Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery

A prospective, randomized, multicenter, pragmatic trial: POEMAS study (PeriOperative goal-directed thErapy in Major Abdominal Surgery)

David Pestaña, Elena Espinosa, Arieh Eden, Diana Nájera, Luis Collar, César Aldecoa, Eva Higuera, Soledad Escribano, Dmitri Bystritski, Francisco Pascual-Ramirez, Pilar Fernández-Garijo, Blanca De Prada, Alfonso Muriel, Reuven Pizov

Research output: Contribution to journalArticle

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Abstract

BACKGROUND:: In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality. METHODS:: A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to explanatory trials) to mimic real practice and obtain maximal external validity for the study. RESULTS:: Fluid administration was similar except for the number of colloid boluses (2.4 ± 1.8 [treated] vs 1.3 ± 1.4 [control]; P < 0.001) and packed red blood cell units (0.6 ± 1.3 [treated] vs 0.2 ± 0.6 [control]; P = 0.019). Dobutamine was used in 25% (intraoperatively) and 19.4% (postoperatively) of the treated patients versus 1.4% and 0% in the control group (P < 0.001). We have observed a reduction in reoperations in the treated group (5.6% vs 15.7%; P = 0.049). However, no significant differences were observed in overall complications (40% vs 41%; relative risk 0.99 [0.67-1.44]; P = 0.397), length of stay (11.5 [8-15] vs 10.5 [8-16]; P = 0.874), time to first flatus (62 hours [40-76] vs 72 hours [48-96]; P = 0.180), wound infection (7 vs 14; P = 0.085), anastomotic leaks (2 vs 5; P = 0.23), or mortality (4.2% vs 5.7%; P = 0.67). CONCLUSIONS:: The results of our pragmatic study indicate that a perioperative hemodynamic protocol guided by a noninvasive cardiac output monitor was not associated with a decrease in the incidence of overall complications or length of stay in major abdominal surgery.

Original languageEnglish (US)
Pages (from-to)579-587
Number of pages9
JournalAnesthesia and Analgesia
Volume119
Issue number3
DOIs
StatePublished - Jan 1 2014
Externally publishedYes

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Pragmatic Clinical Trials
Cardiac Output
Multicenter Studies
Length of Stay
Hemodynamics
Anastomotic Leak
Wound Infection
Incidence
Flatulence
Peristalsis
Cardiac Volume
Colorectal Surgery
Dobutamine
Mortality
Colloids
Therapeutics
Gastrectomy
Reoperation
Tertiary Care Centers
Stroke Volume

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery : A prospective, randomized, multicenter, pragmatic trial: POEMAS study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). / Pestaña, David; Espinosa, Elena; Eden, Arieh; Nájera, Diana; Collar, Luis; Aldecoa, César; Higuera, Eva; Escribano, Soledad; Bystritski, Dmitri; Pascual-Ramirez, Francisco; Fernández-Garijo, Pilar; De Prada, Blanca; Muriel, Alfonso; Pizov, Reuven.

In: Anesthesia and Analgesia, Vol. 119, No. 3, 01.01.2014, p. 579-587.

Research output: Contribution to journalArticle

Pestaña, David ; Espinosa, Elena ; Eden, Arieh ; Nájera, Diana ; Collar, Luis ; Aldecoa, César ; Higuera, Eva ; Escribano, Soledad ; Bystritski, Dmitri ; Pascual-Ramirez, Francisco ; Fernández-Garijo, Pilar ; De Prada, Blanca ; Muriel, Alfonso ; Pizov, Reuven. / Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery : A prospective, randomized, multicenter, pragmatic trial: POEMAS study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). In: Anesthesia and Analgesia. 2014 ; Vol. 119, No. 3. pp. 579-587.
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abstract = "BACKGROUND:: In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality. METHODS:: A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to explanatory trials) to mimic real practice and obtain maximal external validity for the study. RESULTS:: Fluid administration was similar except for the number of colloid boluses (2.4 ± 1.8 [treated] vs 1.3 ± 1.4 [control]; P < 0.001) and packed red blood cell units (0.6 ± 1.3 [treated] vs 0.2 ± 0.6 [control]; P = 0.019). Dobutamine was used in 25{\%} (intraoperatively) and 19.4{\%} (postoperatively) of the treated patients versus 1.4{\%} and 0{\%} in the control group (P < 0.001). We have observed a reduction in reoperations in the treated group (5.6{\%} vs 15.7{\%}; P = 0.049). However, no significant differences were observed in overall complications (40{\%} vs 41{\%}; relative risk 0.99 [0.67-1.44]; P = 0.397), length of stay (11.5 [8-15] vs 10.5 [8-16]; P = 0.874), time to first flatus (62 hours [40-76] vs 72 hours [48-96]; P = 0.180), wound infection (7 vs 14; P = 0.085), anastomotic leaks (2 vs 5; P = 0.23), or mortality (4.2{\%} vs 5.7{\%}; P = 0.67). CONCLUSIONS:: The results of our pragmatic study indicate that a perioperative hemodynamic protocol guided by a noninvasive cardiac output monitor was not associated with a decrease in the incidence of overall complications or length of stay in major abdominal surgery.",
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T1 - Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery

T2 - A prospective, randomized, multicenter, pragmatic trial: POEMAS study (PeriOperative goal-directed thErapy in Major Abdominal Surgery)

AU - Pestaña, David

AU - Espinosa, Elena

AU - Eden, Arieh

AU - Nájera, Diana

AU - Collar, Luis

AU - Aldecoa, César

AU - Higuera, Eva

AU - Escribano, Soledad

AU - Bystritski, Dmitri

AU - Pascual-Ramirez, Francisco

AU - Fernández-Garijo, Pilar

AU - De Prada, Blanca

AU - Muriel, Alfonso

AU - Pizov, Reuven

PY - 2014/1/1

Y1 - 2014/1/1

N2 - BACKGROUND:: In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality. METHODS:: A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to explanatory trials) to mimic real practice and obtain maximal external validity for the study. RESULTS:: Fluid administration was similar except for the number of colloid boluses (2.4 ± 1.8 [treated] vs 1.3 ± 1.4 [control]; P < 0.001) and packed red blood cell units (0.6 ± 1.3 [treated] vs 0.2 ± 0.6 [control]; P = 0.019). Dobutamine was used in 25% (intraoperatively) and 19.4% (postoperatively) of the treated patients versus 1.4% and 0% in the control group (P < 0.001). We have observed a reduction in reoperations in the treated group (5.6% vs 15.7%; P = 0.049). However, no significant differences were observed in overall complications (40% vs 41%; relative risk 0.99 [0.67-1.44]; P = 0.397), length of stay (11.5 [8-15] vs 10.5 [8-16]; P = 0.874), time to first flatus (62 hours [40-76] vs 72 hours [48-96]; P = 0.180), wound infection (7 vs 14; P = 0.085), anastomotic leaks (2 vs 5; P = 0.23), or mortality (4.2% vs 5.7%; P = 0.67). CONCLUSIONS:: The results of our pragmatic study indicate that a perioperative hemodynamic protocol guided by a noninvasive cardiac output monitor was not associated with a decrease in the incidence of overall complications or length of stay in major abdominal surgery.

AB - BACKGROUND:: In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality. METHODS:: A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to explanatory trials) to mimic real practice and obtain maximal external validity for the study. RESULTS:: Fluid administration was similar except for the number of colloid boluses (2.4 ± 1.8 [treated] vs 1.3 ± 1.4 [control]; P < 0.001) and packed red blood cell units (0.6 ± 1.3 [treated] vs 0.2 ± 0.6 [control]; P = 0.019). Dobutamine was used in 25% (intraoperatively) and 19.4% (postoperatively) of the treated patients versus 1.4% and 0% in the control group (P < 0.001). We have observed a reduction in reoperations in the treated group (5.6% vs 15.7%; P = 0.049). However, no significant differences were observed in overall complications (40% vs 41%; relative risk 0.99 [0.67-1.44]; P = 0.397), length of stay (11.5 [8-15] vs 10.5 [8-16]; P = 0.874), time to first flatus (62 hours [40-76] vs 72 hours [48-96]; P = 0.180), wound infection (7 vs 14; P = 0.085), anastomotic leaks (2 vs 5; P = 0.23), or mortality (4.2% vs 5.7%; P = 0.67). CONCLUSIONS:: The results of our pragmatic study indicate that a perioperative hemodynamic protocol guided by a noninvasive cardiac output monitor was not associated with a decrease in the incidence of overall complications or length of stay in major abdominal surgery.

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