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Cited by 175Hemodynamic Monitoring and TherapyCardiac and Coronary Surgery TechniquesSepsis Diagnosis and Treatment

Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review

Osawa, Eduardo A., Rhodes, Andrew, Landoni, Giovanni, Galas, Filomena R. B. G., Fukushima, Julia T., Park, Clarice H. L., Almeida, Juliano P., Nakamura, Rosana E. +21 more·2016·Critical Care Medicine
DOI 10.1097/ccm.0000000000001479
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Abstract

OBJECTIVES: To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. DESIGN: A prospective randomized controlled trial and an updated metaanalysis of randomized trials published from inception up to May 1, 2015. SETTING: Surgical ICU within a tertiary referral university-affiliated teaching hospital. PATIENTS: One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair. INTERVENTIONS: Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64). In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed therapy group received a greater median (interquartile range) volume of IV fluids than the usual care group (1,000 [625-1,500] vs 500 [500-1,000] mL; p < 0.001], with no differences in the administration of either inotropes or RBC transfusions. The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037). The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome (6.5% vs 26.6%; p = 0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3-4] vs 5 [4-7] d; p < 0.001) and hospital length of stay (9 [8-16] vs 12 [9-22] d; p = 0.049) in the goal-directed therapy compared with the usual care group. There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410 [11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26-0.63]; p < 0.0001) and decreased the hospital length of stay (mean difference, -5.44 d; 95% CI, -9.28 to -1.60; p = 0.006) with no difference in postoperative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio, 0.61 (95% CI, 0.26-1.47), and p = 0.27. CONCLUSIONS: Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.

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Authors
Osawa, E. A., Rhodes, A., Landoni, G., Galas, F. R. B. G., Fukushima, J. T., Park, C. H. L., Almeida, J. P., Nakamura, R. E., Strabelli, T. M. V., Pileggi, B., Leme, A. C., Fominskiy, E., Sakr, Y., Lima, M., Franco, R. A., Chan, R. P. C., Piccioni, M. A., Mendes, P., Menezes, S. R., Bruno, T., Gaiotto, F. A., Lisboa, L. A., Dallan, L. A. O., Hueb, A. C., Pomerantzeff, P. M., Kalil Filho, R., Jatene, F. B., Auler Junior, J. O. C., & Hajjar, L. A.
Affiliations
Vita-Salute San Raffaele University (IT)
ORCID
Venue
Critical Care Medicine
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2016-04
Volume
44
Issue
4
Pages
724-733
ISSN
0090-3493 (ISSN-L)
DOI
10.1097/ccm.0000000000001479
OpenAlex
W2192248897
Cited by
173
References
0
Citations by year
2026: 10 · 2025: 17 · 2024: 19 · 2023: 11 · 2022: 10 · 2021: 20 · 2020: 20 · 2019: 18 · 2018: 14 · 2017: 22 · 2016: 11 · 2015: 1
FWCI
16.13
Type
journal article
Language
en
Open access
closed
Locations
  • Critical Care Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
  • Health Sciences › Medicine › Surgery › Cardiac and Coronary Surgery Techniques
  • Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
Keywords
goal-directed therapy, cardiac surgery, cardiac output monitoring, cardiac index, coronary artery bypass grafting, valve repair, 30-day mortality, postoperative complications, low cardiac output syndrome, postoperative infection, dobutamine, fluid resuscitation, inotropic agents, red blood cell transfusion, ICU length of stay, high-risk patients, meta-analysis
MeSH terms
Aged, Aged, 80 and over, Cardiac Output, Dobutamine, Female, Fluid Therapy, Cardiac Surgical Procedures, Hemodynamics, Humans, Intensive Care Units, Length of Stay, Male, Middle Aged, Postoperative Complications, Meta-Analysis as Topic, Treatment Outcome, Adrenergic beta-1 Receptor Agonists

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