Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a
Maxime Cannesson1,2, Davinder Ramsingh3, Joseph Rinehart4
1Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA. mcanness@uci.edu.
Insights
Implementing perioperative goal-directed therapy (PGDT) in high-risk abdominal surgeries significantly reduced fluid administration and improved patient outcomes. This performance improvement project led to shorter hospital stays and fewer postoperative complications.
Area of Science:
- Anesthesiology
- Surgical Outcomes
- Quality Improvement
Background:
- Perioperative goal-directed therapy (PGDT) shows potential for improving outcomes in high-risk surgery patients.
- Slow adoption of PGDT necessitates targeted implementation strategies.
- A performance improvement (PI) project was initiated in 2012 to enhance PGDT during high-risk abdominal surgeries.
Purpose of the Study:
- To evaluate the effectiveness of a PI project focused on implementing PGDT.
- To standardize fluid management and hemodynamic optimization in high-risk abdominal surgeries.
- To assess the impact of PGDT implementation on postoperative outcomes.
Main Methods:
- Historical prospective quality improvement study design.
- Protocol included standardized crystalloid administration (3 ml/kg/hour) with additional boluses guided by PGDT.
- Outcomes assessed included length of hospital stay (LOS) and postoperative complications using the NSQIP database.
Main Results:
- Fluid administration decreased from 9.9 ml/kg/hour to 6.6 ml/kg/hour post-implementation (p < 0.01).
- Hospital LOS decreased from 10 days to 7 days (p = 0.0001), representing an 18% reduction.
- Incidence of NSQIP complications decreased from 39% to 25% (p = 0.04).
Conclusions:
- Implementation of a PI program for PGDT effectively transformed fluid administration practices.
- PGDT implementation significantly improved postoperative outcomes in high-risk abdominal surgery patients.
- This approach demonstrates a successful strategy for enhancing patient care through standardized protocols.
Introduction:
Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention.
Methods:
This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database).
Results:
In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1-13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7-9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6-16) days to 7 (5-11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18% (95% confidence interval 9-27%). The incidence of NSQIP complications decreased from 39% to 25% (p = 0.04).
Conclusion:
These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries.
Trial Registration:
Clinicaltrials.gov NCT02057653. Registered 17 December 2013.