Directorate of Gastroenterology, Theatres and Pain, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth PL6 8DH, UK.
Br J Anaesth. 2012 Jan;108(1):53-62. doi: 10.1093/bja/aer273. Epub 2011 Aug 26.
Intraoperative fluid therapy regimens using oesophageal Doppler monitoring (ODM) to optimize stroke volume (SV) (goal-directed fluid therapy, GDT) have been associated with a reduction in length of stay (LOS) and complication rates after major surgery. We hypothesized that intraoperative GDT would reduce the time to surgical readiness for discharge (RfD) of patients having major elective colorectal surgery but that this effect might be less marked in aerobically fit patients.
In this double-blinded controlled trial, 179 patients undergoing major open or laparoscopic colorectal surgery were characterized as aerobically 'fit' (n=123) or 'unfit' (n=56) on the basis of their performance during a cardiopulmonary exercise test. Within these fitness strata, patients were randomized to receive a standard fluid regimen with or without ODM-guided intraoperative GDT.
GDT patients received an average of 1360 ml of additional intraoperative colloid. The mean cardiac index and SV at skin closure were significantly higher in the GDT group than in controls. Times to RfD and LOS were longer in GDT than control patients but did not reach statistical significance (median 6.8 vs 4.9 days, P=0.09, and median 8.8 vs 6.7 days, P=0.09, respectively). Fit GDT patients had an increased RfD (median 7.0 vs 4.7 days; P=0.01) and LOS (median 8.8 vs 6.0 days; P=0.01) compared with controls.
Intraoperative SV optimization conferred no additional benefit over standard fluid therapy. In an aerobically fit subgroup of patients, GDT was associated with detrimental effects on the primary outcome.
UK NIHR CRN 7285, ISRCTN 14680495. http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=7285.
使用食道多普勒监测（ODM）优化每搏量（SV）的术中液体治疗方案（目标导向液体治疗，GDT）与主要手术后住院时间（LOS）和并发症发生率的降低相关。我们假设，在接受主要择期结直肠手术的患者中，术中 GDT 会减少其准备出院的时间（RfD），但在有氧适能较好的患者中，这种效果可能不那么明显。
在这项双盲对照试验中，根据心肺运动测试期间的表现，将 179 例接受大切口或腹腔镜结直肠手术的患者分为有氧“适应”（n=123）或“不适应”（n=56）。在这些适应能力的亚组中，患者随机接受标准液体方案或 ODM 指导的术中 GDT。
GDT 患者接受了平均 1360 毫升的额外术中胶体。皮肤关闭时，GDT 组的平均心指数和 SV 明显高于对照组。RfD 和 LOS 的时间在 GDT 组比对照组更长，但没有达到统计学意义（中位数分别为 6.8 天和 4.9 天，P=0.09 和中位数分别为 8.8 天和 6.7 天，P=0.09）。与对照组相比，有氧 GDT 患者的 RfD（中位数 7.0 天比 4.7 天；P=0.01）和 LOS（中位数 8.8 天比 6.0 天；P=0.01）均增加。
与标准液体治疗相比，术中 SV 优化没有带来额外的益处。在有氧适能较好的患者亚组中，GDT 与主要结局的不良影响相关。
英国国家卫生与临床优化研究所 CRN 7285，ISRCTN 14680495。http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=7285。
