title: Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass.
abstract: BACKGROUND
  There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management.
  
  
  METHODS
  Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2 ), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac™ , PreSep™ , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study.
  
  
  RESULTS
  Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study.
  
  
  CONCLUSIONS
  The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of - 0.331, -0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.
authors.affiliation: Department of Cardiac Anaesthesia, Cardio Thoracic Centre, AIIMS, New Delhi, India.
authors.forename: Poonam Malhotra
authors.initials: PM
authors.lastname: Kapoor
authors.affiliation: Department of Cardiac Anaesthesia, Cardio Thoracic Centre, AIIMS, New Delhi, India.
authors.forename: Rohan
authors.initials: R
authors.lastname: Magoon
authors.affiliation: Department of Cardiac Anaesthesiology, Salalah Heart Center, Salalah, Sultanate of Oman.
authors.forename: Rajinder Singh
authors.initials: RS
authors.lastname: Rawat
authors.affiliation: Department of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India.
authors.forename: Yatin
authors.initials: Y
authors.lastname: Mehta
authors.affiliation: Department of Cardiac Anaesthesia, Naval Base Hospital, Mumbai, Maharashtra, India.
authors.forename: Sameer
authors.initials: S
authors.lastname: Taneja
authors.affiliation: Department of Statistics, Lady Shri Ram College, University of Delhi, New Delhi, India.
authors.forename: R
authors.initials: R
authors.lastname: Ravi
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, AIIMS, New Delhi, India.
authors.forename: Milind P
authors.initials: MP
authors.lastname: Hote
mesh_terms: D002302:Cardiac Output / Q000502:physiology; D047549:Coronary Artery Bypass, Off-Pump / Q000379:methods*; D005260:Female; D006040:Goals; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control*; D011446:Prospective Studies; D012306:Risk; D013318:Stroke Volume / Q000502:physiology; D016896:Treatment Outcome; D014655:Vascular Resistance / Q000502:physiology