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Goal Directed Fluid Therapy 2012. R.W. McIntyre, MD Tampa VA Hospital, Florida May,2012. Goal Directed Fluid Therapy - 2012. R.W.McIntyre MD Tampa VA Hospital. Enhanced Recovery After Surgery ERAS. Decrease complications Early mobility Early GI (Gut) function

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Goal Directed Fluid Therapy 2012

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Goal directed fluid therapy 2012

Goal Directed Fluid Therapy 2012

R.W. McIntyre, MD

Tampa VA Hospital, Florida

May,2012


Goal directed fluid therapy 20121

Goal Directed Fluid Therapy - 2012

R.W.McIntyre MD

Tampa VA Hospital


Enhanced recovery after surgery eras

Enhanced Recovery After SurgeryERAS

  • Decrease complications

  • Early mobility

  • Early GI (Gut) function

    Early discharge: It takes guts


Enhanced recovery after surgery eras anesthesia

Enhanced Recovery After SurgeryERAS - Anesthesia

  • Effective analgesia

  • Decrease PONV

Goal Directed Fluid Therapy


Perioperative fluids

Perioperative Fluids

  • What is our practice ?

  • What do we know?

  • Where are we going ?


What are we talking about

What are we talking about ?

Too long or too short?

Too high or to low ?

Too much or too little?


Too high or too low

Too high or too Low ?

SBP: 120DBP: 80

HR: 72

CVP: 12


Fluids too much or too little

Fluids – Too much or too little?

  • Liberal

  • Restrictive

    “OPTIMAL”


Goal directed fluid therapy 2012

a

Bellamy, British Journal of Anesthesia 2006; 97: 755-7


Goal directed fluid therapy 2012

SVV 10

SVV 20


Fluid optimization

Fluid optimization

RESTRICTION (Too little)

  • Hypotension

  • Decreased end- organ oxygen delivery

    LIBERAL (Too Much)

  • Multi - organ edema

    GI/ GUT Complications


  • Perioperative fluids1

    Perioperative Fluids

    • What is our practice ?

    • What do we know?

    • Where are we going ?


    Anesthesia practice 2009 asa 73 7 11

    Anesthesia Practice 2009(ASA, 73; 7 – 11)

    • Tradition: Rituals and customs

    • Dogma: Arrogant declaration of opinion

    • Myth: Widely held but false notion


    What are you going to do cascade of decision making in medical practice

    What are you going to do?Cascade of decision-making in medical practice

    • Suggestions

    • Recommendations

    • Guidelines

    • Policies

    • Mandates

    Knowledgeand experience


    Everyday goals

    EVERYDAY GOALS

    • BLOOD PRESSURE

    • HEART RATE

    • URINE


    Words

    Words

    • Deficit

    • Maintenance

    • Third space

    • Urine


    Standard fluid management

    “Standard” fluid management

    • Deficit (Maintenance x hrs. fasting)

    • Maintenance 4:2:1

    • 3rd (Third) space losses (5 – 15 mL/kg/hr)

    • Blood loss ( 3:1 replacement )


    The daily double

    The Daily Double

    • Hypotension (Negative – ino dilators)

    • Flood


    Too much

    Too much !

    YOU ARE DROWNING MY PATIENT !


    Uk enquiry into perioperative deaths

    UK Enquiry into Perioperative Deaths

    “Errors in fluid management – usually fluid excess – is the most common cause of perioperative morbidity and mortality”

    (Lobo DN, Best Pract Res ClinAnaesth 2006;20(3):439)


    Change in fluid management

    Change in Fluid Management

    Goal – directed vs Traditional

    Important component of :

    Enhanced Recovery After Surgery


    Goals 2012 flow management

    GOALS 2012FLOW MANAGEMENT

    OXYGEN DELIVERY (Flow and oxygen content)

    CARDIAC OUTPUT

    FLUID OPTIMIZATION (GDT)


    How new technology

    HOW ? NEW TECHNOLOGY

    • GOALS: What is the purpose ?

    • EVIDENCE: What is the evidence ?

    • RETURN ON INVESTMENT ?


    History goals

    History - Goals

    • 1988 Shoemaker:

      Supra-normal goals: CO > 4.5 L/min (Full tank)

    • 2001 Rivers:

      Svo2 >70%

    • 2009 Kehlet - Goal – directed Fluid Therapy (GDT)

      Non –invasive monitoring


    1988 shoemaker

    1988 - Shoemaker

    • Supranormal values of survivors …as GOALS

      DO2 600 mL/min/m2

      (Chest 1988;94:1176-86)


    2001 rivers

    2001 – Rivers

    Early GOAL - DIRECTED THERAPY……SEPSIS…

    SvO2 > 70 %

    Improved outcome

    (N Engl J Med 2001;345:1368-77)


    2009 kehlet

    2009 - Kehlet

    “……….GOAL DIRECTED FLUID THERAPY ……

    For optimization of fluid management

    …………………..and OUTCOME

    (Anesthesiology 2009;110:453-55)


    Evidence fluids 2012

    EVIDENCE – FLUIDS 2012

    DATA BEAT OPINION


    2011 hamilton

    2011 - Hamilton

    “Pre-emptive … hemodynamic monitoring and

    therapy reduces mortality and morbidity”

    (AnesthAnalg 2011;112:1392-402)


    Mortality from severe sepsis

    Mortality from Severe Sepsis


    Operative mortality for high risk surgery

    Operative Mortality for High –Risk Surgery

    • high-risk surgery procedures (1999 – 2008)

      (3.2 million cases)

    • Mortality

      (N Engl J Med 2011;364:2128)


    Results high risk surgery

    Results – High Risk Surgery

    Decreased mortality:

    11% Esophagectomy

    19% Pancreatectomy

    36% AAA


    Outcome with gdt

    OUTCOME WITH GDT

    LENGTH OF HOSPITAL STAY (LOS) REDUCED BY 3.7 DAYS

    (Kuper M et al BMJ 2011;342:d3016)


    2011 miller

    2011 - Miller

    Why Poor Adoption of Hemodynamic Optimization ?

    • Show us the data

    • No immediate “tangible “ benefits

    • Resistance to new technology (ROI)

      Are We Practicing Substandard Care?

      (AnesthAnalg 2011;112;1274-76)


    Where are we

    Where are we ?

    • Translational

    • Using new technology to improve outcome

      “Progress is precarious” (Paul Barash)


    Fluids 2012 out

    FLUIDS – 2012 - OUT

    OUT:

    • Pulmonary Artery Catheter

    • CVP/PAWP

    • Urine chasing

    • “Third space”


    Fluid therapy 2012 in

    Fluid Therapy – 2012 - IN

    Goal Directed Fluid Therapy (GDT)

    Non - invasive monitors


    Goal direcected fluid therapy

    GOAL DIRECECTED FLUID THERAPY

    Stroke Volume Variation

    (SVV)

    Fluid Responsiveness


    New non invasive cvs monitoring

    New non-invasive CVS monitoring

    • Esophageal Doppler

    • Thoracic bio-reactance (Nicom)

    • Pulse contour analysis ( Vigileo/ Flotrac)


    What do new monitors measure

    What do new monitors measure ?

    1. Flow (C.O./C.I/S.V)

    • Stroke Volume Variation (SVV)

      (Continuous but with limitations)


    What is stroke volume variation svv

    What is Stroke Volume Variation ?(SVV)

    1. The difference in stroke volume (SV) during inspiration vs. expiration

    2. ~13 % ( 9 – 13 = grey zone)

    3. A measure of fluid responsiveness


    Goal directed fluid therapy 2012

    (Edwards)


    Fluid responsiveness

    Fluid responsiveness

    Treating fluid responsiveness can increase

    cardiac performance and oxygen delivery


    Goal directed fluid therapy 2012

    SVV 10

    SVV 20


    Non invasive monitors when

    Non – invasive monitors – When?

    Major surgery – Blood and Fluids

    Organ protection

    (Decrease RISKS OF COMPLICATIONS)


    Successful implementation of gdt uk

    Successful implementation of GDT (UK)

    1. Campaign to adopt GDT (Complication reduction)

    2. National Health Service (NHS) :

    Technology Adoption Center

    3. Resource support (Fiscal and technical)


    Tampa va gdt

    Tampa VA - GDT

    2009 - Introduction of GDT/SVV

    Selection and implementation of non – invasive technology

    Use

    2010 2011

    Nicom 200 250

    Vigileo 165 190

    Total 365 440 (+20%)


    Purpose gdt

    Purpose - GDT

    • To optimize fluid therapy

    • Not too much or too little

      To support intraoperative carewith evidence - based data


    2012 recommendations

    2012 - RECOMMENDATIONS

    • 1 – 2 ml/hr maintenance

    • 250 mL boluses (colloid)

      ( AnesthAnalg 2011;201;1274 – 76 )


    Goal directed fluid therapy 2012

    GOAL?

    Improve care


    Early recovery after surgery eras

    Early Recovery After Surgery - ERAS

    • Intensive interdisciplinary preparation

    • Complication reduction (Infection,tubes,

      analgesia, PONV)

    • Goal Directed Fluid Therapy (GDT)


    2012 what do patients want

    2012 - What do patients want ?

    • On – time surgery

    • Preoperative meeting with anesthesiologist

    • PONV prevention

    • Adequate pain control

    • Immediate post-operative discussion with surgeon

      GOOD OUTCOME


    Enhanced recovery after surgery what can we do

    Enhanced recovery after surgery - What can WE do ?

    • Infection control

    • PONV prevention

    • Analgesia

    • Complication prevention

      Optimize Fluids (GDT)


    Summary gdt

    Summary - GDT

    Optimize and individualize fluid therapy via :

    Goal Directed Fluid Therapy (GDT)


    Goal directed fluid therapy 2012

    a

    Bellamy, British Journal of Anesthesia 2006; 97: 755-7


    Length of hospital stay

    Length of Hospital Stay

    Goal-directed intraoperative fluid administration reduces length of hospital stay …

    (Anesthesiology 2002;97:820 – 6)


    Goal directed fluid therapy 2012

    GDT

    “The volume of Lactated Ringer’s solution required to maintain preload and cardiac index during open and laparoscopic surgery”

    OPEN : ~ 6 ml/kg/hr

    LAPAROSCOPIC: ~ 3.5 ml/kg/hr

    (Concha, AnesthAnalg 2009;108:616-21)


    Goal directed fluid therapy 2012

    Goal-directed Colloid Administration Improves the Microcirculation of Healthy and Perianastomotic Colon

    Tissue Oxygenation

    GD-C 150 ± 31%

    Colon:

    GD-RL 123± 40%

    Perianastomotic: GD-C 245±93%

    Conclusion : Goal – directed colloid fluid therapy (GDT) increases oxygen tension and perfusion in healthy and injured colon tissue

    (Anesthesiology 2009; 110:721-8)


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