The evaluation of intraoperative hemodynamic monitoring and a goaldirected fluid therapy optimization protocol in patients undergoing highrisk surgery to improve postoperative outcomes: a before-after trial.

Schoo, Y.M. (Yolanda) (2016) The evaluation of intraoperative hemodynamic monitoring and a goaldirected fluid therapy optimization protocol in patients undergoing highrisk surgery to improve postoperative outcomes: a before-after trial. thesis, Medicine.

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Abstract

Introduction. From the literature it appears that perioperative goal-directed fluid therapy (GDFT) improves postoperative outcomes in patients undergoing high-risk surgery (HRS). In February 2015, a GDFT protocol has been implemented in the Department of Anesthesiology of the University Medical Center Groningen (UMCG). The primary aim of this study was to examine whether an SVV- and SV-guided fluid optimization therapy in the perioperative care of HRS patients has a beneficial effect on postoperative outcomes in comparison with HRS patients undergoing the same procedure before the implementation of the protocol in this university center. Materials and Methods. In this before after trial, we studied the beneficial effects of the implemented GDFT-protocol in the UMCG using stroke volume variation (SVV) and stroke volume (SV) on postoperative complications (POC) and length of hospital stay (LOS) in HRS patients undergoing predefined major procedures. These included colorectal resection, open abdominal aortic aneurysm (AAA) repair, esophagus resection, hyperthermic intraperitoneal chemotherapy (HIPEC), pylorus preserving pancreaticoduodenectomie (PPPD), and femoral-popliteal (fem-pop) bypass surgery. Perioperative monitoring of SVV and SV using the EV1000/FloTrac hemodynamic monitoring system was used to guide intravenous fluid administration. Using the same surgical procedures, groups of HRS patients after implementation (n=107) of the GDFT protocol were compared to those before its implementation (n=176). Primary outcome measures were complications that occurred within 30 days after surgery, graded by the Expanded Accordion Classification Model, and LOS including readmission to the hospital within 30 days of discharge. Secondary outcome measures were the average costs per patient (CPP) of hospital stay in the intensive care unit (ICU) and nursing department (ND). Results. In HRS patients undergoing colorectal resection, open AAA repair and esophagus resection we found a decrease by 41%, 58% and 44%, respectively in the total number of POC per patient and the total average CPP (by 21%, 43% and 30% (p = 0.025), respectively) after implementation of the GDFT protocol. In patients undergoing a colorectal resection, LOS in the ND decreased significantly (from 18 [9 – 36] to 9 [7-16], p = 0.001) after protocol implementation. Also a significant decrease of LOS in the ICU in patients undergoing an esophagus resection was shown (from 1.9 [1.1 – 10.9] to 0.8 [0.7 – 0.9], p = 0.027). In contrast, in HRS patients undergoing a HIPEC and PPPD procedure the total number of POC per patient tended to increase by 26% and 12%, respectively. Also the total average CPP in these groups tended to increase by 5% and 40%, respectively. In HRS patients undergoing a fem-pop bypass procedure there was no difference in total number of POC per patient, however a significant increase of LOS (0 [0-0.6] to 0.5 [0 – 1], p=0.038) and average CPP (by 147%, p=0.021) in the ICU was seen. Conclusion. This study suggest that the implementation of a SVV- and SV-guided GDFT-protocol in the perioperative care of patients undergoing a colorectal resection, open AAA repair or esophagus resection had a beneficial effect on POC and average CPP. All investigated HRS groups showed a shorter LOS in the ICU or ND. Future studies should investigate why GDFT did not work in the other surgical procedures studied and which further procedures might benefit from GDFT.

Item Type:	Thesis (Thesis)
Supervisor name:	Faculty supervisor: and Scheeren, Prof. dr. T.W.L and Supervisor: and Meyer, Dr. P.
Faculty:	Medical Sciences
Date Deposited:	25 Jun 2020 11:02
Last Modified:	25 Jun 2020 11:02
URI:	https://umcg.studenttheses.ub.rug.nl/id/eprint/2178

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