Clinical decisions for each defect versus an overall therapeutic plan

In the traditional 'one at a time' approach, each monitored variable is identified, measured, and corrected. Often, simple solutions are applied to complex problems although the underlying pathophysiology is not understood. For example, if the pressure goes down, fluids are given; if that does not work, dopamine is given. Then the next deficiency is diagnosed, measured, and corrected, and so on. This results in an uncoordinated, disorganized, and sometimes contradictory therapeutic plan. Eventually all the appropriate therapy may be given, but not always at the right time, in the right doses, and in the right order.

An alternative is to use the physiological patterns of survivors as therapeutic goals. The survivors developed a pattern of supranormal cardiac index, Do2, and Vo2. The hypothesis is that if high-risk patients are prophylactically driven to the survival pattern with early aggressive therapy that optimizes cardiac output, Do2, and Vo2, there will be improved outcome.

In a prospective preoperatively randomized trial of this hypothesis, each high-risk patient was identified preoperatively and randomized to one of three groups:

1. the central venous catheter;

2. the pulmonary artery catheter with normal values as the goal of therapy;

3. the pulmonary artery catheter protocol group with supranormal values as the goal.

If normal values were the goal, the central venous catheter was as effective as the pulmonary artery catheter. In contrast, the mortality of the pulmonary artery supranormal group was significantly reduced from 32 per cent to 4 per cent (p <0.02), there was a significant reduction of 67 per cent in ventilator days, a reduction of 30 per cent in intensive care unit and hospital days, and a reduction of 25 per cent in the cost of treatment ( Sh2em§k§Le.t...a!: 1988).

Of interest was a group of high-risk patients who were not considered to be sick enough to need invasive monitoring. This 'non-randomized group' had the highest mortality and highest percentage of organ failure; ironically, 60 per cent had a pulmonary artery catheter placed postoperatively after they developed a life-threatening postoperative cardiorespiratory event. However, placement of the pulmonary artery catheter at this time did not improve the overall group mortality. This suggests that the pulmonary artery catheter can prevent but is not able to reverse lethal organ failure.

The cardiac index values of group 3 reached optimal values within 8 to 12 h postoperatively, while the values of group 1 remained at the preoperative levels. There were no significant differences in the other hemodynamic variables. Similarly, the oxygen transport values of group 1 were maintained at their preoperative normal values, while the Do2 and Vo2 values of group 3 reached their optimum goals in the first 12 h postoperatively. There were no significant differences in blood gases, hematocrit, or other oxygen transport variables.

The striking difference between the groups was the incidence of organ failure. Group 3 had only one patient with acute respiratory distress syndrome, while group 1 had significantly greater numbers of patients with organ failures. There were no significant differences between the groups in the incidence of complications not due to organ failure. The protocol did not protect against local mechanical or anatomic complications such as wound infection, dehiscence, and postoperative bleeding

( et,M 1988). The importance of early therapy has been demonstrated in a meta-analysis. Seven randomized studies performed early showed improved outcome, but seven others performed late, after onset of acute respiratory distress syndrome or other organ failures, did not show improvement.

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