Otimização perioperatória: fluxo
ou pressão?
Bruno Tomazini
Sem conflitos de interesse
Shoemaker WC, Appel PL, Kram HB. Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery. Critical care medicine. 1993; 21(7):977-90.
Sobreviventes
•Maior PAm
•Maior IC
•Maior DO2
•Maior VO2
•Menor PAPm
•Menor PAPO
•Menor RVP
•Menor OER
Shoemaker WC, Appel PL, Kram HB. Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery. Critical care medicine. 1993; 21(7):977-90.
X
Pressão
Monk TG, Bronsert MR, Henderson WG, et al. Association between Intraoperative Hypotension and Hypertension and 30-day Postoperative Mortality in Noncardiac Surgery.
Anesthesiology. 2015; 123(2):307-19.
Sun LY, Wijeysundera DN, Tait GA, Beattie WS. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology. 2015; 123(3):
515-23.
Pressão
Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical
definition of hypotension. Anesthesiology. 2013; 119(3):507-15.
Definição?
Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical
definition of hypotension. Anesthesiology. 2013; 119(3):507-15.
Definição?
<65
<65
<65
<80
<70
<70
<60
<60
Futier E, Lefrant J, Guinot P, et al. Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients
Undergoing Major Surgery JAMA. 2017; 318(14):1346-.
Futier E, Lefrant J, Guinot P, et al. Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients
Undergoing Major Surgery JAMA. 2017; 318(14):1346-.
65-79mmHg
80-95mmHg
96-110mmHg
Wu X, Jiang Z, Ying J, Han Y, Chen Z. Optimal blood pressure decreases acute kidney injury after gastrointestinal surgery in elderly hypertensive patients: A randomized study
Journal of Clinical Anesthesia. 2017; 43:77-83.
Asfar P, Meziani F, Hamel J, et al. High versus Low Blood-Pressure Target in Patients with Septic Shock N Engl J Med. 2014; 370(17):1583-1593.
Fluxo (IC)
Shoemaker WC, Appel PL, Kram HB. Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery. Critical care medicine. 1993; 21(7):977-90.
DO2 IC
>4.5
IC
SV
Max SV
DO2 IC
DO2 IC
>2.5
>3.5
>4.5
DO2 IC
>2.5
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;
94(6):1176-86.
Boyd O. A Randomized Clinical Trial of the Effect of Deliberate Perioperative Increase of Oxygen Delivery on Mortality in High-Risk Surgical Patients JAMA. 1993; 270(22):2699-.
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Crit Care. 2005; 9(6):R687-.
Pearse RM, Harrison DA, MacDonald N, et al. Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal
Surgery JAMA. 2014; 311(21):2181-.
“but if you dig deep enough…”
Hamilton MA, Cecconi M, Rhodes A. A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients Anesthesia &
Analgesia. 2011; 112(6):1392-1402.
Pearse RM, Harrison DA, MacDonald N, et al. Effect of a Perioperative, Cardiac Output–Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery JAMA. 2014; 311(21):2181-.
Complicações
“Consistência”
• PAm 60-65mmHg
•
Individualizar
+/- 10% SBP basal ou
~80mmHg se HAS
• Otimizar pré carga
• Manter IC ótimo
•2.5k pts.
•Infecção PO 30d
•Outubro 2020
•7.6k pts.
•Mortalidade 90d
•Janeiro 2022
bmtomazini@gmail.com
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