Optimizing patient blood management through intraoperative goal-directed fluid therapy protocol within an enhanced recovery after cardiac surgery program.

Abstract

This study assessed the impact of intraoperative goal-directed fluid therapy integrated within an Enhanced Recovery After Surgery program on early coagulation parameters, transfusion requirements, hemoglobin levels, chest tube output, and hemodynamic profiles in patients undergoing elective cardiac surgery. In this single-center, retrospective ancillary analysis, patients who underwent elective cardiac procedures between 2015 and 2021 were stratified based on the implementation of an Enhanced Recovery After Surgery protocol incorporating goal-directed fluid therapy. Propensity score matching generated 1026 well-balanced pairs. Primary end points included platelet count, fibrinogen concentration, prothrombin time, activated partial thromboplastin time, and hemoglobin levels measured at intensive care unit admission and on postoperative day 1. Secondary outcomes included transfusions (red blood cells, allogeneic blood components, coagulation factor concentrates), chest tube output, glomerular filtration rate, mean arterial pressure, central venous pressure, and vasoactive-inotropic score at intensive care unit admission and postoperative day 1. At intensive care unit admission, the Enhanced Recovery After Surgery group demonstrated significantly higher platelet count, fibrinogen, prothrombin time, and hemoglobin (all P < .001). Red blood cell transfusion rates were significantly lower intraoperatively and at postoperative day 1 (P < .001), whereas transfusion of other blood products and coagulation factor concentrates did not differ between groups. At postoperative day 1, the Enhanced Recovery After Surgery group exhibited significantly lower chest tube output (P < .001) and higher glomerular filtration rate (P = .042). Although mean arterial pressure remained comparable, central venous pressure was significantly lower and vasoactive-inotropic score was higher at intensive care unit admission in the Enhanced Recovery After Surgery group, with both parameters normalizing by postoperative day 1. Goal-directed fluid therapy within an Enhanced Recovery After Surgery program reduces intraoperative hemodilution, improves coagulation integrity, reduces postoperative bleeding, decreases transfusion needs, and maintains end-organ perfusion after elective cardiac surgery.