Intended for healthcare professionals

Rapid response to:

Practice Quality Improvement Report

Intraoperative fluid management guided by oesophageal Doppler monitoring

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3016 (Published 24 May 2011) Cite this as: BMJ 2011;342:d3016

Rapid Response:

Re:Central venous oxygenation is a cost effective alternative to Oesophageal Doppler monitoring

We are disappointed to read of this 'non-randomised "before and
after" project' that merely reproduces the randomised trial outcomes of
Wakeling et al (1) and Noblett et al (2) amongst others. There would
appear to be little sense in creating a further study that does not
advance our knowledge of goal-directed fluid therapy in major surgery.

Despite this study being headed under the umbrella of 'quality
improvement', we are surprised that there is no mention of advice (if not
approval) sought from the Research Ethics Committee. The assumption is
therefore made that this effort is actually 'service evaluation'?

According to the pre-operative patient data given, there must be
doubts raised as to whether the control and intervention groups are
comparable. The intervention group seemingly contains a much higher
number of younger patients (<60) who possess less morbidity (almost 10%
more ASA 3 in control). The project group does, in fairness, recognise
this difference despite the matching process, and utilises POSSUM scoring
in order to justify outcomes. Perhaps statistics of the group
demographics could be revealed? It is difficult to consider that these
groups are comparable on the basis of a single physiological scoring
system.

We note the inconsistent choice of colloid solution across sites -
gelatin-based at Derby and Whittington versus starch-based at Manchester.
Can observations of cardiac output be comparable when the two have
dissimilar pharmacokinetics?

Incidentally an editing error is noted in Table 4 regarding length of
stay - we are certain that all 658 patients did not require critical care
post-operatively!

We have taken the liberty of perusing the web-based guide that has
been generated as a resource - the 'How to why to Guide' under NTAC. To
quote one of the 'care delivery principles':

"The effectiveness of Doppler-guided fluid management in reducing
hospital stay by an average of 3 days has not resulted in an increase in
readmission or reoperation rates. In fact, observational data from our
implementation sites has shown a 25% reduction in reoperation rates and
33% reduction in readmission rates when compared to our historical control
data"

If the re-admission and re-operation figures are not statistically
significant (Table 5), then the statements that have been created are
certainly very bold.

We are curious as to what level of resource was expended in order to
construct the trademark 'How to why to Guide', let alone the NHS
Technology Adoption Centre - when a similar resource may have been
produced using the increasingly popular NHS Networks platform, which is a
free resource that was specifically developed to promote the sharing of
ideas and pooling of experience amongst NHS employees.

To conclude, it seems a shame that much effort and resource has been
expended on this 'implementation project', which cites the evidence-base
of no less than eight RCTs, and yet produces outcomes that cannot be
justified by the specific data presented.

References

1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay
GR, et al.
Intraoperative oesophageal Doppler guided fluid management shortens
postoperative
hospital stay after major bowel surgery. Br J Anaesth 2005;95:634-42
2. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical
trial assessing
the effect of Doppler-optimized fluid management on outcome after elective
colorectal
resection. Br J Surg 2006;93:1069-76.

Competing interests: No competing interests

09 June 2011
Miura
Specialty Registrar Anaesthetics
Krzysztof Kurzatkowski, Specialty Registrar Anaesthetics, Richard Griffiths, Consultant Anaesthetist
Peterborough & Stamford Hospitals NHS Trust