Weinberg Laurence, Ianno Damian, Churilov Leonid, Chao Ian, Scurrah Nick, Rachbuch Clive, Banting Jonathan, Muralidharan Vijaragavan, Story David, Bellomo Rinaldo, Christophi Chris, Nikfarjam Mehrdad
Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia.
Anaesthesia and Perioperative and Pain Medicine Unit, The University of Melbourne, Parkville, Victoria, Australia.
PLoS One. 2017 Sep 7;12(9):e0183313. doi: 10.1371/journal.pone.0183313. eCollection 2017.
We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. "precision" fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.
我们旨在评估接受胰十二指肠切除术的患者在采用或不采用心输出量目标导向治疗（GDT）算法时的围手术期结局。我们在四个大型肝胆胰外科中心进行了一项多中心随机对照试验。我们评估了术中液体优化算法的额外影响是否会影响液体输入量、减少与液体相关的并发症并缩短住院时间。连续招募了52名成年患者。GDT组手术的中位（四分位间距）持续时间为8.6小时（7.1:9.6），而常规治疗组为7.8小时（6.8:9.0）（p = 0.2）。GDT组术中液体平衡为1005mL（475:1873），而常规治疗组为3300mL（2474:3874）（p<0.0001）。GDT组术中给予的液体总量也较低：2050mL（1313:2700）对比4088mL（3400:4525），p<0.0001，且血管活性药物使用更频繁。总体并发症患者比例无显著差异（p = 0.179）；然而，GDT组发生的并发症较少：44例对比92例（发病率比：0.41；95%置信区间0.24至0.69，p = 0.001）。GDT组的中位（四分位间距）住院时间为9.5天（四分位间距：7.0，14.3），而常规治疗组为12.5天（四分位间距：9.0，22.3），发病率比为0.64（95%置信区间0.48至0.85，p = 0.002）。总之，在该队列患者中使用针对手术和患者的目标导向限制性液体治疗算法，可以在不引起水肿的情况下合理使用足够的液体，同时在不引起血容量不足的情况下尽可能少用液体，即“精准”液体治疗。我们的研究结果支持使用围手术期血流动力学优化方案，该方案通过合理使用液体治疗、合理使用血管活性药物和及时应用强心药物，优先维持心输出量和器官灌注压。它们还表明需要进一步开展更大规模的研究来证实其研究结果。
