title: Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia.
abstract: BACKGROUND
  Total hip replacement is one of the most commonly performed major orthopaedic operations. Goal-directed therapy (GDT) using haemodynamic monitoring has previously demonstrated outcome benefits in high-risk surgical patients under general anaesthesia. GDT has never been formally assessed during regional anaesthesia.
  
  
  METHODS
  Patients undergoing total hip replacement while under regional anaesthesia were randomised to either the control group (CTRL) or the protocol group (GDT). Patients in the GDT group, in addition to standard monitoring, were connected to the FloTrac sensor/Vigileo monitor haemodynamic monitoring system, and a GDT protocol was used to maximise the stroke volume and target the oxygen delivery index to > 600 mL/minute/m2.
  
  
  RESULTS
  Patients randomised to the GDT group were given a greater volume of intravenous fluids during the intraoperative period (means ± standard deviation (SD): 6,032 ± 1,388 mL vs. 2,635 ± 346 mL; P < 0.0001), and more of the GDT patients received dobutamine (0 of 20 CTRL patients vs. 11 of 20 GDT patients; P < 0.0003). The GDT patients also received more blood transfused during the intraoperative period (means ± SD: 595 ± 316 mL vs. 0 ± 0 mL; P < 0.0001), although the CTRL group received greater volumes of blood replacement postoperatively (CTRL patients 658 ± 68 mL vs. GDT patients 198 ± 292 mL; P < 0.001). Overall blood consumption (intraoperatively and postoperatively) was not different between the two groups. There were an increased number of complications in the CTRL group (20 of 20 CTRL patients (100%) vs. 16 of 20 GDT patients (80%); P = 0.05). These outcomes were predominantly due to a difference in minor complications (20 of 20 CTRL patients (100%) vs. 15 of 20 GDT patients (75%); P = 0.047).
  
  
  CONCLUSIONS
  GDT applied during regional anaesthesia in patients undergoing elective total hip replacement changes intraoperative fluid management and may improve patient outcomes by decreasing postoperative complications. Larger trials are required to confirm our findings.
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, Dipartimento di Scienze Mediche, Sperimentalie Cliniche, University of Udine, Piazzale Santa Maria della Misericordia, Udine, Italy. m.cecconi@nhs.net
authors.forename: Maurizio
authors.initials: M
authors.lastname: Cecconi
authors.forename: Nicola
authors.initials: N
authors.lastname: Fasano
authors.forename: Nicola
authors.initials: N
authors.lastname: Langiano
authors.forename: Michele
authors.initials: M
authors.lastname: Divella
authors.forename: Maria G
authors.initials: MG
authors.lastname: Costa
authors.forename: Andrew
authors.initials: A
authors.lastname: Rhodes
authors.forename: Giorgio
authors.initials: G
authors.lastname: Della Rocca
mesh_terms: D000368:Aged; D000765:Anesthesia, Conduction; D019644:Arthroplasty, Replacement, Hip / Q000379:methods*; D017558:Elective Surgical Procedures; D005240:Feasibility Studies; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D011183:Postoperative Complications / Q000517:prevention & control; D016896:Treatment Outcome