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184 Australasian Anaesthesia 2011Cardiac output monitoring in non-cardiac surgery: how and why? 185However, there are still reasons to question these conclusions. All the randomised controlled trials (RCTs) usingA more intensive algorithm targeting blood flow, or cardiac index (CI) first, and blood pressure second, is as shownminimally invasive monitors included in these meta-analyses have been small single centre studies, few with greaterin Figure 6.than 100 – 200 patients. Trials of this size are typically “efficacy studies” which can reflect the intense interest of acentre or research group in an intervention, but may not reflect the results of that intervention in more widespreadFigure 6. An intensive goal directed haemodynamic strategy targeting cardiac index first, andpractice. Research funded by commercial interests or negative studies in a field of research can encounter publicationincorporating the possibility of using an inotrope/chronotrope (such as dobutamine for example),bias and this can affect the results of meta-analyses. 37 There are a number of salient examples in the anaestheticwhere preload appears adequate but cardiac index remains low, implying cardiac dysfunction.and medical literature of failure of a meta-analysis of small RCTs to be confirmed by a subsequent large RCTconducted across a large number of centres. 38,39 There is a need for a large multicentre RCT of goal directed fluidand haemodynamic management in major surgery, to confirm the findings of research to date in this field. Theincreasing availability of minimally invasive monitors in clinical practice should make this feasible in the near future.A higher standard of evidence for the benefits goal directed management will assist in the wider adoption of theseCI < 2.5 L/min.m 2 ?devices.The slow penetration of these technologies into routine clinical practice up till now has been limited by otherYesSVV > 13% ?FTc < 350 msec?SV |^> 10%?Nofactors as well. These include lack of familiarity of the clinician and cost considerations, particularly of single-usedisposable components. These devices add to the complexity of the conduct of anaesthesia and may be perceivedas a distraction to the anaesthetist. Most of the available devices are marketed as stand-alone systems, and lackof integration with the rest of the patient monitoring system, contribute to this perception.Better integration into anaesthesia delivery and monitoring platforms will improve this. For example, integrationwith invasive or non-invasive blood pressure measurement allows automatic calculation of haemodynamic indicessuch as SVR which gives further data to guide fluid and vasopressor therapy. Indices of oxygen delivery areautomatically available when oximetry data is incorporated. Full integration allows optimal data display and alarmYesNoSVI
186 Australasian Anaesthesia 2011Cardiac output monitoring in non-cardiac surgery: how and why? 18712. Peyton P, Chong SW. Minimally invasive measurement of cardiac output during surgery and critical care:A meta-analysis of accuracy and precision. Anesthesiology, 2010; 113 (5): 1220-35.13. Runciman, W. B., A. H. Ilsley, J. G. Roberts. Thermodilution cardiac output – a systematic error. Anaesth IntensCare 9: 135-9, 1981.14. Tournadre, J.P., D. Chassard and R. Muchada. Overestimation of low cardiac output measured by thermodilution.Br J Anaesth 79: 514-6, 1997.15. Van Grondelle, A., R. V. Ditchey, B. M. Groves, W. W. Wagner and J. T. Reeves. Thermodilution methodoverestimates low cardiac output in humans. Am J Physiol (Heart Circ Physiol) 14: H690-2, 1983.16. Bein B, Renner J, Scholz J, Tonner PH: Comparing different methods of cardiac output determination: A callfor consensus. Eur J Anaesthesiol 2006; 23: 710.17. Linton NWF, Linton RA, Della Rocca G, Costa MG: Is comparison of changes in cardiac output, assessed bydifferent methods, better than only comparing cardiac output to the reference method? Br J Anaesth 2002;89: 336-7.18. Feldman JM: Is It a Bird? Is It a Plane? The Role of Patient Monitors in Medical Decision Making. Anesth Analg2009; 108: 707-10.19. Critchley LA, Yang XX, Lee A. Assessment of Trending Ability of Cardiac Output Monitors by Polar PlotMethodology. J J Cardiothorac Vasc Anesth 2011; 25(3): 536-546.20. Bein B, Meybohm P, Carvus E, Renner J, Tonner P, Steinfath M, Scholz J, Doerges V. The Reliability of PulseContour-Derived Cardiac Output During Hemorrhage and After Vasopressor Administration. Anesth Analg, 105(1): 107-13, 2007.21. Collange O, Xavier L, Kuntzman H, Calon B, Schaeffer R, Pottecher T, Diemunsch P, Pessaux P. FloTrac formonitoring arterial pressure and cardiac output during phaeochromocytoma surgery. Eur J Anaesthesiology.25: 779-80, 2008.22. Vannucci A, Krejci V, Kangrga I: Performance of Vigileo and LiDCOplus cardiac output monitors during a prolongedcardiac arrest and resuscitation. Eur J Anaesthesiol 2009; 26: 885-7.23. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluidresponsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med2009;37:2642–7.24. Bendjelid K, Romand JA. Fluid responsiveness in mechanically ventilated patients: a review of indices used inintensive care. Intensive Care Med 2003; 29:352-360.25. Kungys G, Rose DD, Fleming NW. Stroke Volume Variation During Acute Normovolemic Hemodilution. AnesthAnalg 2009;109:1823–30.26. Gurgel ST, do Nascimento P Jr. Maintaining tissue perfusion in high-risk surgical patients: a systematic reviewof randomized clinical trials. Anesth Analg 2011; 112:1384-91.27. Davies SJ, David Yates D, Wilson RJT. Dopexamine Has No Additional Benefit in High-Risk Patients ReceivingGoal-Directed Fluid Therapy Undergoing Major Abdominal Surgery. Anesth Analg 2011;112:130-8.28. Gopal S, Jayakumar D, Nelson PN. Meta-analysis on the effect of dopexamine on in-hospital mortality.Anaesthesia 2009;64: 589-94.29. Brandstrup B. Fluid therapy for the surgical patient. Best Practice & Research Clinical Anaesthesiology 2006;Vol. 20(2): 265-283.30. Abbas SM, Hill Ag. Systematic review of the literature for the use of oesophageal Doppler monitor for fluidreplacement in major abdominal surgery. Anaesthesia, 2008, 63, pages 44-51.31. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinalcomplications in major surgery: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia2009; 103 (5): 637-46.32. Rahbari NN, Zimmermann JB, Schmidt T, Koch M, Weigand MA, Weitz J. Meta-analysis of standard, restrictiveand supplemental fluid administration in colorectal surgery. British Journal of Surgery 2009; 96: 331-341.33. Roche AM, Miller TE, Gan TJ. Goal-directed fluid management with trans-oesophageal Doppler. Best Practice& Research Clinical Anaesthesiology. 2009; 23: 327-334.34. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptivehemodynamic interventionto improve postoperative outcomes in moderate- and high-risk surgical patients.Anesth Analg 2011; 112:1392-402.35. Miller TE, Roche AM, Gan TJ. Poor Adoption of Hemodynamic Optimization During Major Surgery: Are WePracticing Substandard Care? Anesth Analg 2011; 112(6): 1274-6.36. www.nice.org.uk/guidance/MTG3.37. Pogue J, Yusuf S. Overcoming the limitations of current meta-analysis of randomised controlled trials. Lancet1998; 351: 47-52.38. LeLorier J, Grégoire G, Benhaddad A, Lapierre J, Derderian F. Discrepancies between meta-analyses andsubsequent large randomised, controlled trials. N Engl J Med 1997; 337: 536-542.39. Rigg JRA, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS, for the MASTER AnaesthesiaTrial Study Group. Epidural Anaesthesia and Analgesia and Outcome of Major Surgery: a Randomised Trial.Lancet, 2002; 359: 1276-82.40. Slagt C, Breukers RM, Groeneveld ABJ. Choosing patient-tailored hemodynamic monitoring Critical Care 2010,14:208-13.
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