Nishkantha Arulkumaran

Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups

Patients with limited cardiac reserve are less likely to survive and develop more complications following major surgery. By augmenting oxygen delivery index (DO2I) with a combination of intravenous fluids and inotropes (goal directed therapy (GDT)), postoperative mortality and morbidity of high-risk patients may be reduced. However, although most studies suggest that GDT may improve outcome in high-risk surgical patients, it is still not widely practiced. We set out to test the hypothesis that GDT results in greatest benefit in terms of mortality and morbidity in patients with the highest risk of mortality and have undertaken a systematic review of the current literature to see if this is correct. We performed a systematic search of Medline, Embase and CENTRAL databases for randomized controlled trials (RCTs) and reviews of GDT in surgical patients. To minimize heterogeneity we excluded studies involving cardiac, trauma, and paediatric surgery. Extremely high risk, high risk and intermediate risks of mortality were defined as >20%, 5 to 20% and <5% mortality rates in the control arms of the trials, respectively. Meta analyses were performed and Forest plots drawn using RevMan software. Data are presented as odd ratios (OR; 95% confidence intervals (CI), and P-values). A total of 32 RCTs including 2,808 patients were reviewed. All studies reported mortality. Five studies (including 300 patients) were excluded from assessment of complication rates as the number of patients with complications was not reported. The mortality benefit of GDT was confined to the extremely high-risk group (OR = 0.20, 95% CI 0.09 to 0.41; P < 0.0001). Complication rates were reduced in all subgroups (OR = 0.45, 95% CI 0.34 to 0.60; P < 0.00001). The morbidity benefit was greatest amongst patients in the extremely high-risk subgroup (OR = 0.27, 95% CI 0.15 to 0.51; P < 0.0001), followed by the intermediate risk subgroup (OR = 0.43, 95% CI 0.27 to 0.67; P = 0.0002), and the high-risk subgroup (OR 0.56, 95% CI 0.36 to 0.89; P = 0.01). Despite heterogeneity in trial quality and design, we found GDT to be beneficial in all high-risk patients undergoing major surgery. The mortality benefit of GDT was confined to the subgroup of patients at extremely high risk of death. The reduction of complication rates was seen across all subgroups of GDT patients.

Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis

Patients with limited cardiopulmonary reserve are at risk of mortality and morbidity after major surgery. Augmentation of oxygen delivery index (DO2I) with i.v. fluids and inotropes (goal-directed therapy, GDT) has been shown to reduce postoperative mortality and morbidity in high-risk patients. Concerns regarding cardiac complications associated with fluid challenges and inotropes may prevent clinicians from performing GDT in patients who need it most. We hypothesized that GDT is not associated with an increased risk of cardiac complications in high-risk, non-cardiac surgical patients. We performed a systematic search of Medline, Embase, and CENTRAL databases for randomized controlled trials (RCTs) of GDT in high-risk surgical patients. Studies including cardiac surgery, trauma, and paediatric surgery were excluded. We reviewed the rates of all cardiac complications, arrhythmias, myocardial ischaemia, and acute pulmonary oedema. Meta-analyses were performed using RevMan software. Data are presented as odds ratios (ORs), [95% confidence intervals (CIs)], and P-values. Twenty-two RCTs including 2129 patients reported cardiac complications. GDT was associated with a reduction in total cardiovascular (CVS) complications [OR=0.54, (0.38-0.76), P=0.0005] and arrhythmias [OR=0.54, (0.35-0.85), P=0.007]. GDT was not associated with an increase in acute pulmonary oedema [OR=0.69, (0.43-1.10), P=0.12] or myocardial ischaemia [OR=0.70, (0.38-1.28), P=0.25]. Subgroup analysis revealed the benefit is most pronounced in patients receiving fluid and inotrope therapy to achieve a supranormal DO2I, with the use of minimally invasive cardiac output monitors. Treatment of high-risk surgical patients GDT is not associated with an increased risk of cardiac complications; GDT with fluids and inotropes to optimize DO2I during early GDT reduces postoperative CVS complications.

End-of-life care in patients with end-stage renal disease

As the population ages, the number of patients with end-stage renal disease (ESRD) and associated comorbidities is increasing [1]. Survival from critical illness may be reduced but expectations of medical treatment remain high and increasingly complex treatment options are offered. Understanding the risks and benefits of such treatment and the quality of survival can be extremely difficult. Consequently, the need to provide advance care planning (ACP) and end-of-life care in this cohort of patients is imperative [2]. As clinicians, our focus should be on care and not just cure. We are obliged to establish the impact of chronic comorbidity on individual patients’ quality of life and their wishes when it comes to the end of life (EOL). Frequent contact with health care services presents an opportunity to establish, document and regularly review patients’ values and attitudes towards critical illness and EOL situations. Nephrologists are in a position to approach patients with ESRD about ACP, preferably long before critical care services are required. ACP has been proposed as a tool to establish a patient’s wishes concerning his own health care should he be unable to make his own decisions in the event of serious illness. ACP focuses more on goals for care and less on specific treatments [3]. Advance directives (AD) are legal documents that may include instructions about a patient’s future wishes regarding medical care. They may nominate a friend or family member as their representative, empowering them to make decisions on their behalf should they lack the capacity. This power however is limited to the decisions specified in the AD. The wider term ACP will be used which encompasses both the legal and less formal discussions that there may be. AD will be used if specifically indicated. All ACPs should ideally include whether cardiopulmonary resuscitation (CPR) would be wanted and what levels of critical care support would be acceptable to the patient for any given likely outcome. Patients can refuse treatment but cannot demand an intervention if deemed inappropriate or futile. The treating clinician has a responsibility to inform the patient of the different treatment options available but is responsible for ensuring the management is ultimately appropriate. This may include withdrawal of treatment in the event of critical illness. Patients may need help to identify, clarify and prioritize factors that influence their decision making about future medical conditions: explaining common end-of-life medical conditions and life-sustaining treatment; helping patients express a coherent set of wishes. Patients should be encouraged to engage family and friends and to identify a spokesperson on their behalf should they be unable to speak for themselves. Including other medical teams and health providers is likely to greatly improve the chance of successful ACP. [4]. The process of ACP is patient specific and a different approach will be needed for different patients. However, the underlying principles remain the same. The responsible doctor needs to determine what is most important to the patient, what medical conditions they would want treated, what degree of functional impairment they would consider intolerable and who they would want as a spokesperson [4]. The survey by McAdoo et al. [5] provides important data on our current practise. It reflects the need for significant improvement in the quality of EOL care provided to patients with advanced kidney disease. Sixty-nine percent of the 138 deaths occurred during an in-patient admission; yet, only 28% of these patients had discussed EOL issues with their medical team in the year prior to death. The majority of in-patient deaths occurred either within the first 48 h or more than 1 month after admission. Continuation of treatment and ‘futile’ admissions to critical care may ultimately prolong death rather than preserve life. However, defining ‘futile’ is difficult. The EOL decision may mean the cessation of maintenance dialysis [6], although this was done in just 40% of patients. Management of consequent symptoms is complex and was achieved in only 52% of the patients. Multidisciplinary teamwork may improve this [7]. The palliative care team was involved in just 34% of cases. Palliation is often viewed as part of cancer-specific ACP and not considered applicable for other progressive diseases; however, there are many aspects common to end-of-life care for all patients and their families including management of physical symptoms (pain,

Hemodynamic optimization in severe trauma: a systematic review and meta-analysis.

Objective Severe trauma can be associated with significant hemorrhagic shock and impaired organ perfusion. We hypothesized that goal-directed therapy would confer morbidity and mortality benefits in major trauma. Methods The MedLine, Embase and Cochrane Controlled Clinical Trials Register databases were systematically searched for randomized, controlled trials of goal-directed therapy in severe trauma patients. Mortality was the primary outcome of this review. Secondary outcomes included complication rates, length of hospital and intensive care unit stay, and the volume of fluid and blood administered. Meta-analysis was performed using RevMan software, and the data presented are as odds ratios for dichotomous outcomes and as mean differences (MDs) and standard MDs for continuous outcomes. Results Four randomized, controlled trials including 419 patients were analyzed. Mortality risk was significantly reduced in goal-directed therapy-treated patients, compared to the control group (OR=0.56, 95%CI: 0.34-0.92). Intensive care (MD: 3.7 days 95%CI: 1.06-6.5) and hospital length of stay (MD: 3.5 days, 95%CI: 2.75-4.25) were significantly shorter in the protocol group patients. There were no differences in reported total fluid volume or blood transfusions administered. Heterogeneity in reporting among the studies prevented quantitative analysis of complications. Conclusion Following severe trauma, early goal-directed therapy was associated with lower mortality and shorter durations of intensive care unit and hospital stays. The findings of this analysis should be interpreted with caution due to the presence of significant heterogeneity and the small number of the randomized, controlled trials included.