Scripties UMCG - Rijksuniversiteit Groningen
 
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The effects of the compliance of a goal-directed fluid therapy protocol on postoperative complications in patients undergoing high-risk surgery: a before-after trial

(2017) Boekel, M.F.

Introduction. The use of perioperative goal-directed fluid therapy (GDFT), a protocol aiming to improve the haemodynamic status of patients, had been shown beneficial on the postoperative outcome of patients undergoing high-risk surgery. However, the effects of protocol compliance (the degree to which a specific protocol is performed correctly) has yet to be studied. The primary aim of this study was to assess the influence of protocol compliance on complications and mortality rate postoperatively in high-risk surgical procedures guided by a GDFT protocol.
Materials and Methods. In this observational study we included 211 patients before the implementation (08-2013 – 01-2015) and 227 patients after the implementation of the GDFT protocol (02-2015 – 06-201). For this study we used a quality improvement programme to implement the protocol to better reflect the real effects of the protocol, with less oversight in protocol use. Included high-risk procedures were: pylorus preserving pancreaticoduodenectomy (PPPD), abdominoperineal colorectal resection, open abdominal aortic aneurysm repair, oesophagus resection, femoral popliteal bypass surgery, or total hip replacement. In the GDFT protocol multiple variables such as stroke volume variation (SVV), stroke volume index (SVI), and cardiac index (CI) were used to guide intravenous fluid and dobutamine administration. These variables were measured using the EV1000/FloTrac hemodynamic monitoring system. The primary outcome was protocol compliance on postoperative complications. Secondary outcomes were the severity of complications, graded with the Expanded Accordion Classification Model.
Results. When comparing procedures before the implementation of the GDFT protocol and procedure after implementation, the complication rate showed a reductive trend of 25% in the group after implementation of the GDFT protocol compared to the group before implementation (mean complication rate per patient of 1.7 versus 1.3 respectively, P = 0.144). All individual surgical procedures showed a trend towards reduction in complication rate after the implementation, expect for PPPD and total hip replacement procedures. Furthermore, when analysing the severity of complications, there was also a non-significant trend towards reduction in the severe complication after the implementation of the GDFT. The overall protocol compliance was low with only 48% of the procedures reaching a sufficient SVV/SVI compliance of 80% or above, while only 20% of the procedures had a CI compliance that was above the set threshold. Procedures that had an SVV/SVI compliance above 80% showed a significant decrease in mild/moderate complication rate (1.16 versus 0.77, P = 0.017), a strong trend in reducing severe complication rate (0.26 versus 0.19, P = 0.054) and a significant reduction in the total complication rate (1.42 versus 0.96 , P = 0.015). CI compliance above or below 80% did not have any significant influence on the total amount of complications or the severity of complications.
Conclusion. This study shows that a low compliance of the GDFT protocol greatly influences the postoperative outcome. Having a high protocol compliance (especially for SVV/SVI) was associated with a lower complication rate, in both mild/moderate complications and total complications.






 
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