The effect of compliance with a perioperative goal-directed therapy protocol on outcomes after high-risk surgery: a before-after study

Abstract

Perioperative goal-directed therapy is considered to improve patient outcomes after high-risk surgery. The association of compliance with perioperative goal-directed therapy protocols and postoperative outcomes is unclear. The purpose of this study is to determine the effect of protocol compliance on postoperative outcomes following high-risk surgery, after implementation of a perioperative goal-directed therapy protocol. Through a before-after study design, patients undergoing elective high-risk surgery before (before-group) and after implementation of a perioperative goal-directed therapy protocol (after-group) were included. Perioperative goal-directed therapy in the after-group consisted of optimized stroke volume variation or stroke volume index and optimized cardiac index. Additionally, the association of protocol compliance with postoperative complications when using perioperative goal-directed therapy was assessed. High protocol compliance was defined as ≥ 85% of the procedure time spent within the individual targets. The difference in complications during the first 30 postoperative days before and after implementation of the protocol was assessed. In the before-group, 214 patients were included and 193 patients in the after-group. The number of complications was higher in the before-group compared to the after-group (n = 414 vs. 282; p = 0.031). In the after-group, patients with high protocol compliance for stroke volume variation or stroke volume index had less complications compared to patients with low protocol compliance for stroke volume variation or stroke volume index (n = 187 vs. 90; p = 0.01). Protocol compliance by the attending clinicians is essential and should be monitored to facilitate an improvement in postoperative outcomes desired by the implementation of perioperative goal-directed therapy protocols.

Perioperative goal-directed therapy in high-risk abdominal surgery. A multicenter randomized controlled superiority trial

“…However, in the preoperative assessment, echocardiography was not standard practice, and data regarding left ventricular ejection fraction were not available. Third, impaired protocol compliance by attending personnel might influence the effectivity of the algorithm [31]. Therefore, all personnel received a thorough explanation of the algorithm and training sessions.…”

What is new in hemodynamic monitoring and management?

“…Perioperative goal-directed therapy, especially cardiac output-guided goal-directed therapy may improve patient outcomes in high-risk non-cardiac surgery [ 35 ]. In a before and after trial, Boekel et al [ 36 ] investigated (1) the effect of implementation of a perioperative goal-directed therapy protocol and (2) the compliance to the protocol on postoperative outcomes (defined using the “Expanded Accordion Severity Classification Model” [ 37 ]) in 402 patients after high-risk non-cardiac surgery. Data before implementation of the goal-directed therapy protocol (n = 214) were collected retrospectively, whereas data after implementation of the goal-directed therapy protocol (n = 188) were collected prospectively.…”

Assisted Fluid Management Software Guidance for Intraoperative Fluid Administration

“…9,10 However, the complexity and variety of goal-directed therapy algorithms make them challenging to implement; consequently, adherence to such algorithms is often poor. 11,12 For example, in one of the largest goal directed therapy trials, only 30% of fluid boluses resulted in an appropriate SV increase, highlighting poor assessment of fluid responsiveness with an SV maximization protocol. 13 To overcome these challenges, Acumen Assisted Fluid Management software (Edwards Lifesciences, USA) was developed to automate the assessment of fluid responsiveness.…”