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Impact of conventional vs. goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver
Dragos Chirnoaga1, Sean Coeckelenbergh, Brigitte Ickx
1From the Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels (DC, SC, BI, LVO, AJ), Unit of Hepatobiliary Surgery and Liver Transplantation, Department of Digestive Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (VL), Department of Anesthesiology, Sauvegarde Clinic, Ramsay Santé, Lyon, France (OD), Department of Anesthesiology and Pain Medicine, Université de Montréal, Centre de recherche du CHUM, Montreal, Québec, Canada (F-MC), MiCo, Denens, Switzerland (FM), Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (J-LV), Department of Anaesthesiology and Intensive Care, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Bicetre Hospital, Paris, France (JD) and Department of Anaesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium (PVdL).
Background:
Although fluid administration is a key strategy to optimise haemodynamic status and tissue perfusion, optimal fluid administration during liver surgery remains controversial.
Objective:
To test the hypothesis that a goal-directed fluid therapy (GDFT) strategy, when compared with a conventional fluid strategy, would better optimise systemic blood flow and lead to improved urethral tissue perfusion (a new variable to assess peripheral blood flow), without increasing blood loss.
Design:
Single-centre prospective randomised controlled superiority study.
Setting:
Erasme Hospital.
Patients:
Patients undergoing liver surgery.
Intervention:
Forty patients were randomised into two groups: all received a basal crystalloid infusion (maximum 2 ml kg-1 h-1). In the conventional fluid group, the goal was to maintain central venous pressure (CVP) as low as possible during the dissection phase by giving minimal additional fluid, while in the posttransection phase, anaesthetists were free to compensate for any presumed fluid deficit. In the GDFT group, patients received in addition to the basal infusion, multiple minifluid challenges of crystalloid to maintain stroke volume (SV) variation less than 13%. Noradrenaline infusion was titrated to keep mean arterial pressure more than 65 mmHg in all patients.
Main Outcome Measure:
The mean intra-operative urethral perfusion index.
Results:
The mean urethral perfusion index was significantly higher in the GDFT group than in the conventional fluid group (8.70 [5.72 to 13.10] vs. 6.05 [4.95 to 8.75], P = 0.046). SV index (ml m-2) and cardiac index (l min-1 m-2) were higher in the GDFT group (48 ± 9 vs. 33 ± 7 and 3.5 ± 0.7 vs. 2.4 ± 0.4, respectively; P < 0.001). Although CVP was higher in the GDFT group (9.3 ± 2.5 vs. 6.5 ± 2.9 mmHg; P = 0.003), intra-operative blood loss was not significantly different in the two groups.
Conclusion:
In patients undergoing liver surgery, a GDFT strategy resulted in a higher mean urethral perfusion index than did a conventional fluid strategy and did not increase blood loss despite higher CVP.
Trial Registration:
NCT04092608.
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