goal directed fluid therapy 2012
Download
Skip this Video
Download Presentation
Goal Directed Fluid Therapy 2012

Loading in 2 Seconds...

play fullscreen
1 / 58

Goal Directed Fluid Therapy 2012 - PowerPoint PPT Presentation


  • 118 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Goal Directed Fluid Therapy 2012' - sani


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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: 120 DBP: 80

HR: 72

CVP: 12

fluids too much or too little
Fluids – Too much or too little?
  • Liberal
  • Restrictive

“OPTIMAL”

slide9
a

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

slide10
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)

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

fluid responsiveness
Fluid responsiveness

Treating fluid responsiveness can increase

cardiac performance and oxygen delivery

slide44
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 care with evidence - based data

2012 recommendations
2012 - RECOMMENDATIONS
  • 1 – 2 ml/hr maintenance
  • 250 mL boluses (colloid)

( AnesthAnalg 2011;201;1274 – 76 )

slide50
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)

slide55
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)

slide57
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)

slide58
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)

ad