Fluid management guided by a continuous non-invasive arterial pressure device is associated with decreased postoperative morbidity after total knee and hip replacement

Abstract

BackgroundThe use of goal directed fluid protocols in intermediate risk patients undergoing hip or knee replacement was studied in few trials using invasive monitoring. For this reason we have implemented two different fluid management protocols, both based on a novel totally non-invasive arterial pressure monitoring device and compared them to the standard (no-protocol) treatment applied before the transition in our academic institution.MethodsThree treatment groups were compared in this prospective study: the observational (CONTROL, N = 40) group before adoption of fluid protocols and two randomized groups after the transition to protocol fluid management with the use of the continuous non-invasive blood pressure monitoring (CNAP®) device. In the PRESSURE group (N = 40) standard variables were used for restrictive fluid therapy. Goal directed fluid therapy using pulse pressure variation was used in the GDFT arm (N = 40). The influence on the rate of postoperative complications, on the hospital length of stay and other parameters was assessed.ResultsBoth protocols were associated with decreased fluid administration and maintained hemodynamic stability. Reduced rate of postoperative infection and organ complications (22 (55 %) vs. 33 (83 %) patients; p = 0.016; relative risk 0.67 (0.49–0.91)) was observed in the GDFT group compared to CONTROL. Lower number of patients receiving transfusion (4 (10 %) in GDFT vs. 17 (43 %) in CONTROL; p = 0.005) might contribute to this observation. No significant differences were observed in other end-points.ConclusionIn our study, the use of the fluid protocol based on pulse pressure variation assessed using continuous non-invasive arterial pressure measurement seems to be associated with a reduction in postoperative complications and transfusion needs as compared to standard no-protocol treatment.Trial registrationACTRN12612001014842Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-015-0131-8) contains supplementary material, which is available to authorized users.

Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence

“…A recent trial randomized 120 patients to no-protocol (control, n ¼ 40), conservative (n ¼ 40), or GDFT using a non-invasive arterial pressure monitoring device based on pulse pressure variation. 110 Results were significant for reduced postoperative infection, organ complications, and risk of blood transfusion in the GDFT group compared with control. Unlike other surgical subspecialties, in elective joint replacement the role, type, and volume of i.v.…”

The added value of cardiac index and pulse pressure variation monitoring to mean arterial pressure-guided volume therapy in moderate-risk abdominal surgery (COGUIDE): a pragmatic multicentre randomised controlled trial

“…proved the feasibility of non‐invasive arterial blood pressure‐guided fluid administration through a closed‐loop system that included the assessment of stroke volume (SV), cardiac index (CI) and dynamic elastance . In another study, volume therapy guided by pulse pressure variation (PPV) in patients undergoing total knee or hip replacement surgery was associated with fewer postoperative complications when compared with a control group . In contrast, in patients undergoing major abdominal surgery, no benefits of mean arterial pressure (MAP) or CI‐based haemodynamic guidance could be observed .…”

Current concepts in fluid therapy and non-invasive haemodynamic monitoring

“…Further validation, especially in outcome studies, and probably some technological improvements are needed before they can be definitely recommended for clinical use. However, they definitely seem to be a useful haemodynamic tool for patients who would otherwise not be included in GDT protocols due to lack of appropriate monitoring, like those undergoing hip-replacement procedures (28).…”

“…But since the actual purpose of monitors is to guide therapy, studies are needed to determine if a non-invasive haemodynamic monitor coupled with an interventional protocol effects patients' outcome. Some have already been conducted and the results seem promising (28).…”