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

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

3. Ernest Henry Starling 1866 - 1927 Fibre length vs Work Frank-Starling law of the heart - 1915 - 1919 Hormones, Peristalsis, Water & DCT

4. “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

5. 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 1919 - 2003

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

7. PAC Swan-Ganz

8. 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.

9. “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”

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

17. Arterial ‘swing’

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

21. Surgical Burden >234 million MAJOR surgical procedures undertaken each year  Healthcare expenditure = more operations Weiser; Lancet 2008,372,139-44 295 vs 11,000

22. 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”

23. Surgical Complications 84,730 patients 2005-2007 Mortality 3.5 – 6.9% Complications 24.6-26.9% Avoidance & Recognition NEJM 2009

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

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

27. 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

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

29. Results-Mortality OR 0.48 [0.33-0.7] p=0.0002 29

30. Results - Complications OR 0.44 [0.35-0.55] p<0.00001

31. Control Group Mortality vs Time 7% 29% 14%

32. Decade-Mortality

33. Decade-Complications 35% 29% 30%

34. MORTALITY Outcome and SubgroupNumber of studiesNumber of patientsControl group mortalityOdds ratio[95% CI] Monitor ODM989428/448(6%)0.75[0.41,1.37] PAFC153511179/1739(10%)0.35[0.19,0.65]* Other540017/198(9%)0.61[0.27,1.35] Therapy Fluids1070016/350(5%)0.44[0.19,1.06] Fluids & Inotropes194105208/2035(10%)0.47[0.29,0.76]* Goals CI/DO 2 173350183/1657(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]

35. COMPLICATIONS Outcome and SubgroupNumber of studiesNumber of patients Number of patients with complications in control group Odds ratio[95% CI] Monitor ODM9987163/469(35%)0.41[0.30,0.57]* PAFC101085108/537(20%)0.54[0.33,0.88]* Other432076/158(48%)0.32[0.19,0.54]* Therapy Fluids9742126/372(34%)0.38[0.26,0.55]* Fluids & Inotropes141650221/792(28%)0.47[0.35,0.64]* Goals CI/DO 2 12982169/461(37%)0.52[0.37,0.74]* FTc/SV8849135/423(32%)0.41[0.28,0.58]* Other356143/280(15%)0.26[0.13,0.52]* Resuscitation Target Supranormal6469133/227(59%)0.42[0.29,0.63]* Normal171923214/937(23%)0.43[0.31,0.60]*

36. COMPLICATIONS Outcome and SubgroupNumber of studiesNumber of patients Number of patients with complications in control group Odds ratio[95% CI] Monitor ODM9987163/469(35%)0.41[0.30,0.57]* PAFC101085108/537(20%)0.54[0.33,0.88]* Other432076/158(48%)0.32[0.19,0.54]* Therapy Fluids9742126/372(34%)0.38[0.26,0.55]* Fluids & Inotropes141650221/792(28%)0.47[0.35,0.64]* Goals CI/DO 2 12982169/461(37%)0.52[0.37,0.74]* FTc/SV8849135/423(32%)0.41[0.28,0.58]* Other356143/280(15%)0.26[0.13,0.52]* Resuscitation Target Supranormal6469133/227(59%)0.42[0.29,0.63]* Normal171923214/937(23%)0.43[0.31,0.60]*

37. April 2010 1993

38. P=0.01

39. P<0.0001

40. ns

41. Haemodynamic Monitoring + Goal Directed therapy What do I do?

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

43. Intraoperative ODM

45. 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

46. Mythen 1995, Arch. Surg.,130(4), 423-429 Wakeling 2005, BJA, 95(5), 634-642

47. 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

48. FTc 330 360 Time 75% of Fluid 25% of the Time

49. Colloid administration +ve 671mls (580 – 762)

50. Crystalloid -ve 156mls (274– 38)

51. 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)

54. Beyond Clinical Trials

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

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

60. 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

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

67. Thank you!