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Invasive Hemodynamic Monitoring of Aortic and Pulmonary Artery Hemodynamics in a Large Animal Model of ARDS
Published on: November 26, 2018
Towards individualized perioperative, goal-directed haemodynamic algorithms for patients of advanced age:
E Bartha1, C Arfwedson2, A Imnell2
1Karolinska University Hospital, Huddinge, Department of Anaesthesia and Intensive Care, Karolinska Institutet, CLINTEC, Stockholm, Sweden erzsebet.bartha@karolinska.se.
Insights
Elderly patients undergoing hip surgery showed limited response to goal-directed haemodynamic treatment (GDHT). Baseline stroke volume and oxygen delivery indices predicted patient response to interventions, suggesting personalized approaches are needed.
Area of Science:
- Anesthesiology
- Geriatric Medicine
- Critical Care Medicine
Background:
- Intraoperative goal-directed haemodynamic treatment (GDHT) did not improve cardiac performance in elderly patients as expected in a prior study (NCT01141894).
- Hypothesis: Individual patient characteristics may predict responsiveness to haemodynamic interventions in this demographic.
Purpose of the Study:
- To identify predictors of haemodynamic response to goal-directed haemodynamic treatment (GDHT) in elderly patients undergoing hip-fracture surgery.
- To evaluate the effectiveness of GDHT compared to routine fluid management in this patient population.
Main Methods:
- A single-centre, randomized controlled trial involving patients aged ≥70 years undergoing hip-fracture surgery.
- Haemodynamic parameters monitored using LiDCOplus™. GDHT group received oxygen delivery-guided fluid challenges and dobutamine; control group received clinician-guided fluid management.
- Multiple logistic regression analysis used to identify independent predictors of fluid challenge response (stroke volume increase ≥10%) and overall intervention response (maintained/increased oxygen delivery).
Main Results:
- In the GDHT group, 39% responded to the first fluid challenge and 47% maintained or increased oxygen delivery by the end of surgery.
- Baseline stroke volume index (<28 ml m⁻²) predicted response to the first fluid challenge.
- Baseline oxygen delivery index (<330 ml min⁻¹ m⁻²) predicted maintained or increased oxygen delivery at the end of surgery.
Conclusions:
- Fewer elderly patients responded to goal-directed haemodynamic treatment (GDHT) than anticipated.
- Individual baseline haemodynamic characteristics, specifically stroke volume and oxygen delivery indices, can predict patient response to GDHT interventions.
Background:
During a previous study on intraoperative goal-directed haemodynamic treatment (GDHT) in elderly patients, cardiac performance did not improve as anticipated (ClinicalTrials.gov NCT01141894). We hypothesized that in this group, responsiveness to interventions could be predicted by individual patient characteristics.
Methods:
Data for the present study were collected during a previously performed, single-centre, open, randomized, and controlled parallel-group superiority trial in patients aged ≥70 yr undergoing hip-fracture surgery. Haemodynamic parameters were collected by the LiDCOplus™ monitor. The GDHT group received oxygen delivery-guided fluid challenges and dobutamine infusion. Management in the routine fluid treatment group was clinician guided without access to LiDCOplus™ readings. In the GDHT group, independent predictors were assessed by multiple logistic regression analyses of two outcomes: first fluid challenge response (defined as increase of stroke volume by ≥10%); and overall intervention response (maintenance of oxygen delivery at the end of surgery).
Results:
Data from 72 routine fluid treatment and 70 GDHT patients were analysed. Clinician-guided pre-anaesthesia fluid loading increased the stroke volume in 14% of patients, and 17% of patients increased or maintained oxygen delivery at the end of surgery. The GDHT-guided first and subsequent fluid challenges were associated with increased stroke volume in 39 and 9% of patients, respectively, and increased or maintained oxygen delivery was present in 47% of patients at the end of surgery. In the GDHT group, a baseline stroke volume index (<28 ml m(-2)) was an independent predictor of first fluid challenge response, and a baseline oxygen delivery index (<330 ml min(-1) m(-2)) was a predictor of maintained or increased oxygen delivery.
Conclusions:
Fewer patients responded to GDHT than anticipated. Our data suggest that individual characteristics could predict the haemodynamic responses.
Clinical Trial Registration:
NCT01141894.
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