Multimodal intraoperative monitoring: Observational case series in major peripheral vascular surgery

Patient Population
High-risk peripheral vascular surgery.

LiDCO Monitor
LiDCOrapid as the hemodynamic part of a multimodal monitoring approach.

Trial Design
Actual mortality after multimodal approach vs predicted V-POSSUM.

Outcome Impact
30-day mortality at 0.8% significantly lower than the 9% mortality predicted by the V-POSSUM amputation rate less than 2% after one year. Post-operatively only 8% (10 patients) went to a high dependency unit (HDU).

BACKGROUND
Recent guidelines from the National Institute for Health and Care Excellence (NICE) and the UK National Health Service (NHS) have stipulated that intra-operative flow monitoring should be used in high-risk patients undergoing major surgery to improve outcomes and reduce costs. Depth of anesthesia monitoring is also recommended for patients where excessive anesthetic depth is poorly tolerated, along with cerebral oximetry in patients with proximal femoral fractures.

OBJECTIVE
The aims of this descriptive case series were to evaluate the impact of a multimodal intra-operative strategy and its effect on mortality and amputation rate for patients with critical leg ischaemia.

METHODS
In an observational case series, 120 elderly patients undergoing major infra-inguinal bypass between 2007 and 2012 were included in this retrospective analysis of prospectively collected data. Nominal cardiac output (nCO, LiDCOrapid), bispectral index to monitor depth of anaesthesia (BIS, Medtronic) and cerebral oxygenation, rSO2 (Invos, Medtronic) readings were obtained before induction of general anesthesia and throughout surgery. 30-day, 1-year mortality and amputation rates were analysed. Demographics and physiological parameters including correlation with V-POSSUM, age, gender and other co-morbidities were statistically analysed.

RESULTS
Thirty-day mortality rate was 0.8% (n = 1). V-POSSUM scoring indicated a predicted mortality of 9%. Amputation rate was less than 2% at one year. Only 8% of patients (10 of 120) were admitted to a high dependency unit (HDU) postoperatively. 30-day mortality in our case series was lower than predicted by V-POSSUM scoring.

CONCLUSIONS
Use of multimodal intra-operative monitoring with the specific aim of limiting build-up of oxygen debt should be subjected to a randomised controlled study to assess the reproducibility of these results.

Green D, Bidd H, Rashid H. Multimodal intraoperative monitoring: An observational case series in high risk patients undergoing major peripheral vascular surgery. Int J Surg (2014);12(3):231-6. doi: 10.1016/j.ijsu.2013.12.016. Epub 2014 Jan 8.

30-day mortality at 0.8% significantly lower than the 9% mortality predicted by the V-POSSUM amputation rate less than 2% after one year. Post-operatively only 8% (10 patients) went to a high dependency unit (HDU).

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