PREVENT COMPLICATIONS IN MAJOR SURGERY · AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS...
Transcript of PREVENT COMPLICATIONS IN MAJOR SURGERY · AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS...
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PREVENT COMPLICATIONS IN MAJOR SURGERY
Dept of Anesthesia and ICM
(Prof. G. Della Rocca)
Azienda Ospedaliero-Universitaria
University of Udine. Udine, Italy
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Crit Care Med 1982;10(6):398-403
CLINICAL TRIAL OF SURVIVORS’ CARDIORESPIRATORY PATTERNS AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS
Shoemaker WC, Appel Pl, Waxmax K
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Crit Care Med 1982;10(6):398-403
CLINICAL TRIAL OF SURVIVORS’ CARDIORESPIRATORY PATTERNS AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS
Shoemaker WC, Appel Pl, Waxmax K
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Critical Care 2006, 10:R81
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Exclusion criteria: endoscopyday-case surgcardio-thoracneurosurgorgan txobstetricsburns
From Jan 1999 to Oct 2004 (70 months)
94 Hosp in UK
All surgical procedures (HRG)
n = 4 117 727
Critical Care 2006, 10:R81
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Critical Care 2006, 10:R81
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Critical Care 2006, 10:R81
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Critical Care 2006, 10:R81
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Critical Care 2006, 10:R81
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Critical Care 2006, 10:R81
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• Renal: fluids!!! (fenoldopam?)
• Infections: sepsis
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Critical Care 2005; 9:R687-693
RCT, HR surgical patients (n=122 pts)
DO2I 600 mL min-1 m-2 vs conventional management
Cardiac Output (LidCO System)
60 days
SVI/DO2I
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Critical Care 2005; 9:R687-693
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Critical Care 2005; 9:R687-693
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Critical Care 2005; 9:R687-693
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Critical Care 2005; 9:R687-693
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Anesthesiology 2002; 97:820-826
Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery.
TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass
FTc
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Anesthesiology 2002 ; 97: 820-6
Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery.
TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass
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Anesthesiology 2002 – Gan et al.
Anesthesiology 2002 ; 97: 820-6
Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery.
TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass
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Wakeling HG et al BJA 2005; 95(5): 634-42
SV vs CVP:
decreased LOS and complications
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Preop eval Surgery ICU discharge Hospital discharge
High Risk patientsdefinition
OPTIMIZATION∆ outcome
High risk population“Supposed” normal goals ≠ “supranormal” goals
PERIOP HEMODYNAMIC OPTIMIZATION
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DO2 = CO x CaO2
PERIOP HEMODYNAMIC OPTIMIZATION
(CVP, SV,ABF-FTc, SvO2, Lac, dynamic indexes)
(AP, HR, diuresis)
(DO2 >600 mL/min/m2)
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Anesth Analg 2005;100:1093-106
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Anesth Analg 2005;100:1093-106
How should fluid be administered
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“SUPPOSED” NORMAL GOALS
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Cardiac surgeryCardiac surgery
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Orthopedic surgeryOrthopedic surgery
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Major abdominal surgeryMajor abdominal surgery
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Br J Anesth 2007;99:500-8
n = 32 prospective study
Liberal fluid regimen:
transiet pulmonary improvement but postop Hypoxiemia
tendency to deacrease in morbidity
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Br J Anesth 2007;99:500-8
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Br J Anesth 2007;99:500-8
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Br J Anesth 2007;99:500-8
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Vasc Endovasc Surg 2008;June 25
Retrospective Study
n = 41 divided in 2 groups: < 3L vs >3L intraop
- Restricted regimen: <LOS (MV?) ICU and Hospital
- No difference in morbidity
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Vasc Endovasc Surg 2008;June 25
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Eur J Vasc Endovasc Surg 2007;34:522-7
Conclusion: more fluids more complications!
n = 100: retrospective study
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Eur J Vasc Endovasc Surg 2007;34:522-7
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Intraoperative fluid management duringorthotopic liver transplantation
RA Schroeder, BH Collins, E Tuttle-Newhall, K Robertson, J Plotkin, LB Johnson, PC Kuo
J Cardiothorac Vasc Anesth 2004;18(4): 438-441
2 liver transplant centers experience
low CVP method vs normal CVP method
clinical safety of a low CVP fluid management strategy in
patients undergoing Ltx
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J Cardiothorac Vasc Anesth 2004;18(4): 438-441
“despite sussess in lowering blood transfusion requirements in liver
resection patients, a low CVP should be avoided in patients
undergoing liver transplantation”
Intraoperative fluid management duringorthotopic liver transplantation
RA Schroeder, BH Collins, E Tuttle-Newhall, K Robertson, J Plotkin, LB Johnson, PC Kuo
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J Cardiothor Vasc Anesth 2008; 22(2):311-4
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Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)
“We aimed to investigate the effects of DO2I
optimization,
with and without dobutamine,
on the incidence of perioperative complication
in HR surgical patients”
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Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)
dobutaminevolume
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Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)
dobutamine
volume
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Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)
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Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)
PAC-guided hemodynamic optimization using
dobutamine determines better outcomes,
whereas fluids alone increase the incidence of
postoperative complications in patients with
high risk of perioperative death.
Conclusion
IS SUPRANORMAL DO2 NECESSARY?
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Use it only when you need and not only because of protocols….
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NIV AND PERIOPERATIVE OPTIMIZATION
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Incluison criteria:
ASA I-II
Major abdominal surgery
PaO2/FiO2 < 300 1 hr after extubation
Exclusion criteria:
Cardiac, Respiratory and Obese patients
Recent Major surgery, CT, immunosuppression
Acidosis, hipercapnia (CO2>50 mmHg)
SpO2<80 %
Hypoalbuminemia, renal insufficiency, anemia, ARDS
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1 hr after extubation:
CTRL group → 6 h Venti Mask FiO2 0.5
PROT group → 6h CPAP 7.5 cmH2O FiO2 0.5 (Helmet)
After 6 h
1 h Venti Mask FiO2 0.3 and then:
If PaO2/FiO2 < 300→ back to the assigned group
> 300→stop treatment
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Preop eval Surgery ICU discharge Hospital discharge
High Risk patientsdefinition
OPTIMIZATION∆ outcome
High risk population“Supposed” normal goals ≠ “supranormal” goals
Postoperative NIV.
PERIOP HEMODYNAMIC OPTIMIZATION
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Is ICU postoperative care necessary forHR patients?
Yes but to optimize and not to “monitor” …..
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HEMODYNAMIC OPTIMIZATION
Volume/dobutamine/ITBVI (intraop or eary ICU)
(No recent MI-ischemia or ↑ ß-blocker therapy)
Lung protection: EVLWI (early predictor of mortality/latewarning system)
Fast track anesthesia + NIV (if PaO2/FiO2<300)
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Renalprotection
Lungprotection
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When? Early!