Early goal directed therapy reduces morbidity and length of hospital stay following high-risk surgery

Introduction

Several studies have described the successful use of goal directed therapy to guide fluid and inotropic therapies in patients at high risk of postoperative complications. This has mainly been performed in either the pre-operative or intra-operative period. It is unclear whether this is effective solely in the postoperative period. The aim of this study was to evaluate the effect of an early goal directed therapy (EGDT) protocol that does not utilize the pulmonary artery catheter, when commenced immediately after general surgery in patients at high risk of complications.

Methods

A prospective, randomized controlled trial in high-risk surgical patients on a general ITU. Patients were randomized to conventional treatment or EGDT for 8 hours immediately following surgery. The goals for EGDT were to optimize volume status by maximizing stroke volume with fluid challenges and then to increase the oxygen delivery index (DO₂I) to 600 ml/min/m² with dopexamine if required. Control group patients received fluid guided by central venous pressure. Other therapeutic targets were the same for both groups. Stroke volume and DO₂I were measured in both groups using lithium indicator dilution and pulse contour analysis (LiDCOplus system). Postoperative complications were predefined and patients were followed up for 60 days. Data are presented as medians ± standard error or percentage.

Results

One hundred and twenty-two patients (control = 60, EGDT = 62) were randomized. There were no significant differences between the two groups at baseline. Most patients underwent gastrointestinal, vascular or urological surgery. Patients in the EGDT group subsequently achieved higher DO₂I than controls (P < 0.0001) and more EGDT patients achieved a DO₂I of 600 ml/min/m² (82% vs 42%, P < 0.0001). The DO₂I target was achieved as a result of increases in both stroke volume (P = 0.02) and heart rate (P < 0.0001). The EGDT group received more intravenous fluid (3015 ± 146 ml vs 2280 ± 164 ml, P = 0.0006) and more EGDT patients received dopexamine (89% vs 2%, P < 0.0001). The EGDT group developed fewer complications (0.7 vs 1.5 per patient, P = 0.002) and had a shorter hospital stay (11 ± 3 days vs 14 ± 5 days, P = 0.002). Infectious complications in the EGDT group were half that of the control group (24 episodes vs 49 episodes, P = 0.0004). The EGDT group utilized 640 less hospital bed-days. There was no difference in 28-day (9.7% vs 10%) or 60-day (11.3% vs 11.7%) mortality.

Discussion

EGDT immediately following general surgery in high-risk patients reduces complications and length of hospital stay. This approach is both practical and effective.