Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery

Abstract

Objective To assess whether a nurse led, flow monitored protocol for optimising circulatory status in patients after cardiac surgery reduces complications and shortens stay in intensive care and hospital. Design Randomised controlled trial. Setting Intensive care unit and cardiothoracic unit of a university teaching hospital. Participants 174 patients who underwent cardiac surgery between April 2000 and January 2003. Interventions Patients were allocated to conventional haemodynamic management or to an algorithm guided by oesophageal Doppler flowmetry to maintain a stroke index above 35 ml/m 2 . Results 26 control patients had postoperative complications (two deaths) compared with 17 (four deaths) protocol patients (P = 0.08). Duration of hospital stay in the protocol group was significantly reduced from a median of nine (interquartile range 7-12) days to seven (7-10) days (P = 0.02). The mean duration of hospital stay was reduced from 13.9 to 11.4 days, a saving in hospital bed days of 18% (95% confidence interval − 12% to 47%). Usage of intensive care beds was reduced by 23% ( − 8% to 59%). Conclusion A nurse delivered protocol for optimising circulatory status in the early postoperative period after cardiac surgery may significantly shorten hospital stay.

Perioperative haemodynamic monitoring by oesophageal Doppler improves outcome of patients with abdominal aortic aneurysm repair

“…Patients in the Doppler group were administered more fl uids (crystalloid, colloids) in the perioperative period, the postoperative recovery was found to be signifi cantly faster, and the frequency of major serious complications was lower. Our fi ndings are in agreement with the results of other studies comparing the perioperative Dopplerguided intravascular volume replacement strategies with conventional clinical volume replacement in groups of patiens surgically treated for orthopaedic, urologic, gynaecologic, abdominal, and cardiac disorders, as well as those treated for multiple trauma (8)(9)(10)(11)(12)(13)(14)(15)(16)(17). In these ten published studies, the investigators used different experimental protocols and all of these studies conclusively report benefi cial effects in the Doppler-guided groups (18,19).…”

Transesophageal Doppler devices: A technical review

“…Clinical studies comparing TED guided protocols to conventional approaches of volume replacement (guided by clinical assessment and/or central venous pressure) conclusively report beneficial effects in the Doppleroptimized groups, including a reduced risk of postoperative morbidity and a shorter length of hospital or ICU stay [11][12][13][14][15][16][17][18][19]. In addition to fluid optimization, other clinical applications such as early detection of hemodynamic changes associated with transurethral resection syndrome have also been reported [95].…”

“…However, up to now data to support its usefulness in guiding inotopic or vasoactive therapy in such patients is limited and the potential of TED to replace more invasive techniques in critical care units needs to be further determined. In contrast, the role of TED in optimizing perioperative volume replacement has been well characterized [11][12][13][14][15][16][17][18][19]. TED allows assessment of fluid responsiveness by monitoring changes in stroke volume secondary to fluid challenges, allowing individual titration of fluids to maximize CO while avoiding excessive fluid loading.…”

“…A major advantage of TED is that it allows extended monitoring and facilitates hemodynamic optimization in patients in whom advanced hemodynamic parameters such as CO would otherwise not be monitored. Compared to conventional clinical assessment, fluid management guided by TED to optimize stroke volume has been shown to improve patient outcome and to reduce the length of hospital stay [10][11][12][13][14][15][16][17][18][19], suggesting that this technique can be a valuable supplement to current standard hemodynamic monitoring.…”

Stroke Volume Optimization Versus Central Venous Pressure in Fluid Management

“…However, multiple studies [1][2][3][4][5][6][7][8][9] have shown that physicians and nurses cannot accurately assess volume status with the current techniques. Measuring stroke volume only recently became feasible.…”