Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients [ISRCTN42445141]

Lobo, Suzana M.; Lobo, Francisco; Polachini, Carlos A.; Patini, D; Yamamoto, A; Oliveira, Neymar Elias de; Serrano, Patricia; Sanches, H; Spegiorin, Marco A; Queiroz, Marcio M; Christiano, A; Savieiro, Elisangela F; Alvarez, P; Teixeira, Silvia P; Cunrath, Geni Satomi

doi:10.1186/cc4913

Cited by 79 publications

(20 citation statements)

References 34 publications

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“…A baseline mortality rate of >20% is unusual in current practice [4,96]; in this sense it is interesting to note that two of five studies with a baseline mortality rate of >20% were carried out within the past decade. Neither of these studies demonstrated a survival benefit with GDT [80,97]. One of these studies demonstrated a reduction in complication rates [97], whilst the other demonstrated a trend towards a reduction in complication rates [80].…”

Section: Discussionmentioning

confidence: 99%

Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups

et al. 2012

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Patients with limited cardiac reserve are less likely to survive and develop more complications following major surgery. By augmenting oxygen delivery index (DO2I) with a combination of intravenous fluids and inotropes (goal directed therapy (GDT)), postoperative mortality and morbidity of high-risk patients may be reduced. However, although most studies suggest that GDT may improve outcome in high-risk surgical patients, it is still not widely practiced. We set out to test the hypothesis that GDT results in greatest benefit in terms of mortality and morbidity in patients with the highest risk of mortality and have undertaken a systematic review of the current literature to see if this is correct. We performed a systematic search of Medline, Embase and CENTRAL databases for randomized controlled trials (RCTs) and reviews of GDT in surgical patients. To minimize heterogeneity we excluded studies involving cardiac, trauma, and paediatric surgery. Extremely high risk, high risk and intermediate risks of mortality were defined as >20%, 5 to 20% and <5% mortality rates in the control arms of the trials, respectively. Meta analyses were performed and Forest plots drawn using RevMan software. Data are presented as odd ratios (OR; 95% confidence intervals (CI), and P-values). A total of 32 RCTs including 2,808 patients were reviewed. All studies reported mortality. Five studies (including 300 patients) were excluded from assessment of complication rates as the number of patients with complications was not reported. The mortality benefit of GDT was confined to the extremely high-risk group (OR = 0.20, 95% CI 0.09 to 0.41; P < 0.0001). Complication rates were reduced in all subgroups (OR = 0.45, 95% CI 0.34 to 0.60; P < 0.00001). The morbidity benefit was greatest amongst patients in the extremely high-risk subgroup (OR = 0.27, 95% CI 0.15 to 0.51; P < 0.0001), followed by the intermediate risk subgroup (OR = 0.43, 95% CI 0.27 to 0.67; P = 0.0002), and the high-risk subgroup (OR 0.56, 95% CI 0.36 to 0.89; P = 0.01). Despite heterogeneity in trial quality and design, we found GDT to be beneficial in all high-risk patients undergoing major surgery. The mortality benefit of GDT was confined to the subgroup of patients at extremely high risk of death. The reduction of complication rates was seen across all subgroups of GDT patients.

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Section: Discussionmentioning

confidence: 99%

Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups

et al. 2012

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“…Indeed, in patients with a high risk of perioperative death, PAC-guided hemodynamic optimization using dobutamine to obtain DO 2 >600 ml/minute/m 2 was associated with better outcomes, whereas fluids alone increased the incidence of postoperative complications [45]. The use of two different treatment algorithms of GDT comparing fluids alone with fluids and dobutamine suggests that dobutamine was associated with better recovery of the left ventricular stroke work index during operative trauma and with higher tolerance to fluids.…”

Section: What Are the Best Hemodynamic Targets?mentioning

confidence: 99%

“…In spite of the multifactorial origin of postoperative complications, compromised physiologic reserves and multiple comorbidities in combination with extensive surgery seem to be a hallmark of high complication and mortality rates [44]. In general, these patients are older, undergoing extensive ablative surgery with limited cardiopulmonary reserve, and/or with other organ dysfunctions/comorbidities (Figure 2) [38,45,65]. Shoemaker and colleagues' criteria for identifying a high-risk of perioperative complications will also identify patients to be managed in this group [35].…”

Section: Which Targets For Which Patients?mentioning

confidence: 99%

Clinical review: What are the best hemodynamic targets for noncardiac surgical patients?

Lobo

Oliveira

2013

Crit Care

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Perioperative hemodynamic optimization, or goal-directed therapy (GDT), has been show to significantly decrease complications and risk of death in high-risk patients undergoing noncardiac surgery. An important aim of GDT is to prevent an imbalance between oxygen delivery and oxygen consumption in order to avoid the development of multiple organ dysfunction. The utilization of cardiac output monitoring in the perioperative period has been shown to improve outcomes if integrated into a GDT strategy. GDT guided by dynamic predictors of fluid responsiveness or functional hemodynamics with minimally invasive cardiac output monitoring is suitable for the majority of patients undergoing major surgery with expected significant volume shifts due to bleeding or other significant intravascular volume losses. For patients at higher risk of complications and death, such as those with advanced age and limited cardiorespiratory reserve, the addition of dobutamine or dopexamine to the treatment algorithm, to maximize oxygen delivery, is associated with better outcomes.

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“…O desbalanço entre oferta e consumo de oxigênio tecidual ocorre particularmente no intraoperatório e nas primeiras horas após o término da cirurgia. A redução da oferta de oxigênio nesse contexto está associada à redução da oxigenação global, hipoperfusão tecidual e a maior ocorrência de complicações pós-operatórias [274][275][276][277][278][279][280] .…”

Section: ) Monitorização Hemodinâmicaunclassified

I Diretriz Brasileira de Cardio-Oncologia da Sociedade Brasileira de Cardiologia

Filho¹,

Hajjar²,

Bacal³

et al. 2011

Arq. Bras. Cardiol.

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Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients [ISRCTN42445141]

Cited by 79 publications

References 34 publications

Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups

Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups

Clinical review: What are the best hemodynamic targets for noncardiac surgical patients?

I Diretriz Brasileira de Cardio-Oncologia da Sociedade Brasileira de Cardiologia

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