Goal Directed Fluid Therapy
2012
R.W. McIntyre, MD
Tampa VA Hospital, Florida
May,2012
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Goal Directed Fluid Therapy 2012
R.W.McIntyre MD
Tampa VA Hospital
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Enhanced Recovery After Surgery
ERAS
• Decrease complications
• Early mobility
• Early GI (Gut) function
Early discharge: It takes guts
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Enhanced Recovery After Surgery
ERAS - Anesthesia
• Effective analgesia
• Decrease PONV
Goal Directed Fluid Therapy
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Perioperative Fluids
• What is our practice ?
• What do we know?
• Where are we going ?
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What are we talking about ?
Too long or too short?
Too high or to low ?
Too much or too little?
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Too high or too Low ?
SBP: 120
DBP: 80
HR: 72
CVP: 12
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Fluids – Too much or too little?
• Liberal
• Restrictive
“OPTIMAL”
Bellamy, British Journal of Anesthesia 2006; 97: 755-7
a
SVV 10
SVV 20
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Fluid optimization
RESTRICTION (Too little)
• Hypotension
• Decreased end- organ oxygen delivery
LIBERAL (Too Much)
• Multi - organ edema
GI/ GUT Complications
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Perioperative Fluids
• What is our practice ?
• What do we know?
• Where are we going ?
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Anesthesia Practice 2009
(ASA, 73; 7 – 11)
• Tradition: Rituals and customs
• Dogma: Arrogant declaration of opinion
• Myth: Widely held but false notion
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What are you going to do?
Cascade of decision-making in medical practice
Knowledge and experience
•
•
•
•
•
Suggestions
Recommendations
Guidelines
Policies
Mandates
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EVERYDAY GOALS
• BLOOD PRESSURE
• HEART RATE
• URINE
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Words
• Deficit
• Maintenance
• Third space
• Urine
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“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 )
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The Daily Double
• Hypotension (Negative – ino dilators)
• Flood
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Too much !
YOU ARE DROWNING MY PATIENT !
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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)
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Change in Fluid Management
Goal – directed vs Traditional
Important component of :
Enhanced Recovery After Surgery
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GOALS 2012
FLOW MANAGEMENT
OXYGEN DELIVERY (Flow and oxygen content)
CARDIAC OUTPUT
FLUID OPTIMIZATION (GDT)
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HOW ? NEW TECHNOLOGY
• GOALS: What is the purpose ?
• EVIDENCE: What is the evidence ?
• RETURN ON INVESTMENT ?
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History - Goals
• 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
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1988 - Shoemaker
• Supranormal values of survivors …as GOALS
DO2 600 mL/min/m2
(Chest 1988;94:1176-86)
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2001 – Rivers
Early GOAL - DIRECTED THERAPY……SEPSIS…
SvO2 > 70 %
Improved outcome
(N Engl J Med 2001;345:1368-77)
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2009 - Kehlet
“……….GOAL DIRECTED FLUID THERAPY ……
For optimization of fluid management
…………………..and OUTCOME
(Anesthesiology 2009;110:453-55)
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EVIDENCE – FLUIDS 2012
DATA BEAT OPINION
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2011 - Hamilton
“Pre-emptive … hemodynamic monitoring
and
therapy reduces mortality and morbidity”
(Anesth Analg 2011;112:1392-402)
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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)
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2011 - Miller
Why Poor Adoption of Hemodynamic Optimization ?
• Show us the data
• No immediate “tangible “ benefits
• Resistance to new technology (ROI)
Are We Practicing Substandard Care?
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(Anesth Analg 2011;112;1274-76)
Where are we ?
• Translational
• Using new technology to improve outcome
“Progress is precarious” (Paul Barash)
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FLUIDS – 2012 - OUT
OUT:
• Pulmonary Artery Catheter
• CVP/PAWP
• Urine chasing
• “Third space”
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Fluid Therapy – 2012 - IN
Goal Directed Fluid Therapy (GDT)
Non - invasive monitors
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GOAL DIRECECTED FLUID THERAPY
Stroke Volume Variation
(SVV)
Fluid Responsiveness
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New non-invasive CVS monitoring
• Esophageal Doppler
• Thoracic bio-reactance (Nicom)
• Pulse contour analysis ( Vigileo/ Flotrac)
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What do new monitors measure ?
1. Flow (C.O./C.I/S.V)
2. Stroke Volume Variation (SVV)
(Continuous but with limitations)
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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
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(Edwards)
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Fluid responsiveness
Treating fluid responsiveness can increase
cardiac performance and oxygen delivery
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SVV 10
SVV 20
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Non – invasive monitors – When?
Major surgery – Blood and Fluids
Organ protection
(Decrease RISKS OF COMPLICATIONS)
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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)
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Tampa VA - GDT
2009 - Introduction of GDT/SVV
Selection and implementation of non – invasive technology
Use
2010
2011
Nicom
Vigileo
200
165
250
190
Total
365
440 (+20%)
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Purpose - GDT
• To optimize fluid therapy
• Not too much or too little
To support intraoperative care
with evidence - based data
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2012 - RECOMMENDATIONS
• 1 – 2 ml/hr maintenance
• 250 mL boluses (colloid)
( Anesth Analg 2011;201;1274 – 76 )
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GOAL?
Improve care
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Early Recovery After Surgery - ERAS
• Intensive interdisciplinary preparation
• Complication reduction (Infection,tubes,
analgesia, PONV)
• Goal Directed Fluid Therapy (GDT)
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2012 - What do patients want ?
• On – time surgery
• Preoperative meeting with anesthesiologist
• PONV prevention
• Adequate pain control
• Immediate post-operative discussion with surgeon
GOOD OUTCOME
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Enhanced recovery after surgery What can WE do ?
• Infection control
• PONV prevention
• Analgesia
• Complication prevention
Optimize Fluids (GDT)
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Summary - GDT
Optimize and individualize fluid therapy via :
Goal Directed Fluid Therapy (GDT)
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Bellamy, British Journal of Anesthesia 2006; 97: 755-7
a
Length of Hospital Stay
Goal-directed intraoperative fluid
administration reduces length of hospital stay …
(Anesthesiology 2002;97:820 – 6)
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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%
GD-RL
123± 40%
Colon:
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)
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