1. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Goal directed perioperative monitoring Univ.-Prof. Dr. Michael Sander Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin Campus Charité Mitte, Campus Virchow-Klinikum Charité - Universitätsmedizin Berlin

2. Disclosure Research grants or royalties for lectures:  Edwards Life Science  Fresenius Medical  The Medicines Company  Pulsion Medical Systems

3. Educational objective  Goal-directed perioperative monitoring – Why? – Who? – What? – How?

4. AGENDA  Risks in the OR  Parameters – Blood pressure – Venous saturation – Dynamic parameters of circulation  Conclusion 3

5. Old people – a challenge for the future Jeanne Louise Calment * February, 21th 1875 in Arles, France; † August, 4th 1997 4

6. Old people – a challenge for the future Jeanne Louise Calment * February, 21th 1875 in Arles, France; † August, 4th 1997 5

7. Percentage of older people increases Amount of older people over 65/80 years of entire population 6 part in % over 65 years oldover 80 years old men women

8. Demographic change - a challenge for the future - 7 Siewert, U. et al. (2010). Deutsches Ärzteblatt international, 107(18), 328–334. 20052020 Mecklenburg-VorpommernNumber of cases Change Prevalence - Hypertension618,855650,858+ 5.2 % (+32,003) - Diabetes117,919141,125+ 19.7 % (+23,206) - Myocardial infarction40,97651,549+ 25.8 % (+10,573) - Stroke31,32279,053+ 16.3 % (+5,100) Incidence - Colon carcinoma728936+ 28.6 % (+208) - Cancer (all)8,61210,388+ 20.6 % (+1,776)

9. European Surgical Outcome Study  Results – Inclusion of 46.539 patients – 1.855 patients died (in-hospital mortality 4%)  Conclusion – Strategies to minimise risk  Methods – 7 day cohort study – Time of recruitment: 4.4.2011 to 11.4.2011 – Multi center study (498 centers in Europe)  Patients – Inclusion of all „non cardiac- surgery“ patients (elective and not elective)  Primary endpoint – hospital mortality (maximum follow-up 60 days) 8 Pearse, R. et al. (2012). Lancet, 380(9847), 1059–1065.

10. Improving our care “Now, here, you see, it takes all the running you can do to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!”

11. Patient safety - risk reduction strategy - 10 Risks on patient side: Age Pre-existing conditions Heart and circulation Anaemia Genetic... Risk in surgery: Type of surgery Blood loss Emergency vs. elective... Structural risk: Checklists Monitoring Education Standardized paths for treatments SOP individual goal-directed therapy Sander, M. (2013) Perioperatives Risiko. DIVI Jahrbuch 2012/2013 ISBN: 978-3-941468-84-9

12. Patient safety - risk reduction strategy - 11 Risks on patient side: Age Pre-existing conditions Heart and circulation Anaemia Genetic... Risk in surgery: Type of surgery Blood loss Emergency vs. elective... Structural risk: Checklists Monitoring Education Standardized paths for treatments SOP individual goal-directed therapy hemodynamic management Sander, M. (2013) Perioperatives Risiko. DIVI Jahrbuch 2012/2013 ISBN: 978-3-941468-84-9

13. Fluid management and morbidity morbidity hypovolaemia normovolaemia hypervolaemia Risks  -Hypoperfusion -SIRS -Sepsis -MOV Risks  -Edema -Ileus -PONV -Pulmonary dysf. Habicher, M., Sander, M. (2011). Journal of Cardiothoracic and Vascular Anesthesia, 25(6), 1141–1153. 12

14. morbidity hypovolaemia normovolaemia hypervolaemia Brandstrup, B. et al. (2003). Annals of Surgery, 238(5), 641–648. Fluid at the day of surgery: 2740 ml (1100 – 8050), p<0,01 complications postop: 28 patients (33%), p=0,01 Fluid at the day of surgery: 5388 ml (2700–11083) complications postop: 44 patients (51%) Method: randomised controlled multi center studyl, N=172, median (range) colonic surgery - restrictive vs. liberal liquid management restrictive (n=69) ↔ liberal (n=72) 13 Fluid management and morbidity

15. morbidity hypovolaemia normovolaemia hypervolaemia Holte, K. et al. (2007). British Journal of Anaesthesia, 99(4), 500– 508. Fluid intraop: 1640 ml (935–2250), p<0,01 Complications postop: 6 patients with 18 complications, 38%, p=0,01 Fluid intraop: 5050 ml (3563–8050) complications postop: 1 patients with 1 complication (6%) Method: randomised controlled double blind intervention study, N=32, median (range) colonic surgery - restrictive vs. liberal liquid management restrictiv (n=16) ↔ liberal (n=16) 14 Fluid management and morbidity

16. Individualized hemodynamic goal- directed therapy morbidity hypovolaemia normovolaemia hypervolaemia individualized hemodynamic management restrictive ↔ liberal Habicher, M., Sander, M. (2011). Journal of Cardiothoracic and Vascular Anesthesia, 25(6), 1141–1153. pre-existing condition Typ of intervention Preop loss of blood Preop preload Epidural anaesthesia... 15

17. Classics 16

18. Supranormal DO 2 17 Shoemaker et al. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest (1992) vol. 102 (1) pp. 208-15

19. Adequate oxygen suply consumption supply

20. Does DO 2 increases VO 2 ? 19 Shibutani K. Crit Care Med 1983 Yes ! No !

21. Does DO 2 increases VO 2 ? 20 Sharma, V. K., & Dellinger, R. P. (2003). The International Sepsis Forum’s frontiers in sepsis: high cardiac output should not be maintained in severe sepsis. Critical care (London, England), 7(4), 272. doi:10.1186/cc2350

22. Oxygen supply: DO2  simplified fomula = DO 2 = CO X (Hgb X 1.34 X Sa0 2 ) X 10

23. Oxygen Delivery: What are the components? Oxygen Delivery DO 2 Cardiac Output Heart rate Stroke volume CaO2 PaO2PaO2 SaO2SaO2 Hct Synchrony PreloadAfterloadContractility CVP PCWP PVR SVR Ejection fraction

24. Implementation into practice? Monitoring of circulation: „It was fatal for the development of our understanding of circulation, that blood flow is relatively difficult to measure, whereas blood pressure is easily measured: This is the reason why the blood pressure meter has gained such a fascinating influence, although most organs do not need pressure, but blood flow. Jarisch A. (1928). Deutsche Medizinische Wochenschrift

25. Cannesson et al. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Critical care (London, England) (2011) vol. 15 (4) pp. R197 To the question: “Do you believe that your current hemodynamic management could be improved?” 86.5 % of ASA respondents and 98.1 % of ESA respondents (p < 0.001) answered Yes.

26. Cannesson et al. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Critical care (London, England) (2011) vol. 15 (4) pp. R197

27. Parameters for individualized hemodynamic therapy ? 26 Kastrup, M., Sander, M. et al. (2013). Acta Anaesthesiologica Scandinavica, 57(2), 206–213. Most frequent answers: „which parameters do you use to manage for hemodynamic and volume management“? Data in percent, n = 62 arterial pressure central venous pressure central venous saturation stroke volume pulse pressure variation echocardiography

28. Pressure Arterial pressure and central venous pressure for rmanagement of circulation therapy 27

29. 28 Marik, P. E., & Cavallazzi, R. (2013). Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Critical Care Medicine, 41(7), 1774–1781. doi:10.1097/CCM.0b013e31828a25fd

30. Does CVP predict fluid responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense  There are no data to support the widespread prac- tice of using central venous pressure to guide fluid therapy. This approach to fluid resuscitation should be abandoned. (Crit Care Med 2013; 41:1774–1781) 29 Marik, P. E., & Cavallazzi, R. (2013). Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Critical Care Medicine, 41(7), 1774–1781. doi:10.1097/CCM.0b013e31828a25fd

31. venous saturation 30

32. Hemoglobin Physiology – Oxygen transport Hemoglobin O2O2 CO 2 LungTissue O2O2 Hemoglobin O2O2

33. Venous oximetry SvO2 CO SaO2 HbVO2 Venous saturation in balance between: cardiac output arterial saturation hemoglobin oxygen consumption

34. A low S cv O 2 in the perioperative setting is associated with a higher risk of postoperative complications

35. Review 34 van Beest, P., Wietasch, G., Scheeren, T., Spronk, P., & Kuiper, M. (2011). Clinical review: use of venous oxygen saturations as a goal - a yet unfinished puzzle. Critical care (London, England), 15(5), 232. doi:10.1186/cc10351

36. Limitations 35

37.  A low S cv O 2 indicates that something is wrong, but not what is wrong nor what needs to be done (fluids? inotropics?) But,  If O 2 ER is reduced - especially in high risk surgery patients - normal and high S cv O 2 does not guarantee that perfusion is adequate and that the patient has an ideal state of volume Problems with interpretation of S cv O 2

38. Hemoglobin Hämoglobin Pathophysiology of oxygen transport Hemoglobin Hämoglobin O2O2 CO 2 LungTissue O2O2 Hemoglobin O2O2

39. Hemodynamic monitoring 38

40. Outcome und Monitoring-Device Monitoring-DeviceNumber of studies PA – Catheter stroke volume13 Pulse contour stroke volume7 Doppler11 central venous saturation1 39 Grocott, M. P., et al. (2012). Cochrane database of systematic reviews, 11, CD004082.

41. 388 critically ill and hemodynamic instabil patients in 3 european ICUs Randomization: 1.minimal invasive CO Monitoring 2. no CO Monitoring Takala, J. et al.(2011) Crit Care. Jun 15;15(3):R148.

42. Therapeutic Interventions: Hemodynamic stabilization: Study group Control Takala, J. et al.(2011) Crit Care. Jun 15;15(3):R148.

43. Perioperative Optimization 85 patients with elective colectomy Fluid restriction group (n=43) 1500ml crystalloids intraoperative 500ml colloids (Gelofusine) according to heart rate, blood pressure, urine production Blood loss 1:1 substitution with colloids transfusion <10 g/dl respect. < 7g/dl GDFT group (n=42) 1500ml crystalloids colloids according to flow chart Blood loss 1:1 substitution with colloids transfusion <10 g/dl respect. < 7g/dl Srinivasa, S. et al. (2013) British Journal of Surgery; 100: 66–74

44. Perioperative Optimization No difference in outcome Srinivasa, S. et al. (2013) British Journal of Surgery; 100: 66–74

45. Most importantly, one must never forget that it is not the monitoring itself that can improve outcomes but the changes in therapy guided by the data obtained. Vincent, J-L. et al. (2011) Critical Care 15:229.

46. Goal directed hemodynamic monitoring AND therapy 45

47. 46

48. 47 Marik, P. et al. (2009). Critical Care Medicine, 37(9), 2642–2647. Functional hemodynamics - stroke volume, PPV, SVV and TOE vs. CVP - parametersArea under the curve (AUC)95% - CI pulse pressure variation0,940,93 – 0,95 stroke volume variation0,840,78 – 0,88 echocardiography (LVEDAI)0,640,53 – 0,74 CVP0,550,48 – 0,62 Stroke volume optimization and functional hemodynamic parameters are very suitable for individualized management of hemodynamic therapy. methods: metaanalyse of 29 studies, N=685 patients statistics: ROC analyses (AUC; 95% - CI; increase SVI, CI)

49. Individualized hemodynamic treatment strategies Individualized optimization of hemodynmaic reduces incidence of complications as well as length of hospital stay of patients undergoing surgery 48 Grocott, M. P., et al. (2012). Cochrane database of systematic reviews, 11, CD004082. Numnber of patients with complications n (total number of patients N) Protocol group (n/N) Control group (n/N) Risk Ratio95% - CIp valueI2I2 275 / 960350 / 8810,680,58 – 0,800,0000134% Reduction of postoperative hospital lenght of stay (total number of patients N) Protocol group (N) Control group (N) Mean difference (d) 95% - CIp valueI2I2 24032326-1,16-1,89 – -0,430,001987%

50. Conclusion  Hemodynmic monitoring – Alone does not change outcome  Individualized hemodynamic treatment strategies – Do have an impact on patient outcome – „One size does not fit all“ – Individualized approach for hemodynmamic management – Goals of treatment are not static parameters (MAP, CVP, S cv O 2 ) – Goals of treament are functional parameters, i.e. stroke volume optimization, pulse pressure variation and stroke volume variation  Perspective – International guidelines – Clinical implementation  patient safety  49