Haemodynamic Monitoring Dr Mark Hamilton Consultant & Honorary Senior Lecturer Anaesthesia & Intensive Care Medicine St. George’s Hospital & Medical School

Adolf Fick (1829 – 1901) Diffusion – 1855 Cardiac Output – 1870 The Physiologists!

Ernest Henry Starling Fibre length vs Work Frank-Starling law of the heart Hormones, Peristalsis, Water & DCT

“it is as if we had a motor bicycle which automatically opened the throttle as soon as the road began to go uphill” -Ernest Henry Starling Permissive role of the heart Metabolic demand Vascular tone

Guyton Experiments in 1950’s – Cardiac output and Peripheral circulation “The need of the body for oxygen is the real Regulator of cardiac output” Arthur C Guyton

Ronald Bradley The first person to describe the use of a pulmonary-artery catheter in man in …………….1964

PAC Swan-Ganz

PAC 1996 – > 2 millions catheters sold worldwide The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators A F. Connors Jr, T. Speroff, N. V. Dawson, C. Thomas, F. E. Harrell Jr, D. Wagner, N. Desbiens, L. Goldman, A. W. Wu, R. M. Califf, W. J. Fulkerson Jr, H. Vidaillet, S. Broste, P. Bellamy, J. Lynn and W. A. Knaus JAMA 1996; 276: 889–97.

“The information obtained with the PAC should be used to find better treatment strategies, and these strategies, instead of the tool itself, should be tested in clinical trials”

Less Invasive Devices Pulse Pressure Analysis Echocardiography Oesophageal Doppler Bioimpedance, Bioreactance

Arterial ‘swing’

Cardiac Output/ Stroke Volume Intra-vascular volume  v Weil: the fluid challenge Weil Anaesthesia & Analgesia 1979

Surgical Burden >234 million MAJOR surgical procedures undertaken each year  Healthcare expenditure = more operations Weiser; Lancet 2008,372, vs 11,000

105,951 patients 69%  in median survival for 30 day complication “The occurrence of a 30 day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining survival after major surgery”

Surgical Complications 84,730 patients Mortality 3.5 – 6.9% Complications % Avoidance & Recognition NEJM 2009

Preemptive haemodynamic intervention to improve outcome in moderate & high risk surgery A Systematic Review & Meta-analysis Hamilton/Cecconi/Rhodes In Review A&A

Analysis Primary endpoint – Mortality Secondary endpoints – Complications – Length of stay – Cost

Analysis Subgroup Analysis – Mortality & Morbidity Type of Monitor – ODM/PAC/Other Therapy – Fluid/Fluids & Inotropes Goals – CI/DO2 – FTc/SV – Other Resuscitation target – Supranormal – Normal

Further Analysis Time dependent effect on mortality and morbidity – By decade – By Control group mortality

Results-Mortality OR 0.48 [ ] p=

Results - Complications OR 0.44 [ ] p<

Control Group Mortality vs Time 7% 29% 14%

Decade-Mortality

Decade-Complications 35% 29% 30%

MORTALITY Outcome and SubgroupNumber of studiesNumber of patientsControl group mortalityOdds ratio[95% CI] Monitor ODM989428/448(6%)0.75[0.41,1.37] PAFC /1739(10%)0.35[0.19,0.65]* Other540017/198(9%)0.61[0.27,1.35] Therapy Fluids /350(5%)0.44[0.19,1.06] Fluids & Inotropes /2035(10%)0.47[0.29,0.76]* Goals CI/DO /1657(11%)0.38[0.21,0.68]* FTc/SV989428/448(6%)0.75[0.41,1.37] Other356113/280(5%)0.43[0.15,1.19] Resuscitation Target Supranormal80.29[0.18,0.47]89/346(26%)0.29[0.18,0.47]* Normal210.86[0.66,1.13]135/2039(7%)0.86[0.66,1.13]

COMPLICATIONS Outcome and SubgroupNumber of studiesNumber of patients Number of patients with complications in control group Odds ratio[95% CI] Monitor ODM /469(35%)0.41[0.30,0.57]* PAFC /537(20%)0.54[0.33,0.88]* Other432076/158(48%)0.32[0.19,0.54]* Therapy Fluids /372(34%)0.38[0.26,0.55]* Fluids & Inotropes /792(28%)0.47[0.35,0.64]* Goals CI/DO /461(37%)0.52[0.37,0.74]* FTc/SV /423(32%)0.41[0.28,0.58]* Other356143/280(15%)0.26[0.13,0.52]* Resuscitation Target Supranormal /227(59%)0.42[0.29,0.63]* Normal /937(23%)0.43[0.31,0.60]*

COMPLICATIONS Outcome and SubgroupNumber of studiesNumber of patients Number of patients with complications in control group Odds ratio[95% CI] Monitor ODM /469(35%)0.41[0.30,0.57]* PAFC /537(20%)0.54[0.33,0.88]* Other432076/158(48%)0.32[0.19,0.54]* Therapy Fluids /372(34%)0.38[0.26,0.55]* Fluids & Inotropes /792(28%)0.47[0.35,0.64]* Goals CI/DO /461(37%)0.52[0.37,0.74]* FTc/SV /423(32%)0.41[0.28,0.58]* Other356143/280(15%)0.26[0.13,0.52]* Resuscitation Target Supranormal /227(59%)0.42[0.29,0.63]* Normal /937(23%)0.43[0.31,0.60]*

April

P=0.01

P<0.0001

ns

Haemodynamic Monitoring + Goal Directed therapy What do I do?

Haemodynamic Optimisation Intraoperative – Oespohageal Doppler guided Postoperative – Pulse contour and lithium dilution guided

Intraoperative ODM

Intraoperative Monitor – Oespohageal Doppler Technique – goal directed – Bolus administration of Colloid Stroke Volume increase of 10% Normalisation of FTc – Maintenance crystalloid 1-2mls/Kg/hr

Mythen 1995, Arch. Surg.,130(4), Wakeling 2005, BJA, 95(5),

British Journal of Surgery 2006; 93: 1069–1076 Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection S. E. Noblett, CP. Snowden, BK. Shenton and AF. Horgan

FTc Time 75% of Fluid 25% of the Time

Colloid administration +ve 671mls (580 – 762)

Crystalloid -ve 156mls (274– 38)

Postoperative Monitor – Pulse contour analysis with lithium diution Technique – Goal directed therapy Nurse led & protocol driven Oxygen Delivery of 600mls/min/m 2 Bolus administration of colloid – SV increase by 10% Addition of dopexamine (0.25 – 1mcg/Kg/min)

Beyond Clinical Trials

Optimisation outside clinical trials: St. George’s July 2006 – Sep 2007 n = 438

Optimisation outside clinical trials: St. George’s July 2006 – Sep 2007

Multicentre adoption study 3 Centres –London/Manchester/Derby Support and help to adopt technology Educational support Conformed to national benchmark and strategic directions 1,247 patients

Haemodynamic Monitoring + GDT - Conclusions Evidence Real World Application Multiple Methods ✔ ✔ ✔ ✔ ✔ ✔

Thank you!