Department of Anaesthesiology, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto - SP, Brazil.
Intensive Care Unit, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto - SP, Brazil.
Anaesthesiol Intensive Ther. 2020;52(4):297-303. doi: 10.5114/ait.2020.100636.
Current evidence suggests that intraoperative goal-directed haemodynamic therapy (GDT) should be considered for high-risk patients undergoing major gastrointestinal surgery. We aimed to evaluate if an algorithm using venoarterial carbon dioxide difference (CO2 gap) and pulse pressure variation (PPV) as therapeutic targets during GDT would decrease the major complications after gastrointestinal surgery.
This was a before-and-after study (n = 204) performed in a tertiary hospital on patients who underwent elective open major gastrointestinal surgeries. The inclusion criteria were surgeries expected to last more than two hours, family and physician's agreement on total postoperative support, and survival expectancy of at least three months. The exclusion criteria were previous haemodynamic instability, presence of infection, cardiac arrhythmias, and emergency surgery. In the intervention group (IG), an algorithm was applied using fluids, dobutamine, and noradrenaline during the intraoperative period aiming at MAP > 65 mm Hg, SpO2 > 95%, CO2 gap < 6 mm Hg, and PPV < 13%. The control group (CG) comprised consecutive eligible patients who were operated by the same team before the institution of the algorithm.
The rates of moderate and severe postoperative complications were lower in the IG (11% vs. 23%; IC: RR = 0.47, 95% CI: 0.246-0.929; P = 0.025). The respective 90- and 180-day mortality rates in the IG and CG were 9.8% vs. 22.5% (P = 0.014) and 12.6% vs. 25.5% (P = 0.020).
An algorithm aiming to minimise the CO2 gap and normalise PPV was feasible and effective in decreasing rates of moderate and severe complications after surgery in high-risk patients.
目前的证据表明，对于接受重大胃肠道手术的高危患者，应考虑术中目标导向的血流动力学治疗（GDT）。我们旨在评估在 GDT 期间使用动静脉二氧化碳差值（CO2 间隙）和脉搏压变异（PPV）作为治疗目标的算法是否会降低胃肠道手术后的主要并发症。
这是一项在一家三级医院进行的前后对照研究（n = 204），纳入了接受择期开放性重大胃肠道手术的患者。纳入标准为预计手术时间超过 2 小时、患者及其家属同意接受术后全面支持治疗、预计至少存活 3 个月。排除标准为既往血流动力学不稳定、存在感染、心律失常和急诊手术。在干预组（IG）中，在术中期间应用液体、多巴酚丁胺和去甲肾上腺素，目标为平均动脉压（MAP）> 65 mmHg、SpO2 > 95%、CO2 间隙< 6 mmHg 和 PPV < 13%。对照组（CG）包括在该算法实施前由同一团队手术的连续合格患者。
IG 中中度和重度术后并发症的发生率较低（11% vs. 23%；IC：RR = 0.47，95%CI：0.246-0.929；P = 0.025）。IG 和 CG 的 90 天和 180 天死亡率分别为 9.8% vs. 22.5%（P = 0.014）和 12.6% vs. 25.5%（P = 0.020）。
旨在最小化 CO2 间隙和使 PPV 正常化的算法在降低高危患者手术后中重度并发症发生率方面是可行且有效的。
