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The influence of goal-directed fluid therapy on the

prognosis of elderly patients with hypertension
and gastric cancer surgery
This article was published in the following Dove Press journal:
Drug Design, Development and Therapy
29 October 2014
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Kai Zeng* Purpose: We aimed to investigate the influence of perioperative goal-directed fluid therapy
Yanzhen Li* (GDFT) on the prognosis of elderly patients with gastric cancer and hypertension.
Min Liang Methods: Sixty elderly patients (60 years old) with primary hypertension who received
Youguang Gao gastric cancer radical surgery and who were American Society of Anesthesiologists (ASA)
class II or III were enrolled in the current study. Selected patients were divided randomly into
Hongda Cai
two arms, comprising a conventional intraoperative fluid management arm (arm C, n=30) and a
Caizhu Lin
GDFT arm (arm G, n=30). Patients in arm C were infused with crystalloids or colloids accord-
Department of Anesthesia, the First ing to the methods of Millers Anesthesia (6th edition), while those in arm G were infused with
Affiliated Hospital, Fujian Medical
University, Fuzhou, Peoples Republic 200mL hydroxyethyl starch over 15 minutes under the FloTrac/Vigileo monitoring system,
of China with stroke volume variation between 8% and 13%. Hemodynamics and tissue perfusion labo-
*These authors contributed equally ratory indicators in patients were recorded continuously from 30 minutes before the operation
to this work to 24hours after the operation.
Results: Compared with arm C, the average intraoperative intravenous infusion quantity in
arm G was significantly reduced (2,732488 mL versus 3,135346 mL, P0.05), whereas
average colloid fluid volume was significantly increased (1,235360 mL versus 760280 mL,
P0.05). In addition, there were more patients exhibiting intraoperatively and postoperatively
stable hemodynamics and less patients with low blood pressure in arm G. Postoperative com-
plications were less frequent, and the time of postoperative hospital stay shorter, in arm G. No
significant differences were observed in mortality between the two arms.
Conclusion: Our research showed that GDFT stabilized perioperative hemodynamics and
reduced the occurrence of postoperative complications in elderly patients who underwent
gastric cancer surgery.
Keywords: stroke volume variation, gastric cancer, the elderly

Introduction
Fluid therapy is an integral part of daily anesthesia, as well as one of the most debated
issues in perioperative management. With the aging of the population, more and more
patients are in need of large-scale noncardiac surgery.13 Elderly hypertensive patients
with hypovolemia and hypoxia are often unable to tolerate such surgery due to post-
operative complications. The traditional methods normally introduce more liquid,
Correspondence: Caizhu Lin but easily lead to tissue edema and postoperative low blood pressure. These methods
Department of Anesthesia, the First also slow tissue healing and increase the incidence of complications such as pulmo-
Affiliated Hospital, Fujian Medical
University, No. 20 Chazhong Road,
nary infection. Furthermore, rapid rehydration loading within a short time can easily
Fuzhou 350005, Peoples Republic lead to acute pulmonary edema and heart failure, which is often life threatening.47
of China
Tel/fax +86 591 8798 1987
Therefore, more stringent standards are required for fluid administration in elderly
Email [email protected] patients, and anesthetists should operate with great cautiousness. Sincethereare no

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Zeng et al Dovepress

instruments that can accurately assess blood volume or tis- multifunction monitor (Datex-Ohmeda S/5TM type), heart rate
sue perfusion, or accurately predict liquid overload, most (HR), systolic blood pressure (SBP), diastolic blood pres-
studies811 have focused on the selection of types of blood sure (DBP), mean arterial pressure (MAP), central venous
for the perioperative treatment. Clinically, the decision pressure (CVP), oxygen saturation (SpO2), end-tidal carbon
regarding the amount of liquid to use during the surgery still dioxide partial pressure (PETCO2), and other indicators
depends on the anesthesiologists experience and patients were continuously monitored. The FloTrac/Vigileo system
tolerance. (version 1.10; Edwards Lifesciences, Irvine, CA, USA)
Stroke volume variation (SVV) is an accurate and easy was used to obtain cardiac output/cardiac index (CI), stroke
parameter by which to measure fluid responsiveness and volume (SV)/stroke index, SVV, and other hemodynamic
functional hemodynamic parameters. It can be used to guide parameters.
fluid therapy in mechanically ventilated patients. In the pres-
ent study, we aimed to investigate the effect of goal-directed Maintaining anesthesia
fluid therapy (GDFT) on prognosis in elderly hypertensive The patients in both arms underwent the same anesthetic
patients receiving gastric cancer surgery. The purpose is to procedure with drug application before surgery. Anesthesia
provide a more objective basis for intraoperative fluid therapy was induced by midazolam (Jiangsu Nhwa Pharmaceutical
and further refine the technique to improve outcomes for Co., Ltd., Xuzhou, Peoples Republic of China) 0.06 mg/
elderly patients. kg, fentanyl (Yichang Humanwell Pharmaceutical Co., Ltd.,
Yichang, Peoples Republic of China) 4 g/kg, etomidate
Materials and methods (German Braun Corporation, Southborough, Germany)
Patient selection 0.3mg/kg, cis-atracurium (GlaxoSmithKline plc, London,
This study was approved by the ethics committee of Fujian UK) 0.2 mg/kg, followed by intravenous injection. Intubation
Medical University, Fuzhou, Peoples Republic of China. was completed through video-assisted laryngoscopy. After
All patients signed consent forms. Between March 2011 intubation, a Datex-Ohmeda 7,100 ventilator was used to
and December 2012, 60 elderly hypertensive patients (older control breathing during anesthesia. All patients were sup-
than 60 years) undergoing abdominal cancer surgery were plied with 8 mL/kg tidal volume mechanical ventilation to
enrolled in the study. All patients had normal preoperative maintain a respiratory ratio (times of inhale:times of exhale)
blood pressures. According to the standards of the American of 1:2 and respiratory rate of 10 to 14 breaths per minute,
Society of Anesthesiologists (ASA), the preoperative condi- to ensure a PETCO2 level of ~3545 mmHg. The airway
tions of patients were classed as grades II or III. The averaged pressure was kept at less than 25 cm H2O. The anesthesia
body mass index (BMI) was 30 kg/m2, and the averaged was maintained with inhalation of 1.5% to 3% sevoflurane
preoperative hematocrit level was 0.35 L/L. Patients were (Jiangsu Nhwa Pharmaceutical Co., Ltd.), in air mixed with
excluded if they had secondary hypertension, severe car- 50% O2. Intermittent boluses of cis-atracurium 0.04 mg/kg
diopulmonary diseases (coronary heart disease, congenital and fentanyl 1g/kg were administered. A bispectral index
heart disease, pneumonia, tuberculosis, pulmonary malig- of between 40 and 60 was also maintained.
nant tumors, etc), liver and kidney dysfunctions, or clear
arrhythmia. The diagnostic criteria for hypertension were Volume management
based on Chinese Hypertension Prevention Guide, 2010.12 The FloTrac/Vigileo device was used to measure SVV and
All patients received regular preoperative antihypertensive other hemodynamic parameters. Patients in arm C under-
treatments. Using random selection, patients were divided went conventional fluid therapy management according
into two arms: a conventional infusion arm (arm C, n=30) to the methods of Millers Anesthesia (6th edition).13 The
and a GDFT group (arm G, n=30). management objective for arm G was to induce 200 mL of
6% hydroxyethyl starch within 15 minutes each time, with
Perioperative management SVV between 8% and 13%, under the monitoring of the
Preparation before anesthesia FloTrac/Vigileo system. When the measured SVV was 13%
All patients received a restricted diet preoperatively. After above the normal level (lasting for 5minutes), or the cur-
entering the operation room, local anesthesia was adminis- rent subtest reaction was positive (SV increased more than
tered by left radial artery catheterization guided by Doppler 10%), an additional 200 mL of Voluven was introduced.
ultrasound (SKK24-S6 xk 9/1; Zhongxi Yuanda Technology Intraoperatively, insulation blankets and a continuous heat-
Co., Ltd., Beijing, Peoples Republic of China). Using a ing device were used to maintain patient temperatures at

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Dovepress The influence of goal-directed fluid therapy

above 36C. Blood transfusion was conducted if bleeding complications occurred multiple times, patients were
constituted more than one-quarter of the total blood volume. immediately transferred to the intensive care unit. Post-
Finally, all patients were treated postoperatively by the same operative complications were observed by physicians who
team of physicians. were blinded to the two arms in combination with patient
self-reports.
Monitoring indicators
Basic indicators Statistical analysis
Patients were scheduled preoperative visits and vital informa- Data were analyzed by SPSS 18.0 software. Normal dis-
tion was collected, which included sex, age, weight, height, tribution was assessed with mean standard deviation.
blood pressure classification, ASA classification, BMI, hemo- Within arms, data were assessed by using two-factor
globin levels (Hb), preoperative complication type, etc. repeated measures analysis of variance. Analysis between
arms used Students t-test. Ridit analysis was used to
Hemodynamics assess ordinal data. Counts were done by using the 2 test
All patients were continuously monitored in terms of con- or Fishers exact test. P0.05 was considered statistically
ventional hemodynamic parameters, including HR, SBP, significant.
DBP, MAP, CVP, SpO2, and other indicators. The FloTrac/
Vigileo system was used to obtain cardiac output/CI, SV/ Results
stroke index, SVV, and other hemodynamic parameters. There were no significant differences in sex ratio, age,
Hemodynamic indexes of MAP, HR, and CVP were recorded hypertension classification, ASA classification, BMI, Hb,
at the following time points: 30 minutes before surgery (T0); or other general information of the patients between the two
at the beginning of surgery (T1); 1 hour after the initial sur- arms (P0.05), as shown in Table 1.
gery (T2); at the onset of surgery (T3); 6 hours after surgery There were no significant differences in the HR or CVP
(T4); 12 hours after surgery (T5); and 24 hours after surgery values of patients between the two arms. However, MAP
(T6). Also, the perioperative hypotensive events, defined values were statistically different between the two arms.
as SBP 90 mmHg, DBP 50 mmHg, or a 30% drop For patients of the same arm, the values of MAP, HR, and
in blood pressure compared with baseline blood pressure, CVP varied at different time points. There were cross-effects
were recorded. Once hypotensive events occurred, ephedrine between arms and time points. Thus, it can be considered
was administrated to accelerate the infusion rate. We also that the values and rates of change of MAP, HR, and CVP
recorded patients undergoing crystal volumes, colloids, were different at different time points.
blood losses, and urine outputs. Compared with arm C, CVP values were higher at T4,
T5, and T6, and HR values were higher at T3, T4, T5, and T6,
Central venous oxygen saturation (ScvO2) in arm G.
and arterial blood lactate (Lac) From the time point of view, MAP began to rise 1 hour
Blood samples were collected from the jugular vein and radial after surgery and then began to decline to the levels from
artery in all patients at T0, T1, T2, T3, T4, T5, and T6. ScvO2 30 minutes before surgery, continuing to decline until
and Lac were then measured by a blood gas analyzer. 12 hours after the operation. HR began to decline after
surgery, then to rise 6 hours after surgery, reaching peak
Postoperative conditions 12 hours after surgery. CVP began to rise after the start of
The postoperative exhaust times were recorded. If any of surgery, rose to the highest value during surgery, and then
postoperative nausea and vomiting, low blood pressure, began to decline 24 hours after the operation to the level from
cardiac arrhythmia, oliguria, anastomotic fistula, or other the beginning of the operation (Table 2).

Table 1 Basic information of the patients (n=30)

Arm Sex Age Hypertension ASA BMI Hb (g/L) Operation
(M/F) (years) classification (I/II/III) classification (II/III) (kg/m2) time (h)
C 29/11 67.24.3 7/14/9 32/8 24.13.3 129.24.6 4.31.2
G 31/9 66.63.9 6/14/10 31/9 24.44.2 131.26.8 4.11.3
Notes: Arm C received conventional infusion; arm G received goal-directed fluid therapy. Data are presented as number or mean standard deviation.
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; Hb, hemoglobin.

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Table 2 Comparison of hemodynamics of patients between the two arms (n=30)

Time MAP (mmHg) HR (bpm) CVP (cm H2O)
point Arm C Arm G Arm C Arm G Arm C Arm G
T0 106.58.2 106.96.1 71.86.2 75.510.5 7.41.7 7.01.7
T1 107.57.9 107.36.0 68.85.4 71.811.3 8.31.9 7.91.7
T2 109.27.9 110.86.5 70.55.1 70.38.4 10.02.2 9.31.8
T3 100.27.5 110.97.5* 71.85.0 68.58.1 11.11.7 11.92.0
T4 95.37.3 109.66.8* 74.43.8 70.08.0* 9.11.3 10.91.6*
T5 93.96.1 106.06.2* 75.54.0 71.28.7* 7.81.2 9.91.3*
T6 92.15.3 106.14.8* 76.64.1 71.98.6* 7.00.9 8.61.4*
Notes: Data are presented as mean standard deviation. Arm C received conventional infusion; arm G received goal-directed fluid therapy. T0 =30 minutes before surgery;
T1 = at the beginning of surgery; T2 =1 hour after the initial surgery; T3 = at the onset of surgery; T4 =6 hours after surgery; T5 =12 hours after surgery; T6 =24 hours after
surgery. *P0.05 compared to arm C.
Abbreviations: CVP, central venous pressure; HR, heart rate; MAP, mean arterial pressure.

The average volume of intravenous infusion in arm G arm G. The incidences of nausea, vomiting, and hypotension
(2,732488 mL) was significantly lower than the value in were lower in arm G than in arm C. There were no statistical
arm C (3,135346 mL). The amount of colloids was higher in differences in delirium, arrhythmia, pulmonary infection,
arm G (1,235360 mL) than in arm C (760280 mL). There pulmonary edema, pulmonary embolism, wound infection/
were no differences in intraoperative blood losses and urine dehiscence, oliguria, intestinal fistula, mortality, and other
outputs between the two arms. Arm G had a lower incidence complications between the two arms (Table 6).
of hypotensive events, thus patients in this arm had a smaller
chance of requiring ephedrine (Table 3). Discussion
ScvO2 values between the two arms were statistically dif- The debate about appropriate perioperative fluid treatment
ferent. The difference in Lac value was significant between strategy has been going on for nearly half a century. Studies
the two arms. At different time periods, the values of ScvO2 have reported a number of inconsistent or even contradictory
and Lac varied and there were cross-effects between arms points of views. Although clinical trials or meta-analysis with
and time points. large sample sizes have been reported, researchers have failed
Compared with arm C, the averaged values of ScvO2 to prove that one method has overwhelming advantages over
were higher at T2, T3, T4, and T5 in arm G. The Lac values at others.14 Recently, some researches proposed an ideal peri-
T3, T4, and T5 were lower in arm G. From the time point of operative state of the loop.515 These literatures showed that
view, ScvO2 was slightly elevated before surgery, remained for patients at high risk for death, perioperative fluid load or
stable during surgery, started to increase after surgery, and the combination with dobutamine could increase the CI and
then began to decline 12 hours after surgery to the preop- oxygen delivery index (DO2I) to extraordinary values (CI
erative levels. The values of Lac began to decrease during 4.5 L/[minm2], DO2I 650 mL/[minm2]), significantly
surgery to a minimum level 1 hour after surgery, then began reducing patient hospital stay times or mortality. Subsequently,
to rise to the preoperative levels and remained stable there- the GDFT term was introduced in many perioperative fluid-
after (Tables 4 and 5). management studies.16
Patients in arm G exhibited earlier onset of exhaust time In recent years, more and more studies have started to
than patients in arm C. The averaged postoperative start time reveal that the amount of perioperative transfusion is critical
of defecation in arm G was 3.61.4 days, and was 4.31.9 in for maintaining the bodys fluid balance.17 Studies showed that
arm C. The postoperative hospitalization time was shorter in the colloid and crystalloid solutions were not exchangeable,

Table 3 Liquid intake and intraoperative administration of vasoactive drugs (n=30)

Arm Intravenous infusion Colloids Blood Urine output Hypotensive
volume (mL) (mL) loss (mL) (mL/[kgh]) events (n)
C 3,135346 760280 473156 1.770.42 9
G 2,732488* 1,225360* 482168 1.820.35 2*
Notes: Data are presented as mean standard deviation. Arm C received conventional infusion; arm G received goal-directed fluid therapy. *P0.05 compared to arm C.

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Table 4 Comparison of ScvO2 and Lac between the two arms Table 6 Comparison of postoperative complications between
(n=30) the two arms
Time ScvO2 (%) Lac (mmol/L) Indicators Arm C Arm G
point Arm C Arm G Arm C Arm G (n=30) (n=30)
Onset of exhaust time (days) 4.31.9 3.61.4*
T0 71.46.2 69.54.8 1.20.5 1.10.3
Postoperative hospitalization (days) 12.22.4 10.81.9*
T1 72.85.6 73.73.3 1.10.5 1.10.3
Fever 8 3
T2 71.45.4 75.73.0* 1.00.5 1.00.3
Nausea and vomiting 9 2*
T3 73.55.2 78.52.9* 1.40.6 0.90.2*
Delirium 6 2
T4 71.64.8 75.82.4* 1.40.5 1.00.2*
Hypotension 8 1*
T5 70.84.8 74.12.3* 1.30.5 1.00.2*
Arrhythmia 5 1
T6 70.94.2 72.33.0 1.20.5 1.10.2 Heart failure 0 0
Notes: Data are presented as mean standard deviation. Arm C received con- Oliguria 5 2
ventional infusion; arm G received goal-directed fluid therapy. T0 =30 minutes be- Pulmonary infection 4 2
fore surgery; T1 = at the beginning of surgery; T2 =1 hour after the initial surgery;
T3= at the onset of surgery; T4 =6 hours after surgery; T5 =12 hours after surgery;
Pulmonary edema 0 0
T6 =24 hours after surgery. *P0.05 compared to arm C. Pulmonary embolism 0 0
Abbreviations: Lac, arterial blood lactate; ScvO2, central venous oxygen saturation. Wound infection/fracture 2 1
Intestinal anastomosis 1 1
Death 0 0
Notes: Arm C received conventional infusion; arm G received goal-directed fluid
even with an appropriate proportion such as 1:3 to 1:5.1820 therapy. *P0.05 compared to arm C. Data are presented as number or mean
Using a crystal liquid supplement may retain most of the standard deviation.

crystals in the blood vessels. However, it is not always ideal

to use a colloidal solution, as surgeons need to consider vari- in line with previous results.32 Studies on GDFT also showed
ous factors, such as drug indications, contraindications, and that ScvO2 was a reliable parameter to predict postoperative
side effects.2123 effect, with accuracies of 64.4% and 73%.33,34 In the present
The results of our study showed that, although the patients study, the values of ScvO2 were higher at T2, T3, T4, and T5
in arm G received a significantly lower amount of intravenous in arm G, compared to arm C.
infusion, they also received a much higher amount of col- GDFT achieves the goal of optimal oxygen deliv-
loids. Although patients in arm C received more crystalloid, ery by maintaining or increasing cardiac output. Thus,
there was no significant difference in the amount of bleeding the immune cells can be free of the risk of preoperative
between the two arms. Compared with arm C, CVP values hypoperfusion or intestinal disorder-associated lymphoid
were higher at T4, T5, and T6, and HR values lower at T3, T4, tissue damage, thus promoting tissue healing and reducing
T5, and T6, in arm G. For patients in arm G, the probability infection rates. The traditional treatment programs often
of having postoperative hypotension was lower, thus these use a large number of crystal liquid, which can easily lead
patients were more likely to maintain more stable hemody- to tissue edema and postoperative low blood pressure.
namics and good tissue perfusion condition. Postoperative side-effects may affect tissue healing and
Studies have shown that GDFT intervention can not only increase the incidence of complications such as severe
lower the Lac levels within 24 hours after surgery, but also pulmonary infections. In the present study, patients in arm
reduce the incidence of infection.2431 In the present study, we G experienced shorter postoperative hospital stay, better
discovered that Lac concentrations in arm G were lower at postoperative recovery, and faster bowel movement recov-
T3, T4, and T5, as compared to the values in arm C (P0.05), ery. Also, the incidences of postoperative complications

Table 5 Comparison of different indicators between Arm G and Arm C by ANOVA

Indicators Arm Time Arm time
F-value P-value F-value P-value F-value P-value
MAP (mmHg) 23.98 0.00 81.50 0.00 54.35 0.00
HR (bpm) 0.65 0.42 30.26 0.00 31.60 0.00
CVP (cm H2O) 3.38 0.07 195.90 0.00 30.80 0.00
ScvO2 (%) 5.81 0.02 52.38 0.00 25.93 0.00
Lac (mmol/L) 3.05 0.09 9.89 0.00 24.31 0.00
Abbreviations: ANOVA, analysis of variance; CVP, central venous pressure; HR, heart rate; Lac, arterial blood lactate; MAP, mean arterial pressure; ScvO2, central venous
oxygen saturation.

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