Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass

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.

Effect of Goal-directed Hemodynamic Therapy in Postcardiac Surgery Patients

“… 13 A recent study concluded that gold-directed therapy decreases duration of inotropic support in high-risk cardiac patients undergoing off-pump coronary artery bypass. 14 …”

Lack of Impact of Nil-Per-Os (NPO) Time on Goal-Directed Fluid Delivery in First Case versus Afternoon Case Starts: A Retrospective Cohort Study

“…Some of those additional factors contributing to this finding may include patient pathology, condition, higher EBL, epidural vasoplegia, and greater insensible loss typical of more complex surgery as previously noted, though this result remains difficult to interpret in such a broad and multifactorial setting. Nevertheless, the variables affecting this previous result, namely, possible different ASA classifications among the AM vs. PM patient groups [4,16,17], the possible differential epidural placement for different cases [18,19], the possible difference in the number of laparoscopic procedures in the AM vs PM groups [20,21], different possible urine loss in cases of differing nature [22,23], possible different patient demographics in weight [23][24][25] or in age [26][27][28], the different pragmatic scheduling need for surgical procedures of longer duration in the AM vs the PM groups [29][30][31], and the possible different hemodynamic heat rate parameter between surgical cases of different nature among the AM vs PM groups [21,32,33], have all been accounted for in the literature with evidence showing the clear benefit of following the GDFT algorithm. In some regards these limitations result from and are common to how operating rooms actually run.…”

Lack of Impact of Nil-Per-Os (NPO) Time on Goal-Directed Fluid Delivery in First Case versus Afternoon Case Starts: A Retrospective Cohort Study

“…Some of those additional factors contributing to this finding may include patient pathology, condition, higher EBL, epidural vasoplegia, and greater insensible loss typical of more complex surgery as previously noted, though this result remains difficult to interpret in such a broad and multifactorial setting. Nevertheless, the variables affecting this previous result, namely, possible different ASA classifications among the AM vs. PM patient groups [16][17][18] , the possible differential epidural placement for different cases [19][20] , the possible difference in the number of laparoscopic procedures in the AM vs PM groups [21][22] , different possible urine loss in cases of differing nature [23][24] , possible different patient demographics in weight [25][26][27] or in age [28][29][30] , the different pragmatic scheduling need for surgical procedures of longer duration in the AM vs the PM groups [31][32][33] , and the possible different hemodynamic heat rate parameter between surgical cases of different nature among the AM vs PM groups [34][35][36] , have all been accounted for in the literature with evidence showing the clear benefit of following the GDFT algorithm. In some regards these limitations result from and are common to how operating rooms actually run.…”