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 Early discharge: It takes guts

Enhanced Recovery After Surgery ERAS - Anesthesia Effective analgesia Decrease PONV Goal Directed Fluid Therapy

Perioperative Fluids What is our practice ? What do we know? Where are we going ?

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 ? SBP: 120 DBP: 80 HR: 72 CVP: 12

Fluids – Too much or too little? Liberal Restrictive “OPTIMAL”

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

SVV 10 SVV 20

Fluid optimization GI/ GUT Complications Hypotension RESTRICTION (Too little) Hypotension Decreased end- organ oxygen delivery LIBERAL (Too Much) Multi - organ edema GI/ GUT Complications

Perioperative Fluids What is our practice ? What do we know? Where are we going ?

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 Knowledge and experience Suggestions Recommendations Guidelines Policies Mandates

EVERYDAY GOALS BLOOD PRESSURE HEART RATE URINE

Words Deficit Maintenance Third space Urine

“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 Hypotension (Negative – ino dilators) Flood

Too much ! YOU ARE DROWNING MY PATIENT !

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)

Change in Fluid Management Goal – directed vs Traditional Important component of : Enhanced Recovery After Surgery

GOALS 2012 FLOW MANAGEMENT CARDIAC OUTPUT FLUID OPTIMIZATION (GDT) OXYGEN DELIVERY (Flow and oxygen content) CARDIAC OUTPUT FLUID OPTIMIZATION (GDT)

HOW ? NEW TECHNOLOGY GOALS: What is the purpose ? EVIDENCE: What is the evidence ? RETURN ON INVESTMENT ?

History - Goals Non –invasive monitoring 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 (Chest 1988;94:1176-86) Supranormal values of survivors …as GOALS DO2 600 mL/min/m2 (Chest 1988;94:1176-86)

2001 – Rivers Early GOAL - DIRECTED THERAPY……SEPSIS… SvO2 > 70 % Improved outcome (N Engl J Med 2001;345:1368-77)

2009 - Kehlet “……….GOAL DIRECTED FLUID THERAPY …… For optimization of fluid management …………………..and OUTCOME (Anesthesiology 2009;110:453-55)

EVIDENCE – FLUIDS 2012 DATA BEAT OPINION

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

OUTCOME WITH GDT LENGTH OF HOSPITAL STAY (LOS) REDUCED BY 3.7 DAYS (Kuper M et al BMJ 2011;342:d3016)

2011 - Miller Show us the data No immediate “tangible “ benefits 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)

Where are we ? Translational Using new technology to improve outcome “Progress is precarious” (Paul Barash)

FLUIDS – 2012 - OUT Pulmonary Artery Catheter CVP/PAWP Urine chasing “Third space”

Goal Directed Fluid Therapy (GDT) Fluid Therapy – 2012 - IN Goal Directed Fluid Therapy (GDT) Non - invasive monitors

GOAL DIRECECTED FLUID THERAPY Stroke Volume Variation (SVV) Fluid Responsiveness

New non-invasive CVS monitoring Esophageal Doppler Thoracic bio-reactance (Nicom) Pulse contour analysis ( Vigileo/ Flotrac)

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) 1. The difference in stroke volume (SV) during inspiration vs. expiration 2. ~13 % ( 9 – 13 = grey zone) 3. A measure of fluid responsiveness

(Edwards)

Fluid responsiveness Treating fluid responsiveness can increase cardiac performance and oxygen delivery

SVV 10 SVV 20

Non – invasive monitors – When? Major surgery – Blood and Fluids Organ protection (Decrease RISKS OF COMPLICATIONS)

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 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 To optimize fluid therapy Not too much or too little To support intraoperative care with evidence - based data

2012 - RECOMMENDATIONS 1 – 2 ml/hr maintenance 250 mL boluses (colloid) ( Anesth Analg 2011;201;1274 – 76 )

GOAL? Improve care

Early Recovery After Surgery - ERAS Intensive interdisciplinary preparation Complication reduction (Infection,tubes, analgesia, PONV) Goal Directed Fluid Therapy (GDT)

2012 - What do patients want ? GOOD OUTCOME 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 ? Infection control PONV prevention Analgesia Complication prevention Optimize Fluids (GDT)

Summary - GDT Optimize and individualize fluid therapy via : Goal Directed Fluid Therapy (GDT)

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

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)

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)