Elderly patients with poor cardiopulmonary reserve tend to suffer higher risk and develop more complications following major surgery. Quite a few researches have shown the benefits of goal-directed therapy (GDT) using fluid loading or inotropic agents or both to improve outcome during major surgery. However there is concern that inotropic therapy for a supernormal oxygen delivery (DO2I) may lead to an increased incidence of myocardial ischemia. Even though the meta-analysis has stated that DO2I strategy could possibly reduce the incidence of cardiac complication than stroke volume optimization strategy, there are very few evidence available in the literature regarding the effect on myocardial ischemia in surgical patients, especially in non-cardiac surgical patients. This study is undertaken to test the hypothesis that an intraoperative DO2I optimization result in a decreased myocardial ischemia in the elderly high-risk surgical patients.
Elderly patients with poor cardiopulmonary reserve tend to suffer higher risk and develop more complications following major surgery \[1\]. Quite a few researches have shown the benefits of goal-directed therapy(GDT) using fluid loading or inotropic agents or both to improve outcome during major surgery \[2-7\]. The maintenance of adequate tissue perfusion and global oxygen delivery (DO2I) is essential to maintain adequate tissue perfusion and oxygenation in relation to increased metabolic demand during high risk surgery. However, there is concern that inotropic therapy for a supernormal oxygen delivery may lead to an increased incidence of myocardial ischemia \[8\]. Even though the meta-analysis has stated that DO2I optimization could possibly reduce the incidence of cardiac complication than stroke volume optimization strategy \[9\],there are very few evidence available in the literature regarding the effect on myocardial ischemia in surgical patients, especially in non-cardiac surgical patients. This study is undertaken to test the hypothesis that an intraoperative DO2I optimization result in a decreased myocardial ischemia in the elderly high-risk surgical patients. The investigators will conduct a prospective, randomized, controlled, double-blinded trial in seventy patients who scheduled for proximal femur surgery under General anesthesia following nerve block. Both the patients will be allocated to one of two equal groups to receive either intraoperative fluid regimen guided by SV strategy or DO2I strategy. In the control(SV) group, the patients will receive an intravenous infusion of 250 ml Ringer's lactate solution in 5 min as a fluid challenge for stroke volume maximization. In the experimental(DO2I) group, fluid and dobutamine will be given to reach a stroke volume maximization and supernormal oxygen delivery. The primary outcome is preoperative and 24h postoperative serum concentration of troponin T. Secondary outcomes include the incidence of tachycardia, arrhythmia, myocardial infarction, pneumonedema and acute heart failure, blood pressure, pulmonary infection, fluid volume, blood transfusion volume, renal function, PONV, Length of postoperative hospital stay and mortality. Data will be collected and recorded by the clinical teams who are blind to study arm allocation.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
TRIPLE
Enrollment
70
When SpO2 ≥92%, mean arterial pressure (MAP) 65-100 mmHg, HR \<100 bpm, Hb \>8mg/dL and temperature ≥36℃, the patients will receive a 250 ml Ringer's lactate solution in 5 min as a fluid challenge for stroke volume (SV) maximization. The fluid challenge will repeat until the SV failed to increase by a factor of 10%. A reassessment on the SV maximization will be taken every 30 minutes and to restart algorithm when increased SV \>10% or blood loss \>250ml. Blood transfusions will be used to maintain a hemoglobin concentration over 8mg/dL.
Goal directed fluid therapy is administrated as group SV maximization. Then DO2I will be assessed. If at this stage the DO2I can not be greater than 600 mL/m2 (supernormal oxygen delivery goal), then dobutamine will be started at a dose of 2.5 μg/kg/min and increased by the same increment every 20 minutes until the described target is reached or until a maximal dose of 20 μg/kg/min is given. Dobutamine is decreased in dose or discontinued if the heart rate is above 100 beats per minute or shows signs of cardiac ischemia.
Guangzhou First People's Hospital
Guangzhou, Guangdong, China
RECRUITINGChange from baseline in concentration of troponin T at 24 hours postoperatively
Intraoperative supernormal oxygen delivery strategy will reduce the changes in concentration of troponin T at 24 hours postoperatively.
Time frame: preoperative value and 24 hours postoperatively
cardiac complication up to 24 hours postoperatively
Occurrence of newly diagnosed arterial fibrilation ,severe arrhythmia,clinical signs of unstable angina, myocardial infarction,pulmonary edema or therapy-requiring cardiac failure.
Time frame: up to 24 hours postoperatively
blood pressure
Invasive arterial BP(mmHg) is measured through an arterial line at the arm.episode of hypotension (30% decrease in mean BP in relation to baseline values) and hypertension (30% increase in mean BP in relation to baseline values) will be recorded.
Time frame: up to 24 hours postoperatively
heart rate (HR)
HR(beats/min), bradycardia (HR \< 50 beats/min), and tachycardia (HR \> 100 beats/min) will be recorded at the same time as BP recording.
Time frame: up to 24 hours postoperatively
SpO2
SpO2(%) and hypoxemia (SpO2 \<90%) will be recorded at the same time as BP recording.
Time frame: up to 24 hours postoperatively
fluid balance
amount of fluids (ml) infused, amount of fluid losses
Time frame: up to 24hours after surgery
blood transfusion volume
amount of blood transfusion, amount of blood losses.
Time frame: up to 24 hours postoperatively
Acute Kidney Injury
perioperative and 24h postoperative urine volume, serum creatinine, blood urea nitrogen.
Time frame: up to 24 hours postoperatively
Postoperative Nausea and Vomiting (PONV)
Postoperative Nausea and Vomiting, The incidence of PONV will be recorded using a 4-point objective score (1 = no PONV;2 = mild nausea, no vomiting; 3 = excessive nausea or vomiting;4 = vomiting ≥2 times).
Time frame: 24 hours postoperatively
length of postoperative hospital stay
days from end of surgery to hospital discharge
Time frame: 28 days postoperatively
mortality
mortality within 28 days after surgery
Time frame: 28 days postoperatively
cardiac complication at 28 days postoperatively
Occurrence of newly diagnosed arterial fibrilation ,severe arrhythmia,clinical signs of unstable angina, myocardial infarction,pulmonary edema or therapy-requiring cardiac failure.
Time frame: 28 days postoperatively
incidence of pulmonary infection
number of patients having pulmonary infection requiring intravenous antibiotic therapy
Time frame: up to 28 days postoperatively
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