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 journalReview article

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/m2 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
Pages (from-to)724 - 733
Number of pages10
JournalCritical Care Medicine
Volume44
Issue number4
DOIs
Publication statusPublished - Apr 1 2016

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Keywords

  • cardiac surgery
  • goal-directed
  • hemodynamic
  • resuscitation

ASJC Scopus subject areas

  • Medicine(all)
  • Critical Care and Intensive Care Medicine

Cite this

Osawa, E. A., Rhodes, A., Landoni, G., Galas, F. R. B. G., Fukushima, J. T., Park, C. H. L., Almeida, J. P., Nakamura, R. E., Strabelli, T. M. V., Pileggi, B., Leme, A. C., Fominskiy, E., Sakr, Y., Lima, M., Franco, R. A., Chan, R. P. C., Piccioni, M. A., Mendes, P., Menezes, S. R., ... Hajjar, L. A. (2016). Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review. Critical Care Medicine, 44(4), 724 - 733. https://doi.org/10.1097/CCM.0000000000001479