Goal-Directed Haemodynamic Therapy Improves Patient Outcomes in Kidney Transplantation.

Introduction: Kidney transplant graft function depends on optimised haemodynamics. However, high fluid volumes risk hypervolaemic complications. The Edwards Lifesciences ClearSight™ device permits fluid titration through markers of preload and beat-to-beat blood pressure monitoring. We evaluated the implementation of a novel goal-directed haemodynamic therapy protocol to determine whether patient outcomes had improved. Design: A retrospective evaluation of standard care versus goal-directed haemodynamic therapy in adults undergoing kidney transplantation was performed in a single centre between April 2016 and October 2019. Twenty-eight standard-of-care patients received intraoperative fixed-rate infusion and 28 patients received goal-directed haemodynamic therapy. The primary outcome was volume of fluid administered intraoperatively. Secondary outcomes included blood product and vasoactive drug exposure, graft and recipient outcomes. Results: Intraoperative fluid administered was significantly reduced in the goal-directed haemodynamic therapy cohort (4325 vs 2751 ml, P < .001). Exposure to vasopressor (67.9% vs 42.9%, P = .060) and blood products (17.9% vs 3.6%, P = .101) was unchanged. Immediate graft function (82.1% vs 75.0%, P = .515), dialysis requirement (14.3% vs 21.4%, P = .729) and creatinine changes post-operatively were unchanged. In the goal-directed haemodynamic therapy cohort, 1 patient had pulmonary oedema (3.6%) versus 21.4% in the standard cohort. Patients in the goal-directed haemodynamic therapy group were more likely to mobilise within 48 hours of surgery (number needed to treat = 3.5, P = .012). Conclusions: Protocolised goal-directed haemodynamic therapy in kidney transplantation was safe and may improve patient, graft, and surgical outcomes. Clinical trials assessing goal-directed approaches are needed.

The relationship between head injury severity and hemodynamic response to tracheal intubation.

INTRODUCTION: The acutely injured brain is sensitive to fluctuations in blood pressure. During tracheal intubation, airway stimulation provokes acute surges in blood pressure that have the potential to cause further harm in patients with intracranial pathology. Although reduced consciousness is thought to suppress airway reflexes, its influence on these hemodynamic reflexes is unknown.We aimed to investigate the relationship between head injury severity and hemodynamic response to laryngoscopy and intubation. METHODS: This retrospective observational study included 97 consecutive patients with head injuries who underwent prehospital tracheal intubation by a physician-led helicopter emergency medical service. The primary outcome was the acute hemodynamic response to the procedure. Secondary outcomes included the incidence of serious intracranial pathology and mortality. RESULTS: A hypertensive response to laryngoscopy and tracheal intubation occurred in 80% of patients. In 11% of patients, blood pressure increased by ≥100%. The hemodynamic response was attenuated with increasing head injury severity but unpredictably and not to clinically acceptable levels. The incidence of serious intracranial bleeding (61%) and raised intracranial pressure (22%) was high in patients with head injuries, requiring tracheal intubation. CONCLUSION: A clinically significant hemodynamic response to laryngoscopy and intubation is common in patients with head injuries and is not effectively attenuated by increasing head injury severity. The need to attenuate the hemodynamic response should be assessed independently of head injury severity. LEVEL OF EVIDENCE: Therapeutic study, level III.

Introduction of intensive glycaemic control into a neurosurgical intensive care unit: a retrospective cohort study.

BACKGROUND: There is evidence that intensive glycaemic control decreases morbidity and mortality in surgical intensive care unit patients. In traumatic brain injury, hyperglycaemia is a prognostic indicator. OBJECTIVE AND STUDY DESIGN: This retrospective cohort study describes the blood glucose level outcomes before and after the introduction of an intensive insulin protocol to a neurosurgical ICU. METHODS: We analysed data on all patients admitted to a neurosurgical ICU during the year before, and the year after, the introduction in July 2003 of an intensive insulin protocol targeting patient blood glucose level (BGL) to 4.4- 6.1mmol/L. Patients who underwent fewer than 20 BGL measurements during the ICU admission were excluded. Data were obtained from an electronic clinical information system. RESULTS: 121 patients were enrolled: 64 before and 57 after introduction of the protocol. The groups were similar in sex, age, and severity of illness on ICU admission. After introduction of the protocol, BGL was significantly lower (weighted mean BGL, 6.73mmol/L v 7.77mmol/L before; P < 0.001), and proportion of BGL readings in the target range was greater (37% v 21% before; P < 0.001). In addition, BGL variability was greater (weighted mean standard deviation, 2.03 v 1.88 before; P < 0.001), hypoglycaemia was more common (0.58% of BGL readings v 0.20% before; P = 0.06), and ICU stay was significantly longer, but there was no difference in median Glasgow Coma Scale score or ICU discharge status (alive or dead). CONCLUSIONS: The intensive insulin protocol was effective in lowering blood glucose in neurosurgical ICU patients.