Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial

Abstract

Introduction: Several studies have shown that maximizing stroke volume (or increasing it until a plateau is reached) by volume loading during high-risk surgery may improve post-operative outcome. This goal could be achieved simply by minimizing the variation in arterial pulse pressure (deltaPP) induced by mechanical ventilation. We tested this hypothesis in a prospective, randomized, single-centre study. The primary endpoint was the length of postoperative stay in hospital.

Methods: Thirty-three patients undergoing high-risk surgery were randomized either to a control group (group C, n = 16) or to an intervention group (group I, n = 17). In group I, deltaPP was continuously monitored during surgery by a multiparameter bedside monitor and minimized to 10% or less by volume loading.

Results: Both groups were comparable in terms of demographic data, American Society of Anesthesiology score, type, and duration of surgery. During surgery, group I received more fluid than group C (4,618 +/- 1,557 versus 1,694 +/- 705 ml (mean +/- SD), P < 0.0001), and deltaPP decreased from 22 +/- 75 to 9 +/- 1% (P < 0.05) in group I. The median duration of postoperative stay in hospital (7 versus 17 days, P < 0.01) was lower in group I than in group C. The number of postoperative complications per patient (1.4 +/- 2.1 versus 3.9 +/- 2.8, P < 0.05), as well as the median duration of mechanical ventilation (1 versus 5 days, P < 0.05) and stay in the intensive care unit (3 versus 9 days, P < 0.01) was also lower in group I.

Conclusion: Monitoring and minimizing deltaPP by volume loading during high-risk surgery improves postoperative outcome and decreases the length of stay in hospital.

Trial registration: NCT00479011.

Figure 1

Automatic calculation of variation in arterial pulse pressure (ΔPP) from the recordings of arterial pressure and capnographic signals on a regular bedside monitor.

Figure 2

Trial profile.

Figure 3

Numbers of patients with postoperative complications in the control and intervention groups.

Figure 4

Box-and-whiskers representation of the duration (days) of mechanical ventilation (MV), stay in the intensive care unit (ICU), and stay in hospital in the control and intervention groups. The line inside a box denotes the median, the limits of the box denote the 75th centile of the data, and the whiskers represent the 90th centile of the data.