Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery*

Abstract

SummaryOesophageal Doppler monitoring allows non-invasive estimation of stroke volume and cardiac output. We studied the impact of Doppler guided fluid optimisation on haemodynamic parameters, peri-operative morbidity and hospital stay in patients undergoing major bowel surgery. Fifty-seven patients were randomly assigned to Doppler (D) or control (C) groups. All patients received intraoperative fluid therapy at the discretion of the non-investigating anaesthetist. In addition, Group D were given fluid challenges (3 ml.kg Surgical patients undergoing major bowel resection are at high risk of peri-operative complications and death. Centres in the UK report mortality rates in this group of between 4 and 9% [1, 2]. Many of these patients are elderly and suffer comorbid medical conditions as well as the local and systemic effects of colorectal disease. Studies of similar patient groups having major surgery have used fluid, inotrope and oxygen therapy to optimise cardiac output and oxygen delivery; these studies demonstrated reductions in mortality and length of hospital stay [3][4][5]. The method of cardiac output measurement in these reports, pulmonary artery catheterisation, is not commonly used for bowel surgery. Pulmonary artery catheter insertion can be time consuming and has been implicated with complications and excess mortality [6]. Furthermore some trials involving pulmonary artery catheter optimisation of oxygen delivery required pre-operative admission to intensive care which is currently not practical for colorectal resection.The minimally invasive oesophageal Doppler monitor permits real time assessment of cardiac output [7]. Haemodynamic parameters estimated by this device can be used to guide fluid therapy during surgery [8]. A study of patients undergoing repair of femoral neck fracture demonstrated a reduction in length of hospital stay when oesophageal Doppler was used to guide fluid therapy [9].The aim of this study was to examine the effect of oesophageal Doppler guided fluid administration during colorectal resection on haemodynamic performance, hospital stay and postoperative complications.

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).…”

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

“…This should be given rapidly over five to ten minutes, 23 and although there is no consensus on the type of fluid given, most trials in the operating room showing an improved outcome were performed with a colloid. [24][25][26][27][28][29][30][31][32] Importantly, hemodynamic instability does not equate with volume responsiveness; indeed, only 50% of hemodynamically unstable patients in the operating room are ''volume responders''. 33 Moreover, volume responsiveness does not always mean that a fluid bolus is needed.…”

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.…”