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      Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study

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          Abstract

          OBJECTIVES:

          This pilot study was designed to utilize stroke volume variation and cardiac index to ensure fluid optimization during one-lung ventilation in patients undergoing thoracoscopic lobectomies.

          METHODS:

          Eighty patients undergoing thoracoscopic lobectomy were randomized into either a goal-directed therapy group or a control group. In the goal-directed therapy group, the stroke volume variation was controlled at 10%±1%, and the cardiac index was controlled at a minimum of 2.5 L.min -1.m -2. In the control group, the MAP was maintained at between 65 mm Hg and 90 mm Hg, heart rate was maintained at between 60 BPM and 100 BPM, and urinary output was greater than 0.5 mL/kg -1/h -1. The hemodynamic variables, arterial blood gas analyses, total administered fluid volume and side effects were recorded.

          RESULTS:

          The PaO 2/FiO 2-ratio before the end of one-lung ventilation in the goal-directed therapy group was significantly higher than that of the control group, but there were no differences between the goal-directed therapy group and the control group for the PaO 2/FiO 2-ratio or other arterial blood gas analysis indices prior to anesthesia. The extubation time was significantly earlier in the goal-directed therapy group, but there was no difference in the length of hospital stay. Patients in the control group had greater urine volumes, and they were given greater colloid and overall fluid volumes. Nausea and vomiting were significantly reduced in the goal-directed therapy group.

          CONCLUSION:

          The results of this study demonstrated that an optimization protocol, based on stroke volume variation and cardiac index obtained with a FloTrac/Vigileo device, increased the PaO 2/FiO 2-ratio and reduced the overall fluid volume, intubation time and postoperative complications (nausea and vomiting) in thoracic surgery patients requiring one-lung ventilation.

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          Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial

          Marcel Lopes, Marcos A. Oliveira, Vanessa Pereira … (2007)
          Introduction Several studies have shown that maximizing stroke volume (or increasing it until a plateau is reached) by volume loading during high-risk surgery may improve post-operative outcome. This goal could be achieved simply by minimizing the variation in arterial pulse pressure (ΔPP) induced by mechanical ventilation. We tested this hypothesis in a prospective, randomized, single-centre study. The primary endpoint was the length of postoperative stay in hospital. Methods Thirty-three patients undergoing high-risk surgery were randomized either to a control group (group C, n = 16) or to an intervention group (group I, n = 17). In group I, ΔPP was continuously monitored during surgery by a multiparameter bedside monitor and minimized to 10% or less by volume loading. Results Both groups were comparable in terms of demographic data, American Society of Anesthesiology score, type, and duration of surgery. During surgery, group I received more fluid than group C (4,618 ± 1,557 versus 1,694 ± 705 ml (mean ± SD), P < 0.0001), and ΔPP decreased from 22 ± 75 to 9 ± 1% (P < 0.05) in group I. The median duration of postoperative stay in hospital (7 versus 17 days, P < 0.01) was lower in group I than in group C. The number of postoperative complications per patient (1.4 ± 2.1 versus 3.9 ± 2.8, P < 0.05), as well as the median duration of mechanical ventilation (1 versus 5 days, P < 0.05) and stay in the intensive care unit (3 versus 9 days, P < 0.01) was also lower in group I. Conclusion Monitoring and minimizing ΔPP by volume loading during high-risk surgery improves postoperative outcome and decreases the length of stay in hospital. Trial registration NCT00479011
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            Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients.

            Erich Kilger, Matthias Goepfert, Freya Goetz … (2006)
            We examined whether guiding therapy by an algorithm based on optimizing the global end-diastolic volume index (GEDVI) reduces the need for vasopressor and inotropic support and helps to shorten ICU stay in cardiac surgery patients. Single-center clinical study with a historical control group at an university hospital. Forty cardiac bypass surgery patients were included prospectively and compared with a control group. In the goal-directed therapy (GDT) group hemodynamic management was guided by an algorithm based on GEDVI. Hemodynamic goals were: GEDVI above 640 ml/m2, cardiac index above 2.5 l/min/m2, and mean arterial pressure above 70 mmHg. The control group was treated at the discretion of the attending physician based on central venous pressure, mean arterial pressure, and clinical evaluation. In the GDT group duration of catecholamine and vasopressor dependence was shorter (187+/-70 vs. 1458+/-197 min), and fewer vasopressors (0.73+/-0.32 vs. 6.67+/-1.21 mg) and catecholamines (0.01+/-0.01 vs. 0.83+/-0.27mg) were administered. They received more colloids (6918+/-242 vs. 5514+/-171ml). Duration of mechanical ventilation (12.6+/-3.6 vs. 15.4+/4.3 h) and time until achieving status of fit for ICU discharge (25+/-13 vs. 33+/-17h) was shorter in the GDT group. Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery.
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              The ability of stroke volume variations obtained with Vigileo/FloTrac system to monitor fluid responsiveness in mechanically ventilated patients.

              George R. Simon, Henri Musard, R Henaine … (2009)
              Respiratory variations in arterial pulse pressure (DeltaPP) are accurate predictors of fluid responsiveness in mechanically ventilated patients. The aim of our study was to assess the ability of a novel algorithm for automatic estimation of stroke volume variation (SVV) to predict fluid responsiveness in mechanically ventilated patients. We studied 25 patients referred for coronary artery bypass grafting. SVV was continuously displayed by the Vigileo/FloTrac system. All patients were under general anesthesia, mechanical ventilation and were also monitored with a pulmonary artery catheter. SVV and DeltaPP were recorded simultaneously before and after an intravascular volume expansion (VE) (500 mL hetastarch). Responders to VE were defined as patients whose cardiac index obtained using thermodilution increased by more than 15% after VE. Agreement between DeltaPP and SVV over the 50 pairs of collected data was -1.3% +/- 2.8% (mean bias +/- sd). Seventeen patients were responders to VE. A threshold DeltaPP value of 10% allowed discrimination of responders to VE with a sensitivity of 88% and a specificity of 87%. A threshold SVV value of 10% allowed discrimination of responders to VE with a sensitivity of 82% and a specificity of 88%. SVV predicts fluid responsiveness with an acceptable sensitivity and specificity and is also a potential surrogate for continuous monitoring of DeltaPP.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clinics (Sao Paulo)
                Journal ID (iso-abbrev): Clinics (Sao Paulo)
                Title: Clinics
                Publisher: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
                ISSN (Print): 1807-5932
                ISSN (Electronic): 1980-5322
                Publication date (Print): July 2013
                Volume: 68
                Issue: 7
                Pages: 1065-1070
                Affiliations
                Zhejiang University, First Affiliated Hospital College of Medicine, Department of Anesthesiology, Hangzhou, Zhejiang/China.
                Author notes

                Zhang J designed the study, conducted the research, and wrote the manuscript. Chen CQ and Lei XZ helped to design the study, conducted the research, and wrote the manuscript. Feng ZY helped to design the study and conducted the research. Zhu SM is the corresponding author, designed the study and revised the manuscript. All of the authors read and approved the final manuscript.

                E-mail: smzhu20088@ 123456yahoo.com.cn Tel.: 86 571 87236169
                Article
                Publisher ID: cln_68p1065
                DOI: 10.6061/clinics/2013(07)27
                PMC ID: 3715019
                PubMed ID: 23917675
                SO-VID: bd418366-b7f6-421e-89a2-2a37efa641f0
                Copyright © Copyright © 2013 Hospital das Clínicas da FMUSP
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 2 April 2013
                Date revision received : 24 April 2013
                Date accepted : 2 May 2013
                Page count
                Pages: 6
                Categories
                Subject: Rapid Communication

                ScienceOpen disciplines: Medicine
                Keywords: stroke volume,cardiac output,fluid therapy,one-lung ventilation
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: stroke volume, cardiac output, fluid therapy, one-lung ventilation

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