Scripties UMCG - Rijksuniversiteit Groningen
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The evaluation of a hemodynamic optimisation protocol guided by a non-invasively measuring device during total hip arthroplasty: a Quality Improvement Program with a before - after design

(2016) Nanninga, C.J.

The total hip arthroplasty (THA) is one of the most commonly performed orthopaedic surgeries at the UMCG. Postoperative complications (POC) occur frequently after THA. POC induce a prolonged length of stay (LOS) and higher readmission rates, mortality rates and hospital costs in comparison with patients without POC. The exact pathogenesis that leads to POC is not yet completely understood, however evidence shows that hemodynamic instability during high-risk surgery (HRS) plays an important role. Goal-directed therapy (GDT) has been developed to achieve perioperative hemodynamic stability. Dynamic variables like stroke volume variations are proven to be predict fluid responsiveness adequately. A hemodynamic optimisation protocol (HOP) based on the SVV, stroke volume (SV) and cardiac-index (CI) has been implemented in HRS at the UMCG as standard care. The aim of this study was to investigate whether using this HOP in combination with a non-invasive measurement device during THA would reduce POC and the LOS compared to patients having undergone this procedure before the protocol was implemented.
Materials and Methods
This was a before-after study: patients that underwent a THA before the HOP implementation (January 2015 - May 2015) were compared with patients undergoing THA with a HOP (January 2016 - May 2016). Two different HOPs have been developed in the UMCG. HOP A is based on the SVV and the CI, HOP B on the SV and the CI. These hemodynamic variables were measured non-invasively with a Clearsight finger cuff and monitored via the EV1000 clinical platform. Crystalloid and/or colloidal fluid boluses were administered to keep the SVV and SV in the target range (SVV < 12%, SV <10% increase after a bolus) ensuring that the patient was kept on the plateau of the Frank-Starling curve to optimise tissue perfusion. In addition, dobutamine was infused if the CI was below the age-specific target value. The primary outcomes of this study were the occurrence of complications within 30 days after surgery, the severity of the POC (graded according to Accordion Scale of Severity) and the LOS. The secondary outcome was the calculated hospital costs per patient (CPP).
Sixty-eight patients were included in the current study. There were no significant differences in primary and secondary outcomes between the Beforegroup and Aftergroup. However, the amount of POC tended to reduce by 34% after GDT (p=0,444). The mean POC-score per patient based on the Accordion Scale of Severity appeared to be lower in the Aftergroup compared to the Beforegroup (2 vs. 3 respectively). The LOS did not differ between the Before- and Aftergrouo (7 [5-9] vs 8 [5-8] respectively) (p=0,577). GDT induced a potential cost benefit of €325, - per patient (p=0,421). A binary logistic regression model showed no significant influences of the confounders (ASA III, BMI, gender, duration of surgery and age) on POC and LOS in this study. Only the usage of a HOP tended to reduce the presence of POC (Odds rate (OR): 0,6 Confidence Interval (CIt): 0,1-1,4 p=0,166) and the LOS (OR: 0,9 CI: 0,3-3,1 p=0,919).
This before - after study showed that goal-directed therapy based on non-invasive hemodynamic monitoring tended to reduce postoperative complications and costs after total hip arthroplasty. No significant reduction in the length of stay in the hospital was observed. Future studies may benefit from a larger amount of included patients.

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