Frederic Michard

The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials

IntroductionDynamic predictors of fluid responsiveness, namely systolic pressure variation, pulse pressure variation, stroke volume variation and pleth variability index have been shown to be useful to identify in advance patients who will respond to a fluid load by a significant increase in stroke volume and cardiac output. As a result, they are increasingly used to guide fluid therapy. Several randomized controlled trials have tested the ability of goal-directed fluid therapy (GDFT) based on dynamic parameters (GDFTdyn) to improve post-surgical outcome. These studies have yielded conflicting results. Therefore, we performed this meta-analysis to investigate whether the use of GDFTdyn is associated with a decrease in post-surgical morbidity.MethodsA systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through September 2013 was conducted. Data synthesis was obtained by using odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) by random-effects model.ResultsIn total, 14 studies met the inclusion criteria (961 participants). Post-operative morbidity was reduced by GDFTdyn (OR 0.51; CI 0.34 to 0.75; P <0.001). This effect was related to a significant reduction in infectious (OR 0.45; CI 0.27 to 0.74; P = 0.002), cardiovascular (OR 0.55; CI 0.36 to 0.82; P = 0.004) and abdominal (OR 0.56; CI 0.37 to 0.86; P = 0.008) complications. It was associated with a significant decrease in ICU length of stay (WMD -0.75 days; CI -1.37 to -0.12; P = 0.02).ConclusionsIn surgical patients, we found that GDFTdyn decreased post-surgical morbidity and ICU length of stay. Because of the heterogeneity of studies analyzed, large prospective clinical trials would be useful to confirm our findings.

Validation of a new transpulmonary thermodilution system to assess global end-diastolic volume and extravascular lung water

IntroductionA new system has been developed to assess global end-diastolic volume (GEDV), a volumetric marker of cardiac preload, and extravascular lung water (EVLW) from a transpulmonary thermodilution curve. Our goal was to compare this new system with the system currently in clinical use.MethodsEleven anesthetized and mechanically ventilated pigs were instrumented with a central venous catheter and a right (PulsioCath; Pulsion, Munich, Germany) and a left (VolumeView™; Edwards Lifesciences, Irvine, CA, USA) thermistor-tipped femoral arterial catheter. The right femoral catheter was used to measure GEDV and EVLW using the PiCCO2™ (Pulsion) method (GEDV1 and EVLW1, respectively). The left femoral catheter was used to measure the same parameters using the new VolumeView™ (Edwards Lifesciences) method (GEDV2 and EVLW2, respectively). Measurements were made during inotropic stimulation (dobutamine), during hypovolemia (bleeding), during hypervolemia (fluid overload), and after inducing acute lung injury (intravenous oleic acid).ResultsOne hundred and thirty-seven paired measurements were analyzed. GEDV1 and GEDV2 ranged from 701 to 1,629 ml and from 774 to 1,645 ml, respectively. GEDV1 and GEDV2 were closely correlated (r2 = 0.79), with mean bias of -11 ± 80 ml and percentage error of 14%. EVLW1 and EVLW2 ranged from 507 to 2,379 ml and from 495 to 2,222 ml, respectively. EVLW1 and EVLW2 were closely correlated (r2 = 0.97), with mean bias of -5 ± 72 ml and percentage error of 15%.ConclusionsIn animals, and over a very wide range of values, a good agreement was found between the new VolumeView™ system and the PiCCO™ system to assess GEDV and EVLW.

Tackling the economic burden of postsurgical complications: would perioperative goal-directed fluid therapy help?

IntroductionPay-for-performance programs and economic constraints call for solutions to improve the quality of health care without increasing costs. Many studies have shown decreased morbidity in major surgery when perioperative goal directed fluid therapy (GDFT) is used. We assessed the clinical and economic burden of postsurgical complications in the University HealthSystem Consortium (UHC) in order to predict potential savings with GDFT.MethodsData from adults who had a major surgical procedure in 2011 were screened in the UHC database. Thirteen post-surgical complications were tabulated. In-hospital mortality, hospital length of stay and costs from patients with and without complications were compared. The risk ratios reported by the most recent meta-analysis were used to estimate the potential reduction in post-surgical morbidity with GDFT. Potential cost-savings were calculated from the actual and anticipated morbidity rates.ResultsA total of 75,140 patients met the search criteria, and 8,421 patients developed one or more post-surgical complications (morbidity rate 11.2%). In patients with and without complications, in-hospital mortality was 12.4% and 1.4% (P <0.001), mean hospital length of stay was 20.5 ± 20.1 days and 8.1 ± 7.1 days (P <0.001) and mean direct costs were

Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome

47,284 ± 49,170 and

Using pulse pressure variation or stroke volume variation to diagnose right ventricular failure

17,408 ± 15,612 (P <0.001), respectively. With GDFT, morbidity rate was projected to decrease to 8.0 - 9.3%, yielding gross costs savings of

The burden of high-risk surgery and the potential benefit of goal-directed strategies

43 M -

Perioperative hemodynamic therapy: quality improvement programs should help to resolve our uncertainty

73 M for the study population or

Apparatus and computer program for determining a patient's volemic status represented by cardiopulmonary blood volume

569 -

Rational fluid management: dissecting facts from fiction

970 per patient.ConclusionPostsurgical complications have a dramatic impact (+172%) on costs. Potential costs savings resulting from GDFT are substantial. Perioperative GDFT may be recommended not only to improve quality of care but also to decrease costs.

Systems and methods for monitoring and displaying a patient's status

Previous meta-analyses suggest that perioperative goal-directed therapy (GDT) is useful to decrease postoperative morbidity. Most GDT studies analysed were done with pulmonary artery catheters, oesophageal Doppler and calibrated pulse contour methods. Uncalibrated pulse contour (uPC) techniques are an appealing alternative but their accuracy has been questioned. The effects of GDT on fluid management (volumes and volume variability) remain unclear. We performed a meta-analysis of randomized controlled trials investigating the effects of GDT with uPC methods on postoperative outcome. The primary endpoint was postoperative morbidity. Fluid volumes and fluid volume variability (standard deviation/mean) over the GDT period were also studied. Nineteen studies met the inclusion criteria (2159 patients). Postoperative morbidity was reduced with GDT (OR 0.46, 95% CI 0.30-0.70, P<0.001). The volume of colloids was higher [weighted mean difference (WMD) +345 ml, 95% CI 148-541 ml, P<0.001] and the volume of crystalloids was lower (WMD -429 ml, 95% CI -634 to -224 ml, P<0.01) in the GDT group than in the control group. However, the total volume of fluid (WMD -220 ml, 95% CI -590 to 150 ml, P=0.25) and the variability of fluid volume (34% vs 33%, P=0.98) were not affected by GDT. The use of GDT with uPC techniques was associated with a decrease in postoperative morbidity. It was not associated with an increase in total fluid volume nor with a decrease in fluid volume variability.