RCT early GDT after major surgery reduces complications and LOS

Patient Population
Post-surgical intensive care.

LiDCO Monitor
LiDCOplus oxygen delivery (DO2) Early goal-directed therapy (EGDT) target.

Trial Design
Randomised LiDCOplus EGDT target vs usual care.

Outcome Impact
Fewer EGDT patients developed complications – 27 patients (44%) vs 41 patients (68%) LOS was significantly reduced (11 days vs 14 days) and the mean stay was reduced by 12 days (17.5 days versus 29.5 days) a 41% reduction. EGDT decreased costs by £2,631 per patient and by £2,134 per hospital survivor. EGDT was found to prolong quality-adjusted life expectancy (by 9.8 months) and to bring incremental cost savings of £1,285.

INTRODUCTION
Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery.

METHODS
This was a randomised controlled trial with concealed allocation. High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 ml min(-1) m(-2) or to conventional management. Cardiac output was measured by lithium indicator dilution and pulse power analysis. Patients were followed up for 60 days.

RESULTS
Sixty-two patients were randomised to GDT and 60 patients to control treatment. The GDT group received more intravenous colloid (1,907 SD +/- 878 ml versus 1,204 SD +/- 898 ml; p < 0.0001) and dopexamine (55 patients (89%) versus 1 patient (2%); p < 0.0001). Fewer GDT patients developed complications (27 patients (44%) versus 41 patients (68%); p = 0.003, relative risk 0.63; 95% confidence intervals 0.46 to 0.87). The number of complications per patient was also reduced (0.7 SD +/- 0.9 per patient versus 1.5 SD +/- 1.5 per patient; p = 0.002). The median duration of hospital stay in the GDT group was significantly reduced (11 days (IQR 7 to 15) versus 14 days (IQR 11 to 27); p = 0.001). There was no significant difference in mortality (seven patients (11.3%) versus nine patients (15%); p = 0.59).

CONCLUSION
Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission.

Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care. 2005;9 (6):687-693 & Ebm C, Cecconi M, Sutton L, Rhodes A. A Cost-Effectiveness Analysis of Postoperative Goal-Directed Therapy for High-Risk Surgical Patients. Crit Care Med. 2014. DOI: 10.1097/CCM0000000000000164

Fewer EGDT patients developed complications – 27 patients (44%) vs 41 patients (68%) LOS was significantly reduced (11 days vs 14 days) and the mean stay was reduced by 12 days (17.5 days versus 29.5 days) a 41% reduction. EGDT decreased costs by £2,631 per patient and by £2,134 per hospital survivor. EGDT was found to prolong quality-adjusted life expectancy (by 9.8 months) and to bring incremental cost savings of £1,285.

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