A Prospective Comparison of a Noninvasive Cardiac Output Monitor Versus Esophageal Doppler Monitor for Goal-Directed Fluid Therapy in Colorectal Surgery Patients

Anesthesia and analgesia (Impact Factor: 3.47). 03/2014; 118(5). DOI: 10.1213/ANE.0000000000000182
Source: PubMed


Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT.
One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient's stroke volume was optimized using 250-mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared.
Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were -0.96 to +1.95 days (P = 0.5016).
The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.

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Available from: Timothy E Miller, Sep 09, 2014
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    • "differences in hospital length of stay or postoperative recovery when integrated into an ERAS program [72]. These studies suggest that hemodynamic and fluid optimization can be safely achieved with the noninvasive, minimally invasive, or invasive hemodynamic monitors currently available. "
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    ABSTRACT: Perioperative hemodynamic optimization of the high-risk surgical patient is associated with reduced postoperative morbidity and mortality. The hemodynamic parameters to be optimized (using goal-directed algorithms) encompass preload, contractility, afterload, volume responsiveness, and end-organ perfusion. Current hemodynamic monitors facilitate multi-modal monitoring of these macro-hemodynamic targets. This review focuses on the variety of invasive, minimally invasive, and noninvasive hemodynamic monitors available to the clinician. Copyright © 2014 Elsevier Ltd. All rights reserved.
    Full-text · Article · Dec 2014 · Baillière&#x27 s Best Practice and Research in Clinical Anaesthesiology
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    • "Most recently, the use of bioreactance in goal-directed fluid therapy management has been demonstrated. In a prospective study, Waldron and colleagues [74] evaluated the performance of the bioreactance against oesophageal Doppler monitor to guide the goal-directed fluid therapy in 100 surgery adult patients. Results revealed nonsignificant difference and good agreement between the two methods. "
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    ABSTRACT: Noninvasive continuous cardiac output monitoring may have wide clinical applications in anaesthesiology, emergency care and cardiology. It can improve outcomes, establish diagnosis, guide therapy and help risk stratification. The present article describes the theory behind the two noninvasive continuous monitoring methods for cardiac output assessment such as bioimpedance and bioreactance. The review discusses the advantages and disadvantages of these methods and highlights the recent method comparison studies. The use of bioimpedance and bioreactance to estimate cardiac output under haemodynamic challenges is also discussed. In particular, the article focuses on performance of the two methods in the assessment of fluid responsiveness using passive leg raising test and cardiac output response to exercise stress testing. Copyright © 2014 Elsevier Ltd. All rights reserved.
    Full-text · Article · Dec 2014 · Best practice & research. Clinical anaesthesiology
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    • "Other noninvasive technologies that can be used for GDFT include the noninvasive CO monitor (NICOM, Cheetah Medical, Vancouver, WA, USA) and the Nexfin (Edwards, Irving, TX, USA). The NICOM is a bioreactance-based monitor that has been shown to perform similarly to the ED in guiding GDFT [38]. The Nexfin accurately and continuously measures both arterial blood pressure [39] and CO [40] [41] using an inflatable finger cuff. "
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    ABSTRACT: The underlying principles guiding fluid management in any setting are very simple: maintain central euvolemia, and avoid salt and water excess. However these principles are frequently easier to state than to achieve. Evidence from recent literature suggests that avoidance of fluid excess is important, with excessive crystalloid use leading to perioperative weight gain and an increase in complications. A zero balance approach aimed at avoiding fluid excess is recommended for all patients. For major surgery, there is a sizeable body of evidence that an individualized goal directed fluid therapy (GDFT) improves outcomes. However within an Enhanced Recovery program only a few studies have been published yet so far GDFT has not achieved the same benefit. Balanced crystalloids are recommended for most patients. The use of colloids remains controversial; however current evidence suggests they can be beneficial in intraoperative patients with objective evidence of hypovolemia.
    Full-text · Article · Sep 2014 · Baillière&#x27 s Best Practice and Research in Clinical Anaesthesiology
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