department of Critical Care Medicine, Central South University, Xiangya Hospital, Changsha, Hunan Province, China
| | - Feng Dai
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | | | - Yuhang Ai
- Department of Critical Care Medicine, Central South University, Xiangya Hospital, Changsha, Hunan Province, China
| | - Lingzhong Meng
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, New Haven, CT, 208051, USA.
| |
Collapse
|
18
|
Lan H, Zhou X, Xue J, Liu B, Chen G. The ability of left ventricular end-diastolic volume variations measured by TEE to monitor fluid responsiveness in high-risk surgical patients during craniotomy: a prospective cohort study. BMC Anesthesiol 2017; 17:165. [PMID: 29202703 PMCID: PMC5716247 DOI: 10.1186/s12871-017-0456-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/24/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study was aimed to evaluate the ability of left ventricular end-diastolic volume variations (LVEDVV) measured by transesophageal echocardiography (TEE) compared with stroke volume variation (SVV) obtained by the FloTrac/Vigileo monitor to predict fluid responsiveness, in patients undergoing craniotomy with goal direct therapy. METHODS We used SVV obtained by the FloTrac/Vigileo monitor to manage intraoperative hypotension in adult patients undergoing craniotomy (ASA III - IV) after obtaining IRB approval and informed consent. The LVEDVV were measured by TEE through the changes of left ventricular short diameter of axle simultaneously. When cardiac index (CI) ≤ 2.5 and SVV ≥ 15%, comparisons were made between the two devices before and after volume expansion. RESULTS We enrolled twenty-six patients referred for craniotomy in this study and 145 pairs of data were obtained. Mean Vigileo-SVV and TEE-LVEDVV were 17.8 ± 2.78% and 22.1 ± 7.25% before volume expansion respectively, and were 10.95 ± 2.8% and 13.58 ± 3.78% after volume expansion respectively (P < 0.001). The relationship between Vigileo-SVV and TEE-LVEDVV was significant (r2 = 0.55; p < 0.001). Agreement between Vigileo-SVV and TEE-LVEDVV was 3.3% ± 3.9% (mean bias ± SD, Bland-Altman). CONCLUSIONS For fluid responsiveness of patients during craniotomy in ASA III-IV, LVEDVV measured by left ventricular short diameter of axle using M type echocaidiographic measurement seems an acceptable monitoring indicator. This accessible method has promising clinical applications in situations where volume and cardiac function monitoring is of great importance during surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-TRC-13003583 , August 20, 2013.
Collapse
Affiliation(s)
- Haidan Lan
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiaoshuang Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jing Xue
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
| |
Collapse
|
19
|
Kapoor PM, Magoon R, Rawat RS, Mehta Y, Taneja S, Ravi R, Hote MP. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth 2017; 20:83-89. [PMID: 28074802 PMCID: PMC5290703 DOI: 10.4103/0971-9784.197842] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO2), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac™, PreSep™, and EV-1000® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO2, CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.
Collapse
Affiliation(s)
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Cardio Thoracic Centre, AIIMS, New Delhi, India
| | - Rajinder Singh Rawat
- Department of Cardiac Anaesthesiology, Salalah Heart Center, Salalah, Sultanate of Oman
| | - Yatin Mehta
- Department of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Sameer Taneja
- Department of Cardiac Anaesthesia, Naval Base Hospital, Mumbai, Maharashtra, India
| | - R Ravi
- Department of Statistics, Lady Shri Ram College, University of Delhi, New Delhi, India
| | - Milind P Hote
- Department of Cardiothoracic and Vascular Surgery, AIIMS, New Delhi, India
| |
Collapse
|