Haemodynamic optimisation in lower limb arterial surgery: Room for improvement?

Patient Population
High-risk peripheral vascular surgery.

LiDCO Monitor
LiDCOplus oxygen delivery (DO2) GDT target.

Trial Design
Randomised GDT vs standard care.

Outcome Impact
Significantly less fluid or adjusted all complications in the IGFT group.

BACKGROUND
Goal-directed therapy has been proposed to improve outcome in high-risk surgery patients. The aim of this study was to investigate whether individualised goal-directed therapy targeting stroke volume and oxygen delivery could reduce the number of patients with post-operative complications and shorten hospital length of stay after open elective lower limb arterial surgery.

METHODS
Forty patients scheduled for open elective lower limb arterial surgery were prospectively randomised. The LiDCOplus system was used for hemodynamic monitoring. In the intervention group, stroke volume index was optimised by administering 250 ml aliquots of colloid intra-operatively and during the first 6 h post-operatively. Following surgery, fluid optimisation was supplemented with dobutamine, if necessary, targeting an oxygen delivery index level ≥ 600 ml/min(/) m(2) in the intervention group. Central hemodynamic data were blinded in control patients. Patients were followed up after 30 days.

RESULTS
In the intervention group, stroke volume index, and cardiac index were higher throughout the treatment period (45 ± 10 vs. 41 ± 10 ml/m(2), P < 0.001, and 3.19 ± 0.73 vs. 2.77 ± 0.76 l/min(/) m(2), P < 0.001, respectively) as well as post-operative oxygen delivery index (527 ± 120 vs. 431 ± 130 ml/min(/) m(2), P < 0.001). In the same group, 5/20 patients had one or more complications vs. 11/20 in the control group (P = 0.05). After adjusting for pre-operative and intraoperative differences, the odds ratio for ≥ 1 complications was 0.18 (0.04-0.85) in the intervention group (P = 0.03). The median length of hospital stay did not differ between groups.

CONCLUSION
Peri-operative individualised goal-directed therapy may reduce post-operative complications in open elective lower limb arterial surgery.

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