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01-08-2010 | Original

Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study

Authors: Andrew Rhodes, Maurizio Cecconi, Mark Hamilton, Jan Poloniecki, Justin Woods, Owen Boyd, David Bennett, R. Michael Grounds

Published in: Intensive Care Medicine | Issue 8/2010

Abstract

Purpose

Goal-directed therapy in the perioperative setting has been shown to be associated with short-term improvements in outcome. This study assesses the longer-term survival of patients from a previous randomized controlled trial of goal-directed therapy in high-risk surgical patients.

Methods

All patients from a previous randomized controlled study were followed up for 15 years following randomization to ascertain their length of survival following surgery. Factors that may be associated with increased survival were evaluated to determine what influenced long-term outcomes.

Results

Data from 106 of the original 107 patients (99%) were available for analysis. At 15 years, 11 (20.7%) of the goal-directed therapy patients versus 4 (7.5%) of the control group were alive (p = 0.09). Median survival for the goal-directed group was increased by 1,107 days (1,781 vs. 674 days, p = 0.005). Long-term survival was associated with three independent factors: age [hazard ratio (HR) 1.04 (1.02–1.07), p < 0.0001], randomization to the goal-directed group of the study [HR 0.61 (0.4–0.92), p = 0.02], and avoidance of a significant postoperative cardiac complication [HR 3.78 (2.16–6.6), p = 0.007].

Conclusions

Long-term survival after major surgery is related to a number of factors, including patient age and avoidance of perioperative complications. Short-term goal-directed therapy in the perioperative period may improve long-term outcomes, in part due to its ability to reduce the number of perioperative complications.

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Boyd O, Jackson N (2005) How is risk defined in high-risk surgical patient management? Crit Care 9:390–396CrossRefPubMed

Pearse R, Harrison D, James P, Watson D, Hinds C, Rhodes A, Grounds RM, Bennett E (2006) Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care (London, England) 10:R81CrossRef

Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS (1988) Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94:1176–1186CrossRefPubMed

Boyd O, Grounds RM, Bennett ED (1993) A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 270:2699–2707CrossRefPubMed

Sinclair S, James S, Singer M (1997) Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 315:909–912PubMed

Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E (1999) Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 318:1099–1103PubMed

Polonen P, Ruokonen E, Hippelainen M, Poyhonen M, Takala J (2000) A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg 90:1052–1059CrossRefPubMed

Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P (2002) Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 88:65–71CrossRefPubMed

Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS (2002) Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 97:820–826CrossRefPubMed

10.

Kern JW, Shoemaker WC (2002) Meta-analysis of hemodynamic optimization in high-risk patients. Crit Care Med 30:1686–1692CrossRefPubMed

11.

Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett E (2005) Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care (London, England) 9:R687–R693CrossRef

12.

Poeze M, Greve J, Ramsay G (2005) Meta-analysis of hemodynamic optimization: relationship to methodological quality. Crit Care (London, England) 9:R771–R779CrossRef

13.

Silber JH, Rosenbaum PR, Trudeau ME, Chen W, Zhang X, Kelz RR, Mosher RE, Even-Shoshan O (2005) Changes in prognosis after the first postoperative complication. Med Care 43:122–131CrossRefPubMed

14.

Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ (2005) Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 242:326–341 discussion 341–323PubMed

15.

Hutter MM, Rowell KS, Devaney LA, Sokal SM, Warshaw AL, Abbott WM, Hodin RA (2006) Identification of surgical complications and deaths: an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program. J Am Coll Surg 203:618–624CrossRefPubMed

16.

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144CrossRefPubMed

17.

Mangano DT (2004) Perioperative medicine: NHLBI working group deliberations and recommendations. J Cardiothorac Vasc Anesth 18:1–6CrossRefPubMed

18.

Gawande AA, Thomas EJ, Zinner MJ, Brennan TA (1999) The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 126:66–75CrossRefPubMed

19.

Kable A, Gibberd R, Spigelman A (2008) Predictors of adverse events in surgical admissions in Australia. Int J Qual Health Care 20:406–411CrossRefPubMed

20.

Bihorac A, Yavas S, Subbiah S, Hobson CE, Schold JD, Gabrielli A, Layon AJ, Segal MS (2009) Long-term risk of mortality and acute kidney injury during hospitalization after major surgery. Ann Surg 249:851–858CrossRefPubMed

Title: Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study
Authors: Andrew Rhodes
Maurizio Cecconi
Mark Hamilton
Jan Poloniecki
Justin Woods
Owen Boyd
David Bennett
R. Michael Grounds
Publication date: 01-08-2010
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 8/2010
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-010-1869-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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