Early goal-directed therapy in moderate to high-risk cardiac surgery patients

Abstract

Early goal-directed therapy is a term used to describe the guidance of intravenous fluid and vasopressor/inotropic therapy by using cardiac output or similar parameters in the immediate post-cardiopulmonary bypass in cardiac surgery patients. Early recognition and therapy during this period may result in better outcome. In keeping with this aim in the cardiac surgery patients, we conducted the present study. The study included 30 patients of both sexes, with EuroSCORE >or=3 undergoing coronary artery bypass surgery under cardiopulmonary bypass. The patients were randomly divided into two groups, namely, control and early goal-directed therapy (EGDT) groups. All the subjects received standardized care; arterial pressure was monitored through radial artery, central venous pressure through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour and frequent arterial blood gas analysis. In addition, cardiac index monitoring using FloTrac and continuous central venous oxygen saturation using PreSep was used in patients in the EGTD group. Our aim was to maintain the cardiac index at 2.5-4.2 l/min/m2 , stroke volume index 30-65 ml/beat/m2 , systemic vascular resistance index 1500-2500 dynes/s/cm5/m2 , oxygen delivery index 450-600 ml/min/m2 , continuous central venous oximetry more than 70%, stroke volume variation less than 10%; in addition to the control group parameters such as central venous pressure 6-8 mmHg, mean arterial pressure 90-105 mmHg, normal arterial blood gas analysis values, pulse oximetry, hematocrit value above 30% and urine output more than 1 ml/kg/h. The aims were achieved by altering the administration of intravenous fluids and doses of inotropic or vasodilator agents. Three patients were excluded from the study and the data of 27 patients analyzed. The extra volume used (330+/-160 v/s 80+/-80 ml, P=0.043) number of adjustments of inotropic agents (3.4+/-1.5 v/s 0.4+/-0.7, P=0.026) in the EGDT group were significant. The average duration of ventilation (13.8+/-3.2 v/s 20.7+/-7.1 h), days of use of inotropic agents (1.6+/-0.9 v/s 3.8+/-1.6 d), ICU stay (2.6+/-0.9 v/s 4.9+/-1.8 d) and hospital stay (5.6+/-1.2 v/s 8.9+/-2.1 d) were less in the EGDT group, compared to those in the control group. This study is inconclusive with regard to the beneficial aspects of the early goal-directed therapy in cardiac surgery patients, although a few benefits were observed.

State-of-the-art fluid management in the operating room

“…Cecconi et al showed improved outcomes in 40 patients receiving regional anesthesia for hip arthroplasty [33]. Kapoor et al showed a decrease in the duration of mechanical ventilation, ICU LOS, and hospital LOS in patients undergoing cardiac surgery [34]. Targeting a PPV <10% has been shown to improve postoperative outcomes and reduce length of intensive care and hospital stay in high-risk surgical patients [35].…”

Perioperative Haemodynamic Optimisation

“…An increase in intra-thoracic pressure generates an isovolaemic increase in RAP, which decreases dVR and decreases VR. Some of these variables have been used in GDT protocols (37,38). A systolic pressure or a pulse pressure variation of 13% or more in septic patients breathing with a tidal volume of 8 mL kg -1 is highly sensitive and specific for preload responsiveness (39).…”

Can we Improve Outcome in High Risk Surgery?

“…Also there are data showing that keeping the oxygen extraction ratio, calculated from arterial and central venous oxygen saturation, below 27% resulted in less postoperative organ dysfunction and reduced hospital stay of high-risk surgical patients (16). However, early GDT including the maintenance of ScvO 2 higher than 70% in moderate and high risk cardiac surgical patients was found to be inconclusive regarding benefits (39). In a recent observational study in surgical patients, even higher levels of ScvO 2 have been reported (84.7±8.3%) (40).…”