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.

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 IntensivmedizinCampus Charité Mitte, Campus Virchow-Klinikum

Charité - Universitätsmedizin Berlin

Disclosure

Research grants or royalties for lectures:

Edwards Life Science Fresenius Medical The Medicines Company Pulsion Medical Systems

Educational objective

Goal-directed perioperative monitoring – Why?– Who?– What?

– How?

AGENDA Risks in the OR

Parameters– Blood pressure– Venous saturation– Dynamic parameters of circulation

Conclusion

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

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

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Percentage of older people increases Amount of older people over 65/80 years of entire population

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part in % over 65 years old over 80 years old

men

women

Demographic change- a challenge for the future -

8 Siewert, U. et al. (2010). Deutsches Ärzteblatt international, 107(18), 328–334.

2005 2020

Mecklenburg-Vorpommern Number of cases Number of cases Change

Prevalence

- Hypertension 618,855 650,858 + 5.2 % (+32,003)

- Diabetes 117,919 141,125 + 19.7 % (+23,206)

- Myocardial infarction 40,976 51,549 + 25.8 % (+10,573)

- Stroke 31,322 79,053 + 16.3 % (+5,100)

Incidence

- Colon carcinoma 728 936 + 28.6 % (+208)

- Cancer (all) 8,612 10,388 + 20.6 % (+1,776)

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)

9 Pearse, R. et al. (2012). Lancet, 380(9847), 1059–1065.

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!”

Patient safety- risk reduction strategy -

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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

individualgoal-directed therapy

Sander, M. (2013) Perioperatives Risiko. DIVI Jahrbuch 2012/2013ISBN: 978-3-941468-84-9

Patient safety- risk reduction strategy -

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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

individualgoal-directed therapy

hemodynamic management

Sander, M. (2013) Perioperatives Risiko. DIVI Jahrbuch 2012/2013ISBN: 978-3-941468-84-9

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.

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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<0,01complications 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)

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Fluid management and morbidity

morbidity

hypovolaemia normovolaemia hypervolaemia

Holte, K. et al. (2007). British Journal of Anaesthesia, 99(4), 500–508.

Fluid intraop:1640 ml (935–2250), p<0,01Complications 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)

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Fluid management and morbidity

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 conditionTyp of intervention

Preop loss of bloodPreop preload

Epidural anaesthesia...

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Classics

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Supranormal DO2

18 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

Adequate oxygen suply

consumption

supply

Does DO2 increases VO2 ?

20 Shibutani K. Crit Care Med 1983

Yes !No !

Does DO2 increases VO2 ?

21Sharma, 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

Oxygen supply: DO2 simplified fomula =

DO2 = CO X (Hgb X 1.34 X Sa02) X 10

Oxygen Delivery: What are the components?

Oxygen DeliveryDO2

Cardiac Output

Heart rate

Stroke volume

CaO2

PaO2 SaO2 HctSynchrony

Preload Afterload Contractility

CVPPCWP

PVRSVR

Ejectionfraction

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

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 beimproved?” 86.5 % of ASA respondents and 98.1 % of ESA respondents (p < 0.001) answered Yes.

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

Parameters for individualized hemodynamic therapy ?

27 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

arteria

l pressu

re

centra

l venous

pressure

centra

l venous

satu

ration

stroke

volume

pulse pre

ssure

varia

tion

echoca

rdiogra

phy

PressureArterial pressure and central venous pressure for rmanagement of circulation therapy

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29Marik, 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

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)

30Marik, 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

venous saturation

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HemoglobinHemoglobin

Physiology – Oxygen transport

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

O2

CO2CO2

Lung Tissue

O2

HemoglobinHemoglobin

O2

Venous oximetry Venöse Sättigungen zeigen die Balance zwischen:

– Herzzeitvolumen

– Arterielle Sättigung

– Hämoglobingehalt

– Sauerstoffverbrauch

SvO2

Venous saturation in balance between:

cardiac output

arterial saturation

hemoglobin

oxygen consumption

A low ScvO2 in the perioperative setting is associated with a higher risk of postoperative complications

Review

35van 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

Limitations

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A low ScvO2 indicates that something is wrong, but not what is

wrong nor what needs to be done (fluids? inotropics?)

But,

If O2ER is reduced - especially in high risk surgery patients -

normal and high ScvO2 does not guarantee that perfusion is

adequate and that the patient has an ideal state of volume

Problems with interpretation of ScvO2

Hemoglobin

Hämoglobin

Pathophysiology of oxygen transport

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hemoglobin

Hämoglobin

O2

CO2CO2

Lung Tissue

O2

Hemoglobin

O2

Hemodynamic monitoring

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Outcome und Monitoring-Device

Monitoring-Device Number of studies

PA – Catheter stroke volume 13

Pulse contour stroke volume 7

Doppler 11

central venous saturation 1

40 Grocott, M. P., et al. (2012). Cochrane database of systematic reviews, 11, CD004082.

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.

Therapeutic Interventions:

Hemodynamic stabilization:

Study group

Control

Takala, J. et al.(2011) Crit Care. Jun 15;15(3):R148.

Perioperative Optimization85 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

Perioperative Optimization

No difference in outcome

Srinivasa, S. et al. (2013) British Journal of Surgery; 100: 66–74

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.

Goal directed hemodynamic monitoring AND therapy

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48Marik, P. et al. (2009). Critical Care Medicine, 37(9), 2642–2647.

Functional hemodynamics- stroke volume, PPV, SVV and TOE vs. CVP -

parameters Area under the curve (AUC) 95% - CI

pulse pressure variation 0,94 0,93 – 0,95

stroke volume variation 0,84 0,78 – 0,88

echocardiography (LVEDAI) 0,64 0,53 – 0,74

CVP 0,55 0,48 – 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 patientsstatistics: ROC analyses (AUC; 95% - CI; increase SVI, CI)

Individualized hemodynamic treatment strategiesIndividualized optimization of hemodynmaic reduces incidence of complications as well as length of hospital stay of patients undergoing surgery

49 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 Ratio 95% - CI p value I2

275 / 960 350 / 881 0,68 0,58 – 0,80 0,00001 34%

Reduction of postoperative hospital lenght of stay (total number of patients N)

Protocol group(N)

Control group(N)

Mean difference(d)

95% - CI p value I2

2403 2326 -1,16 -1,89 – -0,43 0,0019 87%

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, ScvO2) – 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

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