An augmented approach to perioperative fluid management of complex surgical patients can lower the risk for postoperative morbidity by up to 29% and reduce health care costs by up to $970 per patient.

The projections (Crit Care 2014;18:566) are based on a combination of actual clinical and cost data from the University HealthSystem Consortium (UHC) and findings from studies of the impact of perioperative goal-directed fluid therapy (GDFT).

Lead researcher Gerard Manecke, MD, who is professor in the Department of Anesthesiology at the University of California, San Diego Medical Center, explained that the approach relies on standard vital signs as well as hemodynamic parameters such as stroke volume, cardiac output and oxygen delivery, to monitor and direct administration of bolus fluids.

He said prior studies have demonstrated benefits using the approach and GDFT has been widely adopted in some European countries, but the additional cost of hemodynamic monitoring equipment—which can be up as high as $300 per procedure—has likely been a barrier to its adoption in the United States.

“What we found is that, even using conservative estimates, the savings resulting from the reduced need for treatment of complications thanks to GDFT are significantly greater than the cost of this equipment,” he said.

The analysis used information from 222 medical centers from the UHC, including clinical and cost data from 75,140 adult surgical patients treated in 2011.

The patients had undergone one of 10 noncardiac surgical procedures for which previous findings have found GDFT has the greatest clinical and cost impact, Dr. Manecke said (Table).

Table. Surgical Procedures For Which Goal-Directed Fluid Therapy Has Highest Impact
Abdominal aortic aneurysm open repair
Aorto-iliac and peripheral bypass
Colectomy
Esophagectomy
Femur and hip fracture repair
Gastrectomy
Hepatectomy
Pancreatectomy
Resection of rectum
Total cystectomy

He and his team examined clinical and cost data for patients with and without postoperative complications and projected the potential impact of GDFT in this population. The projections were based on a recent meta-analysis suggesting the approach can reduce the incidence of postoperative morbidity by 17% to 29% (JAMA 2014;311:2181-2190).

A review of the data showed 11.2% of the patients developed at least one of 13 common postsurgical complications, such as stroke, gastrointestinal hemorrhage, catheter-associated urinary tract infection, surgical site reopening, acute myocardial infarction and nosocomial pneumonia.

Mortality rates were higher among those with complications (12.4% vs. 1.4% for complications vs. no complications, respectively; P<0.001), and hospital stays were longer (mean 20.5 vs. 8.1 days, respectively; P<0.001). Additionally, the average direct cost of care was $47,284 for those with complications compared with $17,408 for patients with no complications (P<0.001).

Dr. Manecke’s team projected GDFT could have shaved between $43 million and $73 million off the $252 million direct costs of treating patients with perioperative complications, or between $569 and $970 per patient.

“We used conservative estimates and I think savings could be greater in the private sector,” Dr. Manecke said.

He noted individual institutions can apply the model he and his colleagues used in the current analysis to capture a more tailored picture of the potential effects of implementing GDFT at their institution.

“I would think ambulatory surgical centers that conduct fewer complex procedures would probably benefit less from implementing GDFT than tertiary care centers,” Dr. Manecke said.

Richard Dutton, MD, MBA, who is chief quality officer of the American Society of Anesthesiologists (ASA) and was not involved in the research, broadly agreed with the study’s conclusions, saying, “Better fluid management will likely improve outcomes, since many patients undergoing major operations actually need less fluid—and a lot less salt—than they usually receive.”

However, he said he suspects the magnitude of GDFT may not be as dramatic in “real-world” clinical practice as the current analysis portrayed it to be.

“Early trials and early meta-analyses, like those used in this study to generate their assumptions, tend to exaggerate results of new technologies,” he said. He noted the analysis was sponsored by Edwards Lifesciences.

“What I have mostly taken away from the GDFT literature is that a multimodal, team-based, start-to-finish, systematic protocol for managing complex patients produces better results than our normal haphazard and fragmented system,” said Dr. Dutton.

The ASA has developed the Perioperative Surgical Home philosophy to address this type of fragmentation of care, he added.

—David Wild

Goal-Directed Fluid Therapy Reduces Morbidity, Costs
Goal-Directed Fluid Therapy Reduces Morbidity and Costs

Goal-Directed Fluid Therapy Reduces Morbidity and Costs