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Goal Directed Fluid Therapy 2012

R.W. McIntyre, MDTampa VA Hospital, Florida

May,2012

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Goal Directed Fluid Therapy - 2012

R.W.McIntyre MDTampa VA Hospital

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Enhanced Recovery After SurgeryERAS

• Decrease complications

• Early mobility

• Early GI (Gut) function

Early discharge: It takes guts

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Enhanced Recovery After SurgeryERAS - Anesthesia

• Effective analgesia

• Decrease PONV

Goal Directed Fluid Therapy

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Perioperative Fluids

• What is our practice ?

• What do we know?

• Where are we going ?

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What are we talking about ?

Too long or too short?

Too high or to low ?

Too much or too little?

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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

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SVV 10

SVV 20

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Fluid optimization

RESTRICTION (Too little)

• Hypotension

• Decreased end- organ oxygen delivery

LIBERAL (Too Much)

• Multi - organ edema

GI/ GUT Complications

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Perioperative Fluids

• What is our practice ?

• What do we know?

• Where are we going ?

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• Tradition: Rituals and customs

• Dogma: Arrogant declaration of opinion

• Myth: Widely held but false notion

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

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

• Suggestions• Recommendations• Guidelines• Policies• Mandates

Knowledge and experience

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EVERYDAY GOALS

• BLOOD PRESSURE

• HEART RATE

• URINE

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Words

• Deficit

• Maintenance

• Third space

• Urine

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“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 )

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The Daily Double

• Hypotension (Negative – ino dilators)

• Flood

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Too much !

YOU ARE DROWNING MY PATIENT !

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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 Clin Anaesth 2006;20(3):439)

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Change in Fluid Management

Goal – directed vs Traditional

Important component of :

Enhanced Recovery After Surgery

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GOALS 2012FLOW MANAGEMENT

OXYGEN DELIVERY (Flow and oxygen content)

CARDIAC OUTPUT

FLUID OPTIMIZATION (GDT)

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HOW ? NEW TECHNOLOGY

• GOALS: What is the purpose ?

• EVIDENCE: What is the evidence ?

• RETURN ON INVESTMENT ?

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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

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1988 - Shoemaker

• Supranormal values of survivors …as GOALS

DO2 600 mL/min/m2

(Chest 1988;94:1176-86)

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2001 – Rivers

Early GOAL - DIRECTED THERAPY……SEPSIS…

SvO2 > 70 %

Improved outcome

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

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2009 - Kehlet

“……….GOAL DIRECTED FLUID THERAPY ……

For optimization of fluid management

…………………..and OUTCOME

(Anesthesiology 2009;110:453-55)

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EVIDENCE – FLUIDS 2012

DATA BEAT OPINION

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2011 - Hamilton

“Pre-emptive … hemodynamic monitoring and therapy reduces mortality and morbidity”

(Anesth Analg 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

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OUTCOME WITH GDT

LENGTH OF HOSPITAL STAY (LOS) REDUCED BY 3.7 DAYS

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

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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?

(Anesth Analg 2011;112;1274-76)

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Where are we ?

• Translational

• Using new technology to improve outcome

“Progress is precarious” (Paul Barash)

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FLUIDS – 2012 - OUT

OUT:

• Pulmonary Artery Catheter

• CVP/PAWP

• Urine chasing

• “Third space”

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Fluid Therapy – 2012 - IN

Goal Directed Fluid Therapy

(GDT)

Non - invasive monitors

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GOAL DIRECECTED FLUID THERAPY

Stroke Volume Variation (SVV)

Fluid Responsiveness

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New non-invasive CVS monitoring

• Esophageal Doppler

• Thoracic bio-reactance (Nicom)

• Pulse contour analysis ( Vigileo/ Flotrac)

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What do new monitors measure ?

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

2. Stroke Volume Variation (SVV)

(Continuous but with limitations)

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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

42(Edwards)

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Fluid responsiveness

Treating fluid responsiveness can increase cardiac performance and oxygen delivery

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SVV 10

SVV 20

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Non – invasive monitors – When?

Major surgery – Blood and Fluids

Organ protection

(Decrease RISKS OF COMPLICATIONS)

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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)

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Tampa VA - GDT

2009 - Introduction of GDT/SVV

Selection and implementation of non – invasive technology

Use

2010 2011

Nicom 200 250Vigileo 165 190

Total 365 440 (+20%)

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Purpose - GDT

• To optimize fluid therapy

• Not too much or too little

To support intraoperative carewith evidence

- based data

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2012 - RECOMMENDATIONS

• 1 – 2 ml/hr maintenance

• 250 mL boluses (colloid)

( Anesth Analg 2011;201;1274 – 76 )

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GOAL?

Improve care

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Early Recovery After Surgery - ERAS

• Intensive interdisciplinary preparation

• Complication reduction (Infection,tubes, analgesia, PONV)

• Goal Directed Fluid Therapy (GDT)

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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

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Enhanced recovery after surgery - What can WE do ?

• Infection control

• PONV prevention

• Analgesia

• Complication prevention

Optimize Fluids (GDT)

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Summary - GDT

Optimize and individualize fluid therapy via :

Goal Directed Fluid Therapy (GDT)

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

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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, Anesth Analg 2009;108:616-21)

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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)