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Correspondence |

Using Intraoperative Goal-Directed Hemodynamic Management Shows Dobutamine To Be Effective in Maintaining Central Venous Oxygen Saturation Response FREE TO VIEW

Aaron Joffe, DO
Author and Funding Information

Affiliations: University of Wisconsin School of Medicine and Public Health, Madison, WI,  Marche Polytechnical University, Ancona, Italy,  University Hospital of Liege, Liege, Belgium

Correspondence to: Aaron Joffe, DO, University of Wisconsin School of Medicine and Public Health, Department of Anesthesiology, 600 Highland Ave, B6/331, CSC, Madison, WI 53792; e-mail: ajoffe@uwhealth.org


Chest. 2008;134(1):215-216. doi:10.1378/chest.08-0101
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I read with interest the study of Donati and colleagues1in the December 2007 issue of CHEST. Several clarifications are required, however. Neither the patients nor the surgeries were uniformly high risk. Fully 60% of all surgeries performed carried an intermediate risk,2 and 15% of patients had only mild systemic disease preoperatively. High-risk features for cardiovascular or pulmonary morbidity and mortality were not provided. Further evidence of a lower risk study population than that indicated by the authors was the observed mortality rates of 2.9% and 3%, respectively, in the intervention and study groups.2

Maintenance of a mean arterial pressure of >80 mm Hg throughout the operative period without the administration of any vasopressors (eg, ephedrine or phenylephrine), particularly during induction, is contrary to clinical experience. Yet, according to the authors, this was true for all study patients. In fact, a prescription for the treatment of hypotension (mean arterial pressure < 80 mm Hg) is absent from the treatment algorithm. The use of vasopressors intraoperatively is an independent predictor of postoperative renal failure,3 and not reporting their use would represent an important omission.

Additionally, precise p values and a statement as to whether a p value of < 0.05 represents one-sided or two-sided significance is lacking in their study. Thus, the finding of a decrease in the length of hospital stay between the intervention and standard-treatment groups despite a sample size sufficient to provide just > 50% power to do so may be invalid. Insofar as study enrollment appears to have been difficult (ie, less than four patients per year per hospital), the number of patients screened to reach the target enrollment and their baseline characteristics should be provided so that the groups can be assessed for possible selection bias. With the information provided, the only conclusion the reader can draw is that dobutamine is efficacious in maintaining central venous oxygen saturation. However, the clinical significance in the perioperative period remains uncertain.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The authors have no conflicts of interest to disclose.

Donati, A, Loggi, S, Preiser, JC, et al (2007) Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients.Chest132,1817-1824
 
Fleisher, LA, Beckman, JA, Brown, KA, et al ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery); developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation2007;116,e418-e499
 
Kheterpal, S, Tremper, KK, Englesbe, MJ, et al Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function.Anesthesiology2007;107,892-902
 
To the Editor:

We thank Dr. Joffe for his thoughtful comments on our article.1With respect to the level of risk, American Society of Anesthesiologists (ASA) scores were III or IV in 85% of the patients, and the 3% mortality rate was in the same range as in previous similar studies (for instance 4% in the study by Shoemaker et al2). We are unfortunately unable to provide additional details on the cardiovascular and pulmonary status than those included in the article. However, the use of ASA classification3 is used routinely by anesthesiologists and generally deemed as sufficient to quantify the level of perioperative risk.

The target mean arterial pressure is not unusual, but the way to reach it was left at the discretion of the anesthesiologist, as the use of sedative, narcotic, and vasopressor agents was not standardized. We would like to remind that the goal of this study was rather to evaluate the efficiency of the tested intervention, regardless of the other therapeutic modalities, that are widely variables across hospitals.

The p values represented two-sided significance, and power of the study, both for the different percentage of patients with organ failure in each group (p = 0.021) and for the length of hospital stay (p = 0.013), is > 80%, both for type I error and type II error. Regarding the screening of potential participants, as indicated in the “Results” section, 324 patients were assessed for eligibility (and actually screened) in the nine participating hospitals over 24 months. Of these, 189 were excluded: 153 because they did not met inclusion criteria, and 36 because they refused to participate in the study, leaving 135 participants.

Finally, we respectfully disagree with the contention that the only conclusion is that dobutamine is efficacious in maintaining central venous oxygen saturation. In contrast, the observed decreases in the rate of organ failures and length of stay represent in our view a clinically relevant effect of the use of the tested therapeutic strategy.

References
Donati, A, Loggi, S, Preiser, JC, et al Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients.Chest2007;132,1817-1824
 
Shoemaker, WC, Appel, PL, Kram, HB, et al Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.Chest1988;94,1176-1186
 
American Society of Anesthesiologists.. New classification of physical status.Anesthesiology1963;24,111
 

Figures

Tables

References

Donati, A, Loggi, S, Preiser, JC, et al (2007) Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients.Chest132,1817-1824
 
Fleisher, LA, Beckman, JA, Brown, KA, et al ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery); developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.Circulation2007;116,e418-e499
 
Kheterpal, S, Tremper, KK, Englesbe, MJ, et al Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function.Anesthesiology2007;107,892-902
 
Donati, A, Loggi, S, Preiser, JC, et al Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients.Chest2007;132,1817-1824
 
Shoemaker, WC, Appel, PL, Kram, HB, et al Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.Chest1988;94,1176-1186
 
American Society of Anesthesiologists.. New classification of physical status.Anesthesiology1963;24,111
 
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