Cardiac surgery

The goal-directed resuscitation in high-risk patients undergoing cardiac surgery (GRICS) RCT demonstrated reduced complications and ICU and hospital stay through pre-emptive GDT in high-risk patients undergoing cardiac surgery.

The use of LIDCOrapid during surgery and LIDCOplus 8-hours post-operatively as part of a protocol strategy can decrease the amount of complications seen, with reduced LOS and cost savings.

“LiDCO showed good correlation, marginal bias and acceptable limits of agreement and percentage error. It could therefore potentially replace thermodilution as a means of measuring cardiac output in the ICU, particularly when determination of pulmonary artery pressure is not required.” (Mora et al. 2011)

  • Assessing the fluid status of a patient can be difficult at the end of a cardiothoracic case or in the ICU.
  • Although useful for diagnosing what the cardiac output is the pulmonary artery catheter is neither beat-to-beat nor measures SVV/PPV, or fluid response to fluid challenge. In this way, it has limited use to guide fluid management.
  • Avoiding unnecessary interventions is probably helpful-particularly fluid administration.
  • 2 recent studies using the LiDCO have shown a reduction in complications and length of stay when used to guide fluid and drug management at the end of a case and in the ICU (Osawa et al. 2016, Thomson et al. 2014).

 

  • Identify when a patient is fluid responsive to prevent deterioration in cardiac function and to reduce the incidence of complications, renal failure for example (Osawa et al. 2016, Thomson et al. 2014)
  • Identify when a patient is not fluid responsive
  • Either passive leg raise or stroke volume/pulse pressure variation should be used to see if the patient is fluid responsive or not. Both CVP and PAWP have been shown not to predict fluid responsiveness
  • A fluid challenge guided by the response in the stroke volume should be used when fluids are given to prevent overfilling the patient.
  • If the patient is unresponsive to fluids with a low blood pressure then the appropriate drug can be used
  • The LiDCO can be calibrated with the TEE if accuracy and precision are required for a protocol aimed at reducing complications (Osawa et al. 2016)
  • Meta-analyses studies have shown benefit with no increase in risk to the patient

RCT effect of peri-operative GDHT on cardiac surgery outcomes

RCT effect of peri-operative GDHT on cardiac surgery outcomes

Patient Population
Cardiac surgery.

LiDCO Monitor
LiDCOrapid goal-directed therapy (GDT) targeted cardiac index (CI).

Trial Design
Randomised GDT targeted cardiac index vs standard care.

Outcome Impact
Composite endpoint 30-day mortality and major postoperative complications reduced in the goal-directed therapy group (27.4% vs 45.3%) and GDT patients had less infections (12.9% vs 29.7%), a lower incidence of low cardiac output syndrome (6.5% vs 26.6%), reduced ICU (3 vs 5 days) and hospital stay (9 vs 12 days).

OBJECTIVES
To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery.

DESIGN:
A prospective randomised controlled trial and an updated meta-analysis of randomised 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 post-operative 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.

Osawa EA, Rhodes A, Landoni G, Galas FR, 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. doi: 10.1097/CCM.0000000000001479.

Study showed composite endpoint 30-day mortality and major post-operative complications reduced in the goal-directed therapy group (27.4% vs 45.3%) and GDT patients had less infections (12.9% vs 29.7%), a lower incidence of low cardiac output syndrome (6.5% vs 26.6%), reduced ICU (3 vs 5 days) and hospital stay (9 vs 12 days).

GDT following cardiac surgery and incidence of AKI

GDT following cardiac surgery and incidence of AKI

Patient Population
Cardiac surgery patients following coronary artery bypass grafting and/or aortic valve surgery.

LiDCO Monitor
LiDCOplus.

Trial Design
Prospective observational study in cardiothoracic ICU.

Outcome Impact
A nurse-led GDT protocol targeting maximum SV for 8hrs post surgery showed a reduction in the incidence of AKI and reduction in the number of patients requiring RRT.

PURPOSE
The purpose of this study was to assess the effect of goal directed therapy (GDT), following cardiac surgery, on the incidence of acute kidney injury.

MATERIALS AND METHODS
A total of 264 patients were included with 123 patients in the GDT group and 141 in the control.

RESULTS
Incidence of AKI was reduced in the GDT group (n=8 (6.5%) vs. n=28 (19.9%), P = 0.002). the rate of readmissions to the intensive care was reduced in the GDT group (9.2% vs. 3.3%, P = 0.049)

CONCLUSIONS
Post-operative GDT in patients following cardiac surgery was associated with reduction in the incidence of AKI and a reduction in ICU and hospital duration of stay.

Thomson R, Meeran H, Valencia O, Al-Subaie N. Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury. J Crit Care. 2014;29(6):997-1000

“The significant reduction in the incidence of AKI has both short and log term implication on overall morbidity in addition to the financial impact as result of reducing duration of ICU and hospital stay.”

LiDCOrapid – Hemodynamic Monitoring in Action

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“Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.”
Osawa et al. 2016

“The significant reduction in the incidence of AKI has both short and long term implication on the overall morbidity in additional to the financial impact as a result of reducing duration of ICU and hospital stay.”
Thomson et al. 2014

The LiDCOunity monitor is a single platform which combines both the LiDCOplus and LiDCOrapid functions. This provides a single solution to monitoring needs throughout the hospital. The clinician can choose which mode is most appropriate to the clinical situation. The LiDCOunity can be used non-invasively, minimally invasively with a radial arterial line and can be calibrated with the lithium dilution technique.  Find out more

The LiDCOplus hemodynamic monitor provides a continuous, reliable and accurate assessment of the hemodynamic status of critical care and surgery patients.  The LiDCOplus is comprised of two technologies: a continuous arterial waveform analysis system (PulseCO™) coupled to a single point lithium indicator dilution calibration system.  Find out more

The LiDCOrapid monitor analyses the blood pressure waveform to provide more information in high-risk surgical and critically ill patients to help with fluid and drug management.  The LiDCOrapid uses the PulseCO™ algorithm which converts blood pressure to its constituent parts of flow (CO, SV) and resistance (SVR). The PulseCO™ algorithm is scaled to each patient with a nomogram using age, height, and weight.  Find out more