Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review

Eduardo A. Osawa, Andrew Rhodes, Giovanni Landoni, Filomena R B G Galas, Julia T. Fukushima, Clarice H L Park, Juliano P. Almeida, Rosana E. Nakamura, Tania M V Strabelli, Brunna Pileggi, Alcino C. Leme, Evgeny Fominskiy, Yasser Sakr, Marta Lima, Rafael A. Franco, Raquel P C Chan, Marilde A. Piccioni, Priscilla Mendes, Suéllen R. Menezes, Tatiana BrunoFabio A. Gaiotto, Luiz A. Lisboa, Luiz A O Dallan, Alexandre C. Hueb, Pablo M. Pomerantzeff, Roberto Kalil Filho, Fabio B. Jatene, Jose Otavio Costa Auler Junior, Ludhmila A. Hajjar

Research output: Contribution to journalArticlepeer-review

Abstract

OBJECTIVES:: To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. DESIGN:: A prospective randomized controlled trial and an updated metaanalysis of randomized trials published from inception up to May 1, 2015. SETTING:: Surgical ICU within a tertiary referral university-affiliated teaching hospital. PATIENTS:: One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair. INTERVENTIONS:: Patients were randomized to a cardiac output–guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64). In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU. MEASUREMENTS AND MAIN RESULTS:: The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed therapy group received a greater median (interquartile range) volume of IV fluids than the usual care group (1,000 [625–1,500] vs 500 [500–1,000] mL; p <0.001], with no differences in the administration of either inotropes or RBC transfusions. The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037). The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome (6.5% vs 26.6%; p = 0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3–4] vs 5 [4–7] d; p <0.001) and hospital length of stay (9 [8–16] vs 12 [9–22] d; p = 0.049) in the goal-directed therapy compared with the usual care group. There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410 [11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26–0.63]; p <0.0001) and decreased the hospital length of stay (mean difference, –5.44 d; 95% CI, –9.28 to –1.60; p = 0.006) with no difference in postoperative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio, 0.61 (95% CI, 0.26–1.47), and p = 0.27. CONCLUSIONS:: Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.

Original languageEnglish
JournalCritical Care Medicine
DOIs
Publication statusAccepted/In press - Dec 7 2015

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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