Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: “A clinical outcome and biomarker-based study”

Abstract

Goal-directed therapy (GDT) encompasses guidance of intravenous (IV) fluid and vasopressor/inotropic therapy by cardiac output or similar parameters to help in early recognition and management of high-risk cardiac surgical patients. With the aim of establishing the utility of perioperative GDT using robust clinical and biochemical outcomes, we conducted the present study. This multicenter randomized controlled study included 130 patients of either sex, with European system for cardiac operative risk evaluation ≥3 undergoing coronary artery bypass grafting on cardiopulmonary bypass. The patients were randomly divided into the control and GDT group. All the participants received standardized care; arterial pressure monitored through radial artery, central venous pressure (CVP) through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour, and frequent arterial blood gas (ABG) analysis. In addition, cardiac index (CI) monitoring using FloTrac™ and continuous central venous oxygen saturation (ScVO2) using PreSep™ were used in patients in the GDT group. Our aim was to maintain the CI 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 ScVO2 >70%, and stroke volume variation <10%; in addition to the control group parameters such as CVP 6–8 mmHg, mean arterial pressure 90–105 mmHg, normal ABG values, oxygen saturation, hematocrit value >30%, and urine output >1 ml/kg/h. The aims were achieved by altering the administration of IV fluids and doses of inotropes or vasodilators. The data of sixty patients in each group were analyzed in view of ten exclusions. The average duration of ventilation (19.89 ± 3.96 vs. 18.05 ± 4.53 h, P = 0.025), hospital stay (7.94 ± 1.64 vs. 7.17 ± 1.93 days, P = 0.025), and Intensive Care Unit (ICU) stay (3.74 ± 0.59 vs. 3.41 ± 0.75 days, P = 0.012) was significantly less in the GDT group, compared to the control group. The extra volume added and the number of inotropic dose adjustments were significantly more in the GDT group. The two groups did not differ in duration of inotropic use, mortality, and other complications. The perioperative continuation of GDT affected the early decline in the lactate levels after 6 h in ICU, whereas the control group demonstrated a settling lactate only after 12 h. Similarly, the GDT group had significantly lower levels of brain natriuretic peptide, neutrophil gelatinase-associated lipocalin levels as compared to the control. The study clearly depicts the advantage of GDT for a favorable postoperative outcome in high-risk cardiac surgical patients.

Management with Guidance of Minimally Invasive Cardiac Output Monitoring (PiCCO^®) in Coronary Artery Bypass Surgery and Postoperative Results

“…Inotropic and vasopressor therapy used to improve cardiac functions in cardiovascular surgery are emphasized as the cornerstone of hemodynamic therapy. However, it was shown to increase myocardial oxygen consumption, cause arrythmias and disrupt microcirculation (10,11,12). It is certainly inevitable to use it in case of left ventricular dysfunction and low cardiac output.…”

Perioperative management of geriatric patients

“…Инфузионная терапия Положение 10 При обширных некардиальных операциях рекомендуются как инфузионная стратегия поддержания «нулевого баланса», так и целевая инфузионная терапия. Инфузионная терапия должна быть индивидуализирована в соответствии с видом анестезии (регионарная или общая), объемом потерь жидкости и плазмы и индивидуальной толерантностью к водной нагрузке [68][69][70][71] Уровень достоверности (доказательности) В Уровень убедительности рекомендации IIa Таблица 12. Коррекция доз препаратов Положение 9 Рекомендуется коррекция доз препаратов для анестезии у пожилых людей [54][55][56][57][58][59][60][61][62] Уровень достоверности (доказательности) B Уровень убедительности рекомендации I ность этому фармакокинетика миорелаксантов подвержена существенным изменениям.…”

An Integrative Review of Fluid Management in Cardiac Surgery

“…There were however, no differences in 30-day mortality (Osawa et al). Kapoor et al (2016) studied the effect of GDT on patients undergoing off-pump CABG (Appendix C, Table C-8). They randomized 66 patients to the GDT group and 76 patients to the control group.…”

“…Five of the studies were RCTs, one was a prospective observational study (Thomson et al, 2014) one was a prospective randomized feasibility study (Parke et al, 2015), and one was a prospective study in which the intervention group was compared to a retrospective cohort (Walker & Young, 2015). All the studies except the one by Kapoor et al (2016) were conducted in single centers. Kapoor and colleagues conducted their study in two centers.…”

“…Two of the studies evaluated GDT during the intra-operative period; (Fellahi et al, 2015;Goepfert et al, 2013), three evaluated GDT during the postoperative period (Parke et al, 2015;Thomson et.al, 2014;Walker & Young, 2015), and the last three evaluated the effects of GDT in the intraoperative as well as postoperative phase of surgery (Kapoor et al, 2016;Osawa et al, 2016;Shreshta et al, 2015) The studies were all conducted with CABG or/and valve surgery patients, with three studies specifically conducted with high risk patients (Kapoor et al, 2016;Osawa et al, 2016;Walker & Young, 2015).…”