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Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial
Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för läkemedelsforskning. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Sinnescentrum, Anestesi- och intensivvårdskliniken US.
Linköpings universitet, Institutionen för klinisk och experimentell medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken US.
Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för läkemedelsforskning. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Sinnescentrum, Anestesi- och intensivvårdskliniken US.
2019 (Engelska)Ingår i: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 36, nr 2, s. 153-161Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Goal-directed therapy (GDT) is expected to be of highest benefit in high-risk surgery. Therefore, GDT is recommended during oesophageal resection, which carries a high risk of postoperative complications.

OBJECTIVES: The aim of this study was to confirm the hypothesis that GDT during oesophageal resection improves outcome compared with standard care.

DESIGN: A randomised controlled study.

SETTING: Two Swedish university hospitals, between October 2011 and October 2015.

PATIENTS: Sixty-four patients scheduled for elective transthoracic oesophageal resection were randomised. Exclusion criteria included colonic interposition and significant aortic or mitral valve insufficiency.

INTERVENTION: A three-step GDT protocol included stroke volume optimisation using colloid boluses as assessed by pulse-contour analysis, dobutamine infusion if cardiac index was below 2.5 l min m and norepinephrine infusion if mean arterial blood pressure was below 65 mmHg.

MAIN OUTCOME MEASURE: The incidence of complications per patient at 5 and 30 days postoperatively as assessed using a predefined list.

RESULTS: Fifty-nine patients were available for analysis. Patients in the intervention group received more colloid fluid (2190 ± 875 vs. 1596 ± 759 ml, P < 0.01) and dobutamine more frequently (27/30 vs. 9/29, P < 0.01). The median [interquartile range, IQR] incidence of complications per patient 5 days after surgery was 2 [0 to 3] in the intervention group and 1 [0 to 2] in the control group (P = 0.10), and after 30 days 4 [2 to 6] in the intervention group and 2 [1 to 4] in the control group (P = 0.10).

CONCLUSION: Goal-directed therapy during oesophageal resection did not result in a reduction of the incidence of postoperative complications.

TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01416077.

Ort, förlag, år, upplaga, sidor
Lippincott Williams & Wilkins, 2019. Vol. 36, nr 2, s. 153-161
Nationell ämneskategori
Anestesi och intensivvård
Identifikatorer
URN: urn:nbn:se:liu:diva-156264DOI: 10.1097/EJA.0000000000000908ISI: 000462763800010PubMedID: 30431499Scopus ID: 2-s2.0-85059795456OAI: oai:DiVA.org:liu-156264DiVA, id: diva2:1303622
Anmärkning

Funding agencies: Linkoping Medical Society

Tillgänglig från: 2019-04-10 Skapad: 2019-04-10 Senast uppdaterad: 2019-04-18Bibliografiskt granskad
Ingår i avhandling
1. Goal-directed fluid therapy during major abdominal surgery
Öppna denna publikation i ny flik eller fönster >>Goal-directed fluid therapy during major abdominal surgery
2019 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Background: Both hypo- and hypervolemia increase the risk for postoperative complications after major abdominal surgery. Fluid needs vary amongst patients depending on differences in preoperative dehydration, intraoperative physiology and surgical characteristics. Goal-directed fluid therapy (GDFT) aims to target the right amount of fluid administration in each patient by evaluating the effect of fluid boluses on haemodynamic parameters such as stroke volume. It has been shown to reduce postoperative morbidity and is generally recommended for high-risk surgery. The overall aim of this thesis was to evaluate whether more simple devices for GDFT result in clinical benefit, thus facilitating the application of GDFT in more patients.

Aim: To compare performance and clinical benefit of pleth variability index (PVI), a noninvasive, easy-to-use device for GDFT, with the reference method of oesophageal Doppler; to evaluate methods for measuring preoperative dehydration and its effect on fluid handling by the body; and to confirm the expected clinical benefits of GDFT in patients undergoing oesophageal resection, a high risk procedure.

Methods: In Studies I-III 150 patients scheduled for open abdominal surgery of at least 2 hrs were randomised to GDFT with either PVI or oesophageal Doppler. In the first half of the cohort, both monitors were connected to compare intraoperative performance. In 30 patients preoperative dehydration was analysed. In study IV 64 patients undergoing oesophageal resection were randomised to GDFT using pulse contour analysis or standard treatment.

Results: The concordance between PVI and oesophageal Doppler for indicating the need for and effect of a fluid bolus was low, and both had only limited capacity to predict the effect of a fluid bolus. Both methods resulted in comparable amounts of fluid being administered and similar clinical outcome. Preoperative dehydration was limited but did impact on fluid handling. Patients receiving GDFT during oesophageal resection received more fluid and more dobutamine compared to controls, but this did not result in any clinical benefit.

Conclusions: There are methodological issues as well as uncertainties about the clinical benefit of GDFT. We cannot recommend a strict application of any GDFT strategy, but suggest that its components should be incorporated in a more encompassing assessment of a patient’s fluid needs. The measurement, impact and treatment of preoperative dehydration need to be further clarified.

Ort, förlag, år, upplaga, sidor
Linköping: Linköping University Electronic Press, 2019. s. 83
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1665
Nationell ämneskategori
Anestesi och intensivvård
Identifikatorer
urn:nbn:se:liu:diva-156263 (URN)10.3384/diss.diva-156263 (DOI)9789176851234 (ISBN)
Disputation
2019-05-10, Granitsalen, Universitetssjukhuset, Linköping, 13:00 (Engelska)
Opponent
Handledare
Tillgänglig från: 2019-04-10 Skapad: 2019-04-10 Senast uppdaterad: 2019-04-10Bibliografiskt granskad

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Bahlmann, HansHalldestam, IngvarNilsson, Lena
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Avdelningen för läkemedelsforskningMedicinska fakultetenAnestesi- och intensivvårdskliniken USInstitutionen för klinisk och experimentell medicinKirurgiska kliniken US
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