ANAESTHESIA AND PATIENT MONITORING
Individualised goal directed therapy has long been established as a core component of ERAS within in the intraoperative phase. The aim of fluid management within an ERAS pathway is to deliver the patient to theatre in a normovolaemic state and ensure that they receive the right amount of fluid throughout the procedure.
In order to have an individualised approach to fluid management, it is key to have a haemodynamic monitor which will guide the fluid requirements for a patient. Using parameters such as stroke volume variation, stroke volume and stroke volume response allows the user to accurately gauge the haemodynamic response following a fluid challenge or drug intervention. There are many studies which have shown ERAS programmes have the ability to improve patient outcomes and improve efficiencies.5-9
For example, a study evaluating
the impact of a multidisciplinary ERAS approach in oesophagectomies, found a reduced length of stay from seven days in the ERAS group compared to 17 days in the standard care arm, medical complications reduced from 27% to 7%, readmission rates reduced from 21.4% to 11.5% and mortality reduced from 21.8 % to 15.5%.5
Evidence
There are a number of technology suppliers that are now active in this field including Edwards, Deltex, Maquet, Cheetah and LiDCO and it is estimated that the potential global
market could be worth around $2 billion. LiDCO’s technology is reported to be used in over 50% of NHS hospitals and is supported by over 200 clinical studies. The Society of Critical Care Medicine journal, for example, published a study evaluating the effects of goal directed therapy using LiDCO Rapid in high-risk patients undergoing cardiac surgery. The randomised controlled trial involved 126 patients undergoing coronary artery bypass surgery or valve repair. The authors concluded that using the technology in these high-risk patients for implementing a goal-directed haemodynamic therapy decreased major complications and also reduced ICU and hospital length of stay. The incidence of infection was reduced by 57% and the frequency of low cardiac output syndrome was reduced by 76%. This group stayed in hospital on average three days less than the standard treatment group. This is an important study; high-risk cardiac patients require haemodynamic and fluid management both in surgery and also post operatively in the ICU. Historically this has only been possible through using a highly invasive pulmonary artery catheter. The minimal and non-invasive nature of the LiDCO technology provides advanced monitoring while avoiding additional invasive catheter insertion.6 This approach also features in international guidelines including: NICE Medical technologies guidance (MTG3)10
,
American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative
(POQI) joint consensus statement11 and the
European Intensive Care Society Consensus statement.12
FEDORA trial
The British Journal of Anaesthesia (BJA) has also published a new study on haemodynamic monitoring. The large, positive Randomised Clinical Trial (RCT), which used Deltex Medical’s Oesophageal Doppler Monitoring (ODM) system,13 demonstrated that even surgical patients considered to be at low to medium risk benefit significantly from having goal-directed haemodynamic therapy (GDHT) using ODM. (Goal-directed haemodynamic therapy as opposed to goal-directed fluid therapy (GDFT) offers a protocol that combines both fluid and drugs). The study, titled “Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: a multicentre randomised controlled trial” (FEDORA trial), was conducted in Spain and funded by the Spanish Government.13 In total, 450 patients were randomised to the GDHT group (n=224) or control group (n=226). In the control group, intraoperative fluids were given based on traditional principles. In the GDHT group, the intraoperative goals were to maintain a maximal stroke volume, with mean arterial pressure >70 mm Hg, and cardiac index ≥2.5 litres min−1 m−2. The primary outcome was percentage of patients with
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