Date post: | 02-Apr-2018 |
Category: |
Documents |
Upload: | reza-akbar |
View: | 224 times |
Download: | 0 times |
of 68
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
1/68
Goal Directed Fluid Therapy:Goal Directed Fluid Therapy:A Modern Approach toA Modern Approach toPerioperativePerioperativeFluidFluidManagementManagementBeverly Morningstar, MD, FRCP (C)Beverly Morningstar, MD, FRCP (C)
Department of AnesthesiologyDepartment of Anesthesiology
Sunnybrook Health Sciences CentreSunnybrook Health Sciences CentreToronto ONToronto ON
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
2/68
DisclosureDisclosure
FreseniusFreseniusKabiKabi::SpeakerSpeakers honorarias honoraria
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
3/68
1999 UK Confidential Enquiry into1999 UK Confidential Enquiry into
PerioperativePerioperativeDeathsDeaths
Errors in fluid management (usuallyErrors in fluid management (usuallyfluid excess): most common cause offluid excess): most common cause of
perioperativeperioperativemorbidity, mortalitymorbidity, mortality
Lobo DN. BestLobo DN. Best PractPractResResClinClinAnaesthAnaesth2006;20(3):4392006;20(3):439
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
4/68
Why do we give so much fluid?Why do we give so much fluid?preoppreopfastingfastingsurgical blood losssurgical blood loss
evaporationevaporation
urinary excretionurinary excretion
vasodilationvasodilationcaused by anesthesia,caused by anesthesia,epiduralepidural
transfer totransfer to third spacethird space
transcapillarytranscapillary leak of albumin causedleak of albumin causedby inflammatory mediatorsby inflammatory mediators
Many liters ofMany liters of
fluid during afluid during astandardstandard
operationoperation
Hahn RG.Hahn RG.AnesthAnesthAnalgAnalg2007;105:3042007;105:304
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
5/68
StandardStandardmanagement grosslymanagement grosslyoverestimates iv fluidoverestimates iv fluidrequirementsrequirements
Maintenance:Maintenance:4:2:1 rule4:2:1 rule
Deficit:Deficit:Maintenance x hr fastingMaintenance x hr fasting3rd space losses:3rd space losses:1010--1515 mLmL/kg/hr/kg/hrBlood loss:Blood loss:3:1 replacement with3:1 replacement with
crystalloidcrystalloid
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
6/68
StandardStandardfluid managementfluid management90 kg male, APR,90 kg male, APR,
NPO x 8 hr, 6 hrNPO x 8 hr, 6 hr
surgery, EBL 1500surgery, EBL 1500 mLmL
Using standard formulaUsing standard formula
this patient should getthis patient should get12 L crystalloid12 L crystalloidintraopintraop
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
7/68
How much harm doesHow much harm does
excess fluid really cause?excess fluid really cause?
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
8/68
Aggressive fluidAggressive fluid
strategiesstrategies
adversely affectadversely affecteveryevery systemsystem
and organand organ
ProwleJR et al. Nat Rev Nephrol2010;6:107
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
9/68
Why are patients sensitive toWhy are patients sensitive to
large volumes of crystalloid?large volumes of crystalloid?
clearance of crystalloid during anesthesia and surgeryclearance of crystalloid during anesthesia and surgery
isis 1010--20%20%of that in awake volunteersof that in awake volunteerscrystalloid leaves the plasma space, equilibrates withcrystalloid leaves the plasma space, equilibrates with
interstitial space after 20interstitial space after 20--30 min30 min
Hahn RG.Hahn RG.AnesthAnesthAnalgAnalg2007;105:3042007;105:304
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
10/68
Minerals, protein,glycogen, fat
40%
Minerals, protein,Minerals, protein,glycogen, fatglycogen, fat
40%40%
CapillaryCapillarymembranemembrane
CellCellmembranemembrane
PlasmaPlasma
volume(4.3%)volume(4.3%)InterstitialInterstitial
fluid (15.7%)fluid (15.7%)
ColloidsColloids
Crystalloid:Crystalloid:7575--80% leaves vasculature after 20 minutes80% leaves vasculature after 20 minutes
5% Dextrose5% Dextrose
Body water componentsBody water components
ICFICF
40%40%ECFECF
20%20%
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
11/68
Preoperative measured blood volumePreoperative measured blood volume
PerioperativePerioperative
inputinput}}{{
PerioperativePerioperativeoutputoutput
TotalTotal perioperativeperioperativefluid balancefluid balance
..
Standard infusion 12Standard infusion 12 mL/kg/hmL/kg/hcrystalloid; blood loss replaced 1:1 with colloid.crystalloid; blood loss replaced 1:1 with colloid.
CrystalloidsCrystalloids
ColloidsColloids
PostopPostopmeasured blood vol.measured blood vol.750mL750mL
1,7001,700 mLmL
2,0002,000 mLmL
3,8003,800 mLmL
PreopPreopmeasured blood vol.measured blood vol.
3,8333,833 mLmLmissingmissing
Blood lossBlood loss
UrineUrine
Chappell D et al. Anesthesiology 2008;109:723Chappell D et al. Anesthesiology 2008;109:723
What happens to all thatWhat happens to all that
crystalloid?crystalloid?
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
12/68
Can a healthy person die ofCan a healthy person die of
pulmonary edema?pulmonary edema?
13 patients, death13 patients, deathfrom pulmonaryfrom pulmonaryedema within 36 hredema within 36 hr
postoppostopaverageaverage 7 L +7 L +vevefluidfluidbalancebalance in first 24 hrin first 24 hr
10/13:10/13: ASA IASA I
average age:average age: 38 yr38 yr
ArieffAI. Chest 1999;115:1371-1377
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
13/68
CurrentCurrent perioperativeperioperativefluidfluidtherapytherapy
anesthesiologists haveanesthesiologists havebecome desensitized tobecome desensitized to
administration of high fluidadministration of high fluid
volumes (5volumes (5--6 liters for6 liters formajor surgical procedures)major surgical procedures)
patients typically gain 5 kgpatients typically gain 5 kgof body weight after majorof body weight after major
surgical proceduressurgical procedures
Chappell D et al. Anesthesiology 2008;109:723Chappell D et al. Anesthesiology 2008;109:723
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
14/68
PerioperativePerioperativeweight gain andweight gain andmortalitymortality
Overallm
ortality(%)
Weight gain (%)
More +vefluid balance = worse outcomesLowell JA etal. CritCare Med 1990;18:728
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
15/68
For major surgery, all expertsFor major surgery, all experts
agree...agree...
11--22 mLmL/kg/hr/kg/hrmaximummaximumcrystalloid duringcrystalloid during
OROR
average 100average 100 mLmL/hr/hr
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
16/68
What happens when youWhat happens when you
restrictrestrict perioperativeperioperativefluids?fluids?
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
17/68
Fluid restriction andFluid restriction and postoppostopcomplicationscomplications
Restricted Regimen Standard Regimen
Preloading No preloading 500 mLcolloidThird spaceloss
No replacementNS 7 mL/kg h first hr; 5 mL/kg2nd + 3rd hr, then 3 mL/kg/hr= 1350 mLNS
Fluid loss forfast
500 mLD5W, minus pointake during fast 500 mLN/SBlood loss 500 mLcolloid 1500 mLN/STotal in 1000 mL 3850 mL
141 patients for elective colorectal resectionBased on 90 kg person, 500 ml blood loss:
BrandstrupBrandstrupB et al. AnnB et al. Ann SurgSurg2003;238:6412003;238:641
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
18/68
Com
plicationfreq
uency%
Com
plicationfreq
uency%
Complications related to IV fluid,Complications related to IV fluid,
weight gain on day of operationweight gain on day of operation
BrandstrupBrandstrupB et al. AnnB et al. Ann SurgSurg2003;238:6412003;238:641
PP
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
19/68
RingerRingers lactate onlys lactate only
liberal: av. 3900liberal: av. 3900 mLmL
restrictive: av. 1400restrictive: av. 1400 mLmL
blood loss both groupsblood loss both groupsreplaced 3:1replaced 3:1
NisanevichNisanevichV et al. Anesthesiology 2005;103:25V et al. Anesthesiology 2005;103:25
LiberalLiberal vsvsrestricted:restricted:IntraabdominalIntraabdominal
surgerysurgery
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
20/68
LiberalLiberal vsvsrestricted:restricted:IntraabdominalIntraabdominal
surgerysurgery
RingerRingers lactate onlys lactate only
liberal: av. 3900liberal: av. 3900 mLmL
restrictive: av. 1400restrictive: av. 1400 mLmL
blood loss both groupsblood loss both groupsreplaced 3:1replaced 3:1
NisanevichNisanevichV et al. Anesthesiology 2005;103:25V et al. Anesthesiology 2005;103:25
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
21/68
Even cutting down on IV fluidsEven cutting down on IV fluids
postoppostopspeeds GI recovery!speeds GI recovery!colon resection,colon resection, postoppostopIV fluid 2/3IV fluid 2/3--1/31/3standardstandardatat 125125 mLmL/hr/hrvsvsrestrictedrestrictedatat 8585 mLmL/hr/hrstandard group had:standard group had:
3 kg weight gain3 kg weight gain
more complicationsmore complications
3 day longer hospital stay3 day longer hospital stay
Lobo DN at al. Lancet 2002;359:1812
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
22/68
So too much crystalloid isSo too much crystalloid is
harmful in major surgery...whatharmful in major surgery...whatabout too little?about too little?
GI li ti th
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
23/68
GI complications are theGI complications are the
leading cause of delayedleading cause of delayeddischargedischarge
BennettBennett--Guerrero E et al.Guerrero E et al.AnesthAnesthAnalgAnalg1999;89:5141999;89:514
Percentage
Percentage
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
24/68
GI complicationsGI complications
Major:Major:hemorrhagehemorrhageabscessabscess
gastric/bowelgastric/bowelobstructionobstruction
infectioninfection
fistulafistula
anastomoticanastomotic leakleakGI infarctionGI infarctionanything requiringanything requiringreoperationreoperation
Minor:Minor:severe nausea andsevere nausea andvomiting requiringvomiting requiring
rescuerescue antiemeticantiemeticileusileus
diarrheadiarrhea
abdominal distensionabdominal distensionpancreatitispancreatitis
GiglioGiglioMT et al. Br JMT et al. Br JAnaesthAnaesth2009;103(5):6372009;103(5):637
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
25/68
Why are GI complications soWhy are GI complications so
common?common?healthy patients: 25healthy patients: 25--30%30%
loss of blood volume withloss of blood volume withno change in BP or HRno change in BP or HR
splanchnicsplanchnicperfusion fallsperfusion fallswith only 10with only 10--15%15%decrease in blood volumedecrease in blood volume
gutgut hypoperfusionhypoperfusionoftenoftenoutlastsoutlasts hypovolemiahypovolemiano simple clinicalno simple clinical
monitormonitor
GiglioGiglioMT et al. Br JMT et al. Br JAnaesthAnaesth2009;103:6372009;103:637
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
26/68
The trouble with blood volumeThe trouble with blood volume
assessmentassessment
no direct beside measurementno direct beside measurement
clinical surrogates used:clinical surrogates used:
VS (BP, HR), examination (chest)VS (BP, HR), examination (chest)U/OU/O
lab: Hg, serum and urinary Nalab: Hg, serum and urinary Na++
ongoing losses (EBL, NG, etc.)ongoing losses (EBL, NG, etc.)fluid balance chartsfluid balance chartsCXR (pulmonary congestion)CXR (pulmonary congestion)
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
27/68
surrogate measures:surrogate measures: accurate prediction of volumeaccurate prediction of volume
status
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
28/68
PAOP and CVP fail to predictPAOP and CVP fail to predictventricular filling volume,ventricular filling volume,
cardiac performance, or thecardiac performance, or theresponse to volume infusion inresponse to volume infusion in
normal subjectsnormal subjects
Kumar A et al.Kumar A et al.
Critical Care Medicine 2004;32:691Critical Care Medicine 2004;32:691--699699
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
29/68
Kumar A et al.Kumar A et al. CritCritCare Med 2004;32:691Care Med 2004;32:691
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
30/68
Cardiac fillingCardiac filling
pressures arepressures arepoor measurespoor measures
of preload andof preload andvolumevolume
responsivenessresponsiveness
Kumar A et al.Kumar A et al. CritCritCare Med 2004;32:691Care Med 2004;32:691
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
31/68
...very poor relationship between CVP and blood volume as...very poor relationship between CVP and blood volume aswell as the inability of CVP/well as the inability of CVP/CVP to predict theCVP to predict thehemodynamichemodynamic response to a fluid challenge ...response to a fluid challenge ...
CVP should not be used to make clinical decisions regardingCVP should not be used to make clinical decisions regardingfluid management...fluid management...
...Based on the results of our systematic review, we believe...Based on the results of our systematic review, we believethat CVP should no longer be routinely measured in the ICU,that CVP should no longer be routinely measured in the ICU,
operating room or emergency department.operating room or emergency department.
MarikMarikPE et al. Chest 2008; 134:172PE et al. Chest 2008; 134:172
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
32/68
MarikMarikPE et al. Chest 2008; 134:172PE et al. Chest 2008; 134:172
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
33/68
All great truthsAll great truthsbegin asbegin as
blasphemiesblasphemies
George Bernard ShawGeorge Bernard Shaw18561856 --19501950
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
34/68
Bowel edemaBowel edemaBowel ischemiaBowel ischemia
Too much, too little or just right?Too much, too little or just right?
BundgaardBundgaard--NeilsenNeilsenM et al.M et al.ActaActaAnaesthesiolAnaesthesiolScandScand2009 53:8432009 53:843
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
35/68
The answer:The answer:
GoalGoal--Directed Therapy (GDT)Directed Therapy (GDT)
The gold standard forThe gold standard forperioperativeperioperativefluidfluidmanagement in critical illness, or duringmanagement in critical illness, or duringmajor surgery with significant fluid shiftsmajor surgery with significant fluid shifts
and blood lossand blood loss
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
36/68
intensive monitoring and aggressive management ofintensive monitoring and aggressive management of
perioperativeperioperativehemodynamicshemodynamics in high risk patients toin high risk patients tooptimize oxygen deliveryoptimize oxygen deliveryearly reports in the literature first appeared aroundearly reports in the literature first appeared around
20002000
standard of care:standard of care:
most majormost majorcentrescentresin USin USNICE* guidelines in UK for surgical patientsNICE* guidelines in UK for surgical patientsalmost all currentalmost all current periopperiopfluid literaturefluid literature
GoalGoal--Directed Therapy (GDT)Directed Therapy (GDT)
*NICE: National Institute for Health and Clinical Excellence*NICE: National Institute for Health and Clinical Excellence
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
37/68
Target specific values for cardiac index,Target specific values for cardiac index,OO22 delivery, Odelivery, O22 consumptionconsumption
Use fluids andUse fluids and inotropesinotropes
mortality and morbiditymortality and morbidity++==
Shoemaker WC et al. Chest 1988;94:1176Shoemaker WC et al. Chest 1988;94:1176--8686
GoalGoal--Directed Therapy (GDT)Directed Therapy (GDT)
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
38/68
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
39/68
GoalGoal--directed therapy (GDT):directed therapy (GDT):What goals can we target?What goals can we target?
stroke volume (SV)*stroke volume (SV)*
cardiac index (CI)cardiac index (CI)
stroke volume variation (SVV)stroke volume variation (SVV)oxygen delivery or consumption**oxygen delivery or consumption**
mixed venous oxygen saturation (SvO2)mixed venous oxygen saturation (SvO2)
gastric mucosal pHgastric mucosal pHstroke distance (esophagealstroke distance (esophageal dopplerdoppler))
*most commonly used goal*most commonly used goal**ideal goal**ideal goal
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
40/68
expected blood loss >500expected blood loss >500 mLmL
examples:examples: major abdominalmajor abdominal----gengensurgsurg,, gyngyn, urologic, urologic orthopedic: major spine, hip (orthopedic: major spine, hip (espesprevision)revision) major head and neck oncologymajor head and neck oncology cardiac, thoraciccardiac, thoracic
traumatrauma
patients at high risk of complications (poor LV)patients at high risk of complications (poor LV) uncertain preoperative volume statusuncertain preoperative volume status ICU: sepsis, burns, etc.ICU: sepsis, burns, etc.
GoalGoal--directed therapy (GDT):directed therapy (GDT):What operations? Which patients?What operations? Which patients?
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
41/68
FrankFrank--Starling curve of ventricular functionStarling curve of ventricular function
ItIts all about oxygen delivery!s all about oxygen delivery!
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
42/68
42Funk AnesthAnalg2009;108(3)887
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
43/68
GDT technologies:GDT technologies:EsophagealEsophageal dopplerdoppler
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
44/68
GDT technologies:GDT technologies:OesophagealOesophagealdopplerdoppler
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
45/68
Screenshot from esophagealScreenshot from esophagealdopplerdoppler
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
46/68
GDT technologies:GDT technologies:Fluid administration algorithmFluid administration algorithm
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
47/68
DopplerDoppler--optimized fluid therapyoptimized fluid therapy
RCT, elective colorectalRCT, elective colorectalsurgerysurgery
standard fluid therapystandard fluid therapy vsvsesophagealesophageal dopplerdopplermonitoringmonitoring
postoppostopcare similar in bothcare similar in bothgroupsgroups
NoblettNoblettSE et al. Br JSE et al. Br J SurgSurg2006;93:10692006;93:1069
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
48/68
DopplerDoppler--optimized fluid therapyoptimized fluid therapyResults: GDT group had decreasedResults: GDT group had decreased
time to tolerate diettime to tolerate diet(median 3(median 3 vsvs4 days,4 days,pp=0.003)=0.003)
incidence of unplanned ICU admissionincidence of unplanned ICU admission(0(0 vsvs12%,12%, pp=0.012)=0.012)major complicationsmajor complications(0(0 vsvs12%) and12%) and overalloverallcomplicationscomplications(25%(25% vsvs45%,45%, pp=0.07)=0.07)time to fitness for dischargetime to fitness for discharge(median 7(median 7 vsvs9 days,9 days,pp=0.005)=0.005)
NoblettNoblettSE et al. Br JSE et al. Br J SurgSurg2006;93:10692006;93:1069
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
49/68
DopplerDoppler--optimized fluid therapyoptimized fluid therapy
no difference inno difference in intraopintraopcolloid use or crystalloidcolloid use or crystalloid
use between groupsuse between groups
most of the volume inmost of the volume in
the study group wasthe study group was
administered in the firstadministered in the first
quarter of the operatingquarter of the operating
timetime(i.e., first 40 min)(i.e., first 40 min)NoblettNoblettSE et al. Br JSE et al. Br J SurgSurg2006;93:10692006;93:1069
Functional intravascularFunctional intravascular
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
50/68
Functional intravascularFunctional intravascular
volume deficit in patientsvolume deficit in patientsbefore surgerybefore surgery
Volume of colloid to establish maximal cardiac stroke volumeVolume of colloid to establish maximal cardiac stroke volume
Patients(n
)
Patients(n
)
BundgaardBundgaard--Nielsen M et al.Nielsen M et al.ActaActaAnaesthesiolAnaesthesiolScand 2010;54:464Scand 2010;54:464
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
51/68
GoalGoal--directed fluid therapy:directed fluid therapy:The right fluid, for the rightThe right fluid, for the right
patient, at the right timepatient, at the right time
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
52/68
Goal directed fluid technologies:Goal directed fluid technologies:Pulse contour analysisPulse contour analysis
requires highrequires high--fidelity arterialfidelity arterial
lineline
simple, no manualsimple, no manual
calibrationcalibration
monitor SV, SVI, CO, CI,monitor SV, SVI, CO, CI,SVVSVV
when used with CVP giveswhen used with CVP givesScvOScvO22
updates every 20 sec: realupdates every 20 sec: real
time cardiac outputtime cardiac output
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
53/68
FloTracFloTrac: Stroke Volume: Stroke Volume
Variation (SVV)Variation (SVV)
requires mechanicalrequires mechanicalventilation Vventilation VTT 8mL/kg8mL/kg
affected by PEEPaffected by PEEP
not valid duringnot valid duringarrhythmias (arrhythmias (egeg. a. a
fib)fib)
normal value
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
54/68
Fluid management algorithm usingFluid management algorithm usingFloTracFloTrac--VigileoVigileomonitormonitor
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
55/68
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
56/68
PhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
57/68
Decreased length of stayDecreased length of staywith GDTwith GDT
Decreased time to resume full dietDecreased time to resume full diet with GDTwith GDTPhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
58/68
Decreased morbidityDecreased morbiditywith GDTwith GDTPhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
59/68
Average increased volume colloid 700Average increased volume colloid 700 mLmL
supports the hypothesis thatsupports the hypothesis that sublinicalsublinicalhypovolemiahypovolemiacausescausespostoperative bowel dysfunctionpostoperative bowel dysfunction
preventable by using GDTpreventable by using GDT
PhanPhanTD et al. J AmTD et al. J Am CollCollSurgSurg2008;207:9352008;207:935
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
60/68
GiglioGiglioMT et al. Br JMT et al. Br JAnaesthAnaesth2009;103:6372009;103:637
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
61/68
GiglioGiglioMT et al. Br JMT et al. Br JAnaesthAnaesth2009;103:6372009;103:637
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
62/68
Why is GDT not used routinely?Why is GDT not used routinely?
Fears about uncontrolled implementation?Fears about uncontrolled implementation?
(cost of PA catheter,(cost of PA catheter, cordiscordis/central line kit, CXR?)/central line kit, CXR?)
$250 disposable$250 disposable $210 disposable$210 disposable
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
63/68
Why is GDT not used routinely?Why is GDT not used routinely?
NiceNice
AnesthestistAnesthestist ORORManagementManagement
OncologyOncologyFundingFunding
Ministry ofMinistry ofHealthHealth
IIM LOOKINGM LOOKING
FOR FUNDING FORFOR FUNDING FOR
GDT MONITORINGGDT MONITORING
ItIt s fors for
the OR notthe OR not
the floorthe floor
It helpsIt helps
the floorthe floor
not the ORnot the OR
Show me the money !Show me the money !
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
64/68
Why is GDT not used routinely?Why is GDT not used routinely?
lack of immediate results (notlack of immediate results (not intraopintraopor earlyor early postoppostop))lack of userlack of user--friendly equipment, lack offriendly equipment, lack oftraining/knowledgetraining/knowledge
no largeno large--scalescale RCTsRCTs, only systematic reviews, only systematic reviews
skepticism about clinical effectivenessskepticism about clinical effectivenessAnesthAnesthAnalgAnalg2011;112:12742011;112:1274
S f l i l t ti fS f l i l t ti f
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
65/68
Successful implementation ofSuccessful implementation of
GDTGDTconcern aboutconcern about postoppostopcomplications related to fluidcomplications related to fluidcampaign to adopt GDT (campaign to adopt GDT (esophesoph.. dopplerdoppler) in 3 large) in 3 large
hospitals in Englandhospitals in England
consultantconsultant anaesthetistanaesthetist, divisional manager, audit, divisional manager, auditfacilitator at each sitefacilitator at each site
business case prepared with support from NHSbusiness case prepared with support from NHS
Technology Adoption Centre to overcome unequalTechnology Adoption Centre to overcome unequalspread of costs vs. benefitsspread of costs vs. benefits
clinician and manufacturer training support forclinician and manufacturer training support for
anaesthestistsanaesthestistsKuperKuperM et al. BMJ 2011;342:d3016M et al. BMJ 2011;342:d3016
S f l i l t ti fS f l i l t ti f
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
66/68
compared patient outcomescompared patient outcomes~~650 matched pairs 12 months650 matched pairs 12 months
before and after implementationbefore and after implementation
use of GDTuse of GDT from 11% to 65%from 11% to 65%of eligible operationsof eligible operations
LOS reduced 3.7 daysLOS reduced 3.7 days
1 complication (pulmonary edema)1 complication (pulmonary edema)
www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidewww.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativedIntraoperative
KuperKuperM et al. BMJ 2011;342:d3016M et al. BMJ 2011;342:d3016
Successful implementation ofSuccessful implementation of
GDTGDT
http://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperativehttp://www.ntac.nhs.uk/HowToWhyToGuides/DopplerGuidedIntraoperative7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
67/68
GDTGDT vsvsrestrictive fluid balancerestrictive fluid balance150 pts elective colorectal surgery (laparoscopic and150 pts elective colorectal surgery (laparoscopic and
open)open)
randomized to (A) GDT to max SV, orrandomized to (A) GDT to max SV, or
(B) zero fluid balance, normal body wt(B) zero fluid balance, normal body wtno difference in complications:no difference in complications:
majormajor
minorminorcardiopulmonarycardiopulmonarytissuetissue--healinghealing
BrandstrupBrandstrupB et al.B et al. EurEurJJAnaesthAnaesth2010;27:42010;27:4
7/27/2019 2011-A Modern Approach to Perioperative Fluid Management-Beverly Morningstar
68/68
SummarySummaryhypovolemiahypovolemia is common, unrecognized andis common, unrecognized andpotentially avoidablepotentially avoidable
standard monitoring methods of fluid managementstandard monitoring methods of fluid managementhave failed ushave failed us
crystalloid excess is not the answercrystalloid excess is not the answer
GDT improves patient outcomesGDT improves patient outcomes
fluids must be individualizedfluids must be individualized
the right fluid, for the right patient, at the right timethe right fluid, for the right patient, at the right time
our nursing colleagues must be champions for GDT!our nursing colleagues must be champions for GDT!