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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 1  |  Page : 27-34
Early goal-directed therapy in moderate to high-risk cardiac surgery patients


1 Department of Cardiac Anaesthesia, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
2 Department of Cardiothoracic Surgery, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
3 Department of Cardiac Biochemistry, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

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   Abstract 

Early goal-directed therapy is a term used to describe the guidance of intravenous fluid and vasopressor/inotropic therapy by using cardiac output or similar parameters in the immediate post-cardiopulmonary bypass in cardiac surgery patients. Early recognition and therapy during this period may result in better outcome. In keeping with this aim in the cardiac surgery patients, we conducted the present study. The study included 30 patients of both sexes, with EuroSCORE ≥3 undergoing coronary artery bypass surgery under cardiopulmonary bypass. The patients were randomly divided into two groups, namely, control and early goal-directed therapy (EGDT) groups. All the subjects received standardized care; arterial pressure was monitored through radial artery, central venous pressure through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour and frequent arterial blood gas analysis. In addition, cardiac index monitoring using FloTrac™ and continuous central venous oxygen saturation using PreSep™ was used in patients in the EGTD group. Our aim was to maintain the cardiac index at 2.5-4.2 l/min/m 2 , stroke volume index 30-65 ml/beat/m 2 , systemic vascular resistance index 1500-2500 dynes/s/cm 5 /m 2 , oxygen delivery index 450-600 ml/min/m 2 , continuous central venous oximetry more than 70%, stroke volume variation less than 10%; in addition to the control group parameters such as central venous pressure 6-8 mmHg, mean arterial pressure 90-105 mmHg, normal arterial blood gas analysis values, pulse oximetry, hematocrit value above 30% and urine output more than 1 ml/kg/h. The aims were achieved by altering the administration of intravenous fluids and doses of inotropic or vasodilator agents. Three patients were excluded from the study and the data of 27 patients analyzed. The extra volume used (330 ± 160 v/s 80 ± 80 ml, P = 0.043) number of adjustments of inotropic agents (3.4 ± 1.5 v/s 0.4 ± 0.7, P = 0.026) in the EGDT group were significant. The average duration of ventilation (13.8 ± 3.2 v/s 20.7 ± 7.1 h), days of use of inotropic agents (1.6 ± 0.9 v/s 3.8 ± 1.6 d), ICU stay (2.6 ± 0.9 v/s 4.9 ± 1.8 d) and hospital stay (5.6 ± 1.2 v/s 8.9 ± 2.1 d) were less in the EGDT group, compared to those in the control group. This study is inconclusive with regard to the beneficial aspects of the early goal-directed therapy in cardiac surgery patients, although a few benefits were observed.

Keywords: Cardiac surgery, early goal-directed therapy, haemodynamic monitoring, outcome measures, perioperative

How to cite this article:
Kapoor PM, Kakani M, Chowdhury U, Choudhury M, Lakshmy R, Kiran U. Early goal-directed therapy in moderate to high-risk cardiac surgery patients. Ann Card Anaesth 2008;11:27-34

How to cite this URL:
Kapoor PM, Kakani M, Chowdhury U, Choudhury M, Lakshmy R, Kiran U. Early goal-directed therapy in moderate to high-risk cardiac surgery patients. Ann Card Anaesth [serial online] 2008 [cited 2017 Jun 22];11:27-34. Available from: http://www.annals.in/text.asp?2008/11/1/27/38446



   Introduction Top


Approximately 10% of patients require prolonged postoperative care after undergoing cardiac surgery because of haemodynamic instability, organ dysfunction or multiple organ failure. [1] This results in increased costs for intensive care unit (ICU) and hospital resource utilisation and health care. Although multiple factors are responsible for the above mentioned requirements, limited cardiovascular resources and inadequate haemodynamic response to the postoperative surgical stress have recently been shown to be independent predictors of prolonging the ICU stay. [2] As a result of continually improving surgical strategies and the supportive technologies, it has now become possible to conduct cardiac surgery in high-risk population. [3] These high-risk patients undergoing cardiac surgery carry higher risks of morbidity and mortality. [4] The survivors of major operations have also been shown to demonstrate consistently higher postoperative cardiac output and oxygen delivery than those patients who die. [4] It has been suggested that the mortality rate in high-risk surgical patients may be reduced if the haemodynamic parameters noted in the survivors were used as goals in high-risk patients. [4] Global tissue hypoxia is a key indicator of serious illness or low cardiac output. [5] In the immediate postcardiopulmonary bypass period, the recognition and treatment of low cardiac output produces benefit in terms of outcome. [6] Early goal-directed therapy (EGDT) describes the early alteration of haemodynamic parameters to guide the intravenous fluid and inotropic therapy to achieve preset goals. [7] Perioperative volume optimization has been shown to improve the outcome in cardiac surgery patients, whereas inadequate oxygen delivery after cardiac surgery was recognized as an independent predictor of prolonged ICU stay. [8],[9] A more definitive support strategy appears to be goal-oriented manipulation of cardiac preload, afterload and contractility to achieve a balance between the systemic oxygen delivery and demand. Sparse literature is available with regard to EGDT in high-risk cardiac surgery patients; therefore, we decided to study the outcome of EGDT in patients with moderate to high risk (EuroSCORE ≥3). Our aims were to maintain the cardiac index (CI) between 2.5-4.2 l/min/m 2 ; stroke volume index (SVI), 30-65 ml/beat/m 2 ; systemic vascular resistance index (SVRI), 1500-2500 dynes/s/cm 5 /m 2 ; oxygen delivery index (DO 2 I), 450-600 ml/min/m 2 ; continuous central venous oximetry (ScVO 2 ), more than 70% and stroke volume variation (SVV), less than 10%. Other routinely used parameters complimented in achieving the early goals. The parameters and the normal accepted range were the following: central venous pressure (CVP), 6-8 mmHg; mean arterial pressure (MAP), 90-105 mmHg, pulse oximetry (SpO 2 ), more than 95%; arterial blood gas analysis (ABG), pH 7.35-7.45; partial arterial oxygen tension (PaO 2 ), more than 100 mmHg; partial arterial carbon dioxide tension (PaCO 2 ), 35-45 mmHg; (ventilatory parameters set at respiratory rate of 14-16 breaths/min, tidal volume of 8-10 ml/kg, fractional inspired oxygen concentration (FiO 2 ) of 0.6, pressure-regulated volume-controlled mode of ventilation), hematocrit value more than 30% and urine output more than 1ml/kg/h. [10] We used the FloTrac™ (a new minimally invasive cardiac output monitor) cardiac output sensor, and the PreSep™ catheter in conjunction with the vigileo monitor (Edwards Life Sciences, Irvine, CA, USA) to provide all the data required for the study without using the pulmonary artery catheter (PAC).


   Materials and Methods Top


We obtained ethical clearance from the institutional review board and informed consent from the patients; 30 patients were enrolled in this prospective randomized controlled study. The patients were divided randomly into two groups, namely, control and EGDT groups, by the sealed envelope technique. Patients of both sexes undergoing coronary artery bypass surgery on CPB with an EuroSCORE ≥3 (Appendix 2) were included. Patients with cardiac dysrhythmias and contraindication to the central venous cannulation were excluded. Patients requiring the initiation of intraaortic balloon pump (IABP) therapy were excluded because the FloTrac™ is not equipped to identify the waveforms of arterial pressure waveform while using IABP.

All patients received standard care as per our institutional protocol. Premedication comprising 0.1 mg/kg morphine and 0.25 mg/kg promethazine (maximum dose of 25 mg), was administered intramuscularly 30 min prior to surgery. In the operation theater, electrocardiogram, noninvasive blood pressure and pulse oximetry were monitored. In addition, the CI using FloTrac and the central venous oxygen saturation using PreSep catheter were monitored in the EGTD group. Supplemental oxygen was administered through a facemesk. Fentanyl (2 µg/kg) was administered intravenously (IV). A 20-G cannula was placed in the right radial artery. FloTrac™ cardiac output monitoring sensor was connected to the radial arterial cannula in the EGDT group. Additionally 2 µg/kg fentanyl and 1 mg midazolam was administered intravenously. A triple-lumen central venous catheter in the control group or PreSep™ catheter (continuous central venous oximetry) in the EGDT group was inserted under local anaesthesia in the right internal jugular vein. Baseline readings (T1) of heart rate (HR), MAP, CVP, SpO 2 and ABG were recorded.

Equipment characteristics

FloTrac™ is a novel device to measure cardiac output based on the analysis of the systemic arterial pressure waveform in conjunction with the patient's demographic data. It does not require catheterization of the pulmonary artery or calibration with another method. The processing unit applies a proprietary algorithm to the digitized wave and reports the cardiac output, CI, SV, SVI and SVV. If the value of central venous pressure is entered in the computer, it calculates the SVR and SVRI. When used with a central venous oximetry catheter, the vigileo also provides the values of ScvO 2 and DO 2 I.

In the EGDT group, the additional baseline readings (T1) of CI, SVRI, DO 2 I, SVI, SVV and ScVO 2 were recorded. General anaesthesia was induced with sleep dose of thiopentone. Rocuronium (1 mg/kg, IV) was administered to facilitate endotracheal intubation. Patients were mechanically ventilated with air:oxygen mixtures (50:50) to maintain end-tidal carbon dioxide (ETCO 2 ) values between 30 and 35 mmHg. Anaesthesia was maintained with 1 MAC value of sevoflurane. Additional intermittent intravenous doses of fentanyl, midazolam and pancuronium were administered as deemed necessary. Nasopharyngeal temperature, urinary output and ETCO 2 were recorded. CPB was initiated after heparinization with an intravenous dose of 4 mg/kg. Mild hypothermia (32 °C) was maintained during CPB. Cardioplegia was composed of cold crystalloid solution, and blood in 1:4 ratio was infused through the root cardioplegia cannula after aortic cross clamping. Every 20 min, cardioplegia was repeated as per the institutional protocol. MAP was maintained in the range 50-70 mmHg during CPB. Termination of CPB was initiated, if necessary by administering intravenous infusion of dopamine at the dose of 5 µgm/kg/min and vasodilatation with infusion of 0.5 µg/kg/min nitroglycerin. The parameters recorded at the closure of sternum were designated as T2. All patients were mechanically ventilated for 6-8 h in the ICU.

In the control group, postoperative management was carried out according to the institutional protocol. All patients received 500 ml/m 2 /d of crystalloid solution. [11] CVP was maintained between 6 and 8 mmHg. MAP was maintained between 90 and 105 mmHg by altering the dosage of the inotropic agent if already being infused and initiating (dopamine) or adding other inotropic agents (adrenaline, noradrenaline and milrinone). ABG and urinary output were monitored at hourly basis, and the biochemical abnormalities were corrected as necessary. Hematocrit value was maintained at or above 30% with packed cell transfusions, if necessary. HR, MAP, SpO 2 , CVP and peripheral temperature were monitored continuously and recorded at 0 (T3), 2 (T4), 4 (T5) and 8 (T6) h after transfer to the ICU.

In the EGDT group, if the cardiac index was less than 2.5 l/min/m 2 , CVP less than 6 mmHg or SVV more than 10%, fluids (100 ml aliquots of colloid) were administered given till the target CVP and SVV levels were achieved (Appendix 1). Inotropic agents and vasodilators were adjusted to maintain the parameters within the target values. The choice of inotropic agent selection was determined by MAP, SV and SVRI. All parameters were recorded at similar time intervals (T2 to T6). If ScVO 2 was less than 70%, packed red cells were administered to maintain the hematocrit value at more than 30% and if ScVO 2 continued to be less than 70%, EGDT was initiated to achieve the CI at 2.5-4.2 l/min/m 2 , SVI at 30-65 ml/beat/m 2 , SVRI at 1500-2500 dyne/s/cm -5 /m 2 , DO 2 I at 450-600 ml/min/m 2 , ScVO 2 more than 70% and SVV less than 10%, in addition to the goals in the standard care such as CVP 6-8 mmHg, MAP at 90-105 mmHg, ABG analysis values (pH 7.35-45, PaO 2 more than 100 mmHg and PaCO 2 35-45 mm Hg), SpO 2 more than 95%, hematocrit value more than 30% and urine output more than 1 ml/kg/h. [10] The monitoring was gradually withdrawn after 8 h.

Weaning from ventilator and extubation criteria

The patients were considered appropriate for weaning from ventilator when they were awake, showed normal skeletal muscle power, were haemodynamically stable and not having arrhythmias, ABG values within the physiological range, chest X-ray normal, rewarmed to the outer temperature more than 33 °C, chest-tube drainage less than 100 ml/h and urine output more than 1 ml/kg/h. Patients were reassessed every 2 h in the event of failure of weaning. All extubated patients were transferred from the ICU on the morning of the postoperative day two, unless the use of inotropic or vasodilator drugs were necessary. [12] The criteria for discharge from hospital included stable cardiac rhythm, oral temperature less than 99 °F, hematocrit value ≥25%, oral intake of atleast 1000 calories per day, successful completion of an exercise test that included independent ambulation or the ability to climb one flight of stairs, no significant wound complications and adequate home support system. [12]

The duration of ventilation (hours), duration of use of inotropic agents (days), the amount of extra volume used (ml) and the number of times inotropic agents were changed, length of stay in the ICU (LOS ICU) (days), hospital stay (days), occurrence of organ dysfunction and mortality were noted. The same surgeon operated on all patients

The results were analyzed with SPSS software for windows (SPSS Inc., version 10, Chicago, Illinois, USA). Student's t test or Mann-Whitney tests were used as appropriate to analyze the data. Two-way ANOVA test was used to analyze the data within the same group at various time intervals. All the values are reported as mean ± SD.


   Results Top


Each group contained 15 patients. One patient each from both the groups was excluded because of use of IABP and another in the EGDT group because of the postoperative atrial fibrillation, which occurred 1 h after transferring to ICU. The results of the remaining 14 patients in the control group and 13 in the EGDT group were analyzed. Demographic data and EuroSCORE, duration of CPB, duration of aortic cross clamping (AOXCL) and average number of grafts/patient were comparable [Table - 1]. HR, MAP, CVP, SpO 2 and ABG at various time intervals were comparable between the groups [Table - 2]. The patients in the EGDT group produced more urine during the study period, which was not statistically significant from the result of the control [Figure - 1]. ScVO 2 , CI, SVV, SVRI, SVI and DO 2 I were maintained within the physiological values [Table - 3]. However; statistically significant difference was noted with regard to CI and SVI at various time intervals, but they were maintained within the range of goals. There was statistically significant difference in the extra volume used (80 ± 80 v/s 330 ± 160, P = 0.043) and the number of times the inotropic agent was changed (0.4 ± 0.7 v/s 3.4 ± 1.5, P = 0.026) in the control and EGDT groups, respectively [Table - 4]. The duration of ventilatory support (20.7 ± 7 v/s 13.8 ± 3.2 h, P = 0.304), duration of use of inotropic agent (3.8 ± 1.6 v/s 1.6 ± 0.9 d, P = 0.136), LOS ICU (4.9 ± 1.8 v/s 2.6 ± 0.9 d, P = 0.142) and LOS hospital (8.8 ± 2.1 v/s 5.8 ± 1.2 d, P = 0.161) were less in the EGDT group, but not significant [Table - 4]. One patient each in both groups had renal dysfunction, which improved by administering diuretics [Table - 5]. One patient in the control group had ventricular fibrillation (VF) on the second postoperative day [Table - 5] probably due to hypokalaemia (K + = 2.9 mEq/L). He required ventilation for a day and was transferred from ICU to the ward on day 5. There were no respiratory, central nervous systems, gastrointestinal or hematological complications [Table - 5] in the patients of any group. No patient in this series suffered from perioperative myocardial infarction. There was no mortality in the series during the study period.


   Discussion Top


Organ dysfunction and multiple organ failure are the main causes of prolonged hospital stay after cardiac surgery. [1] Enhanced oxygen delivery and utilisation have been associated with improved outcome. [13] Cardiac surgery patients are at risk of inadequate perioperative oxygen delivery caused by extracorporeal circulation and limited cardiovascular reserves. [9]

The aim of EGDT is to maintain the CI, CVP, MAP, SVRI, DO 2 I, SVI, SVV, ScVO 2 , ABG and urine output within the physiological limits in the early postoperative period by active intervention. Polonen et al. , studied 403 elective cardiac surgery patients and concluded that by maintaining mixed venous oxygen saturation (SvO 2 ) more than 70%, decreases the LOS-ICU and LOS hospital is decreased. [13] They concluded that increasing SvO 2 in the postoperative period (8 h) after cardiac surgery decreases hospital stay and mortality. EuroSCORE is a simple, objective and up-to-date system for assessing the patient outcome after heart surgery. [14] Patients in the high-risk group tend to have increased morbidity and mortality rates in the postoperative period. [14] They may benefit from intensive monitoring and early interventions. Therefore, in this study, we wished to study the utility of EGDT in patients who with EuroSCORE ≥3 points (medium and high risk).

Mixed venous oxygen saturation can be measured by measuring the oxygen content of the blood withdrawn from the pulmonary artery through PAC. Goldman et al. , studied the central venous oxygen saturation (ScvO 2 ) in 31 patients with myocardial infarction. [15] ScvO 2 correlated well with the patient's clinical course. They concluded that the serial measurements of ScvO 2 appear a useful method for monitoring changes in myocardial function in patients with myocardial infarction. PreSep™ Central Venous Oximetry Catheter can be used to continuously monitor the central venous oxygen saturation. ScvO 2 is not similar to SvO 2 but correlates well with SvO 2 . The mixed venous oxygen saturation estimated from the superior vena cava was found to be 5-13% lower than that estimated from the pulmonary artery. [16] Hence, this method was decided to be used. To account for the overestimation by this method, a higher target was selected.

In cardiac surgery, EGDT has been commenced in the immediate postoperative period by many using a noninvasive method such as oesophageal Doppler probe demonstrating a decrease in the length of hospital stay instead of the pulmonary artery catheter to measure the cardiac output. [17],[18],[19] Unlike the FloTrac™, Doppler probe is not readily tolerated by conscious patients, restricting its use to patients who are ventilated following surgery, and the PAC is invasive with its own set of complications. [7]

A few studies by Manecke, McGee and Chakravarthy et al. , have validated the vigileo system. [20],[21],[22] These studies showed that the CI obtained by FloTrac™ is interchangeable with the measurement obtained by using the pulmonary artery catheter. In addition to accuracy, it is a minimally invasive device that provides data without the need for calibration, which is near real time. However, Opdam et al. , performed the cardiac output measurements in six patients with FloTrac™ and showed a limited correlation for CI with the two devices (r (2) = 0.1218, bias = 0.21, 95% limits of agreement -0.81, 1.23). [23] In their study, CI measurements obtained with the intermittent bolus PAC showed better correlation with the FloTrac™ CI values (r (2) = 0.2693, bias = -0.0057, 95% limits of agreement -1.2042, 1.1929) than did those obtained with the continuous cardiac output PAC (r (2) = 0.0557, bias = 0.2436, 95% limits of agreement -0.7350, 1.2222). They concluded that CO measurements obtained using the FloTrac™ cardiac output monitor showed a limited correlation with PAC. They suggested that further evaluation is required before recommending this device for use in the clinical setting.

In the control group, the parameters were maintained within the baseline. There was no difference in HR, MAP, CVP, SpO 2 , ABG, urine output between the two groups at various time intervals. In the EGDT group, fluids were administered even if CVP was normal, but if SVV was more than 10%. The dose of inotropic agents and vasodilators were changed to maintain the values of CI, SVI, SVRI and DO 2 I within the baseline limits. In the control group, the duration of ventilation ranged between 15 and 21 h. One patient required IABP and was ventilated for 56 h. Another patient had arrhythmia on the second day and was reintubated, requiring ventilation for 39 h. In the EGDT group, the duration of ventilation was 11-16 h, while one patient was ventilated for 22 h. The duration of use of the inotropic agents ranged between 1 and 6 d in the control group. While in the EGDT group, the duration of use of inotropic agent was 1-2 d.

The average number of times the inotropic agent adjusted during the study period was 0.4 ± 0.7 and 3.4 ± 1.5 in the control and EGDT group, respectively, which was statistically significant. Similarly, the duration of inotropic usage was 3.8 ± 1.6 and 1.6 ± 0.9 d (statistically not significant). This shows that by actively adjusting the inotropic agent to optimize the haemodynamic parameters near the baseline in the early recovery period, recovery can be hastened and the duration of use of inotropic agent can be reduced. The duration of ICU stay was 2-8 d in the control group and 2-5 d in the EGDT group. Similarly, the duration of hospital stay was 5-12 and 5-9 d, respectively. Longer duration of ventilation, use of inotropic agent, ICU and hospital stay was noted in patients with complications. Three patients in the control group (one each with IABP, arrhythmia and renal dysfunction) had complications. One patient in the EGDT group required inotropic agent for 4 d. Incidentally, this patient's ScvO 2 was persistently low, and later he developed renal dysfunction. In this patient, despite optimal inotropic support to achieve the goals of EGDT, only target ScvO 2 could not be achieved during the study period. This was not noted in case of any other patient, and this case as an exception could be explained due to inherent patient-related factors, which may result in complications despite instituting EGDT. As shown by other authors, monitoring of CI, SVRI, SVI, SvO 2 and DO 2 I may help clinicians in initiating therapy early in the postoperative period and improve the outcome. [13] By using continuous minimally invasive monitoring, outcome may be improved. Similar results may be obtained by intermittently monitoring the SvO 2 through PAC.

This study had a few limitations: the number of subjects involved in the study is considerably small, the study could not be blinded and single center trial. Larger cohorts in multicenter trials are required to validate our data and show the cost effectiveness. Although the use of PreSep™ and FloTrac™ increases the cost, a decrease in the duration of ventilation and ICU stays, resulting from its use may render it a cost effective approach.


   Conclusion Top


EGDT may be a useful strategy in patients with risk factors for adverse outcome. Although a few benefits were observed in the EGDT group, this study did not conclusively show beneficial effects. Including more number of subjects in the study may clarify the issue.

 
   References Top

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Correspondence Address:
Poonam Malhotra Kapoor
Department of Cardiac Anaesthesiology, 7th Floor, CN Centre, AIIMS, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.38446

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[Pubmed] | [DOI]
8 Perioperative fluid theory: a statement from the international Fluid Optimization Group
Lais Helena Camacho Navarro,Joshua A Bloomstone,Jose Otavio Costa Auler,Maxime Cannesson,Giorgio Della Rocca,Tong J Gan,Michael Kinsky,Sheldon Magder,Timothy E Miller,Monty Mythen,Azriel Perel,Daniel A Reuter,Michael R Pinsky,George C Kramer
Perioperative Medicine. 2015; 4(1)
[Pubmed] | [DOI]
9 Goal-Directed Resuscitation Aiming Cardiac Index Masks Residual Hypovolemia: An Animal Experiment
Krisztián Tánczos,Márton Németh,Domonkos Trásy,Ildikó László,Péter Palágyi,Zsolt Szabó,Gabriella Varga,József Kaszaki
BioMed Research International. 2015; 2015: 1
[Pubmed] | [DOI]
10 Efficacy of Goal-Directed Therapy Using Bioreactance Cardiac Output Monitoring after Valvular Heart Surgery
Sak Lee,Seung Hyun Lee,Byung-Chul Chang,Jae-Kwang Shim
Yonsei Medical Journal. 2015; 56(4): 913
[Pubmed] | [DOI]
11 Systematic review of uncalibrated arterial pressure waveform analysis to determine cardiac output and stroke volume variation
C. Slagt,I. Malagon,A. B. J. Groeneveld
British Journal of Anaesthesia. 2014;
[Pubmed] | [DOI]
12 Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis
N. Arulkumaran,C. Corredor,M. A. Hamilton,J. Ball,R. M. Grounds,A. Rhodes,M. Cecconi
British Journal of Anaesthesia. 2014;
[Pubmed] | [DOI]
13 Fluid management in the cardiothoracic intensive care unit
Giovanni Mariscalco,Francesco Musumeci
Current Opinion in Anaesthesiology. 2014; 27(2): 133
[Pubmed] | [DOI]
14 The effects of goal directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials
Jan Benes,Mariateresa Giglio,Nicola Brienza,Frederic Michard
Critical Care. 2014; 18(5)
[Pubmed] | [DOI]
15 State-of-the-art fluid management in the operating room
Timothy E. Miller,Karthik Raghunathan,Tong J. Gan
Best Practice & Research Clinical Anaesthesiology. 2014;
[Pubmed] | [DOI]
16 The Vigileo-FloTracTM System: Arterial Waveform Analysis for Measuring Cardiac Output and Predicting Fluid Responsiveness: A Clinical Review
Koichi Suehiro,Katsuaki Tanaka,Tadashi Matsuura,Tomoharu Funao,Tokuhiro Yamada,Takashi Mori,Kiyonobu Nishikawa
Journal of Cardiothoracic and Vascular Anesthesia. 2014;
[Pubmed] | [DOI]
17 Venous oxygen saturation
Christiane Hartog,Frank Bloos
Best Practice & Research Clinical Anaesthesiology. 2014;
[Pubmed] | [DOI]
18 A specialized post-anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial
Stefan Probst,Christof Cech,Dirk Haentschel,Markus Scholz,Joerg Ender
Critical Care. 2014; 18(4): 468
[Pubmed] | [DOI]
19 Impact of hemodynamic monitoring on clinical outcomes
Emily A. Downs,James M. Isbell
Best Practice & Research Clinical Anaesthesiology. 2014;
[Pubmed] | [DOI]
20 Improved Performance of the Fourth-Generation FloTrac/Vigileo System for Tracking Cardiac Output Changes
Koichi Suehiro,Katsuaki Tanaka,Mika Mikawa,Yuriko Uchihara,Taiki Matsuyama,Tadashi Matsuura,Tomoharu Funao,Tokuhiro Yamada,Takashi Mori,Kiyonobu Nishikawa
Journal of Cardiothoracic and Vascular Anesthesia. 2014;
[Pubmed] | [DOI]
21 Early goal-directed therapy based on endotracheal bioimpedance cardiography: a prospective, randomized controlled study in coronary surgery
Jean-Luc Fellahi,David Brossier,Fabien Dechanet,Marc-Olivier Fischer,Vladimir Saplacan,Jean-Louis Gérard,Jean-Luc Hanouz
Journal of Clinical Monitoring and Computing. 2014;
[Pubmed] | [DOI]
22 Update on clinical trials for the prevention of acute kidney injury in patients undergoing cardiac surgery
Alsabbagh, M.M. and Asmar, A. and Ejaz, N.I. and Aiyer, R.K. and Kambhampati, G. and Ejaz, A.A.
American Journal of Surgery. 2013; 206(1): 86-95
[Pubmed]
23 Goal-directed therapy in cardiac surgery: A systematic review and meta-analysis
Aya, H.D. and Cecconi, M. and Hamilton, M. and Rhodes, A. and Mahajan, R.P.
British Journal of Anaesthesia. 2013; 110(4): 510-517
[Pubmed]
24 Echocardiography-Based Hemodynamic Management in the Cardiac Surgical Intensive Care Unit
Martin Geisen,Dominic Spray,S. Nicholas Fletcher
Journal of Cardiothoracic and Vascular Anesthesia. 2013;
[Pubmed] | [DOI]
25 Goal-Directed Therapy in Cardiac Surgery: Are We There Yet?
Byron D. Fergerson,Gerard R. Manecke
Journal of Cardiothoracic and Vascular Anesthesia. 2013; 27(6): 1075
[Pubmed] | [DOI]
26 Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review
British Journal of Anaesthesia. 2013;
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27 Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis
H. D. Aya,M. Cecconi,M. Hamilton,A. Rhodes
British Journal of Anaesthesia. 2013; 110(4): 510
[Pubmed] | [DOI]
28 Update on clinical trials for the prevention of acute kidney injury in patients undergoing cardiac surgery
Mourad M. Alsabbagh,Abdo Asmar,Noel I. Ejaz,Ravi K. Aiyer,Ganesh Kambhampati,A. Ahsan Ejaz
The American Journal of Surgery. 2013; 206(1): 86
[Pubmed] | [DOI]
29 A systematic review of goal directed fluid therapy: Rating of evidence for goals and monitoring methods
H.R. Wilms,A. Mittal,M.D. Haydock,M.E. van den Heever,M. Devaud,J.A. Windsor
Journal of Critical Care. 2013;
[Pubmed] | [DOI]
30 Algorithms: What Computers Do Best
Gerard R. Manecke
Journal of Cardiothoracic and Vascular Anesthesia. 2012; 26(5): 759
[Pubmed] | [DOI]
31 Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca
J.L. Pérez Vela,J.C. Martín Benítez,M. Carrasco González,M.A. De la Cal López,R. Hinojosa Pérez,V. Sagredo Meneses,F. del Nogal Saez
Medicina Intensiva. 2012; 36(4): e1
[Pubmed] | [DOI]
32 Implementation of Molecular Phenotyping Approaches in the Personalized Surgical Patient Journey
Reza Mirnezami,James M. Kinross,Panagiotis A. Vorkas,Robert Goldin,Elaine Holmes,Jeremy Nicholson,Ara Darzi
Annals of Surgery. 2012; 255(5): 881
[Pubmed] | [DOI]
33 Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups
Maurizio Cecconi,Carlos Corredor,Nishkantha Arulkumaran,Gihan Abuella,Jonathan Ball,R Michael Grounds,Mark Hamilton,Andrew Rhodes
Critical Care. 2012; 17(2): 209
[Pubmed] | [DOI]
34 Protocoled resuscitation and the prevention of acute kidney injury
Nicola Brienza,Maria Teresa Giglio,Lidia Dalfino
Current Opinion in Critical Care. 2012; 18(6): 613
[Pubmed] | [DOI]
35 Perioperative hemodynamic monitoring
Matthew E. Cove,Michael R. Pinsky
Best Practice & Research Clinical Anaesthesiology. 2012; 26(4): 453
[Pubmed] | [DOI]
36 Clinical review: Volume of fluid resuscitation and the incidence of acute kidney injury - a systematic review
John R Prowle,Horng-Ruey Chua,Sean M Bagshaw,Rinaldo Bellomo
Critical Care. 2012; 16(4): 230
[Pubmed] | [DOI]
37 Comparison of Goal-Directed Hemodynamic Optimization Using Pulmonary Artery Catheter and Transpulmonary Thermodilution in Combined Valve Repair: A Randomized Clinical Trial
Vsevolod V. Kuzkov, Konstantin V. Paromov, Andrey I. Lenkin, Mikhail Y. Kirov, Alexey A. Smetkin, Mons Lie, Lars J. Bjertnæs
Critical Care Research and Practice. 2012; 2012: 1
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38 Haemodynamic goal-directed therapy in cardiac and vascular surgery. A systematic review and meta-analysis
M. Giglio,L. Dalfino,F. Puntillo,G. Rubino,M. Marucci,N. Brienza
Interactive CardioVascular and Thoracic Surgery. 2012; 15(5): 878
[Pubmed] | [DOI]
39 Protocoled resuscitation and the prevention of acute kidney injury
Brienza, N. and Giglio, M.T. and Dalfino, L.
Current Opinion in Critical Care. 2012; 18(6): 613-622
[Pubmed]
40 Perioperative hemodynamic monitoring
Cove, M.E. and Pinsky, M.R.
Best Practice and Research: Clinical Anaesthesiology. 2012; 26(4): 453-462
[Pubmed]
41 Haemodynamic goal-directed therapy in cardiac and vascular surgery. A systematic review and meta-analysis
Giglio, M. and Dalfino, L. and Puntillo, F. and Rubino, G. and Marucci, M. and Brienza, N.
Interactive Cardiovascular and Thoracic Surgery. 2012; 15(5): 878-887
[Pubmed]
42 Alternative Methods to Central Venous Pressure for Assessing Volume Status in Critically Ill Patients
Lisa Stoneking,Lawrence A. DeLuca,Albert B. Fiorello,Brendan Munzer,Nicola Baker,Kurt R. Denninghoff
Journal of Emergency Nursing. 2012;
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43 Algorithms: What computers do best
Manecke Jr., G.R.
Journal of Cardiothoracic and Vascular Anesthesia. 2012; 26(5): 759-761
[Pubmed]
44 Clinical review: Volume of fluid resuscitation and the incidence of acute kidney injury - a systematic review
Prowle, J.R. and Chua, H.-R. and Bagshaw, S.M. and Bellomo, R.
Critical Care. 2012; 16(4)
[Pubmed]
45 Clinical practice guide for the management of low cardiac output syndrome in the postoperative period of heart surgery [Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca]
Pérez Vela, J.L. and Martín Benítez, J.C. and Carrasco González, M. and De la Cal López, M.A. and Hinojosa Pérez, R. and Sagredo Meneses, V. and del Nogal Saez, F.
Medicina Intensiva. 2012; 36(4): e1-e44
[Pubmed]
46 Implementation of molecular phenotyping approaches in the personalized surgical patient journey
Mirnezami, R. and Kinross, J.M. and Vorkas, P.A. and Goldin, R. and Holmes, E. and Nicholson, J. and Darzi, A.
Annals of Surgery. 2012; 255(5): 881-889
[Pubmed]
47 Effects of advanced haemodynamic monitoring on perioperative outcome in high-risk patients [Hämodynamisches Monitoring - Verbessertes Outcome durch Erweitertes Perioperatives Hämodynamisches Monitoring]
Weyland, A. and Scheeren, T.
Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie. 2012; 47(2): 92-99
[Pubmed]
48 Haemodynamic changes after induction of anaesthesia with sevoflurane vs. propofol
Potočnik, I. and Janković, V.N. and Štupnik, T. and Kremžar, B.
Signa Vitae. 2011; 6(2): 52-57
[Pubmed]
49 Venous oximetry and the assessment of oxygen transport balance
Bronicki, R.A.
Pediatric Critical Care Medicine. 2011; 12(4 SUPPL.): S21-S26
[Pubmed]
50 A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients
Hamilton, M.A. and Cecconi, M. and Rhodes, A.
Anesthesia and Analgesia. 2011; 112(6): 1392-1402
[Pubmed]
51 Maintaining tissue perfusion in high-risk surgical patients: A systematic review of randomized clinical trials
Gurgel, S.T. and Do Nascimento Jr., P.
Anesthesia and Analgesia. 2011; 112(6): 1384-1391
[Pubmed]
52 Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery
Pintaric, T.S. and Potocnik, I. and Hadzic, A. and Stupnik, T. and Pintaric, M. and Jankovic, V.N.
Regional Anesthesia and Pain Medicine. 2011; 36(3): 256-260
[Pubmed]
53 Pulse Pressure Variation Predicts Fluid Responsiveness in Elderly Patients After Coronary Artery Bypass Graft Surgery
Alexandre Yazigi, Eliane Khoury, Sani Hlais, Samia Madi-Jebara, Fadia Haddad, Gemma Hayek, Khalil Jabbour
Journal of Cardiothoracic and Vascular Anesthesia. 2011;
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54 Venous oximetry and the assessment of oxygen transport balance :
Ronald A. Bronicki
Pediatric Critical Care Medicine. 2011; 12: S21
[VIEW] | [DOI]
55 Relationship Between Plethysmographic Waveform Changes and Hemodynamic Variables in Anesthetized, Mechanically Ventilated Patients Undergoing Continuous Cardiac Output Monitoring
Robert H. Thiele, Douglas A. Colquhoun, James Patrie, Sarah H. Nie, Julie L. Huffmyer
Journal of Cardiothoracic and Vascular Anesthesia. 2011; 25(6): 1044
[VIEW] | [DOI]
56 Maintaining Tissue Perfusion in High-Risk Surgical Patients : A Systematic Review of Randomized Clinical Trials
Sanderland T. Gurgel, Paulo do Nascimento
Anesthesia & Analgesia. 2011; 112(6): 1384
[VIEW] | [DOI]
57 Patient blood management during cardiac surgery: Do we have enough evidence for clinical practice?
Journal of Thoracic and Cardiovascular Surgery. 2011;
[VIEW] | [DOI]
58 The relationship between inotrope exposure, six-hour postoperative physiological variables, hospital mortality and renal dysfunction in patients undergoing cardiac surgery
Jason Shahin, Benoit deVarennes, Chun Tse, Dan-Alexandru Amarica, Sandra Dial
Critical Care. 2011; 15(4): R162
[VIEW] | [DOI]
59 Comparison of Continuous Thoracic Epidural With Paravertebral Block on Perioperative Analgesia and Hemodynamic Stability in Patients Having Open Lung Surgery :
Tatjana Stopar Pintaric, Iztok Potocnik, Admir Hadzic, Tomaz Stupnik, Miha Pintaric, Vesna Novak Jankovic
Regional Anesthesia and Pain Medicine. 2011; 36(3): 256
[VIEW] | [DOI]
60 Stellenwert des perioperativen SzvO2-Monitorings
F. Bloos
Intensivmedizin und Notfallmedizin. 2010; 47(5): 338
[VIEW] | [DOI]
61 Perioperative haemodynamic therapy :
Hernandez, G., Peña, H., Cornejo, R., Rovegno, M., Retamal, J., Navarro, J.L., Aranguiz, I., (...), Bruhn, A. Mikhail Y Kirov, Vsevolod V Kuzkov, Zsolt Molnar
Current Opinion in Critical Care. 2010; 16(4): 384
[VIEW] | [DOI]
62 Contemporary Fluid Management in Cardiac Anesthesia
Marit Habicher, Albert Perrino, Claudia D. Spies, Christian von Heymann, Ulrike Wittkowski, Michael Sander
Journal of Cardiothoracic and Vascular Anesthesia. 2010;
[VIEW] | [DOI]
63 Perioperative haemodynamic therapy
Kirov, M.Y. and Kuzkov, V.V. and Molnar, Z.
Current Opinion in Critical Care. 2010; 16(4): 384-392
[Pubmed]
64 Importance of perioperative ScvO2 monitoring [Stellenwert des perioperativen SzvO2-Monitorings]
Bloos, F.
Intensivmedizin und Notfallmedizin. 2010; 47(5): 338-344
[Pubmed]
65 Clinical review: Goal-directed therapy in high risk surgical patients
Lees, N. and Hamilton, M. and Rhodes, A.
Critical Care. 2009; 13(5)
[Pubmed]
66 Minimally invasive cardiac output monitoring in the perioperative setting
Funk, D.J. and Moretti, E.W. and Gan, T.J.
Anesthesia & Analgesia. 2009; 108(3): 887-897
[Pubmed]
67 Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study.
Brienza, N. and Giglio, M.T. and Marucci, M. and Fiore, T.
Critical Care Medicine. 2009; 37(6): 2079-2090
[Pubmed]
68 Minimally Invasive Cardiac Surgery
Hughes, J. and Piatt, K.
Cardiac Surgery Essentials for Critical Care Nursing. 2009; : 93
[Pubmed]
69 Impact of emergency intubation on central venous oxygen saturation in critically ill patients: A multicenter observational study
Hernandez, G., Peña, H., Cornejo, R., Rovegno, M., Retamal, J., Navarro, J.L., Aranguiz, I., (...), Bruhn, A.
Critical Care. 2009; 13(3): R63
[Pubmed]
70 Minimally Invasive Cardiac Output Monitoring in the Perioperative Setting
Duane J. Funk,Eugene W. Moretti,Tong J. Gan
Anesthesia & Analgesia. 2009; 108(3): 887
[Pubmed] | [DOI]
71 Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study
Nicola Brienza,Maria Teresa Giglio,Massimo Marucci,Tommaso Fiore
Critical Care Medicine. 2009; 37(6): 2079
[Pubmed] | [DOI]
72 Physiological changes of pregnancy and monitoring
Andrew Carlin,Zarko Alfirevic
Best Practice & Research Clinical Obstetrics & Gynaecology. 2008; 22(5): 801
[Pubmed] | [DOI]
73 Correlation between central venous oxygen saturation and oxygen delivery changes following fluid therapy : Correlation between ScvO2 and DO2
A. YAZIGI, H. ABOU-ZEID, S. MADI-JEBARA, F. HADDAD, G. HAYEK, K. JABBOUR
Acta Anaesthesiologica Scandinavica. 2008; 52(9): 1213
[VIEW] | [DOI]
74 Using ventilation-induced plethysmographic variations to optimize patient fluid status
Desebbe, O., Cannesson, M.
Current Opinion in Anaesthesiology. 2008; 21(6): 772-778
[Pubmed]
75 Using ventilation-induced plethysmographic variations to optimize patient fluid status
Olivier Desebbe,Maxime Cannesson
Current Opinion in Anaesthesiology. 2008; 21(6): 772
[Pubmed] | [DOI]
76 Correlation between central venous oxygen saturation and oxygen delivery changes following fluid therapy
Yazigi, A. and Abou-Zeid, H. and Madi-Jebara, S. and Haddad, F. and Hayek, G. and Jabbour, K.
Acta Anaesthesiologica Scandinavica. 2008; 52(9): 1213-1217
[Pubmed]
77 Physiological changes of pregnancy and monitoring
Carlin, A. and Alfirevic, Z.
Best Practice & Research Clinical Obstetrics & Gynaecology. 2008; 22(5): 801-823
[Pubmed]
78 Cardiac output--have we found theægold standardæ?
Chakravarthy, M.
Annals of cardiac anaesthesia. ; 11(1): 1
[Pubmed]



 

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