Objectives:Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have

Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care

Editor’s PerspectiveWhat We Already Know about This TopicCrystalloid solutions leave the circulation quickly, whereas colloids remain for hours, thus promoting hemodynamic stability. However, colloids are expensive and promote renal toxicity in critical care patients. Whether goal-directed intraoper

https://www.zora.uzh.ch/id/eprint/177171/1/document%281%29.pdf

Effect of Intraoperative Goal-directed Balanced Crystalloid versus Colloid Administration on Major Postoperative Morbidity: A Randomized Trial.

Venous oxygen saturation.

Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.

Clinical guidelines for perioperative hemodynamic management of non cardiac surgical adult patients

Preventable postsurgical complications are increasingly recognized as a major clinical and economic burden. A recent meta-analysis showed a 17–29 % decrease in postoperative morbidity with goal-directed fluid therapy. Our objective was to estimate the potential economic impact of perioperative goal-directed fluid therapy. We studied 204,680 adult patients from 541 US hospitals who had a major non-cardiac surgical procedure between January 2011 and June 2013. Hospital costs (including 30-day readmission costs) in patients with and without complications were extracted from the Premier Inc. research database, and potential cost-savings associated with a 17–29 % decrease in postoperative morbidity were estimated. A total of 76,807 patients developed one or more postsurgical complications (morbidity rate 37.5 %). In patients with and without complications, hospital costs were US$27,607 ± 32,788 and US$15,783 ± 12,282 (p < 0.0001), respectively. Morbidity rate was anticipated to decrease to 26.6–31.1 % with goal-directed fluid therapy, yielding potential gross cost-savings of US$153–263 million for the study period, US$61–105 million per year, or US$754–1286 per patient. Potential savings per patient were highly variable from one surgical procedure to the other, ranging from US$354–604 for femur and hip-fracture repair to US$3515–5996 for esophagectomies. When taking into account the volume of procedures, the total potential savings per year were the most significant (US$32–55 million) for colectomies. Postsurgical complications occurred in more than one third of our study population and had a dramatic impact on hospital costs. With goal-directed fluid therapy, potential cost-savings per patient were US$754–1286. The highest cost-savings per year were observed for colectomies. These projections should help hospitals estimate the return on investment when considering the implementation of goal-directed fluid therapy.

/pdf/potential-return-on-investment-for-implementation-of-ewfx3s6nr7.pdf

Potential return on investment for implementation of perioperative goal-directed fluid therapy in major surgery: a nationwide database study

Objectives:Patients undergoing major surgery are at high risk of increased postoperative morbidity and mortality. Goal-directed therapy has been shown to improve outcomes when commenced in the early postoperative period, yet the economic impact remains unclear. The aim of our study was to assess the

A cost-effectiveness analysis of postoperative goal-directed therapy for high-risk surgical patients.

Cost-effectiveness in goal-directed therapy: are the dollars spent worth the value?

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A cost-effectiveness analysis of postoperative goal-directed therapy for high-risk surgical patients.

Cost-effectiveness in goal-directed therapy: are the dollars spent worth the value?