ANAESTHESIA AND PATIENT MONITORING
moderate or severe postoperative complications during the first 180 days after surgery.
Results
There were significantly fewer complications in the GDHT group (8.6% vs 16.6%, P=0.018). Length of hospital stay was also shorter in the GDHT group. There was no significant difference in mortality between groups. The paper therefore concluded that monitoring all low-medium risk patients with ODM, then intervening with the right technology significantly reduces post- operative complications, improving patient safety and saving money.
Deltex Medical’s managing director, Andy Mears, commented: “The ability to reduce post-operative complications and therefore length of stay, delivers benefits to the patient, clinician and healthcare provider in terms of higher quality clinical outcomes and reduced cost of care.” These study findings add to a growing body of evidence demonstrating the clinical and cost benefits of Deltex Medical’s ODM system. Mears points out that employing haemodynamic monitoring to guide appropriate interventions yields statistically significant reductions of between 75% and 100% in specific major complications. These include acute kidney injury, acute pulmonary oedema, respiratory distress syndrome, pneumonia, and superficial or deep surgical site infection. The Deltex technology, which is used to guide fluid optimisation during surgery in approximately 14,000 procedures in England, annually, also features in the NICE Medical Technology Guidance for CardioQ- ODM Oesophageal Doppler Monitor (MTG3),14
and was investigated by
high-risk surgery and high-risk patients. In particular, there is strong evidence to support the increased uptake of capnography and haemodynamic monitoring in theatres to ensure increased patient safety, improved recovery and optimised care. Ultimately, the AAGBI states that the use of additional monitoring is at the “discretion of the anaesthetist”. As with all technologies, Trusts should review the evidence, conduct trials if necessary, understand the risks and benefits, and ensure staff are fully trained and competent before adoption.
References
The British Consensus Guidelines on Intravenous Therapy for Adult Surgery (GIFTASUP),15
The NHS Technology Adoption Centre (NTAC) as part of an audit involving over 1300 patients in three NHS hospitals.16 As part of an NHS initiative to speed up adoption of proven technologies, NTAC wanted to determine whether clinicians could be trained to use ODM in ‘real world’ hospital settings and gain the same benefits observed in the tightly controlled clinical studies. The results showed that Doppler- guided fluid management was able to: l Reduce post-operative stay by 3.5 days l Reduce Level 3 ICU stay by 5 days l Reduce central venous catheter use by 23%
l Reduce readmission rates by 29% l Reduce reoperations by 30%. l Following these findings, ODM has since been adopted as a standard of care in these hospitals.
Conclusion
Measuring vital signs of patients is a key part of perioperative practice, but there is also a growing body of evidence to support the use of additional technologies to improve outcomes following surgery, especially in
1 AAGBI, Recommendations for standards of monitoring during anaesthesia and recovery 2015, accessed at:
https://www.aagbi.org/sites/default/ files/Standards_of_monitoring_2015_0.pdf
2. AAGBI, Checking Anaesthetic Equipment 2012, accessed at:
https://www.aagbi.org/sites/default/ files/checking_anaesthetic_equipment_2012.pdf
3. Lam T, et al, Continuous Pulse Oximetry and Capnography Monitoring for Postoperative Respiratory Depression and Adverse Events: A Systematic Review and Meta-analysis. Anesth Analg. 2017 Dec;125(6):2019-2029. doi: 10.1213/ANE.0000000000002557.
4. Saugel B, et al, Measurement of blood pressure, Best Practice & Research Clinical Anaesthesiology, Volume 28, Issue 4, December 2014, Pages 309-322
5. Preston SR, Markar SR, Baker CR, Soon Y, Singh S, Low DE, Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer. Preston SR, Markar SR, Baker CR, Soon Y, Singh S, Low DE, Br J Surg. 2013 Jan;100(1):105-12. doi: 10.1002/ bjs.8974. Epub 2012 Nov 12.
6 Eduardo A. Osawa; Andrew Rhodes; Giovanni Landoni; Filomena R. B. G. Galas; Julia T. Fukushima, et al. Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review, Crit Care Med. 2016 Apr; 44(4):724-33. doi: 10.1097/CCM.0000000000001479
7 A. Karran, J. Wheat, D. Chan, P. Blake, R. Barlow, W. 70 I
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G. Lewis. Propensity Score Analysis of an Enhanced Recovery Programme in Upper Gastrointestinal Cancer Surgery. World J Surg (2016) 40:1645-1654. DOI 10.1007/s00268-016-3473-6
8 Fitzgerald T, Mosquera C, Koutlas N, Vohra N, Lee K, Zervos E. Enhanced recovery after surgery in a single high-volume surgical oncology unit: Details matter. Surgery Research and Practice Volume 2016 (2016), Article ID 6830260
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9 Guang Han, Kun Liu, Hang Xue, Ping Zhao. Application of Lidco Rapid in peri-operative fluid therapy for aged patients undergoing total hip replacement. Int J Clin Exp Med 2016;9(2):4473- 4478,
www.ijcem.com/ISSN:1940-5901/ IJCEM0010819
10 NICE Medical technologies guidance [MTG3].
https://www.nice.org.uk/guidance/mtg3/resources
11 Thiele et al, American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioperative Medicine (2016) 5:24 DOI 10.1186/s13741-016- 0049-9
12 Cecconi et al, Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med DOI 10.1007/s00134-014- 3525-z
13 Calvo-Vecino JM, et al, Effect of goal-directed haemodynamic therapy on postoperative complications in low–moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial), British Journal of Anaesthesia, April 2017.
14 NICE Medical Technology Guidance for CardioQ- ODM Oesophageal Doppler Monitor (MTG3),
https://guidance.nice.org.uk/MTG3
15 British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients,
https://www.bapen.org.uk/pdfs/bapen_pubs/ giftasup.pdf
16 Intraoperative Fluid Management Technologies Adoption Pack, http://webarchive.
nationalarchives.gov.uk/20130701151030/http://
www.ntac.nhs.uk/web/FILES/Intra_Operative_ Fluid_Management/IOFM_Adoption_pack_ update_Jan_2013.pdf
SEPTEMBER 2018
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