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Title: Barriers to the use of goal directed therapy in a high risk surgical patient group
Author: Macdonald, Neil
Awarding Body: Queen Mary University of London
Current Institution: Queen Mary, University of London
Date of Award: 2019
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Background Goal directed therapy, the utilisation of fluids and inotropes to optimise cardiovascular performance of tissue oxygen delivery during surgery, has been shown in small studies to reduce complications after major surgery. The OPTIMISE trial was conducted to see if this benefit of morbidity reduction seen with the use of goal directed therapy was replicated in a larger pragmatic trial. I hypothesised that there were potential barriers to the use of goal directed therapy under these conditions that may reduce the clinical effectiveness of this treatment approach. Methods This thesis is based on sub-studies of the OPTIMISE trial examining the difficulties in utilising goal directed therapy as a treatment that focused primarily on the administration of fluids via an algorithm and the effect of goal directed therapy on a specific complication. Acute kidney injury was chosen as an important postoperative complication that was directly affected by fluid administration. Results OPTIMISE did not demonstrate a statistically significant effect of a reduction in complications in a population of 732 high risk surgical patients receiving goal directed therapy. Compliance to the goal directed therapy algorithm was mostly good across seventeen hospital sites. The use of dynamic fluid markers was not shown to be beneficial as indicators of when to give fluid boluses in the perioperative period. Goal directed therapy did not protect against acute kidney injury in the high risk surgical population. There was no difference in the incidence of acute kidney injury in the goal directed therapy group and the usual care group as measured by standardised criteria and measured by a urinary biomarker. Conclusions Goal directed therapy did not result in a significant reduction in complications in a high risk surgical population. However, there are some barriers to the use of goal directed therapy particularly the evidence base for the effectiveness of goal directed therapy and understanding the mechanisms, if any, by which goal directed therapy improves outcomes. Further work should focus on establishing supporting the current evidence base for goal directed therapy and seeking the mechanism by which this may improve outcomes.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: Goal directed therapy ; Acute kidney injury ; high risk surgical patients ; post surgical complication ; isotropes ; fluid boluses ; cardiac output ; oxygen delivery