title: Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study.
abstract: BACKGROUND
  Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention.
  
  
  METHODS
  This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database).
  
  
  RESULTS
  In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1-13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7-9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6-16) days to 7 (5-11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18% (95% confidence interval 9-27%). The incidence of NSQIP complications decreased from 39% to 25% (p = 0.04).
  
  
  CONCLUSIONS
  These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT02057653. Registered 17 December 2013.
authors.affiliation: Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA. mcanness@uci.edu.|Health Policy Research Institute, University of California, Irvine, CA, USA. mcanness@uci.edu.
authors.forename: Maxime
authors.initials: M
authors.lastname: Cannesson
authors.affiliation: Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA. dramsing@uci.edu.
authors.forename: Davinder
authors.initials: D
authors.lastname: Ramsingh
authors.affiliation: Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA. jrinehar@uci.edu.
authors.forename: Joseph
authors.initials: J
authors.lastname: Rinehart
authors.affiliation: Department of Surgery, University of California, Irvine, CA, USA. demirjia@uci.edu.
authors.forename: Aram
authors.initials: A
authors.lastname: Demirjian
authors.affiliation: Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA. vut@uci.edu.
authors.forename: Trung
authors.initials: T
authors.lastname: Vu
authors.affiliation: Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA. svakhari@uci.edu.
authors.forename: Shermeen
authors.initials: S
authors.lastname: Vakharia
authors.affiliation: Department of Surgery, University of California, Irvine, CA, USA. dkimagaw@uci.edu.
authors.forename: David
authors.initials: D
authors.lastname: Imagawa
authors.affiliation: Department of Statistics, University of California, Irvine, CA, USA. zhaoxia@ics.uci.edu.
authors.forename: Zhaoxia
authors.initials: Z
authors.lastname: Yu
authors.affiliation: Health Policy Research Institute, University of California, Irvine, CA, USA. sgreenfi@uci.edu.
authors.forename: Sheldon
authors.initials: S
authors.lastname: Greenfield
authors.affiliation: Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA. zkain@uci.edu.
authors.forename: Zeev
authors.initials: Z
authors.lastname: Kain
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000368:Aged; D002140:California / Q000453:epidemiology; D057186:Comparative Effectiveness Research; D000077324:Crystalloid Solutions; D017707:Erythrocyte Transfusion / Q000706:statistics & numerical data; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D007552:Isotonic Solutions / Q000008:administration & dosage*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D019990:Perioperative Care; D011183:Postoperative Complications / Q000453:epidemiology*
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions