The effect of adding goal-directed hemodynamic management for elective patients in an established enhanced recovery program for colorectal surgery: results of quasi-experimental pragmatic trial.

Autor: McEvoy MD; Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA. matthew.d.mcevoy@vumc.org., Wanderer JP; Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA., Shi Y; Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA., Ramanujan KS; Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA., Geiger TM; Department of Surgery, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA., Shotwell MS; Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA., Shaw AD; Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, Alberta, Canada., Hawkins AT; Department of Surgery, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA., Martin BJ; Department of Quality, Safety & Risk Prevention, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA., Mythen MG; University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, UK., Sandberg WS; Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN, 37232, USA.
Jazyk: angličtina
Zdroj: Perioperative medicine (London, England) [Perioper Med (Lond)] 2020 Nov 23; Vol. 9 (1), pp. 35. Date of Electronic Publication: 2020 Nov 23.
DOI: 10.1186/s13741-020-00163-3
Abstrakt: Background: Recent literature has demonstrated that hemodynamic instability in the intraoperative period places patients at risk of poor outcomes. Furthermore, recent studies have reported that stroke volume optimization and protocolized hemodynamic management may improve perioperative outcomes, especially surgical site infection (SSI), in certain high-risk populations. However, the optimal strategy for intraoperative management of all elective patients within an enhanced recovery program remains to be elucidated.
Methods: We performed a pre-post quasi-experimental study to assess the effect of adding goal-directed hemodynamic therapy to an enhanced recovery program (ERP) for colorectal surgery on SSI and other outcomes. Three groups were compared: "Pre-ERP," defined as historical control (before enhanced recovery program); "ERP," defined as enhanced recovery program using zero fluid balance; and "ERP+GDHT," defined as enhanced recovery program plus goal-directed hemodynamic therapy. Outcomes were obtained through our National Surgical Quality Improvement Program participation.
Results: A total of 623 patients were included in the final analysis (Pre-ERP = 246, ERP = 140, and ERP + GDHT = 237). Demographics and baseline clinical characteristics were balanced between groups. We did not observe statistically significant differences in SSI or composite complication rates in unadjusted or adjusted analysis. There was no evidence of association between study group and 30-day readmission. American Society of Anesthesiologists status ≥ 3 and open surgical approach were significantly associated with increased risk of SSI, composite complication, and 30-day readmission (p < 0.05 for all) in all groups.
Conclusions: There was no evidence that addition of goal-directed hemodynamic therapy for all patients in an enhanced recovery program for colorectal surgery affects the risk of SSI, composite complications, or 30-day readmission. Further research is needed to investigate whether there is benefit of goal-directed hemodynamic therapy for select high-risk populations.
Trial Registration: NCT03189550. Registered 16 June 2017-Retrospectively registered, https://www.clinicaltrials.gov/ct2/results?cond=&term=NCT03189550&cntry=&state=&city=&dist=.
Databáze: MEDLINE
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