Intra-operative Gut Mucosal Hypoperfusion is Associated with Increased Post-operative Complications and Cost

Objectives: To determine CO and gastric mucosal perfusion in patients during elective major surgery; to seek a relationship with subsequent outcome.

Design: Prospective descriptive study.

Setting: University hospital.

Patients: 51 patients undergoing elective major surgery of an anticipated duration of greater than 2 h who were at risk of developing gut mucosal hypoperfusion and postoperative organ failure.

Measurements And Results: CO was determined by oesophageal Doppler measurement of aortic blood flow. Gastric mucosal perfusion was determined by tonometric assessment of gastric mucosal pH (pHi). Blood pressure and urine flow were measured. At the end of surgery no patients were oliguric or hypotensive. Post-operatively morbidity, mortality, duration and cost of stay in the ITU and hospital were assessed. There were 32 patients with evidence of gastric mucosal ischaemia at the end of surgery (pHi < 7.32) despite maintenance of CO. This group of patients spent a mean of 4.7 (range 0-33) days in the ITU, 14 developed major complications (7 with multiple organ failure [MOF] and 6 died. In 19 patients gut mucosal perfusion was maintained during surgery (pHi > or = 7.32); these patients demonstrated an increase in CO of 48.4% (95% confidence interval 21.3 -75.6) and spent a mean of 1.0 (range 0-4) days in the ITU. Only one developed a major complication and none died. The total cost of post-operative care for the 51 patients was estimated at pounds 356650. Mean cost per patient in the low pHi group was significantly greater at pounds 8845 (range pounds 600--pounds 42,700) compared to pounds 3874 (range pounds 2,600--pounds 9,600) in the normal pHi group. The total.cost of post-operative care for the 7 patients who developed MOF was pounds 171,450 i.e. 48% of the total cost.

Conclusion: A low gastric pHi measured during the intraoperative period in a group of patients undergoing major (mainly cardiovascular) surgery is associated with increased post-operative complications and cost.