title: Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review.
abstract: OBJECTIVE
  To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery.
  
  
  METHODS
  A prospective randomized controlled trial and an updated metaanalysis of randomized trials published from inception up to May 1, 2015.
  
  
  METHODS
  Surgical ICU within a tertiary referral university-affiliated teaching hospital.
  
  
  METHODS
  One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair.
  
  
  METHODS
  Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64). In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU.
  
  
  RESULTS
  The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed therapy group received a greater median (interquartile range) volume of IV fluids than the usual care group (1,000 [625-1,500] vs 500 [500-1,000] mL; p < 0.001], with no differences in the administration of either inotropes or RBC transfusions. The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037). The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome (6.5% vs 26.6%; p = 0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3-4] vs 5 [4-7] d; p < 0.001) and hospital length of stay (9 [8-16] vs 12 [9-22] d; p = 0.049) in the goal-directed therapy compared with the usual care group. There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410 [11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26-0.63]; p < 0.0001) and decreased the hospital length of stay (mean difference, -5.44 d; 95% CI, -9.28 to -1.60; p = 0.006) with no difference in postoperative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio, 0.61 (95% CI, 0.26-1.47), and p = 0.27.
  
  
  CONCLUSIONS
  Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.
authors.affiliation: 1Surgical Intensive Care Unit and Department of Anesthesiology, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. 2Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, London, United Kingdom. 3Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele Scientific Institute, Milan, Italy. 4Department of Anesthesiology and Intensive Care, Friedrich Schiller University Hospital, Jena University, Jena, Germany. 5Department of Cardiopneumology, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
authors.forename: Eduardo A
authors.initials: EA
authors.lastname: Osawa
authors.forename: Andrew
authors.initials: A
authors.lastname: Rhodes
authors.forename: Giovanni
authors.initials: G
authors.lastname: Landoni
authors.forename: Filomena R B G
authors.initials: FR
authors.lastname: Galas
authors.forename: Julia T
authors.initials: JT
authors.lastname: Fukushima
authors.forename: Clarice H L
authors.initials: CH
authors.lastname: Park
authors.forename: Juliano P
authors.initials: JP
authors.lastname: Almeida
authors.forename: Rosana E
authors.initials: RE
authors.lastname: Nakamura
authors.forename: Tania M V
authors.initials: TM
authors.lastname: Strabelli
authors.forename: Brunna
authors.initials: B
authors.lastname: Pileggi
authors.forename: Alcino C
authors.initials: AC
authors.lastname: Leme
authors.forename: Evgeny
authors.initials: E
authors.lastname: Fominskiy
authors.forename: Yasser
authors.initials: Y
authors.lastname: Sakr
authors.forename: Marta
authors.initials: M
authors.lastname: Lima
authors.forename: Rafael A
authors.initials: RA
authors.lastname: Franco
authors.forename: Raquel P C
authors.initials: RP
authors.lastname: Chan
authors.forename: Marilde A
authors.initials: MA
authors.lastname: Piccioni
authors.forename: Priscilla
authors.initials: P
authors.lastname: Mendes
authors.forename: Suéllen R
authors.initials: SR
authors.lastname: Menezes
authors.forename: Tatiana
authors.initials: T
authors.lastname: Bruno
authors.forename: Fabio A
authors.initials: FA
authors.lastname: Gaiotto
authors.forename: Luiz A
authors.initials: LA
authors.lastname: Lisboa
authors.forename: Luiz A O
authors.initials: LA
authors.lastname: Dallan
authors.forename: Alexandre C
authors.initials: AC
authors.lastname: Hueb
authors.forename: Pablo M
authors.initials: PM
authors.lastname: Pomerantzeff
authors.forename: Roberto
authors.initials: R
authors.lastname: Kalil Filho
authors.forename: Fabio B
authors.initials: FB
authors.lastname: Jatene
authors.forename: Jose Otavio Costa
authors.initials: JO
authors.lastname: Auler Junior
authors.forename: Ludhmila A
authors.initials: LA
authors.lastname: Hajjar
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058665:Adrenergic beta-1 Receptor Agonists / Q000627:therapeutic use; D002302:Cardiac Output; D006348:Cardiac Surgical Procedures / Q000379:methods / Q000401:mortality; D004280:Dobutamine / Q000627:therapeutic use; D005440:Fluid Therapy / Q000379:methods; D006439:Hemodynamics / Q000502:physiology; D007362:Intensive Care Units; D007902:Length of Stay; D015201:Meta-Analysis as Topic; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control; D016896:Treatment Outcome
chemical_list: D058665:Adrenergic beta-1 Receptor Agonists; D004280:Dobutamine