Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review

Author(s):Show less -

Osawa, Eduardo A. ^{[1, 2]} ; Rhodes, Andrew ^{[3, 4]} ; Landoni, Giovanni ^{[5, 6]} ; Galas, Filomena R. B. G. ^{[1, 2]} ; Fukushima, Julia T. ^{[1, 2]} ; Park, Clarice H. L. ^{[1, 2]} ; Almeida, Juliano P. ^{[1, 2]} ; Nakamura, Rosana E. ^{[1, 2]} ; Strabelli, Tania M. V. ^{[1, 2]} ; Pileggi, Brunna ^{[1, 2]} ; Leme, Alcino C. ^{[1, 2]} ; Fominskiy, Evgeny ^{[5, 6]} ; Sakr, Yasser ^[7] ; Lima, Marta ^{[1, 2]} ; Franco, Rafael A. ^{[1, 2]} ; Chan, Raquel P. C. ^{[1, 2]} ; Piccioni, Marilde A. ^{[1, 2]} ; Mendes, Priscilla ^{[1, 2]} ; Menezes, Suellen R. ^{[1, 2]} ; Bruno, Tatiana ^{[1, 2]} ; Gaiotto, Fabio A. ^[8] ; Lisboa, Luiz A. ^[8] ; Dallan, Luiz A. O. ^[8] ; Hueb, Alexandre C. ^[8] ; Pomerantzeff, Pablo M. ^[8] ; Kalil Filho, Roberto ^[8] ; Jatene, Fabio B. ^[8] ; Costa Auler Junior, Jose Otavio ^{[1, 2]} ; Hajjar, Ludhmila A. ^{[1, 2]}

Affiliation

^[1] Univ Sao Paulo, Hosp Clin, Fac Med, Surg Intens Care Unit, Sao Paulo - Brazil

^[2] Univ Sao Paulo, Hosp Clin, Fac Med, Heart Inst InCor, Dept Anesthesiol, Sao Paulo - Brazil

^[3] St Georges Healthcare NHS Trust, Dept Intens Care Med, London - England

^[4] St Georges Univ London, London - England

^[5] IRCCS San Raffaele Sci Inst, Dept Anesthesia & Intens Care, Milan - Italy

^[6] Vita Salute San Raffaele Sci Inst, Milan - Italy

^[7] Univ Jena, Friedrich Schiller Univ Hosp, Dept Anesthesiol & Intens Care, Jena - Germany

^[8] Univ Sao Paulo, Hosp Clin, Fac Med, Heart Inst InCor, Dept Cardiopneumol, Sao Paulo - Brazil

• Document type: Review article
• Source: Critical Care Medicine; v. 44, n. 4, p. 724-733, APR 2016.
• Web of Science Citations: 44

Abstract

Objectives: To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. Design: A prospective randomized controlled trial and an updated metaanalysis of randomized trials published from inception up to May 1, 2015. Setting: Surgical ICU within a tertiary referral university-affiliated teaching hospital. Patients: One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair. Interventions: 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(2) was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU. Measurements and Main 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. (AU)

• FAPESP's process: 11/11987-5 - Randomized study on the evaluation of goal directed therapy in high risk cardiac surgery
• Grantee: Ludhmila Abrahão Hajjar
• Support Opportunities: Regular Research Grants