- Journal club critique
- Open Access
Protocolized resuscitation with esophageal Doppler monitoring may improve outcome in post-cardiac surgery patients
© BioMed Central Ltd 2005
- Published: 28 April 2005
Evidence-Based Medicine Journal Club EBM Journal Club Section Eric B Milbrandt
McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M: Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ 2004, 329:258-261 .
Four hours of nurse-led, flow-monitored protocolized resuscitation reduces complications and shortens stay in intensive care and hospital for post-operative cardiac surgery subjects compared to usual care.
Randomized controlled trial.
Intensive care unit and cardiothoracic unit of a university teaching hospital between April 2000 and January 2003.
174 adults who had cardiac surgery with cardiopulmonary bypass. Subjects undergoing off-pump surgery, aged <18 years, or with relative contraindications to the use of the esophageal Doppler probe, such as esophageal disease, were excluded. Subjects were also excluded postoperatively if on admission to intensive care there was excessive bleeding, unstable arrhythmias, a need for intra-aortic balloon counterpulsation, or inotrope requirements ≥10 μg/kg/min of dopamine or dobutamine or ≥0.16 μg/kg/min of epinephrine or norepinephrine.
Subjects were allocated to conventional hemodynamic management (control group) or to an algorithm guided by esophageal Doppler flowmetry (protocol group). An esophageal Doppler probe was inserted within 10 minutes of arrival in the intensive care unit in both groups. In the protocol group, the bedside nurse followed an algorithm that instructed repeated 200 ml colloid boluses until the stroke volume index no longer increased by >10% and was ≥35 ml/m2. Thereafter, the algorithm provided additional instructions for vasoactive agents based on blood pressure and stroke volume index (refer to figure 1 in original article). The algorithm was run until 4 hours post-probe insertion or until extubation if <4 h. In the control group, probe readings were obtained by a study nurse on insertion and at four hours or at extubation if <4 h, but the clinical team was blinded to these readings. The control group received standard postoperative care, using markers of tissue perfusion such as urine output and arterial base deficit, and monitoring cardiac output if clinically indicated.
The primary outcomes were length of stay in intensive care and hospital. The secondary outcome was postoperative complications.
There were 89 subjects in the protocol group and 85 in the control group with both groups well matched for age, sex, weight, Parsonnet cardiac risk score, APACHE II score, and type of surgery. After four hours, protocol subjects had received a greater volume of colloid (1667 ml vs. 1042 ml, P < 0.001) than control subjects, but the volume of crystalloids did not differ (353 ml vs. 328 ml, P = 0.09). Protocol subjects saw greater increases in stroke volume and cardiac output, but no difference in base excess. Median duration of hospital stay was significantly lower in the protocol group than the control group (7 days vs. 9 days, P = 0.02), though ICU length of stay did not differ. There was a trend toward fewer postoperative complications in the protocol group (19.1% vs. 30.6%, P = 0.08).
A nurse-delivered protocol to optimize circulatory status in the early postoperative period after cardiac surgery may significantly shorten hospital stay.
Until more information is available, we cannot recommend widespread adoption of EDM outside the clinical research arena. Nevertheless, the results strongly merit the conduct of a confirmatory trial, along with evaluation of the impact of this intervention on other endpoints. Furthermore, protocolized resuscitation with EDM may have benefits in other conditions where there is significant risk of under-resuscitation, such as other postoperative groups and subjects with sepsis, burns, or trauma.
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