CON: Fluid Restriction for Cardiac Patients During Major Noncardiac Surgery Should be Replaced by Goal-Directed Intravascular Fluid Administration

University Hospital of Lausanne, Lausanne, Vaud, Switzerland
Anesthesia and analgesia (Impact Factor: 3.47). 03/2006; 102(2):344-6. DOI: 10.1213/01.ane.0000196511.48033.0b
Source: PubMed


oncerns have been expressed that over- hydration may result in pulmonary edema, car- diac complications, delayed recovery of gastro- intestinal motility, compromised tissue oxygenation, wound healing problems, and blood coagulation im- pairment (1-3). Patients with a cardiac comorbidity undergoing major noncardiac surgery may be partic- ularly vulnerable and, therefore, perioperative fluid restriction might appear to be beneficial. However, there are at least 4 prospective random- ized trials showing that a goal-directed perioperative plasma volume expansion decreases major postoper- ative morbidity and the duration of hospitalization significantly (4-7). In all these studies, stroke volume in the descending aorta was assessed by esophageal Doppler monitoring. Two hundred mL of colloids were given over 10 min and stroke volume was as- sessed every 15 min. This was repeated until no fur- ther increase in stroke volume was detected. Indeed,

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    • "Kimberger and colleagues [31] recently investigated the influence of different volume regimens on tissue perfusion in an animal model and found a significantly increased microcirculatory blood flow and tissue oxygen tension with goal-directed administration of colloids. The ongoing discussion about the 'optimal' amount and type of fluid can at least partially be resolved, as evidence grows that individually titrated, goal-directed administration of primarily colloid solutions improves patient outcome in patients undergoing major abdominal surgery [2,25,32]. "
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    ABSTRACT: Several studies have shown that goal-directed hemodynamic and fluid optimization may result in improved outcome. However, the methods used were either invasive or had other limitations. The aim of this study was to perform intraoperative goal-directed therapy with a minimally invasive, easy to use device (FloTrac/Vigileo), and to evaluate possible improvements in patient outcome determined by the duration of hospital stay and the incidence of complications compared to a standard management protocol. In this randomized, controlled trial 60 high-risk patients scheduled for major abdominal surgery were included. Patients were allocated into either an enhanced hemodynamic monitoring group using a cardiac index based intraoperative optimization protocol (FloTrac/Vigileo device, GDT-group, n = 30) or a standard management group (Control-group, n = 30), based on standard monitoring data. The median duration of hospital stay was significantly reduced in the GDT-group with 15 (12 - 17.75) days versus 19 (14 - 23.5) days (P = 0.006) and fewer patients developed complications than in the Control-group [6 patients (20%) versus 15 patients (50%), P = 0.03]. The total number of complications was reduced in the GDT-group (17 versus 49 complications, P = 0.001). In high-risk patients undergoing major abdominal surgery, implementation of an intraoperative goal-directed hemodynamic optimization protocol using the FloTrac/Vigileo device was associated with a reduced length of hospital stay and a lower incidence of complications compared to a standard management protocol. Clinical trial registration information: Unique identifier: NCT00549419.
    Full-text · Article · Feb 2010 · Critical care (London, England)
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    • "Instead of targeting a given threshold value of cardiac index or of oxygen delivery during surgery, other authors have proposed to guide intraoperative fluid administration by using individual Frank-Starling curves [1-4,12,23]. Several studies have shown that monitoring and maximizing stroke volume by fluid loading (until stroke volume reaches a plateau, actually the plateau of the Frank-Starling curve) during high-risk surgery is associated with improved postoperative outcome [1-4]. "
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    ABSTRACT: Several studies have shown that maximizing stroke volume (or increasing it until a plateau is reached) by volume loading during high-risk surgery may improve post-operative outcome. This goal could be achieved simply by minimizing the variation in arterial pulse pressure (deltaPP) induced by mechanical ventilation. We tested this hypothesis in a prospective, randomized, single-centre study. The primary endpoint was the length of postoperative stay in hospital. Thirty-three patients undergoing high-risk surgery were randomized either to a control group (group C, n = 16) or to an intervention group (group I, n = 17). In group I, deltaPP was continuously monitored during surgery by a multiparameter bedside monitor and minimized to 10% or less by volume loading. Both groups were comparable in terms of demographic data, American Society of Anesthesiology score, type, and duration of surgery. During surgery, group I received more fluid than group C (4,618 +/- 1,557 versus 1,694 +/- 705 ml (mean +/- SD), P < 0.0001), and deltaPP decreased from 22 +/- 75 to 9 +/- 1% (P < 0.05) in group I. The median duration of postoperative stay in hospital (7 versus 17 days, P < 0.01) was lower in group I than in group C. The number of postoperative complications per patient (1.4 +/- 2.1 versus 3.9 +/- 2.8, P < 0.05), as well as the median duration of mechanical ventilation (1 versus 5 days, P < 0.05) and stay in the intensive care unit (3 versus 9 days, P < 0.01) was also lower in group I. Monitoring and minimizing deltaPP by volume loading during high-risk surgery improves postoperative outcome and decreases the length of stay in hospital. NCT00479011.
    Full-text · Article · Sep 2007 · Critical care (London, England)
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    • "Ces patients à risque chirurgical élevé relèvent donc probablement d'un monitorage hémodynamique permettant ce type de stratégie de remplissage vasculaire, et donc, en première intention, du débit cardiaque. Chez les patients sous ventilation contrôlée et dont le rythme cardiaque est régulier, on peut faire l'hypothèse que le monitorage de la précharge-dépendance par un indice dérivé de la variation respiratoire de la pression artérielle invasive permet également la maximalisation du débit cardiaque sur le versant de la précharge [18] [19]. L'objectif de maintenir en peropératoire la variation de la pression artérielle pulsée, dont le monitorage automatisé commence à être disponible, à une valeur de l'ordre de 10 % devrait conduire à un remplissage vasculaire proche de celui reçu par les patients des groupes « optimisation » dans les études citées plus haut. "

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