Goal-directed medical therapy and point-of-care testing improve outcomes after congenital heart surgery

Objective: A goal-directed therapy algorithm based on serial lactate values obtained from a point-of-care testing device was utilized in an attempt to reduce the mortality of patients after congenital heart surgery. Design: Prospective study of patients undergoing surgery utilizing a goal-directed therapy algorithm in the postoperative period. The results of this group are compared with a historical cohort. Operative risk was determined using the RACHS-1 scoring system. Setting: A 12-bed cardiac intensive care unit (ICU) in a pediatric hospital. Patients: Patients undergoing surgery from July 2001 through September 2003 ( group B, n = 710) were compared to cohorts from June 1995 through June 2001 ( group A, n = 1,656). Group B patients were smaller and younger ( median weight 6.2 vs 8 kg, p< 0.001; median age 184 vs 327 days, p = 0.004). Interventions: Beginning in July 2001, blood lactate measurements were performed serially for 24 h after heart surgery. Based on lactate values and trends, therapy was amended. Measurements and results: Mortality was lower for group B (1.8 vs 3.7%, p = 0.02). A reduction in mortality between group B and group A was noted in neonates (3.4 vs 12%, p = 0.02), but not in older patients. Group B patients undergoing higher risk operations ( Risk Adjustment for Congenital Heart Surgery-1 [RACHS-1] categories 3 - 6) had a significant reduction in mortality when compared to group A ( 3 vs 9%, p = 0.006), no difference was noted in patients undergoing lower risk operations (RACHS-1 categories 1 and 2). Conclusions: The combination of goal-directed therapy and point-of-care testing was associated with a marked decrease in mortality for patients undergoing congenital heart surgery. Improvement was greatest in the highest risk patients.