title: Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study.
abstract: Perioperative hemodynamic optimisation improves postoperative outcome for patients undergoing high-risk surgery (HRS). In this prospective randomized multicentre study we studied the effects of an individualized, goal-directed fluid management based on continuous stroke volume variation (SVV) and stroke volume (SV) monitoring on postoperative outcomes. 64 patients undergoing HRS were randomized either to a control group (CON, n = 32) or a goal-directed group (GDT, n = 32). In GDT, SVV and SV were continuously monitored (FloTrac/Vigileo) and patients were brought to and maintained on the plateau of the Frank-Starling curve (SVV <10 % and SV increase <10 % in response to fluid loading). Organ dysfunction was assessed using the SOFA score and resource utilization using the TISS score. Patients were followed up to 28 days for postoperative complications. Main outcome measures were the number of complications (infectious, cardiac, respiratory, renal, hematologic and abdominal post-operative complications), maximum SOFA score and cumulative TISS score during ICU stay, duration of mechanical ventilation, length of ICU stay, and time until fit for discharge. 12 patients had to be excluded from final analysis (6 in each group). During surgery, GDT received more colloids than CON (1,589 vs. 927 ml, P < 0.05) and SVV decreased in GDT (from 9.0 to 8.0 %, P < 0.05) but not in CON. The number of postoperative wound infections was lower in GDT (0 vs. 7, P < 0.01). Although not statistically significant, the proportion of patients with at least one complication (46 vs. 62 %), the number of postoperative complications per patient (0.65 vs. 1.40), the maximum sofa score (5.9 vs. 7.2), and the cumulative TISS score (69 vs. 83) tended to be lower. This multicentre study shows that fluid management based on a SVV and SV optimisation protocol is feasible and decreases postoperative wound infections. Our findings also suggest that a goal-directed strategy might decrease postoperative organ dysfunction.
authors.affiliation: Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands. t.w.l.scheeren@umcg.nl
authors.forename: Thomas W L
authors.initials: TW
authors.lastname: Scheeren
authors.forename: Christoph
authors.initials: C
authors.lastname: Wiesenack
authors.forename: Herwig
authors.initials: H
authors.lastname: Gerlach
authors.forename: Gernot
authors.initials: G
authors.lastname: Marx
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D005260:Female; D005440:Fluid Therapy / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D020896:Hypovolemia / Q000517:prevention & control; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000517:prevention & control; D011446:Prospective Studies; D012307:Risk Factors; D013318:Stroke Volume / Q000502:physiology*
references.citation: N Engl J Med. 2011 Jun 30;364(26):2483-95
references.pmid: 21615299
references.citation: N Engl J Med. 1995 Oct 19;333(16):1025-32
references.pmid: 7675044
references.citation: N Engl J Med. 2011 Jun 2;364(22):2128-37
references.pmid: 21631325
references.citation: Anesth Analg. 2011 Jun;112(6):1392-402
references.pmid: 20966436
references.citation: Crit Care Med. 2006 Feb;34(2):344-53
references.pmid: 16424713
references.citation: Crit Care Med. 1996 Jan;24(1):64-73
references.pmid: 8565541
references.citation: Br J Anaesth. 2006 Jul;97(1):4-11
references.pmid: 16751640
references.citation: Crit Care. 2008;12(3):R74
references.pmid: 18533029
references.citation: Intensive Care Med. 2005 Apr;31(4):517-23
references.pmid: 15754196
references.citation: Anesthesiology. 2002 Oct;97(4):820-6
references.pmid: 12357146
references.citation: Br J Anaesth. 2005 Jul;95(1):33-42
references.pmid: 15486006
references.citation: Intensive Care Med. 1997 Jan;23(1):85-90
references.pmid: 9037645
references.citation: Br J Anaesth. 2004 Jul;93(1):121-8
references.pmid: 15121729
references.citation: Ann Surg. 2005 Sep;242(3):326-41; discussion 341-3
references.pmid: 16135919
references.citation: Br J Anaesth. 2002 Oct;89(4):622-32
references.pmid: 12393365
references.citation: N Engl J Med. 2001 Nov 8;345(19):1368-77
references.pmid: 11794169
references.citation: Am J Med. 2005 Oct;118(10):1134-41
references.pmid: 16194645
references.citation: Crit Care. 2011 Jun 15;15(3):R148
references.pmid: 21676229
references.citation: Crit Care. 2006;10(3):R81
references.pmid: 16749940
references.citation: Crit Care. 2005;9(6):642-4
references.pmid: 16356256
references.citation: Crit Care Med. 2009 Sep;37(9):2642-7
references.pmid: 19602972
references.citation: Crit Care. 2011 Jun 24;15(3):R154
references.pmid: 21702945
references.citation: Crit Care Med. 1993 Jul;21(7):977-90
references.pmid: 8319478
references.citation: Br J Surg. 2006 Sep;93(9):1069-76
references.pmid: 16888706
references.citation: Crit Care. 2009;13(5):231
references.pmid: 19863764
references.citation: Anesth Analg. 2011 Apr;112(4):877-83
references.pmid: 20530615
references.citation: Crit Care. 2010;14(3):R118
references.pmid: 20553586
references.citation: Chest. 2007 Dec;132(6):1817-24
references.pmid: 17925428
references.citation: Acta Anaesthesiol Scand. 2007 Mar;51(3):331-40
references.pmid: 17390421
references.citation: BMJ. 2004 Jul 31;329(7460):258
references.pmid: 15242867
references.citation: Intensive Care Med. 2011 Sep;37(9):1466-72
references.pmid: 21732168
references.citation: N Engl J Med. 2003 Jan 2;348(1):5-14
references.pmid: 12510037
references.citation: Intensive Care Med. 1998 Oct;24(10):1009-17
references.pmid: 9840233
references.citation: Anaesthesia. 2008 Jul;63(7):695-700
references.pmid: 18489613
references.citation: Surgery. 1997 Sep;122(3):584-92
references.pmid: 9308617
references.citation: Intensive Care Med. 2002 May;28(5):599-608
references.pmid: 12029409
references.citation: Anesthesiology. 2010 May;112(5):1105-15
references.pmid: 20418691
references.citation: Crit Care Med. 2009 Jun;37(6):2079-90
references.pmid: 19384211
references.citation: Crit Care. 2000;4 Suppl 2:S3-7
references.pmid: 11255592
references.citation: Br J Anaesth. 2009 Nov;103(5):637-46
references.pmid: 19837807
references.citation: Anesth Analg. 2005 Apr;100(4):1093-1106
references.pmid: 15781528
references.citation: Br J Anaesth. 2011 Mar;106(3):289-91
references.pmid: 21317226
references.citation: Ann Surg. 2010 Mar;251(3):535-41
references.pmid: 20134313
references.citation: Crit Care Med. 1996 Mar;24(3):517-24
references.pmid: 8625644
references.citation: Intensive Care Med. 2010 Aug;36(8):1327-32
references.pmid: 20376431
references.citation: Anesth Analg. 1999 Aug;89(2):514-9
references.pmid: 10439777
references.citation: Emerg Med J. 2010 Jun;27(6):470-2
references.pmid: 20360482