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Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial.
PLoS One. 2017; 12(9):e0183313.Plos

Abstract

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.

Authors+Show Affiliations

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.Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia.Statistics and Decision Analysis Academic Platform, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia.Department of Anaesthesia, Box Hill Hospital, Box Hill, Victoria, Australia.Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia.Department of Anaesthesia, Box Hill Hospital, Box Hill, Victoria, Australia.Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia.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.Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia.Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia.Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia.

Pub Type(s)

Journal Article
Multicenter Study
Randomized Controlled Trial

Language

eng

PubMed ID

28880931

Citation

Weinberg, Laurence, et al. "Restrictive Intraoperative Fluid Optimisation Algorithm Improves Outcomes in Patients Undergoing Pancreaticoduodenectomy: a Prospective Multicentre Randomized Controlled Trial." PloS One, vol. 12, no. 9, 2017, pp. e0183313.
Weinberg L, Ianno D, Churilov L, et al. Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial. PLoS ONE. 2017;12(9):e0183313.
Weinberg, L., Ianno, D., Churilov, L., Chao, I., Scurrah, N., Rachbuch, C., Banting, J., Muralidharan, V., Story, D., Bellomo, R., Christophi, C., & Nikfarjam, M. (2017). Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial. PloS One, 12(9), e0183313. https://doi.org/10.1371/journal.pone.0183313
Weinberg L, et al. Restrictive Intraoperative Fluid Optimisation Algorithm Improves Outcomes in Patients Undergoing Pancreaticoduodenectomy: a Prospective Multicentre Randomized Controlled Trial. PLoS ONE. 2017;12(9):e0183313. PubMed PMID: 28880931.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial. AU - Weinberg,Laurence, AU - Ianno,Damian, AU - Churilov,Leonid, AU - Chao,Ian, AU - Scurrah,Nick, AU - Rachbuch,Clive, AU - Banting,Jonathan, AU - Muralidharan,Vijaragavan, AU - Story,David, AU - Bellomo,Rinaldo, AU - Christophi,Chris, AU - Nikfarjam,Mehrdad, Y1 - 2017/09/07/ PY - 2017/01/22/received PY - 2017/07/31/accepted PY - 2017/9/8/entrez PY - 2017/9/8/pubmed PY - 2017/10/17/medline SP - e0183313 EP - e0183313 JF - PloS one JO - PLoS ONE VL - 12 IS - 9 N2 - 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. SN - 1932-6203 UR - https://www.unboundmedicine.com/medline/citation/28880931/Restrictive_intraoperative_fluid_optimisation_algorithm_improves_outcomes_in_patients_undergoing_pancreaticoduodenectomy:_A_prospective_multicentre_randomized_controlled_trial_ L2 - http://dx.plos.org/10.1371/journal.pone.0183313 DB - PRIME DP - Unbound Medicine ER -