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Goal Directed Fluid Therapy 2012

Goal Directed Fluid Therapy 2012

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Goal Directed Fluid Therapy 2012

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  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 SurgeryERAS • Decrease complications • Early mobility • Early GI (Gut) function Early discharge: It takes guts

  4. Enhanced Recovery After SurgeryERAS - 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 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 • Suggestions • Recommendations • Guidelines • Policies • Mandates Knowledgeand experience

  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 ClinAnaesth 2006;20(3):439)

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

  22. GOALS 2012FLOW MANAGEMENT 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 • 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 • Supranormal values of survivors …as GOALS DO2 600 mL/min/m2 (Chest 1988;94:1176-86)

  26. 2001 – Rivers Early GOAL - DIRECTED THERAPY……SEPSIS… SvO2 > 70 % Improved outcome (N Engl J Med 2001;345:1368-77)

  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” (AnesthAnalg 2011;112:1392-402)

  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 Why Poor Adoption of Hemodynamic Optimization ? • Show us the data • No immediate “tangible “ benefits • Resistance to new technology (ROI) Are We Practicing Substandard Care? (AnesthAnalg 2011;112;1274-76)

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

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

  37. Fluid Therapy – 2012 - 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 2010 2011 Nicom 200 250 Vigileo 165 190 Total 365 440 (+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) ( AnesthAnalg 2011;201;1274 – 76 )

  50. GOAL? Improve care