Brienza N, Giglio MT, Marucci M, Fiore T. Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study

Department of Emergency and Organ Transplantation, Anesthesia and Intensive Care Unit, University of Bari, Italy.
Critical care medicine (Impact Factor: 6.31). 05/2009; 37(6):2079-90. DOI: 10.1097/CCM.0b013e3181a00a43
Source: PubMed


Postoperative acute deterioration in renal function, producing oliguria and/or increase in serum creatinine, is one of the most serious complication in surgical patients. Most cases are due to renal hypoperfusion as a consequence of systemic hypotension, hypovolemia, and cardiac dysfunction. Although some evidence suggests that perioperative monitoring and manipulation of oxygen delivery by volume expansion and inotropic drugs may decrease mortality in surgical patients, no study analyzed this approach on postoperative renal dysfunction. The objective of this investigation is to perform a meta-analysis on the effects of perioperative hemodynamic optimization on postoperative renal dysfunction. DATA SOURCES, STUDY SELECTION, DATA EXTRACTION: A systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through January 2008 was conducted and 20 studies met the inclusion criteria (4220 participants). Data synthesis was obtained by using odds ratio (OR) with 95% confidence interval (CI) by random-effects model.
Postoperative acute renal injury was significantly reduced by perioperative hemodynamic optimization when compared with control group (OR 0.64; CI 0.50-0.83; p = 0.0007). Perioperative optimization was effective in reducing renal injury defined consistently with risk, injury, failure, and loss and end-stage kidney disease and Acute Kidney Injury Network classifications, and in studies defining renal dysfunction by serum creatinine and/or need of renal replacement therapy only (OR 0.66; CI 0.50-0.88; p = 0.004). The occurrence of renal dysfunction was reduced when treatment started both preoperatively and intraoperatively or postoperatively, was performed in high-risk patients, and was obtained by fluids and inotropes. Mortality was significantly reduced in treatment group (OR 0.50; CI 0.31-0.80; p = 0.004), but statistical heterogeneity was observed.
Surgical patients receiving perioperative hemodynamic optimization are at decreased risk of renal impairment. Because of the impact of postoperative renal complications on adverse outcome, efforts should be aimed to identify patients and surgery that would most benefit from perioperative optimization.

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Available from: Maria Teresa Giglio, Jul 18, 2014
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    • "In questa recente meta-analisi sono compresi un'eterogenea raccolta di studi di popolazione, vari tipi di procedure chirurgiche, metodi di monitoraggio e strategie di trattamento [59]. La strategia di base della goal-directed Therapy per prevenire l'AKI nel periodo perioperatorio si basa su protocolli che evitano l'ipotensione, che ottimizzano l'ossigenazione e comprendono un'attenta gestione dei fluidi, di vasopressori quando indicati , agenti inotropi ed emoderivati se necessari [59]. I relativi rischi e benefici: il rapporto rischio-beneficio di ogni singolo elemento della EGDT nella rianimazione dei pazienti con shock settico richiede ulteriori studi. "
    03/2015; 32(2).
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    • "Under these circumstances cost-effectiveness, or preferably cost savings, from new therapeutic approaches may be vital for their adoption, especially, if these new treatments are accompanied by higher initial acquisition or maintenance costs. Hemodynamic optimization and goal directed therapy (GDT) of high risk surgical patients improves postoperative outcomes by decreasing the number of complications and hospital length of stay as showed by many clinical trials and meta-analyses [1-3]. Additionally, according to pooled data from recently published meta-analysis an impact on postoperative mortality may be observed in the groups with high control-group mortality [4]. "
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    ABSTRACT: Perioperative goal directed therapy (GDT) can substantially improve the outcomes of high risk surgical patients as shown by many clinical studies. However, the approach needs initial investment and can increase the already very high staff workload. These economic imperatives may be at least partly responsible for weak adherence to the GDT concept. A few models are available for the evaluation of GDT cost-effectiveness, but studies of real economic data based on a recent clinical trial are lacking. In order to address this we have performed a retrospective analysis of the data from the “Intraoperative fluid optimization using stroke volume variation in high risk surgical patients” trial (ISRCTN95085011). The health-care payers perspective was used in order to evaluate the perioperative hemodynamic optimization costs. Hospital invoices from all patients included in the trial were extracted. A direct comparison between the study (GDT, N = 60) and control (N = 60) groups was performed. A cost tree was constructed and major cost drivers evaluated. The trial showed a significant improvement in clinical outcomes for GDT treated patients. The mean cost per patient were lower in the GDT group 2877 ± 2336€ vs. 3371 ± 3238€ in controls, but without reaching a statistical significance (p = 0.596). The mean cost of all items except for intraoperative monitoring and infusions were lower for GDT than control but due to the high variability they all failed to reach statistical significance. Those costs associated with clinical care (68 ± 177€ vs. 212 ± 593€; p = 0.023) and ward stay costs (213 ± 108€ vs. 349 ± 467€; p = 0.082) were the most important differences in favour of the GDT group. Intraoperative fluid optimization with the use of stroke volume variation and Vigileo/FloTrac system showed not only a substantial improvement of morbidity, but was associated with an economic benefit. The cost-savings observed in the overall costs of postoperative care trend to offset the investment needed to run the GDT strategy and intraoperative monitoring. Trial registration ISRCTN95085011
    BMC Anesthesiology 05/2014; 14(1):40. DOI:10.1186/1471-2253-14-40 · 1.38 Impact Factor
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    • "< 0.01 Postoperative ileus duration (days) 6 [4–8] 4 [3–5] < 0.01 ICU hospitalization (days) 7 [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] "
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    ABSTRACT: Liver transplantation carries major risks during the perioperative period. Few studies focused on the hemodynamics of patients undergoing liver transplantation. The present study was aimed to evaluate the impact of the implementation of a protocol including goal-directed therapy in patients undergoing liver transplantation. Our first goal was to determine its impact on the fluid balance. Secondarily, we evaluated possible improvements in the patient outcomes. A before and after study. Fifty patients undergoing liver transplantation were included during two successive six-month periods. During the first period, the management of the patients was left at the discretion of the senior physicians (control group, n=25). During the second period, the patients were treated according to a predetermined protocol including a specific hemodynamic monitoring (protocol group, n=25). The fluid balance was negative in the protocol group and positive in the control group at 24h (-606mL vs. +3445mL, P<0.01) and 48h (-2315mL vs. +1170mL, P<0.01) after liver transplantation. The volume of the crystalloid administration was lower in the protocol group than in the control group (5000mL vs. 8000mL, P<0.01, and 1500mL vs. 6000mL, P<0.01, during surgery and 48h after liver transplantation, respectively). The duration of mechanical ventilation and postoperative ileus were significantly reduced in the protocol group, as compared with the control group, 20h vs. 94h (P<0.01) and 4days vs. 6days (P<0.01), respectively. For patients undergoing liver transplantation, the implementation of a protocol aiming to optimize hemodynamics was associated with reduced fluid balance and decreased requirement for mechanical ventilation and postoperative ileus duration.
    Annales francaises d'anesthesie et de reanimation 01/2014; 33(4). DOI:10.1016/j.annfar.2013.12.016 · 0.84 Impact Factor
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