FEDORA Study “Take-Homes” for clinicians
Clinician-led disseminator of medical news, TopMedTalk has reviewed the landmark FEDORA study into Goal-Directed Haemodynamic Therapy (GDHT).
Reinforcing the conclusions from meta-analysis of 70 other studies, FEDORA supports the use of Oesophageal Doppler to derive clinical parameters that will guide the use and timing of fluid, inotropes and vasopressors.
So how should ODM’s accurate, real-time haemodynamic data be used by the clinician?
Taken from the TopMedTalk review, which can be found here, we look at what GDHT looks like in the real world clinical setting. Prof Monty Mythen summarises it neatly: “Is there a problem? What do you think is causing the problem? Measure Haemodynamic variables, then use your brain. Is there a deficit in any area? Does the patient need volume, vasoconstrictor, vasodilator or heart contractility?”
The GDHT management algorithm is based on monitoring of “trimodal” parameters, Stroke Volume(SV), Cardiac Interval(CI) and Mean Arterial Pressure(MAP) with calls to action as follows:
- If SV is correct, MAP is >65 and CI is >2.5, then you only need to monitor the patient.
- If MAP is inadequate, but CI is OK, give a vasopressor (22% of patients in the FEDORA study have this protocol).
- If CI is inadequate, give inotrope (1% of patients in the FEDORA study have this protocol)
One striking observation in FEDORA is the similarity between control and GDHT groups in terms of the amount of fluid or drugs given. This reinforces the point that it’s all about delivering the right thing at the right time. Precision management of patients’ key parameters is what seemingly makes the difference. The result is a statistically significantly reduced Acute Kidney Injury(1.44% vs 8.53%), Pulmonary complications (cardiopulmonary oedema 0% vs 6.16%) and infection-derived complications (eg deep SSI 1.91% vs 8.06%).
The FEDORA study clearly supports routine use of Goal-Directed Haemodynamic Therapy, even in low to moderate risk patients undergoing major surgery. TopMedTalk’s review usefully presents this evidence in the form of a simple management protocol for anaesthetists.