Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study

Abstract

IntroductionPerioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention.MethodsThis is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database).ResultsIn the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1–13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7–9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6–16) days to 7 (5–11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18 % (95 % confidence interval 9–27 %). The incidence of NSQIP complications decreased from 39 % to 25 % (p = 0.04).ConclusionThese results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries.Trial registrationClinicaltrials.gov NCT02057653. Registered 17 December 2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0945-2) contains supplementary material, which is available to authorized users.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery

“…71 First, euvolemia should be targeted and individualized to the patient such that patients are only given fluid boluses when there is a demonstrated need for augmentation of perfusion status and when they have been shown to be volume responsive. [107][108][109] Weighing the patient daily to target zero weight gain and closely following hemodynamic targets and urine output may be of benefit. Second, fluids should be treated as drugs with potentially harmful side effects.…”

Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients

“…None of the four hospitals included stroke volume-guided haemodynamic optimisation as a standard of care [29,30], general documentation of early resuscitation was poor and ICU admission rates were relatively low (24%), indicating lack of standardised practice in this high-risk surgical population and the need for a national multidisciplinary quality improvement program, similar to that developed in the UK [31]. Among the sub-group of early deaths (< 72 h), analysis of Clavien-Dindo complications is of questionable value since these occur during a period of pronounced organ instability.…”

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

“…Goal‐directed therapy is frequently applied with the intention to optimise peri‐operative haemodynamic profiles and maximise oxygen delivery in patients undergoing abdominal surgery . The beneficial effects of goal‐directed therapy on outcome have been investigated predominately in patients with a high‐risk profile undergoing major procedures .…”