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Hemodynamic Optimization through Perioperative Goal-Directed Therapy
Why and How?Why and How?
Dr XHospital Y
• Paid consultant for Edwards Lifesciences• Affiliation• Other (as appropriate)
2
Disclosures
WHY?3
• Complications are not exceptions
4
Hemodynamic Optimization: Why?
5
Infection— Pneumonia— Urinary tract infection— Superficial wound infection— Deep wound infection— Organ-space wound infection— Systemic sepsis or septic shock
Gastro-intestinal— Nausea and vomiting— Ileus (paralytic or functional)— Acute bowel obstruction— Anastomotic leak— Gastro-intestinal hypertension— Hepatic dysfunction— Pancreatitis
Respiratory— Prolonged mechanical ventilation (>48h)— Unplanned intubation or reintubation— Respiratory failure or ARDS— Pleural effusion
Renal— Renal insufficiency (increase in creatinine levels or decrease in urine output)— Renal failure (requiring dialysis)
Cardiovascular— Deep venous thrombosis— Pulmonary embolism— Myocardial infraction— Hypotension— Arrhythmia— Cardiogenic pulmonary edema— Cardiogenic shock— Infarction of GI track— Distal ischemia— Cardiac arrest (exclusive of death)
Neuro— Stroke or cerebro-vascular accident— Coma— Altered mental status or cognitive dysfunction or
delirium
Hemato— Bleeding requiring transfusion— Anemia— Coagulopathy
Other— Vascular graft of flap failure— Wound dehiscence— Peripheral nerve injury— Pneumothorax
Most Common Post-Surgical Complications
http://www.patient.co.uk/doctor/common-postoperative-complications
6
• 84,730 inpatients• General or vascular surgery• NSQIP database (designed to record
post-surgical complications until day 30)
Variation in Hospital Mortality Associated with Inpatient Surgery.
Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, M.D., M.P.H.
N Engl J Med 2009
7
NSQIP Complications M = Major m = minor
Infection M— Pneumonia m— Urinary tract infection m— Superficial wound infection M— Deep wound infection M— Organ-space wound infection M— Systemic sepsis or septic shock
Gastro-intestinal— Nausea and vomiting— Ileus (paralytic or functional)— Acute bowel obstruction— Anastomotic leak— Gastro-intestinal hypertension— Hepatic dysfunction— Pancreatitis
Respiratory M— Prolonged mechanical ventilation (>48h) M— Unplanned intubation or reintubation
— Respiratory failure or ARDS— Pleural effusion
Renalm — Renal insufficiency (increase in creatinine levels
or decrease in urine output) M— Renal failure (requiring dialysis)
Cardiovascular m— Deep venous thrombosis M— Pulmonary embolism M— Myocardial infraction
— Hypotension— Arrhythmia— Cardiogenic pulmonary edema— Cardiogenic shock— Infarction of GI track— Distal ischemia— Cardiac arrest (exclusive of death)
Neuro M— Stroke or cerebro-vascular accident
— Coma— Altered mental status or cognitive dysfunction or delirium
Hemato M— Bleeding requiring transfusion
— Anemia— Coagulopathy
Other M— Vascular graft of flap failure M— Wound dehiscence
— Peripheral nerve injury— Pneumothorax
http://www.patient.co.uk/doctor/common-postoperative-complications
8
• Complication rate was 24.6-26.9%• Major complication rate was 16.2-18.2%
Variation in Hospital Mortality Associated with Inpatient Surgery.
Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, M.D., M.P.H.
N Engl J Med 2009
129,233 casesComplication rates depend on the surgical procedure
Surgery Morbidity rate %
Esophagectomy 55.1
Pelvic exenteration 45.0
Pancreatectomy 34.9
Colectomy 28.9
Gastrectomy 28.7
Liver resection 27
Prioritizing Quality Improvement in General Surgery.
Schilling et al. J Am Coll Surg. 2008; 207:698–704.
129,546 casesComplication rates depend on the patient
Risk factor Odd ratio
ASA 4/5 vs 1/2 1.9
ASA 3 vs 1/2 1.5
Dyspnea at rest vs. none 1.4
History of COPD 1.3
Dyspnea with minimal exertion vs. none
1.2
Successful Implementation of the Department of Veterans Affairs’ NSQIP in the Private
Sector: The Patient Safety in Surgery Study. Khuri et al. Ann Surg 2008
• Complications are not exceptions• Complications are costly
11
Hemodynamic Optimization: Why?
Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012
Extra cost $
$6358$12802
$42790
2250 Patients Undergoing General and Vascular Surgery
Synergistic Implications of Multiple Postoperative Outcomes.
Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D.
Am J Med Quality 2012
13
All Complications(6 Studies)
Acute Kidney Injury(4 Studies) Surgical Site Infections(7 Studies)Hosp Assoc Pneumonia (8 Studies)Urinary Tract Infection(5 Studies)Major GI Complications(4 Studies)
Minor GI Complications(3 Studies)
$42,790$4,278
$22,023$2,590
$27,969$2,425
$64,544$3,237
$12,828$767
$77,483$6,214
$8,296$5,412
Complications Have a Cost
Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012
14
All Complications(6 Studies)
Acute Kidney Injury(4 Studies) Surgical Site Infections(7 Studies)Hosp Assoc Pneumonia (8 Studies)Urinary Tract Infection(5 Studies)Major GI Complications(4 Studies)
Minor GI Complications(3 Studies)
$42,790$4,278
$22,023$2,590
$27,969$2,425
$64,544$3,237
$12,828$767
$77,483$6,214
$8,296$5,412
Wide range!
Complications Have a Cost
Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012
15
All Complications(6 Studies)
Acute Kidney Injury(4 Studies) Surgical Site Infections(7 Studies)Hosp Assoc Pneumonia (8 Studies)Urinary Tract Infection(5 Studies)Major GI Complications(4 Studies)
Minor GI Complications(3 Studies)
$42,790$4,278
$22,023$2,590
$27,969$2,425
$64,544$3,237
$12,828$767
$77,483$6,214
$8,296$5,412
Reliable?
Complications Have a Cost
Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012
16
More Reliable Approach
Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012
17
+ $18,000
2250 Patients Undergoing General and Vascular Surgery
Synergistic Implications of Multiple Postoperative Outcomes.
Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D.
Am J Med Quality 2012
Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012
• Complications are not exceptions• Complications are costly• Complications are responsible for
prolonged LOS and readmissions
18
Hemodynamic Optimization: Why?
Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012
19Number of Postoperative Events
Mar
gina
l Len
gth
of S
tay
Synergistic Implications of Multiple Postoperative Outcomes.
Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D.
Am J Med Quality 2012
12,767 colectomiesAverage excess LOS for adverse events = 9.8 days
Prioritizing Quality Improvement in General Surgery.
Schilling et al. J Am Coll Surg. 2008; 207:698–704.
21
Association Between Occurrence of a Postoperative Complication and Readmission.
Implications for Quality Improvement and Cost SavingsElise H. Lawson, M.D. MSHS, Bruce Lee Hall, M.D. Ph.D, MBA, Rachel Louie, MS,
Susan L. Ettner, Ph.D., David S. Zingmond, M.D., Ph.D, Lein Han, Ph.D, Michael Rapp, M.D., JD and Clifford Y. Ko, M.D. MS, MSHS
Ann Surg 2013
• Complications are not exceptions• Complications are costly• Complications are responsible for
prolonged LOS and readmissions• Complications affect long-term survival
22
Hemodynamic Optimization: Why?
Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications. Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D., Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program Ann Surg 2005
23
• 105,951 surgical patients (GI, vasc, hip)• 8 year follow-up
Determinants of Long-Term Survival After Major Surgery and the Adverse Effect
of Postoperative Complications.Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D.,Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program
Ann Surg 2005
24
• « The most important determinant of decreased postoperative survival was the occurrence, within 30 days postop, of any complication »
Determinants of Long-Term Survival After Major Surgery and the Adverse Effect
of Postoperative Complications.Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D.,Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program
Ann Surg 2005
25
• « The most important determinant of decreased postoperative survival was the occurrence, within 30 days postop, of any complication »
• « Independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69% »
Determinants of Long-Term Survival After Major Surgery and the Adverse Effect
of Postoperative Complications.Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D.,Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program
Ann Surg 2005
• Complications are not exceptions• Complications are costly• Complications are responsible for
prolonged LOS and readmissions• Complications affect long-term survival• Hemodynamic Optimization through
PGDT is a KEY to prevent post-surgical complications
26
Hemodynamic Optimization: Why?
Data on file.
27
• Patho-physiology
Hemodynamic Optimization through PGDT is KEY
Data on file.
28
• Low preload, low cardiac output, low blood pressure, low perfusion• Arrhythmia (hypovolemia)
• GI dysfunction (hypoperfusion)
• Postoperative ileus, PONV• Upper GI bleeding• Anastomotic leak
• Infectious complication (tissue hypoperfusion)
• Acute renal insufficiency or failure (decreased renal blood flow)2002; 89: 622-632.
Effects of Low Volume Fluid Administration
Data on file.
29
• Pulmonary edema, prolonged mechanical ventilation• GI dysfunction
• Abdominal compartment syndrome• Ileus• Anastomotic leak
• Hemodilution and coagulopathy002; 89: 622-632.
Effects of High Volume Fluid Administration
Data on file.
30
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290Editorial by M. C. Bellamy
Where Do We Want to Be?
31
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
32
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
HOW DO YOU KNOW?
33
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
CVP?
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
34
A Low CVP Does Not Mean Your Patient Needs Fluid
Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis
and a Plea for Some Common Sense.Paul E. Marik, M.D., FCCM, Rodrigo Cavallazzi, M.D.
Crit Care Med 2013; 41:1774-1781
REVIEW ARTICLES
35
A Low CVP Does Not Mean Your Patient Needs Fluid
Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis
and a Plea for Some Common Sense.Paul E. Marik, M.D., FCCM, Rodrigo Cavallazzi, M.D.
Crit Care Med 2013; 41:1774-1781
REVIEW ARTICLES
CONCLUSION: There are no data to support the widespread practice of using central venous pressure to guide the fluid therapy. This approach to fluid resuscitation should be abandoned.
36
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
Blood Pressure?
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
37
Can Changes in Arterial Pressure be Used to Detect Changes in Cardiac Output During Volume
Expansion in the Perioperative Period?Yannick Le Manach, M.D., Ph.D., Christoph K. Hofer, M.D., Ph.D.
Jean-Jacques Lehot, M.D., Ph.D., Benoit Vallet, M.D., Ph.D., Jean-Pierre Goarin, M.D.Benoit Tavernier, M.D., Ph.D., Maxime Cannesson, M.D., Ph.D.
Anesthesiology 2013
PERIOPERATIVE MEDICINE
Changes in Blood Pressure do not Reflect Changes in Blood Flow
38
PERIOPERATIVE MEDICINE
NO!
Can Changes in Arterial Pressure be Used to Detect Changes in Cardiac Output During Volume
Expansion in the Perioperative Period?Yannick Le Manach, M.D., Ph.D., Christoph K. Hofer, M.D., Ph.D.
Jean-Jacques Lehot, M.D., Ph.D., Benoit Vallet, M.D., Ph.D., Jean-Pierre Goarin, M.D.Benoit Tavernier, M.D., Ph.D., Maxime Cannesson, M.D., Ph.D.
Anesthesiology 2013
PERIOPERATIVE MEDICINE
Changes in Blood Pressure do not Reflect Changes in Blood Flow
39
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
HOW DO YOU KNOW?
Preload
Stroke Volume
Frank-Starling relationship between preload and stroke volume
Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290
Preload
Stroke Volume
TARGET ZONE
Frank-Starling relationship between preload and stroke volume
Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290
Preload
Stroke Volume
TARGET ZONEHYPO HYPER
Frank-Starling relationship between preload and stroke volume
Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290
Preload
Stroke Volume
∆P = fluid-induced increase in preload
∆SV >> 10% ∆SV > 10%
∆SV < 10%
HYPO HYPER
The Stroke Volume Optimization Strategy
Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290
Preload
Stroke Volume
SVV >> 10%
SVV > 10% SVV < 10%
The Stroke Volume Optimization Strategy
Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290
Preload
Stroke Volume
SVV >> 10%
SVV > 10% SVV < 10%
HYPO HYPER
The Stroke Volume Optimization Strategy
Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290
46
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
HOW DO YOU KNOW?
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
47
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
Flow parameters!
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
48
TARGET ZONE
Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study
SVV to preditct fluid responsiveness
SV/CO to assess the effects of fluid
Where Do We Want to Be?
Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)
Doi:10.1093/bja/ae1290
• Plug and play techniques• Non-operator dependent• Stroke Volume (SV) and Cardiac output (CO)• Stroke Volume Variation (SVV) = reliable
predictor of fluid responsiveness• Option for patients with an A-line =
Arterial Pressure –based Cardiac Output• Option for patients without an A-line =
Arterial Pulse Contour Analysis49
Monitoring Flow Parameters is Easywith Pulse Contour Methods
50
• Patho-physiology• Outcome studies
Hemodynamic Optimization through PGDT is KEY
Evidence-Based Medicine: Using a Hemodynamic Protocol with Specific Goals
(Perioperative Goal-Directed Therapy) Based on Flow Measurements is Useful
N.I.C.E. (NHS) Protocol - National institute for health and clinical excellence / national health system (NHS) Perioperative Goal-Directed Therapy protocol
• > 30 positive RCTs• Several meta-analyses• Several QIPs
52
Superiority of Hemodynamic Optimization Over Standard Fluid Management
53
Reduction in Average odd or risk ratio (confidence interval)
Author (reference)
Acute kidney injury 0.64 (0.50-0.83) 0.71 (0.57-0.90)0.67 (0.46-0.98)
Brienza (9)Grocott (13)
Corcoran (14)
Minor GI complications 0.29 (0.17-0.50) Giglio (10)
Minor GI complications 0.42 (0.27-0.65) Giglio (10)
Surgical site infection 0.58 (0.46-0.74)0.65 (0.50-0.84)
Dalfino (11)Grocott (13)
Urinary tract infection 0.44 (0.22-0.88) Dalfino (11)
Pneumonia 0.71 (0.55-0.92)0.74 (0.57-0.96)
Dalfino (11)Corcoran (14)
Respiratory failure 0.51 (0.28-0.93) Grocott (13)
Total morbidity rate 0.44 (0.35-0.55)0.68 (0.58-0.80)
Hamilton (12)Grocott (13)
Clinical Benefits of Hemodynamic Optimization Over Standard Fluid Management
54
Reduction in Average odd or risk ratio (confidence interval)
Author (reference)
Hospital length of stay 1.16 (0.43-1.89)1.95 (0.57-0.90)
Grocott (13)Corcoran (14)
Effects of Hemodynamic Optimization on HLOS
• Highly selected patients• Extra-resources• Hawthorne effect
Main RCTs Limitations
Hamilton2010; Dalfino2011; Giglio2009; Corcoran2012; Grocott2013; Brienza2009
RCTs Are Not Real Life
RCT QIP
58
Period 1 Period 2
Now Comparative Evaluation
Data collection 1From an e-database(mortality, ICU LOS, HLOS, morbidity)
Data collection 2From an e-database(mortality, ICU LOS, HLOS, morbidity)
ImplementationTreatment protocol
Before-After Comparison
Perioperative hemodynamic therapy: quality improvement programs should help to resolve our uncertainty Frederic Michard*1, Maxime Cannesson2 and Benoit Vallet3 Michard et al. Critical Care 2011, 15:445 http://ccforum.com/content/15/5/445
Quality Improvement ReportKuper et al.
BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016
Age Control (n=658) Intervention (n=649)≤60 196 (29.8) 237 (36.5)
61-70 175 (26.6) 167 (25.7)
≥71 287 (43.6) 245 (37.8)
Surgical specialty:
Colorectal 339 (51.5) 355 (54.7)
Gynecological 4 (0.6) 9 (1.4)
Orthopaedic 139 (21.1) 133 (20.5)
Kidney or pancreas transplant 48 (7.3) 33 (5.1)
Upper gastrointestinal 79 (12.0) 55 (8.5)
Urology 21 (3.2) 45 (6.9)
Vascular 28 (12.6) 19 (2.9)
Mean (SD) POSSUM score 34.3 (8.3) 34.0 (8.5)
ASA physical status grade: 83 (12.6) 108 (16.6)
1
2 299 (45.4) 313 (48.2)
3 247(37.5) 185 (28.5)
4 26 (4.0) 41 (6.3)
5 1 (0.2) 1 (0.2)
Mode of surgery:
Urgent or emergency 201(30.5) 177 (27.3)
Elective or scheduled 457 (69.5) 472 (72.7)Quality Improvement Report Kuper et al. BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016
Hemodynamic Optimization Protocol
N.I.C.E. (NHS) Protocol - National institute for health and clinical excellence / national health system (NHS) Perioperative Goal-Directed Therapy protocol
Control InterventionPatient group No Mean (SD) stay No Mean (SD) stay P valueTotal 658 18.7 (24.4) 649 15.1 (16.7) 0.002
Derby 201 10.9 (10.7) 201 8.4 (7.3) 0.007
Manchester 232 25.5 (34.8) 224 19.8 (23.2) 0.043
Whittington 255 15.7 (13.4) 224 13.4 (12.7) 0.108
Postoperative 658 17.2 (24.0) 649 13.6 (15.9) 0.001
HLOS Reduction
Quality Improvement Report Kuper et al. BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016
63
UC Irvine QI Program
Permission obtained from Dr. Cannesson to utilize this information.
64
Pre Implementation (n=128)
Post Implementation (n=116)
Full ERAS package application 8% 62%
Intraoperative fluid administration 10 ml/kg/h 7 ml/kg/h
Surgery duration 456 min 422 min
Estimated blood loss 550 ml 440 ml
LOS ICU 2.5 days 1.6 days
LOS hospital 12.2 days 9.5 days
Blood transfusion 45% 35%
PRBC per patient transfused 4.4 units 2.7 units
Initial Experience
UC Irvine QI Program
Permission obtained from Dr. Cannesson to utilize this information.
65
UC Irvine QI Program
Permission obtained from Dr. Cannesson to utilize this information.
66
• Patho-physiology• Outcome studies• Recommendations and guidelines
Hemodynamic Optimization through PGDT is KEY
67
Perioperative fluid management: ConsensusStatement from the enhanced recovery partnership
Perioperative Medicine 2012
CONSENSUS STATEMENT OPEN ACCESS
2012: Enhanced Recovery Partnership
The Enhanced Recovery Partnership recommends the use of intra-operative fluid management technologies to enhance treatment with the aim of avoiding both hypovolaemia and fluid excess. This should be decided on a case-by-case basis adheringto local guidelines in the context of NICE recommendations, national guidelines and the Innovation, Health and Wealth Review.
Individualized Goal-Directed Fluid Therapy
Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012
The use of intra-operative fluid management technologies are recommended from the ouset in the following types of cases:
• Major surgery with a 30 day mortality rate of > 1%.• Major surgery with an anticipated blood loss of greater
than 500 ml.• Major intra-abdominal surgery.• Intermediate surgery (30 day mortality > 0.5%) in high
risk patients (age > 80 years, history of LVF, MI, CVA or peropheral arterial disease).
• Unexpected blood loss and/or fluid loss requiring > 2 litres of fluid replacement.
The Enhanced Recovery Partnership recommends that all Anaesthetists caring for patients undergoing intermediate or major surgery should have cardiac
output measuring technologies immediately available and be trained to use them.
Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012
Bristish Consensus Guidelines on Intravenous Fluid Therapy for
Adult Surgical PatientsGIFTASUP
Jeremy Powell-Tuck (chair)1, Peter Goslin2, Dileep N. Lobo1,3 , Simon P. Allison1, Gordon L. Carlson3,4, Marcus Gore3 , Andrew J. Lewington5, Rupert M. Pearse6 , Monty G. Mythen6
On behalf of 1BAPEN Medical - a core group of BAPEN, 2 the Associaton for Clinical Biochemistry, 3the Association of Surgeons of Great Britain and Ireland,4the Society of Academic and Research Surgery, 5the Renal Association and 6 the Intensive Care Society.
71
GIFTASUP
In patients undergoing some forms of orthopaedic and abdominal surgery, intraoperative treatment with intravenous fluid to achive an optimal value of stroke volume should be used where possible as this may reduce postoperative complication
rates and duration of hospital stay.Orthopaedic surgery: Evidence level 1b 28, 33
Abdominal surgery: Evidence level 1a30-32,34,48-50
RECOMMENDATION 13
Intraoperative Fluid Management
Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERSA®)
Society RecommendationsU.O. Gustafsson • M. J. Scott • W. Schwenek • N. Demartines • D. Roulin •
N.Francis • C.E. McNaught • J. MacFie • A.S. Liberman • M. Soop •A. Hill • R. H. Kennedy • D.N. Lobo • K. Fearon • O. Ljungqvist
Word J Surg (2013) 37:259-284DOI 10.1007/s00268-012-1772-0
Item Recommendation Evidence level Recommendation grade
Perioperative fluid management
Patients should receive intraoperative fluids(colloids and crystalloids) guided by flow measurements to optimse cardiac output
Balanced crystalloids: High Flowmeasurement in open surgery: High
Strong
• Complications are not exceptions• Complications are costly• Complications are responsible for
prolonged LOS and readmissions• Complications affect long-term survival• Hemodynamic optimization through
Perioperative Goal-Directed Therapy decreases post-surgical complications and hospital LOS
73
You Know Why?
Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERSA®) Society Recommendations U.O. Gustafsson • M. J. Scott • W. Schwenek • N. Demartines • D. Roulin • N.Francis • C.E. McNaught • J. MacFie • A.S. Liberman • M. Soop • Hill • R. H. Kennedy • D.N. Lobo • K. Fearon • O. Ljungqvist Word J Surg (2013) 37:259-284 DOI 10.1007/s00268-012-1772-0
HOW?74
• Assess• Align• Apply• Measure
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Hemodynamic Optimization Program
• Select one or several surgical procedures where a benefit has been established and hence is also expected in your institution
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Assess
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Surgical procedure ICD9 codesEsophagectomy 42.40, 42.41, 42.42, 43.99
Gastrectomy 43.5, 43.6, 43.7, 43.81, 43.89, 43.99
Partial hepatectomy 50.22, 50.3
Pancreatectomy and pancreaticoduodenectomy
52.51-52.53, 52.59, 52.6, 52.7
Colectomy 45.71-45.76, 45.79, 45.81-45.83, 48.41, 48.69
Resection of rectum 48.50-48.52, 48.59, 48.61-48.65, 48.69
Total cystectomy 57.71, 57.79
Femur & hip fracture repair 79.15, 79.25, 79.35, 79.85
Hip replacement 81.51-81.53
Abdominal aortic aneurysm 38.44
Aorto-iliac and peripheral bypass 39.25, 39.29
Surgical procedures, with corresponding ICD codes, part of positiverandomized controlled trials demonstrating the value of perioperative
hemodynamic optimization.
• Select one or several surgical procedures where a benefit has been established and hence is also expected in your institution
• You can (but do not have to) restrict the implementation to a subgroup of patients who have a higher risk to develop complications (eg patients with specific co-morbidities or patients with ASA score > I or patients older than 65 yrs) 78
Assess
• Assess the current morbidity rate using a list of complications and/or assess the current hospital length of stay.
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Assess
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Infection— Pneumonia— Urinary tract infection— Superficial wound infection— Deep wound infection— Organ-space wound infection— Systemic sepsis or septic shock
Gastro-intestinal— Nausea and vomiting— Ileus (paralytic or functional)— Acute bowel obstruction— Anastomotic leak— Gastro-intestinal hypertension— Hepatic dysfunction— Pancreatitis
Respiratory— Prolonged mechanical ventilation (>48h)— Unplanned intubation or reintubation— Respiratory failure or ARDS— Pleural effusion
Renal— Renal insufficiency (increase in creatinine levels
or decrease in urine output)— Renal failure (requiring dialysis)
Cardiovascular— Deep venous thrombosis— Pulmonary embolism— Myocardial infraction— Hypotension— Arrhythmia— Cardiogenic pulmonary edema— Cardiogenic shock— Infarction of GI track— Distal ischemia— Cardiac arrest (exclusive of death)
Neuro— Stroke or cerebro-vascular accident— Coma— Altered mental status or cognitive dysfunction or
delirium
Hemato— Bleeding requiring transfusion— Anemia— Coagulopathy
Other— Vascular graft of flap failure— Wound dehiscence— Peripheral nerve injury— Pneumothorax
Most Common Post-Surgical Complications
http://www.patient.co.uk/doctor/common-postoperative-complications
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Morbidity Rate = 30%
No complicationn=140
1+complicationn=60
Colorectaln=200
• Predict the clinical benefits of our hemodynamic optimization program
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Assess
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Reduction in Average odd or risk ratio (confidence interval)
Author (reference)
Acute kidney injury 0.64 (0.50-0.83) 0.71 (0.57-0.90)0.67 (0.46-0.98)
Brienza (9)Grocott (13)
Corcoran (14)
Minor GI complications 0.29 (0.17-0.50) Giglio (10)
Minor GI complications 0.42 (0.27-0.65) Giglio (10)
Surgical site infection 0.58 (0.46-0.74)0.65 (0.50-0.84)
Dalfino (11)Grocott (13)
Urinary tract infection 0.44 (0.22-0.88) Dalfino (11)
Pneumonia 0.71 (0.55-0.92)0.74 (0.57-0.96)
Dalfino (11)Corcoran (14)
Respiratory failure 0.51 (0.28-0.93) Grocott (13)
Total morbidity rate 0.44 (0.35-0.55)0.68 (0.58-0.80)
Hamilton (12)Grocott (13)
Clinical Benefits of Hemodynamic Optimization Over Standard Fluid Management
1+complicationn=21-33
No complicationn=167-179
Colorectaln=200
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Last Year Next YearHemodynamic Optimization
Odd Ratio
Future Morbidity Rate 10.5-16.5% (Example)
No complicationn=140
1+complicationn=60
Colorectaln=200
• Predict the economic benefits of our hemodynamic optimization program
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Assess
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Cost $2.10M
No complicationn=140
Cost $1.92M
1+complicationn=60
Colorectaln=200
Total cost = $4.02M
Assess (Example)
Cost $2.10M
Cost/patient$15K
No complicationn=140
Cost $1.92M
Cost/patient$32K
1+complicationn=60
Colorectaln=200
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Total cost = $4.02M
Extra cost/patient w/ 1+compl.= $17K
Assess (Example)
Total cost$672-1056K
1+complicationn=21-33
Total cost$2.51-2.69M
No complicationn=167-179
Colorectaln=200
Cost $2.10M
Cost/patient$15K
No complicationn=140
Cost $1.92M
Cost/patient$32K
1+complicationn=60
Colorectaln=200
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Total cost = $4.02M
Extra cost/patient w/ 1+compl.= $17K
Last Year Next YearHemodynamic Optimization
Odd Ratio
Total cost = $3.36-3.57M
Savings/patient = $2,250-3,300
Total savings = $450-660K
Assess (Example)
• Build a team. Your core team should be lead by a champion and include at least one representative of the surgical team, of the anesthesia team, of the anesthesia assistant (AA) and/or certified registered nurse anesthetist (CRNA) team, as well as your quality officer.
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Align
• Choose a treatment protocol. One of your first tasks will be to select the most appropriate hemodynamic optimization protocol for the surgical population you have selected. Several protocols have been shown to be effective
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Align
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• Stroke Volume (SV) optimization with fluid
• Oxygen Delivery Index (iDO2) optimization with fluid and inotropes
• Pulse Pressure Variation (PPV) or Stroke Volume Variation (SVV) optimization with fluid
This summary describes the three main perioperative GDT strategies which have been successfully used in clinical studies or quality improvement programs to decrease
postoperative morbidity and length of stay:
Kuper2011, Cecconi 2011, and Ramsingh 2012
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Kuper2011, Cecconi 2011, and Ramsingh 2012
• Choose a product. Most hemodynamic optimization protocols are based on the monitoring of flow parameters and/or dynamic predictors of fluid responsiveness.
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Align
• Train. All anesthesiologists and AA/CRNA who will ensure hemodynamic optimization must be trained
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Apply
• Ensure optimal compliance. Compliance to guidelines and recommendations is often suboptimal. To ensure hemodynamic optimization protocols are followed properly several actions and tools are useful:
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Apply
• SOP. Defining hemodynamic optimization through Perioperative Goal-Directed Therapy as an official and new Standard Operating Procedure (SOP) for hemodynamic management in your department.
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Apply
• Surgical Safety Checklist. Adding a single item to the current “Sign In” section of the surgical safety checklist, such as “the patient’s eligibility for hemodynamic optimization has been considered”
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Apply
This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
Before induction of anaesthesia Before skin incision Before patient leaves operating room
Surgical Safety Checklist
Before induction of anaesthesia Before skin incision Before patient leaves operating room
Patient’s eligibility for hemodynamic optimization has been considered
Surgical Safety Checklist
• Compliance tools. Tools designed to quantify and track compliance to a specific hemodynamic optimization / PGDT protocol (SV optimization with fluid).
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Apply
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Example of Compliance Tool
• Electronic data recording. Downloading hemodynamic parameters.
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Apply
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Example of SVV e-Recording
Total cost$672-1056K
1+complicationn=21-33
Total cost$2.51-2.69M
No complicationn=167-179
Colorectaln=200
Cost $2.10M
Cost/patient$15K
No complicationn=140
Cost $1.92M
Cost/patient$32K
1+complicationn=60
Colorectaln=200
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Total cost = $4.02M
Extra cost/patient w/ 1+compl.= $17K
Last Year Next YearHemodynamic Optimization
Odd Ratio
Total cost = $3.36-3.57M
Savings/patient = $2,250-3,300
Total savings = $450-660K
Measure (Example)
• Assess• Align• Apply• Measure
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Hemodynamic Optimization Pro
• Retrieved from: http://www.patient.co.uk/doctor/common-postoperative-complications• Variation in Hospital Mortality Associated with Inpatient Surgery. Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B.
Dimick, M.D., M.P.H. N Engl J Med 2009• Prioritizing Quality Improvement in General Surgery. Schilling et al. J Am Coll Surg. 2008; 207:698–704.• Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail
Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012• Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications. Shukri F.
Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D., Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program Ann Surg 2005
• Association Between Occurrence of a Postoperative Complication and Readmission Implications for Quality Improvement and Cost Savings Elise H. Lawson, M.D. MSHS, Bruce Lee Hall, M.D. Ph.D, MBA, Rachel Louie, MS, Susan L. Ettner, Ph.D., David S. Zingmond, M.D., Ph.D, Lein Han, Ph.D, Michael Rapp, M.D., JD and Clifford Y. Ko, M.D. MS, MSHS Ann Surg 2013
• Can Changes in Arterial Pressure be Used to Detect Changes in Cardiac Output During Volume Expansion in the Perioperative Period? Yannick Le Manach, M.D., Ph.D., Christoph K. Hofer, M.D., Ph.D. Jean-Jacques Lehot, M.D., Ph.D., Benoit Vallet, M.D., Ph.D., Jean-Pierre Goarin, M.D. Benoit Tavernier, M.D., Ph.D., Maxime Cannesson, M.D., Ph.D. Anesthesiology 2013
• Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290 Editorial by M. C. Bellamy
• Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense. Paul E. Marik, M.D., FCCM, Rodrigo Cavallazzi, M.D. Crit Care Med 2013; 41:1774-1781
• N.I.C.E. (NHS) Protocol - National institute for health and clinical excellence / national health system (NHS) Perioperative Goal-Directed Therapy protocol
• Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012• Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERSA®) Society
Recommendations U.O. Gustafsson • M. J. Scott • W. Schwenek • N. Demartines • D. Roulin • N.Francis • C.E. McNaught • J. MacFie • A.S. Liberman • M. Soop • Hill • R. H. Kennedy • D.N. Lobo • K. Fearon • O. Ljungqvist Word J Surg (2013) 37:259-284 DOI 10.1007/s00268-012-1772-0
References
• Enhanced Recovery Pathways Optimize Health Outcomes and Resource Utilization: A Meta-Analysis of Randomized Controlled Trials in Colorectal Surgery. Michel Adamina M.D., PD, Henrik Kehlet, M.D. Ph.D., George A. Tomlinson, Anthony J. Senagore, M.D. MS, MBA, and Conor P. Delaney, M.D. MCh, Ph.D., Cleveland, OH; St Gallen, Switzerland; Copenhagen, Denmark; Toronto, Ontario, Canada; and Los Angeles, CA Surgery 2011
• Quality Improvement Report Kuper et al. BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016
• Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012
• Bristish Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients .Jeremy Powell-Tuck (chair)1, Peter Goslin2, Dileep N. Lobo1,3 , Simon P. Allison1, Gordon L. Carlson3,4, Marcus Gore3 , Andrew J. Lewington5, Rupert M. Pearse6 , Monty G. Mythen6 On behalf of 1BAPEN Medical - a core group of BAPEN, 2 the Associaton for Clinical Biochemistry, 3the Association of Surgeon Great Britain and Ireland,4the Society of Academic and Research Surgery, 5the Renal Association and 6 the Intensive Care Society.
References
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Thank you!
Hemodynamic Optimization through Perioperative Goal-Directed Therapy
Why and How?
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