Goal-directed medical therapy and point-of-care testing improve outcomes after congenital heart surgery

Abstract

Objective: A goal-directed therapy algorithm based on serial lactate values obtained from a point-of-care testing device was utilized in an attempt to reduce the mortality of patients after congenital heart surgery.

Design: Prospective study of patients undergoing surgery utilizing a goal-directed therapy algorithm in the postoperative period. The results of this group are compared with a historical cohort. Operative risk was determined using the RACHS-1 scoring system.

Setting: A 12-bed cardiac intensive care unit (ICU) in a pediatric hospital.

Patients: Patients undergoing surgery from July 2001 through September 2003 (group B, n=710) were compared to cohorts from June 1995 through June 2001 (group A, n=1,656). Group B patients were smaller and younger (median weight 6.2 vs 8 kg, p<0.001; median age 184 vs 327 days, p=0.004).

Interventions: Beginning in July 2001, blood lactate measurements were performed serially for 24 h after heart surgery. Based on lactate values and trends, therapy was amended.

Measurements and results: Mortality was lower for group B (1.8 vs 3.7%, p=0.02). A reduction in mortality between group B and group A was noted in neonates (3.4 vs 12%, p=0.02), but not in older patients. Group B patients undergoing higher risk operations (Risk Adjustment for Congenital Heart Surgery-1 [RACHS-1] categories 3-6) had a significant reduction in mortality when compared to group A (3 vs 9%, p=0.006), no difference was noted in patients undergoing lower risk operations (RACHS-1 categories 1 and 2).

Conclusions: The combination of goal-directed therapy and point-of-care testing was associated with a marked decrease in mortality for patients undergoing congenital heart surgery. Improvement was greatest in the highest risk patients.