A Multicenter, Open-Label, Randomized Controlled Trial of a Conservative Fluid Management Strategy Compared With Usual Care in Participants After Cardiac Surgery: The Fluids After Bypass Study.

OBJECTIVES: There is little evidence to guide fluid administration to patients admitted to the ICU following cardiac surgery. This study aimed to determine if a protocolized strategy known to reduce fluid administration when compared with usual care reduced ICU length of stay following cardiac surgery. DESIGN: Prospective, multicenter, parallel-group, randomized clinical trial. SETTING: Five cardiac surgical centers in New Zealand conducted from November 2016 to December 2018 with final follow-up completed in July 2019. PATIENTS: Seven-hundred fifteen patients undergoing cardiac surgery; 358 intervention and 357 usual care. INTERVENTIONS: Randomization to protocol-guided strategy utilizing stroke volume variation to guide administration of bolus fluid or usual care fluid administration until desedation or up to 24 hours. Primary outcome was length of stay in ICU. Organ dysfunction, mortality, process of care measures, patient-reported quality of life, and disability-free survival were collected up to day 180. MEASUREMENTS AND MAIN RESULTS: Overall 666 of 715 (93.1%) received at least one fluid bolus. Patients in the intervention group received less bolus fluid (median [interquartile range], 1,000 mL [250-2,000 mL] vs 1,500 mL [500-2,500 mL]; p < 0.0001) and had a lower overall fluid balance (median [interquartile range], 319 mL [-284 to 1,274 mL] vs 673 mL [38-1,641 mL]; p < 0.0001) in the intervention period. There was no difference in ICU length of stay between the two groups (27.9 hr [21.8-53.5 hr] vs 25.6 hr [21.9-64.6 hr]; p = 0.95). There were no differences seen in development of organ dysfunction, quality of life, or disability-free survival at any time points. Hospital mortality was higher in the intervention group (4% vs 1.4%; p = 0.04). CONCLUSIONS: A protocol-guided strategy utilizing stroke volume variation to guide administration of bolus fluid when compared with usual care until desedation or up to 24 hours reduced the amount of fluid administered but did not reduce the length of stay in ICU.

Design and statistical analysis plan for a trial comparing a conservative fluid management strategy with usual care in patients after cardiac surgery: the FAB study.

BACKGROUND: Cardiac surgery is one of the most frequently performed major surgical procedures. Following surgery, haemodynamic instability and prevention of organ dysfunction may be treated in the intensive care unit (ICU) with intravenous fluid, inotropes and vasopressors. In other surgical groups, liberal intravenous fluid administration and a positive fluid balance have been associated with adverse outcomes and increased risk of morbidity and mortality. There is a paucity of evidence to guide intravenous fluid administration in cardiac surgery patients. We have previously shown that a protocol-guided strategy avoiding unnecessary fluid administration significantly reduces fluid loading. OBJECTIVE: To present the design and statistical analysis plan for a randomised controlled trial comparing a conservative fluid management strategy to usual care in patients after cardiac surgery. METHODS: We designed a prospective, multicentre, parallel-group, randomised controlled trial - the FAB (Fluids After Bypass) study. A total of 700 patients undergoing cardiac surgery using cardiopulmonary bypass who have a European System for Cardiac Operative Risk Evaluation (EuroSCORE) II ≥ 0.9 will be enrolled in this study and randomly allocated to a protocol-guided strategy using stroke volume variation to guide administration of bolus fluid or to usual care fluid administration in a 1:1 ratio, stratified by centre. Study treatment will be administered from post-operative admission to the ICU until de-sedation or for a 24-hour period (whichever is shorter). The primary outcome is ICU length of stay. Secondary endpoints include quality of life and disability-free survival at 3 and 6 months after surgery, and process-of-care, physiological and safety measures. CONCLUSION: This trial aims to determine whether a protocol-guided strategy that avoids unnecessary fluid administration reduces ICU length of stay and improves outcomes in higher-risk adults undergoing cardiac surgery.

Characteristics, incidence, and outcome of patients admitted to the intensive care unit with myasthenia gravis.

BACKGROUND: There are limited data on the characteristics, incidence, and mortality of patients with myasthenia gravis (MG) admitted to the ICU. AIMS: To study the epidemiology, characteristics and outcome of patients with MG in Australian and New Zealand (ANZ) ICUs over a decade. METHODS: We performed a retrospective observational, cross sectional study of data from the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD). We collected data on all adult patients admitted with a primary diagnosis of MG to 159 Australian and 19 New Zealand ICUs between January 1, 2005 and December 31, 2015.We extracted detailed relevant data and performed statistical assessment. RESULTS: We identified 245 patients admitted to ICU with the primary diagnosis of MG, with an incidence increasing from 1 to 2.5 per thousand ICU admissions (P<0.0001) and from 1 to 2.2 per million people (P=0.02). Mean age was 60years with more patients being female (53.7% vs 47.3%) and 91 (37.1%) patients received mechanical ventilation. Hospital mortality occurred in 13 (5.3%) patients with a mortality rate lower than in other ICU patients. CONCLUSIONS: In ANZ, the ICU and population incidence of MG has increased over the last decade. However, its mortality rate was low.

Atrial fibrillation after cardiac surgery: Prevention and management: The Australasian experience.

BACKGROUND: Atrial fibrillation (AF) after cardiac surgery is a major health problem that is associated with a significant financial burden. This paper aims to highlight this problem and review the current guidelines in the prevention and management of AF after cardiac surgery, providing our experience in the Australasian centers. METHODS: We conducted a literature review using mainly PubMed to compare the current practice with the available evidence. EMBASE and Cochrane library were also searched. We concurrently developed an online questionnaire to collect data from other Australasian centers regarding their approach to this problem. RESULTS: We identified 194 studies that were considered relevant to our research. We did not find any formal protocols published in the literature. From our Australasian experience; seven centers (58%) had a protocol for AF prophylaxis. The protocols included electrolytes replacement, use of amiodarone and/or ß-blockers. Other strategies were occasionally used but were not part of a structured protocol. CONCLUSION: The development of an integrated medical and surgical protocol for the prophylaxis of AF after cardiac surgery is an important aspect for the care of postoperative cardiac patients. Considerations of prophylactic strategies other than those routinely used should be included in the protocol. This area should receive considerable attention in order to reduce the postoperative complications and health costs.