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Cardiac output–guided hemodynamic therapy algorithm reduces complications after GI surgery

This week's Journal of the American Medical Association evaluates the effect of a perioperative, cardiac output–guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery.

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Small trials suggest that postoperative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm.

Dr Rupert Pearse and colleagues evaluated the clinical effectiveness of a perioperative, cardiac output–guided hemodynamic therapy algorithm.

OPTIMISE was a pragmatic, multicenter, randomized, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the United Kingdom.

An updated systematic review and meta-analysis were also conducted including randomized trials published from 1966 to 2014.

Patients were randomly assigned to a cardiac output–guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery or to usual care.

The primary outcome occurred in 37% of intervention participants 
JAMA

The team's primary outcome was a composite of predefined 30-day moderate or major complications and mortality.

Secondary outcomes were morbidity on day 7, with infection, critical care–free days, and all-cause mortality at 30 days, all-cause mortality at 180 days, and length of hospital stay.

Baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups.

Care was nonadherent to the allocated treatment for less than 10% of patients in each group.

The team found that the primary outcome occurred in 37% of intervention and 43% of usual care participants.

The researchers found no significant difference between groups for any secondary outcomes.

The team noted that 5 intervention patients experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group.

Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications, and a nonsignificant reduction in hospital, 28-day, or 30-day mortality, and mortality at longest follow-up.

Dr Pearse's team concludes, "In a randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output–guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality."

"However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rates."

JAMA 2014; 311(21):2181-2190 
06 June 2014

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