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Outcomes of individualized goal-directed therapy based on cerebral oxygen balance in high-risk patients undergoing
Xin-Qi Cheng1, Jun-Yan Zhang2, Hao Wu1
1Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, 230022 Hefei, China.
Insights
Optimizing individualized goal-directed therapy (GDT) for cerebral oxygen balance did not reduce postoperative morbidity in high-risk cardiac surgery patients. However, achieving preoperative targets was linked to better outcomes.
Area of Science:
- Anesthesiology and Critical Care Medicine
- Cardiovascular Surgery
- Neurosurgery
Background:
- High-risk surgical patients undergoing cardiac procedures face significant postoperative morbidity.
- Cerebral oxygen balance is a critical factor in perioperative outcomes.
- Goal-directed therapy (GDT) aims to optimize physiological parameters to improve patient outcomes.
Purpose of the Study:
- To determine if optimizing individualized GDT based on cerebral oxygen balance reduces postoperative morbidity in high-risk surgical patients.
- To evaluate the impact of specific GDT targets on patient outcomes during valve replacement and coronary artery bypass surgery.
Main Methods:
- Prospective, randomized, controlled study involving 146 high-risk adult patients undergoing cardiac surgery with cardiopulmonary bypass.
- Patients were randomized to either individualized GDT or usual care.
- Individualized GDT targeted specific levels of regional cerebral oxygen saturation (rScO2), mean arterial pressure (MAP), and bispectral index (BIS).
Main Results:
- No significant difference in early morbidity was observed between the individualized GDT group and the usual care group (39% vs. 53%, P=0.15).
- However, 59% of all patients who achieved their individual preoperative GDT targets experienced significantly less morbidity (RR 3.41, P<0.001).
Conclusions:
- Individualized GDT, as applied in this study, did not improve postoperative morbidity in high-risk cardiac surgery patients.
- Achieving preoperative individualized targets, irrespective of the therapy group, appears to be associated with reduced morbidity.
Study Objective:
To investigate whether optimizing individualized goal-directed therapy (GDT) based on cerebral oxygen balance in high-risk surgical patients would reduce postoperative morbidity.
Design:
This was a prospective, randomized, controlled study.
Setting:
The study was performed in the First Affiliated Hospital of Anhui Medical University, Hefei, China, from April 2017 to July 2018.
Patients:
146 high-risk adult patients undergoing valve replacements or coronary artery bypass surgery with cardiopulmonary bypass (CPB) were enrolled.
Intervention:
Patients were randomized to an individualized GDT group or usual care group. Individualized GDT was targeted to achieve the following goals: A less than 20% decline in the regional cerebral oxygen saturation (rScO2) level from baseline; a less than 20% decline in the mean arterial pressure (MAP) from baseline, as well as a bispectral index (BIS) of 45-60 before and after CPB and 40-45 during CPB.
Measurements:
The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications.
Main Results:
128 completed the trial and were included in the modified intention-to-treat analysis. Early morbidity was similar between the GDT (25 [39%] of 65 patients) and usual care groups (33 [53%] of 63 patients) (relative risk 0.73, 95% CI 0.50-1.08; P = 0.15). Secondary analysis showed that 75 (59%) of 128 patients achieved individual targets (irrespective of intervention) and sustained less morbidity (relative risk 3.41, 95% CI 2.19-5.31; P < 0.001).
Conclusions:
In high-risk patients undergoing cardiac surgery, individualized GDT therapy did not yield better outcomes, however, the achievement of preoperative individual targets may be associated with less morbidity.
Trial Registration:
Clinicaltrials.gov identifier: NCT03103633. Registered on 1 April 2017.
