1. Goal Directed Fluid Therapy 2012
R.W. McIntyre, MD
Tampa VA Hospital, Florida
May,2012

2. Goal Directed Fluid Therapy - 2012
R.W.McIntyre MD
Tampa VA Hospital

3. Enhanced Recovery After Surgery ERAS
Decrease complications
Early mobility
Early GI (Gut) function
Early discharge: It takes guts

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

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

6. What are we talking about ?
Too long or too short?
Too high or to low ?
Too much or too little?

7. Too high or too Low ?
SBP: 120 DBP: 80 HR: 72 CVP: 12

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

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

10. SVV 10
SVV 20

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

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

13. Anesthesia Practice 2009 (ASA, 73; 7 – 11)
Tradition: Rituals and customs
Dogma: Arrogant declaration of opinion
Myth: Widely held but false notion

14. What are you going to do? Cascade of decision-making in medical practice
Knowledge and experience
Suggestions
Recommendations
Guidelines
Policies
Mandates

15. EVERYDAY GOALS
BLOOD PRESSURE
HEART RATE
URINE

16. Words
Deficit
Maintenance
Third space
Urine

17. “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 )

18. The Daily Double
Hypotension (Negative – ino dilators)
Flood

19. Too much !
YOU ARE DROWNING MY PATIENT !

20. 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)

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

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

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

24. 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

25. 1988 - Shoemaker (Chest 1988;94:1176-86)
Supranormal values of survivors …as GOALS
DO mL/min/m2
(Chest 1988;94: )

26. 2001 – Rivers
Early GOAL - DIRECTED THERAPY……SEPSIS… SvO2 > 70 % Improved outcome (N Engl J Med 2001;345: )

27. 2009 - Kehlet “……….GOAL DIRECTED FLUID THERAPY ……
For optimization of fluid management
…………………..and OUTCOME
(Anesthesiology 2009;110:453-55)

28. EVIDENCE – FLUIDS 2012
DATA BEAT OPINION

29. 2011 - Hamilton “Pre-emptive … hemodynamic monitoring and
therapy reduces mortality and morbidity”
(Anesth Analg 2011;112: )

30. Mortality from Severe Sepsis

31. Operative Mortality for High –Risk Surgery
high-risk surgery procedures (1999 – 2008)
(3.2 million cases)
Mortality
(N Engl J Med 2011;364:2128)

32. Results – High Risk Surgery
Decreased mortality: 11% Esophagectomy 19% Pancreatectomy 36% AAA

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

34. 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; )

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

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

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

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

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

40. What do new monitors measure ?
1. Flow (C.O./C.I/S.V)
Stroke Volume Variation (SVV)
(Continuous but with limitations)

41. 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)

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

44. SVV 10
SVV 20

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

46. 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)

47. Tampa VA - GDT 2009 - Introduction of GDT/SVV
Selection and implementation of non – invasive technology
Use
Nicom
Vigileo
Total (+20%)

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

49. 2012 - RECOMMENDATIONS 1 – 2 ml/hr maintenance
250 mL boluses (colloid)
( Anesth Analg 2011;201;1274 – 76 )

50. GOAL?
Improve care

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

52. 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

53. Enhanced recovery after surgery - What can WE do ?
Infection control
PONV prevention
Analgesia
Complication prevention
Optimize Fluids (GDT)

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

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

56. Length of Hospital Stay
Goal-directed intraoperative fluid administration reduces length of hospital stay …
(Anesthesiology 2002;97:820 – 6)

57. 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)

58. Goal-directed Colloid Administration Improves the Microcirculation of Healthy and Perianastomotic Colon
Tissue Oxygenation
GD-C ± 31%
Colon:
GD-RL ± 40%
Perianastomotic: GD-C ±93%
Conclusion : Goal – directed colloid fluid therapy (GDT) increases oxygen tension and perfusion in healthy and injured colon tissue
(Anesthesiology 2009; 110:721-8)