Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: Results

In: Surgical Patients

13 Mar 2015

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: ResultsStatistical Methods
Comparisons of mortality and morbidity figures were done using chi square analysis with Yates’ correction for small cell size where applicable. Hemodynamic data comparisons within groups and between groups were analyzed using either paired or unpaired Student’s t test and ANO\A with Newman-Keuls’ test for significance of individual comparisons. All p values were obtained using two-tailed tests.

Results
Hemodynamic and Oxygen Transport Variables

Table 3 summarizes the hemodynamic and oxygen transport values of series 1 and Table 4 series 2. Data in the preoperative control period and in the immediate postoperative periods are shown for patients with relatively normal preoperative values and for the entire series of the hyperdynamic patients who had sepsis or late stage cirrhosis. Figures 1 to 3 illustrate the temporal sequential patterns in Cl, Do2, Vo2, as well as the most commonly monitored variables for series 1 and Figures 4 and 5 for series 2. The preoperative data demonstrate reasonable comparability between the control and the protocol patients. Postoperatively, however, significantly greater Cl, Do2, and Vo2 values were observed in protocol patients in both series. By contrast, there were no essential differences between the two groups in the other monitored variables.
At their maximum values, Cl, Do2 and Vo2 were 5.6 ± 1.3 L/min*m2, 847 ± 267 ml/min*m2, and 185 ± 46 ml/min*m2, respectively, for PA-protocol patients. Thus, the maximum changes in these three variables irrespective of time were well above the therapeutic goals specified by the protocol and were higher than those of the PA-control group. Hyperdynamic patients had elevated flow and flow-related variables in the preoperative control period. These values were well maintained in the immediate postoperative period in both series. Table 5 compares values of the survivors and nonsurvivors; the data are consistent with previously reported studies- demonstrating greater responses in cardiac output, cardiac output-related values, and oxygen transport values.
Table 3—Comparison of Hemodynamic and Oxygen Transport Values in Control and Protocol Patients of Series I

Preoperative Period Postoperative Period (0-4 days)
Control Protocol Control Protocol
Patients with normal preoperative values (56 Data Sets) (33 Data Sets) (332 Data Sets) (499 Data Sets)
Heart rate (beats per minute) 90± 19 90±21 108± 18t 106 ± 20t
MAP (mm Hg) 98± 18 101 ±18 92 ±21$ 95± 18
Mean PA pressure (mm Hg) 18.3±7.9 17±9.6 24.4 ± 7.7t 21.1±8 It
CVP (mm Hg) 6 ± 4.7 6.3±5.3 10.5±6t 8.8±5.2t
Pulmonary artery WP (mm Hg) 9.4±5.6 8.9±7.2 12.7±5.7t 12.0±6.5t
Cl (L/minnn2) 3.22 ±.75 3.29± .84 3.52 ±.98$ 3.79± l.Ot
Systemic vascular resistance (dynes^sec/cm^m2) 2,409 ±783 2,604 ±633 1,999 ±781t l,946 ± 668t
Pa02 (torr) 112±58 101 ±56 113 ± 49 121 ±52$
Arterial pH 7.42 ±06 7.43 ±.05 7.43 ±.06 7.44± .07
Hct (%) 34.8±4.4 33.9±5.0 32.1 ±5.2$ 33.3±5.0
D02 (ml/minnn2) 473 ±112 477 ±124 495 ±138 561±148t
Vo2 (ml/minnn2) 126 ±30 127 ±39 139 ±36$ 148±41t
Data for the entire series (92 data sets) (73 data sets) (593 data sets) (836 data sets)
Heart rate (beats per minute) 96±23 92 ±20 110 ±19+ 108 ± 20t
MAP (mm Hg) 96± 18 101 ±18 91 ±20$ 92 ± 19t
Mean PA pressure (mm Hg) 8.3±7.9 17.3±8.5 22.4±7.9t 21.7±7.8t
Central venous pressure (mm Hg) 7.4±6.1 7.1 ±5.9 10.7±6.2t 9.8 ±6. It
PA WP (mm Hg) 9.8±6.2 9.7±6.8 12.9±5.9t 12.5±6.5t
Cl (L/minnn2) 3.6± 1.1 3.85± 1.24 3.65± 1.13 4.45±1.51t
Systemic vascular resistance (dynes^sec/cm^m2) 2,194 ±1,042 2,132 ±839 1,964 ± 969$ 1,761 ±747t
Pa02 (torr) 114 ±63 100 ±49 108 ±48 115 ±56$
Arterial pH 7.42± .08 7.43± .05 7.43 ±.07 7.44± .08
Hct (%) 34.1 ±4.8 32.7 ±5.6 31.5±5.3$ 32.6±4.9
Do2 (ml/minnn2) 527 ±159 542 ±164 508 ±166 598 ±217
Vo2 (ml/minmi2) 138 ±37 141 ±52 135 ±46 148 ±38

Table 4 — Comparison of Preoperative and Postoperative Hemodynamic and Oxygen-Transport Values in Control and Protocol Groups of Series 2

Variable Preoperative Control Period Postoperative Period p Value
Control Protocol Control Protocol
Patients with normal preoperative values
Heart rate, beats per minute 89 ±19 84 ±13 100 ±22 102 ±19
MAP, mm Hg 96± 19 95 ± 15 87 ±24 90± 17
CVP, mm Hg 5.9±4.5 7.0±3.5 9.2±4.1 7.7 ±4.5
Mean PA pressure, mm Hg 20 ±7.2 16.7 ±7.6 20.8 ±5.4 19.6±7.7
PA WP, mm Hg 9.8±5.7 8.9±4.3 12.3±4.5 10.8±6.1
Cl, L/minnn2 3.52 ±81 3.62 ±.69 3.6± 1.12 4.25± 1.25t <0.01*
Systemic vascular resistance, dynes^sec/cm^m2 2,329 ±793 2,011 ±651 1,819 ±692 1,668 ±654
Pa02, torr 139 ±107 159 ±109 148 ±64 161 ±82
Arterial pH 7.41 ±.04 7.44 ±.07 7.42 ±07 7.42 ±.07
Hct, % 35.1 ±3.8 36.6 ±4.2 34.1 ±3.5 33.5±4.1
D02, ml/min#m2 541 ±130 583 ±90 561 ±190 663 ± 232t <0.01*
Vo2, ml/min*m2 121 ±31 112 ±24 118 ±43 136 ± 44t <0.01$
Patients with hyperdynamic preoperative values
Heart rate, beats per minute 102 ±22 97 ±28 101 ± 16 107 ±26
MAP, mm Hg 90± 14 98± 15 89 ±10 99± 12
CVP, mm Hg 9.3±4.4 9.0±4.4 11.7±4.7 5.7±4.1
Mean PA pressure, mm Hg 17.3±6.2 13.3±2.3 21.9±5.4 14.6±4.2
PA WP, mm Hg 10.7±4.9 9.0± 1.7 12.4±4.1 7.9±3.4
Cl, L/min*m2 6.21 ± .59 5.37 ±.42 6.59 ±1.57 5.83± .95
Systemic vascular resistance, dynes^sec/cm^ma 1,051 ±221 1,311 ±179 1,003 ±301 1,308 ±249
Pa02, torr 103 ±60 88±9 96±31 116 ±29
Arterial pH 7.41 ±.10 7 .46 ± .05 7.45 ±.04 7.45 ±.04
Hct, % 28.1 ±3.4 28 ±3.5 31.9±2.6 33±4.7
Do2, ml/min*m2 771±121 661 ±118 962 ±240 875 ±196
Vo2, ml/min*m2 147 ±23 156 ±43 149 ±40 158 ±38

Table 5—Comparison of Hemodynamic and Oxygen Transport Values of Surviving and Nonsurviving Patients in the Preoperative and Postoperative Periods

Values Preoperative Period Postoperative Period (0-4 Days)
Survivors (99 Data Sets) Nonsurvivors (41 Data Sets) Survivors (1,233 Data Sets) Nonsurvivors (813 Data Sets)
HR (beats per minute) 91 ±21 102 ±23 109 ± 19t 109 ±19.94:
MAP (mm Hg) 99 ±16 95 ±22 97 ±17 84±20t
Mean PA pressure (mm Hg) 16.9±8.6 18.9±8.8 20.8±7.6t 24. l±7.9t
CVP (mm Hg) 6.1 ±5.1 10.3±6.7 9.2±5.6t 12.0±6.4
PA\V£ wedge pressure (mm Hg) 8.8±6.1 11.9±6.5 11.6±5.7t 14.5±6.5$
Cl (L/min#m2) 3.76± 1.19 3.6± 1.18 4.21 ± 1.27t 3.36± 1.26
SI (ml/m2) 42.7 ± 15.2 36.3 ±12.5 39.8 ± 12.9$ 31.6± 12.5$
SVRI (dynes»sec/cm*m2) 2,182 ±785 2,154 ±1,320 1,812 ± 686t 1,976 ±1,120
PVRI (dynes’sec/cm^m2) 184 ±109 240 ±151 195 ±128 253 ±175
LCWI (kg*m/m2) 5.0± 1.7 4.5± 1.6 5.5 ±1.9$ 3.9± 1.8$
RCWI (kgWm2) 0.81 ±.44 1.03 ±.52 1.17±.53t 1.1 ±.47
LVSWI (gm/m2) 59 ±20 45.9 ±15.9 52.1 ±2.02+ 36.8 ± 19t
RVSWI (gvn/m2) 9.2±5.4 10.4±5.4 11.1 ±5.3t 10.1 ±4.9
Pa02 (torr) 104 ±53 122 ±69 113 ± 48 109 ±51
Sa02 (%) 94.5±3.5 94.9±2.7 95.6±3.1t 94.1 ±6.8
PaCOz (torr) 35±7 36± 11 36 ±7 35±9
pH, arterial 7.43± .05 7.42± .11 7.44 ±.06 7.43± .09
Hct (%) 34.3±5.6 31.8±3.6 32.4 ± 4.9t 31.5±5.5
Do2 (ml/min#m2) 548 ±162 500 ±159 601±189t 461±173
Vo2 (ml/minnn2) 141 ±49 135 ±30 153±41t 136 ±46
02 extraction ratio (%) 26.7±8.2 28.1 ±7.4 26.7 ±7.2 32.0 ± 10.9t

 

Figure 1. Sequential hemodynamic patterns of control and protocol patients in the preoperative, intraoperative and postoperative periods. Dots represent the mean values and vertical lines, the SEM. Note the appreciable increase in Cl of the protocol patients beginning about 4 h postoperatively.

Figure 1. Sequential hemodynamic patterns of control and protocol patients in the preoperative, intraoperative and postoperative periods. Dots represent the mean values and vertical lines, the SEM. Note the appreciable increase in Cl of the protocol patients beginning about 4 h postoperatively.

Figure 2. Sequential patterns of FIo2, arterial blood gases, pH and hematocrit values in control and protocol patients in the preoperative, intraoperative and postoperative periods. There were no essential differences between the two groups.

Figure 2. Sequential patterns of FIo2, arterial blood gases, pH and hematocrit values in control and protocol patients in the preoperative, intraoperative and postoperative periods. There were no essential differences between the two groups.

Figure 3. Sequential patterns of oxygen transport variables of control and protocol patients in the preoperative, intraoperative and postoperative periods. Note the appreciable increase in Do2 and Vo2 patterns of the protocol patients beginning about 4 h postoperatively. The oxygen extraction rate is higher in the control group beginning about 12 h postoperatively.

Figure 3. Sequential patterns of oxygen transport variables of control and protocol patients in the preoperative, intraoperative and postoperative periods. Note the appreciable increase in Do2 and Vo2 patterns of the protocol patients beginning about 4 h postoperatively. The oxygen extraction rate is higher in the control group beginning about 12 h postoperatively.

Figure 4. Sequential patterns of Cl, MAJ^ mean PA pressure, and pulmonary arterial WP for PA-control and PA-protocol patients in the preoperative, intraoperative and during the immediate postoperative period. Differences in Cl in the 36- to 48-h period were significant (p<0.05) by the two-tailed Students t test.

Figure 4. Sequential patterns of Cl, MAJ^ mean PA pressure, and pulmonary arterial WP for PA-control and PA-protocol patients in the preoperative, intraoperative and during the immediate postoperative period. Differences in Cl in the 36- to 48-h period were significant (p<0.05) by the two-tailed Students t test.

Figure 5. Sequential patterns of hematocrit, oxyhemoglobin saturation, Do2, Vo2, and oxygen extraction in the preoperative, intraoperative and during the immediate postoperative period. Differences in oxygen delivery in the 36- to 48-h period, and in Vo2 in the 12- to 24-h period were significant (p<0.05) by the two-tailed Student’s t test.

Figure 5. Sequential patterns of hematocrit, oxyhemoglobin saturation, Do2, Vo2, and oxygen extraction in the preoperative, intraoperative and during the immediate postoperative period. Differences in oxygen delivery in the 36- to 48-h period, and in Vo2 in the 12- to 24-h period were significant (p<0.05) by the two-tailed Student’s t test.


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