Goal directed fluid therapy 2012
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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

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 SurgeryERAS

  • Decrease complications

  • Early mobility

  • Early GI (Gut) function

    Early discharge: It takes guts


Enhanced Recovery After SurgeryERAS - Anesthesia

  • Effective analgesia

  • Decrease PONV

Goal Directed Fluid Therapy


Perioperative Fluids

  • What is our practice ?

  • What do we know?

  • Where are we going ?


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 ?

SBP: 120DBP: 80

HR: 72

CVP: 12


Fluids – Too much or too little?

  • Liberal

  • Restrictive

    “OPTIMAL”


a

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


SVV 10

SVV 20


Fluid optimization

RESTRICTION (Too little)

  • Hypotension

  • Decreased end- organ oxygen delivery

    LIBERAL (Too Much)

  • Multi - organ edema

    GI/ GUT Complications


  • Perioperative Fluids

    • What is our practice ?

    • What do we know?

    • Where are we going ?


    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

    • Suggestions

    • Recommendations

    • Guidelines

    • Policies

    • Mandates

    Knowledgeand experience


    EVERYDAY GOALS

    • BLOOD PRESSURE

    • HEART RATE

    • URINE


    Words

    • Deficit

    • Maintenance

    • Third space

    • Urine


    “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

    • Hypotension (Negative – ino dilators)

    • Flood


    Too much !

    YOU ARE DROWNING MY PATIENT !


    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

    Goal – directed vs Traditional

    Important component of :

    Enhanced Recovery After Surgery


    GOALS 2012FLOW MANAGEMENT

    OXYGEN DELIVERY (Flow and oxygen content)

    CARDIAC OUTPUT

    FLUID OPTIMIZATION (GDT)


    HOW ? NEW TECHNOLOGY

    • GOALS: What is the purpose ?

    • EVIDENCE: What is the evidence ?

    • RETURN ON INVESTMENT ?


    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

    • Supranormal values of survivors …as GOALS

      DO2 600 mL/min/m2

      (Chest 1988;94:1176-86)


    2001 – Rivers

    Early GOAL - DIRECTED THERAPY……SEPSIS…

    SvO2 > 70 %

    Improved outcome

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


    2009 - Kehlet

    “……….GOAL DIRECTED FLUID THERAPY ……

    For optimization of fluid management

    …………………..and OUTCOME

    (Anesthesiology 2009;110:453-55)


    EVIDENCE – FLUIDS 2012

    DATA BEAT OPINION


    2011 - Hamilton

    “Pre-emptive … hemodynamic monitoring and

    therapy reduces mortality and morbidity”

    (AnesthAnalg 2011;112:1392-402)


    Mortality from Severe Sepsis


    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

    Decreased mortality:

    11% Esophagectomy

    19% Pancreatectomy

    36% AAA


    OUTCOME WITH GDT

    LENGTH OF HOSPITAL STAY (LOS) REDUCED BY 3.7 DAYS

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


    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 ?

    • Translational

    • Using new technology to improve outcome

      “Progress is precarious” (Paul Barash)


    FLUIDS – 2012 - OUT

    OUT:

    • Pulmonary Artery Catheter

    • CVP/PAWP

    • Urine chasing

    • “Third space”


    Fluid Therapy – 2012 - IN

    Goal Directed Fluid Therapy (GDT)

    Non - invasive monitors


    GOAL DIRECECTED FLUID THERAPY

    Stroke Volume Variation

    (SVV)

    Fluid Responsiveness


    New non-invasive CVS monitoring

    • Esophageal Doppler

    • Thoracic bio-reactance (Nicom)

    • Pulse contour analysis ( Vigileo/ Flotrac)


    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)

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

    2. ~13 % ( 9 – 13 = grey zone)

    3. A measure of fluid responsiveness


    (Edwards)


    Fluid responsiveness

    Treating fluid responsiveness can increase

    cardiac performance and oxygen delivery


    SVV 10

    SVV 20


    Non – invasive monitors – When?

    Major surgery – Blood and Fluids

    Organ protection

    (Decrease RISKS OF COMPLICATIONS)


    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

    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

    • To optimize fluid therapy

    • Not too much or too little

      To support intraoperative carewith evidence - based data


    2012 - RECOMMENDATIONS

    • 1 – 2 ml/hr maintenance

    • 250 mL boluses (colloid)

      ( AnesthAnalg 2011;201;1274 – 76 )


    GOAL?

    Improve care


    Early Recovery After Surgery - ERAS

    • Intensive interdisciplinary preparation

    • Complication reduction (Infection,tubes,

      analgesia, PONV)

    • Goal Directed Fluid Therapy (GDT)


    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 ?

    • Infection control

    • PONV prevention

    • Analgesia

    • Complication prevention

      Optimize Fluids (GDT)


    Summary - GDT

    Optimize and individualize fluid therapy via :

    Goal Directed Fluid Therapy (GDT)


    a

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


    Length of Hospital Stay

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

    (Anesthesiology 2002;97:820 – 6)


    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 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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