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Practical impact of a decision support for goal-directed fluid therapy on protocol adherence: a clinical implementation study in patients undergoing major abdominal surgery

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Abstract

The purpose of this study was to assess the effects of using a real time clinical decision-support system, “Assisted Fluid Management” (AFM), to guide goal-directed fluid therapy (GDFT) during major abdominal surgery. We compared a group of patients managed using the AFM system with a historical cohort of patients (control group) who had been managed using a manual GDFT strategy. Adherence to the protocol was defined as the relative intraoperative time spent with a stroke volume variation (SVV) < 13%. We hypothesised that patients in the AFM group would have more time during surgery with a SVV < 13% compared to the control group. All patients had a radial arterial line connected to a pulse contour analysis monitor and received a 2 ml/kg/h maintenance crystalloid infusion. Additional 250 ml crystalloid boluses were administered whenever measured SVV ≥ 13% in the control group, and when the software suggested a fluid bolus in the AFM group. We compared 46 AFM-guided patients to 38 controls. Patients in the AFM group spent significantly more time during surgery with a SVV < 13% compared to the control group (median 92% [82, 96] vs. 76% [54, 86]; P < 0.0005), and received less fluid overall (1775 ml [1225, 2425] vs. 2350 ml [1825, 3250]; P = 0.010). The incidence of postoperative complications was comparable in the two groups. Implementation of a decision support system for GDFT guidance resulted in a significantly longer period during surgery with a SVV < 13% with a reduced total amount of fluid administered. Trial registration: Clinical Trials.gov (NCT03141411).

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Notes

  1. The scaled response is calculated as scaled_SV_response = (actual_SV_increase × scaling_factor) where the scaling_factor is a function of the bolus volume delivered.

References

  1. Cannesson M, Ramsingh D, Rinehart J, Demirjian A, Vu T, Vakharia S, Imagawa D, Yu Z, Greenfield S, Kain Z. Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study. Crit Care. 2015;19:261.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Michard F, Giglio MT, Brienza N. Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome. Br J Anaesth. 2017;119(1):22–30.

    Article  CAS  PubMed  Google Scholar 

  3. Bednarczyk JM, Fridfinnson JA, Kumar A, Blanchard L, Rabbani R, Bell D, Funk D, Turgeon AF, Abou-Setta AM, Zarychanski R. Incorporating dynamic assessment of fluid responsiveness into goal-directed therapy: a systematic review and meta-analysis. Crit Care Med. 2017;45(9):1538–45.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Sun Y, Chai F, Pan C, Romeiser JL, Gan TJ. Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2017;21(1):141.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Malbouisson LMS, Silva JM Jr, Carmona MJC, Lopes MR, Assuncao MS, Valiatti J, Simoes CM, Auler JOC Jr. A pragmatic multi-center trial of goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery. BMC Anesthesiol. 2017;17(1):70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Habicher M, Balzer F, Mezger V, Niclas J, Muller M, Perka C, Kramer M, Sander M. Implementation of goal-directed fluid therapy during hip revision arthroplasty: a matched cohort study. Perioper Med. 2016;5:31.

    Article  Google Scholar 

  7. Osawa EA, Rhodes A, Landoni G, Galas FR, Fukushima JT, Park CH, Almeida JP, Nakamura RE, Strabelli TM, Pileggi B, et al. Effect of perioperative goal-directed hemodynamic resuscitation therapy on outcomes following cardiac surgery: a randomized clinical trial and systematic review. Crit Care Med. 2016;44(4):724–33.

    PubMed  Google Scholar 

  8. Benes J, Giglio M, Brienza N, Michard F. The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Crit Care. 2014;18(5):584.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kaufmann KB, Stein L, Bogatyreva L, Ulbrich F, Kaifi JT, Hauschke D, Loop T, Goebel U. Oesophageal Doppler guided goal-directed haemodynamic therapy in thoracic surgery—a single centre randomized parallel-arm trial. Br J Anaesth. 2017;118(6):852–61.

    Article  CAS  PubMed  Google Scholar 

  10. Cannesson M, Pestel G, Ricks C, Hoeft A, Perel A. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care. 2011;15(4):R197.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Joosten A, Rinehart J, Cannesson M. Perioperative goal directed therapy: evidence and compliance are two sides of the same coin. Rev Esp de Anestesiol y Reanim. 2015;62(4):181–3.

    Article  CAS  Google Scholar 

  12. Miller TE, Roche AM, Gan TJ. Poor adoption of hemodynamic optimization during major surgery: are we practicing substandard care? Anesth Analg. 2011;112(6):1274–6.

    Article  PubMed  Google Scholar 

  13. Lilot M, Ehrenfeld JM, Lee C, Harrington B, Cannesson M, Rinehart J. Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis. Br J Anaesth. 2015;114(5):767–76.

    Article  CAS  PubMed  Google Scholar 

  14. Thacker JK, Mountford WK, Ernst FR, Krukas MR, Mythen MM. Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample US surgical populations. Ann Surg. 2016;263(3):502–10.

    Article  PubMed  Google Scholar 

  15. Rinehart J, Le Manach Y, Douiri H, Lee C, Lilot M, Le K, Canales C, Cannesson M. First closed-loop goal directed fluid therapy during surgery: a pilot study. Ann Fr d’anesth et de Reanim. 2014;33(3):e35–41.

    Google Scholar 

  16. Rinehart J, Lilot M, Lee C, Joosten A, Huynh T, Canales C, Imagawa D, Demirjian A, Cannesson M. Closed-loop assisted versus manual goal-directed fluid therapy during high-risk abdominal surgery: a case-control study with propensity matching. Crit Care. 2015;19:94.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Joosten A, Huynh T, Suehiro K, Canales C, Cannesson M, Rinehart J. Goal-Directed fluid therapy with closed-loop assistance during moderate risk surgery using noninvasive cardiac output monitoring: a pilot study. Br J Anaesth. 2015;114(6):886–92.

    Article  CAS  PubMed  Google Scholar 

  18. Rinehart J, Alexander B, Le Manach Y, Hofer C, Tavernier B, Kain ZN, Cannesson M. Evaluation of a novel closed-loop fluid-administration system based on dynamic predictors of fluid responsiveness: an in silico simulation study. Crit Care. 2011;15(6):R278.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Rinehart J, Chung E, Canales C, Cannesson M. Intraoperative stroke volume optimization using stroke volume, arterial pressure, and heart rate: closed-loop (learning intravenous resuscitator) versus anesthesiologists. J Cardiothorac Vasc Anesth. 2012;26(5):933–9.

    Article  PubMed  Google Scholar 

  20. Rinehart J, Lee C, Canales C, Kong A, Kain Z, Cannesson M. Closed-loop fluid administration compared to anesthesiologist management for hemodynamic optimization and resuscitation during surgery: an in vivo study. Anesth Analg. 2013;117(5):1119–29.

    Article  CAS  PubMed  Google Scholar 

  21. Rinehart J, Lee C, Cannesson M, Dumont G. Closed-loop fluid resuscitation: robustness against weight and cardiac contractility variations. Anesth Analg. 2013;117(5):1110–8.

    Article  CAS  PubMed  Google Scholar 

  22. Joosten A, Delaporte A, Ickx B, Touihri K, Stany I, Barvais L, Van Obbergh L, Loi P, Rinehart J, Cannesson M, et al: Crystalloid versus colloid for intraoperative goal-directed fluid therapy using a closed-loop system: a randomized, double-blinded, controlled trial in major abdominal surgery. Anesthesiology 2017;128:55–66.

    Google Scholar 

  23. Arulkumaran N, Corredor C, Hamilton MA, Ball J, Grounds RM, Rhodes A, Cecconi M. Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Br J Anaesth. 2014;112(4):648–59.

    Article  CAS  PubMed  Google Scholar 

  24. Maguire S, Rinehart J, Vakharia S, Cannesson M. Technical communication: respiratory variation in pulse pressure and plethysmographic waveforms: intraoperative applicability in a North American academic center. Anesth Analg. 2011;112(1):94–6.

    Article  PubMed  Google Scholar 

  25. Joosten A, Tircoveanu R, Arend S, Wauthy P, Gottignies P, Van der Linden P. Impact of balanced tetrastarch raw material on perioperative blood loss: a randomized double blind controlled trial. Br J Anaesth. 2016;117(4):442–9.

    Article  CAS  PubMed  Google Scholar 

  26. Gomez-Izquierdo JC, Trainito A, Mirzakandov D, Stein BL, Liberman S, Charlebois P, Pecorelli N, Feldman LS, Carli F, Baldini G. Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: a randomized controlled trial. Anesthesiology. 2017;127(1):36–49.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors wish to gratefully acknowledge Brian Hipszer, PhD; Distinguished Algorithm Engineer, Critical Care; Edwards Lifesciences (Irvine, California, USA) for software data analysis.

Funding

This work was supported by the Department of Anaesthesiology, Erasme Hospital, Brussels.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, CUB Erasme, Hopital ERASME, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium

    Alexandre Joosten, Reda Hafiane, Marco Pustetto, Luc Van Obbergh & Brigitte Ickx

  2. Department of Urology, CUB Erasme, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium

    Thierry Quackels

  3. Department of Colorectal Surgery, CUB Erasme, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium

    Alexis Buggenhout

  4. Department of Intensive Care, CUB Erasme, Université Libre de Bruxelles, 808, route de Lennik, 1070, Brussels, Belgium

    Jean-Louis Vincent

  5. Department of Anesthesiology & Perioperative Care, University of California Irvine, 101 the City Drive South, Orange, CA, USA

    Joseph Rinehart

Authors
  1. Alexandre Joosten
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  2. Reda Hafiane
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  3. Marco Pustetto
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  4. Luc Van Obbergh
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  6. Alexis Buggenhout
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  7. Jean-Louis Vincent
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  8. Brigitte Ickx
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  9. Joseph Rinehart
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Contributions

AJ: Designed the study, recruited patients, analysed the data and drafted the manuscript. RA: Recruited patients, collected and analysed the data and edited the manuscript. MP: Recruited patients, collected and analysed the data and edited the manuscript. LVO: Collected and analysed the data and edited the manuscript. TQ: Collected and analysed the data and edited the manuscript. AB: Collected and analysed the data and edited the manuscript. JLV: Analysed the data and edited the manuscript. BI: Collected and analysed the data and edited the manuscript. JR: Designed the study, analysed the data and edited the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Alexandre Joosten.

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Conflict of interest

Alexandre Joosten is a consultant for Edwards Lifesciences (Irvine, CA, USA). Joseph Rinehart is a consultant for Edwards Lifesciences (Irvine, CA, USA) and is also co-founder of Sironis, a compagny developing closed-loop fluid management systems. The other authors declare that they have no conflicts of interest concerning this study.

Appendices

Appendix 1

See Fig. 1.

Fig. 1
figure 1

Goal directed fluid therapy algorithm

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Appendix 2

See Fig. 2.

Fig. 2
figure 2

Depicts the AFM interface

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Joosten, A., Hafiane, R., Pustetto, M. et al. Practical impact of a decision support for goal-directed fluid therapy on protocol adherence: a clinical implementation study in patients undergoing major abdominal surgery. J Clin Monit Comput 33, 15–24 (2019). https://doi.org/10.1007/s10877-018-0156-x

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  • DOI: https://doi.org/10.1007/s10877-018-0156-x

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