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Pleth variability index or stroke volume optimization during open abdominal surgery: a randomized controlled trial
Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Södertälje Hosp, Sweden.
Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
2018 (English)In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 18, article id 115Article in journal (Refereed) Published
Abstract [en]

Background: The impact of Goal Directed Fluid Therapy (GDFT) based on the non-invasive Pleth Variability Index (PVI) on clinical outcome after abdominal surgery has only sparingly been explored. The purpose of this study was to compare the effect of intraoperative GDFT guided by PVI to a control group using esophageal Doppler on the incidence of complications and length of hospital stay after major abdominal surgery. We hypothesized that there would be no difference between the groups. Methods: This was a randomized controlled trial in a Swedish university hospital between November 2011 and January 2015; 150 patients scheduled for open abdominal surgery lasting 2 h or more were included. Exclusion criteria included hepatic resection or severe cardiac arrhythmia. The patients were randomized 1: 1 to either the intervention group or the control group. The intervention group received intraoperative GDFT by administering fluid boluses of 3 ml/kg tetrastarch aiming at a PVI value below 10%, while GDFT in the control group aimed for optimization of stroke volume as assessed with esophageal Doppler. Blinded observers assessed complications until postoperative day 30 using pre-defined definitions, as well as length of hospital stay. Results: One hundred and-fifty patients were randomized and 146 patients were available for the final data analysis. Median duration of surgery was 3 h. A total of 64 complications occurred in the PVI group (N = 74) and 70 in the Doppler group (N = 72) (p = 0.93). Median (IQR) length of stay was 8.0 (8.0) days in the PVI group and 8.0 (9.5) in the Doppler group (P = 0.57). Conclusions: No difference in clinical outcome, as defined by number of postoperative complications, and length of hospital stay, was found when goal directed fluid therapy was applied using PVI as an alternative to esophageal Doppler. PVI appears to be an acceptable alternative to esophageal Doppler for goal directed fluid therapy during major open abdominal surgery.

Place, publisher, year, edition, pages
BMC , 2018. Vol. 18, article id 115
Keywords [en]
Doppler ultrasonography; Fluid therapy; Laparotomy; Photoplethysmography; Stroke volume; Complications
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:liu:diva-150857DOI: 10.1186/s12871-018-0579-4ISI: 000442038200002PubMedID: 30121072OAI: oai:DiVA.org:liu-150857DiVA, id: diva2:1245906
Note

Funding Agencies|Department of Anesthesiology and Intensive Care, University Hospital Linkoping, Sweden; Region Ostergotland

Available from: 2018-09-06 Created: 2018-09-06 Last updated: 2019-04-30
In thesis
1. Goal-directed fluid therapy during major abdominal surgery
Open this publication in new window or tab >>Goal-directed fluid therapy during major abdominal surgery
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
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.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. p. 83
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1665
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:liu:diva-156263 (URN)10.3384/diss.diva-156263 (DOI)9789176851234 (ISBN)
Public defence
2019-05-10, Granitsalen, Universitetssjukhuset, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2019-04-10 Created: 2019-04-10 Last updated: 2019-04-10Bibliographically approved

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