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Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage.

ABSTRACT: OBJECTIVES:We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation. DESIGN:Experimental human hemorrhage and resuscitation. SETTING:Clinical research laboratory. SUBJECTS:Healthy volunteers. INTERVENTIONS:Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula-based bolus resuscitation; 2) semiautonomous (decision assist) fluid administration; and 3) fully autonomous (closed loop) resuscitation. Hemodynamic variables, volume shifts, fluid balance, and cardiac function were monitored during hemorrhage and resuscitation. Treatment modalities were compared based on resuscitation efficacy and efficiency. MEASUREMENTS AND MAIN RESULTS:All approaches achieved target blood pressure by 60 minutes. Following hemorrhage, the total amount of infused fluid (bolus resuscitation: 30?mL/kg, decision assist: 5.6?±?3?mL/kg, closed loop: 4.2?±?2?mL/kg; p < 0.001), plasma volume, extravascular volume (bolus resuscitation: 17?±?4?mL/kg, decision assist: 3?±?1?mL/kg, closed loop: -0.3?±?0.3?mL/kg; p < 0.001), body weight, and urinary output remained stable under decision assist and closed loop and were significantly increased under bolus resuscitation. Mean arterial pressure initially decreased further under bolus resuscitation (-10?mm Hg; p < 0.001) and was lower under bolus resuscitation than closed loop at 20 minutes (bolus resuscitation: 57?±?2?mm Hg, closed loop: 69?±?4?mm Hg; p = 0.036). Colloid osmotic pressure (bolus resuscitation: 19.3?±?2?mm Hg, decision assist, closed loop: 24?±?0.4?mm Hg; p < 0.05) and hemoglobin concentration were significantly decreased after bolus fluid administration. CONCLUSIONS:We define efficacy of decision-assist and closed-loop resuscitation in human hemorrhage. In comparison with formula-based bolus resuscitation, both semiautonomous and autonomous approaches were more efficient in goal-directed resuscitation of hemorrhage. They provide favorable conditions for the avoidance of over-resuscitation and its adverse clinical sequelae. Decision-assist and closed-loop resuscitation algorithms are promising technological solutions for constrained environments and areas of limited resources.

SUBMITTER: Hundeshagen G

PROVIDER: S-EPMC5600681 | biostudies-literature | 2017 Oct

REPOSITORIES: biostudies-literature

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Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage.

Hundeshagen Gabriel G Kramer George C GC Ribeiro Marques Nicole N Salter Michael G MG Koutrouvelis Aristides K AK Li Husong H Solanki Daneshvari R DR Indrikovs Alexander A Seeton Roger R Henkel Sheryl N SN Kinsky Michael P MP

Critical care medicine 20171001 10

<h4>Objectives</h4>We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation.<h4>Design</h4>Experimental human hemorrhage and resuscitation.<h4>Setting</h4>Clinical research laboratory.<h4>Subjects</h4>Healthy volunteers.<h4>Interventions</h4>Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula- ...[more]

PMID: 28682837

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Project description:Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare the results with those for matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload-independent state, defined as percentage of case time with stroke volume variation less than or equal to 12%.Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team, and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment, each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias.A total of 40 patients were enrolled, 5 were ultimately excluded and 25 matched pairs were selected from among the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95?±?6% of case time versus 87?±?14%, P =0.008). There was no difference in case mean or final stroke volume index (45?±?10 versus 43?±?9 and 45?±?11 versus 42?±?11, respectively) or mean arterial pressure (79?±?8 versus 83?±?9). Case end heart rate was significantly lower in the closed-loop assisted group (77?±?10 versus 88?±?13, P =0.003).In this case-control study with propensity matching, clinician use of closed-loop assistance resulted in a greater portion of case time spent in a preload-independent state throughout surgery compared with manual delivery of goal-directed fluid therapy.ClinicalTrials.gov Identifier: NCT02020863. Registered 19 December 2013.

Dataset Information

Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage.

Publications

Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage.

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