Evidence Base

Evidence_Base_Section

Evidence Base

Optimal management of cardiac output, fluid balance and haemodynamic status is considered to be a key factor in improving the outcomes of high risk surgery and critically ill patients. There are currently eight randomised controlled trials demonstrating that oesophageal doppler monitoring and haemodynamic optimisation alone and in combination with other evidence based interventions can significantly improve surgical outcomes by reducing both the rates of post-operative complications and mortality, as well as significantly reducing both the length of hospital stay and the overall number of ICU / HDU bed days used.

In this section you will find project summary data from the Implementation Sites, relevant trial reports & supporting evidence and other useful reference papers.

NTAC Intraoperative Fluid Management Project Data

Methods and procedures of quantitative, qualitative and periodical measurement and evaluation of Doppler guided intraoperative fluid management were developed by the project teams from the three implementation sites.

These were used in the determination of the impact of the intervention on patient outcomes and hospital productivity.

The project evaluation measures and values were subjected to independent statistical analysis undertaken by York Health Economics Consortium at York University.

  • To access the full project data report in a .pdf file Click here
  • To access summary data presentation in a .pdf file Click here

NICE Guidance

NICE has developed medical technology guidance on the CardioQ-ODM - Click Here

NICE medical technology guidance addresses specific technologies notified to NICE by manufacturers. The 'case for adoption' recommendations are based on the claimed advantages of introducing the specific technology compared with current management of the condition. This 'case' is reviewed against the evidence submitted and expert advice. If the case for adopting the technology is supported, then the technology has been found to offer advantages to patients and the NHS. The specific recommendations on individual technologies are not intended to limit use of other relevant technologies which may offer similar advantages.

Relevant Randomised Controlled Trials

Noblett SE, Snowden CP, Shenton BK, Horgan AF.

Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. British Journal of Surgery 2006;93:1069-1076.

Click Here to view the abstract for this article

Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC.

Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. British Journal of Anaesthesia 2005;95:634-642.

Click Here to view the abstract for this article

Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C.

Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia 2002;57:845-849.

Click Here to view the abstract for this article

Sinclair S, James S, Singer M.

Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. British Medical Journal 1997;315:909-12.

Click Here to view the abstract for this article

Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P.

Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. British Journal of Anaesthesia 2002,88:65-71.

Click Here to view the abstract for this article

Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS.

Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002, 97:820-826.

Click Here to view the abstract for this article

Chytra I, Pradl R, Bosman R, Pelnář P, Kasal E, Židková A

Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Critical Care 2007, 11:R24

Click Here to view the abstract for this article

Mowatt G, Houston G, Hernández R, de Verteuil R, Fraser C, Cuthbertson B, Vale L.

Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients. Health Technol Assess 2009;13(7):1-118

Click Here to view the abstract for this article

Other useful systematic reviews, guidelines and related reference papers

NHS Purchasing and Supply Agency, 2008

Evidence review: Oesophageal Doppler monitoring in patients undergoing high-risk surgery and in critically ill patients. CEP08012:

Abbas SM, Hill AG.

Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008;63:44-51.

Walsh SR, Tang T, Bass S, Gaunt ME.

Doppler-guided intra-operative fluid management during major abdominal surgery: systematic review and meta-analysis. International Journal of Clinical Practice;2008;62:466-470

Dark PM, Singer M.

The validity of trans-esophageal Doppler ultrasonography as a measure of cardiac output in critically ill adults. Intensive Care Med 2004;30:2060-6.

McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M.

Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ 2004;329:258.

Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS.

Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988;94:1176-86.

Pearse RM, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED.

Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care 2005;9:R687-R693.

Sandham JD, Hull RD, Brant RF, et al.

A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. New England Journal of Medicine 2003;348:5-14.

Other useful web links

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP)

The Association of Surgeons of Great Britain and Ireland,SARS, BAPEN Medical, the Intensive Care Society, the Association for Clinical Biochemistry and the Renal Association established a consensus for good perioperative fluid management.

In Section 5 (Guidelines for the assessment of fluid requirements it is stated that "the availability of minimally invasive techniques formeasurement of stroke volume and cardiac output, using trans-oesophageal Doppler or pulse contour analysis, it has been possible to tailor fluid requirements more precisely to the needs of the individual patient".

Clinical trials have demonstrated that fluid therapy guided by measurements of stroke volume and cardiac index result in significantly better clinical outcomes than those associated with traditional intraoperative monitoring. The beneficial effect is likely to relate to the early tailoring of fluid administration to the requirements of the individual patient rather than the blanket administration of extra fluid.

The full report can be accessed at:

http://www.asgbi.org.uk/en/publications/surgical_resources_and_documents

The Improving Surgical Outcomes Group (ISOG)

The Improving Surgical Outcomes Group (ISOG) is an independent medical group comprising surgeons, anaesthetists, critical care consultants and others involved in operative management and care. The group is concerned with improving patient outcomes and modernising care for patients undergoing major surgery.

In section 8 of the report (Improving Perioperative Care) it states "Optimisation of the fluid balance of patients during surgery (haemodynamic optimisation) guided by a cardiac output algorithm can significantly reduce both the rates of complications and mortality, as well as significantly reducing the length of hospital stay" and "haemodynamic optimisation has been made much simpler to perform through the development of less-invasive techniques and is now considered by many to be the standard of care".

Professor Monty Mythen, of ISOG and Portex Professor of Anaesthesia and Critical Care, University College London has said, "This is just the sort of technique that we are trying to encourage hospitals across the UK to adopt."

The full report can be accessed at: http://www.reducinglengthofstay.org.uk/doc/isog_report.pdf

Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988;94:1176-86.

Pearse RM, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED.

Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care 2005;9:R687-R693.

Sandham JD, Hull RD, Brant RF, et al.

A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. New England Journal of Medicine 2003;348:5-14.

Enhanced Recovery Programme

In addition to intra-operative fluid management there are a number of other evidence-based approaches designed to prepare patients for, and reduce the total impact of, surgery, helping them to recover more quickly.

The Enhanced Recovery Programme which is undertaken in partnership with the NHS Institute for Innovation and Improvement, NHS Improvement, the NHS Cancer Action Team, the 18 Weeks Implementation Team, and the Department of Health.

Click Here for more information

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