Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review

被引：124

作者：

Osawa, Eduardo A. ^{[1
,2
]}

Rhodes, Andrew ^{[3
,4
]}

Landoni, Giovanni ^{[5
,6
]}

Galas, Filomena R. B. G. ^{[1
,2
]}

Fukushima, Julia T. ^{[1
,2
]}

Park, Clarice H. L. ^{[1
,2
]}

Almeida, Juliano P. ^{[1
,2
]}

Nakamura, Rosana E. ^{[1
,2
]}

Strabelli, Tania M. V. ^{[1
,2
]}

Pileggi, Brunna ^{[1
,2
]}

Leme, Alcino C. ^{[1
,2
]}

Fominskiy, Evgeny ^{[5
,6
]}

Sakr, Yasser ^{[7
]}

Lima, Marta ^{[1
,2
]}

Franco, Rafael A. ^{[1
,2
]}

Chan, Raquel P. C. ^{[1
,2
]}

Piccioni, Marilde A. ^{[1
,2
]}

Mendes, Priscilla ^{[1
,2
]}

Menezes, Suellen R. ^{[1
,2
]}

Bruno, Tatiana ^{[1
,2
]}

Gaiotto, Fabio A. ^{[8
]}

Lisboa, Luiz A. ^{[8
]}

Dallan, Luiz A. O. ^{[8
]}

Hueb, Alexandre C. ^{[8
]}

Pomerantzeff, Pablo M. ^{[8
]}

Kalil Filho, Roberto ^{[8
]}

Jatene, Fabio B. ^{[8
]}

Costa Auler Junior, Jose Otavio ^{[1
,2
]}

Hajjar, Ludhmila A. ^{[1
,2
]}

机构：

[1] Univ Sao Paulo, Hosp Clin, Fac Med, Surg Intens Care Unit, Sao Paulo, Brazil

[2] Univ Sao Paulo, Hosp Clin, Fac Med, Heart Inst InCor,Dept Anesthesiol, Sao Paulo, Brazil

[3] St Georges Healthcare NHS Trust, Dept Intens Care Med, London, England

[4] St Georges Univ London, London, England

[5] IRCCS San Raffaele Sci Inst, Dept Anesthesia & Intens Care, Milan, Italy

[6] Vita Salute San Raffaele Sci Inst, Milan, Italy

[7] Univ Jena, Friedrich Schiller Univ Hosp, Dept Anesthesiol & Intens Care, Jena, Germany

[8] Univ Sao Paulo, Hosp Clin, Fac Med, Heart Inst InCor,Dept Cardiopneumol, Sao Paulo, Brazil

来源：

CRITICAL CARE MEDICINE | 2016年 / 44卷 / 04期

基金：

巴西圣保罗研究基金会;

关键词：

cardiac surgery; hemodynamic; goal-directed; resuscitation; OFF-PUMP; ON-PUMP; MAJOR SURGERY; HOSPITAL STAY; COMPLICATIONS; OPTIMIZATION; METAANALYSIS; HYPOPERFUSION; MANAGEMENT; MORBIDITY;

D O I：

10.1097/CCM.0000000000001479

中图分类号：

R4 [临床医学];

学科分类号：

1002 ; 100602 ;

摘要：

Objectives: To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. Design: A prospective randomized controlled trial and an updated metaanalysis of randomized 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(2) 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 postoperative 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.

引用

页码：724 / 733

页数：10

共 43 条

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