Edwards Critical Care Education
Perioperative Goal-Directed Therapy Protocol Summary
Issue Date: March 2013
Evidence-based, Perioperative Goal-Directed Therapy (PGDT) protocols
Note: This protocol summary is designed to help inform clinicians
of key published protocols used to guide hemodynamic monitoring
in high-risk surgery. It is not intended to recommend a specific
protocol, but to guide hemodynamic optimization through
Perioperative Goal-Directed Therapy protocols that have
been shown to reduce the number of peri- and postoperative
complications, and improve patient outcomes.1-3 These
protocols represent individual strategies to help physicians either
titrate or tailor fluid therapy in an individual patient or clinical
situation. Since every case is different, physicians must weigh the
risks and benefits of initiating any specific protocol.
Please refer to Edwards Critical Care Education at Edwards.com/ccEducation for updates and additional information.
Issue Date: March 2013
Considering a protocol
The following algorithm is provided to help you select the most
appropriate Perioperative Goal-Directed Therapy (PGDT) protocol
for your patient. Your selection deserves careful consideration.
NO
NONO
YES
YES
Is my patient at risk* of developing post-op complications?
Consider PGDTConventional care
(eg BP, CVP, HR,urine output)
Any limitation† to the use of SVV?
Use an SV-based treatment protocol
(NHS, Cecconi)
Use an SVV-based treatment protocol
(Benes, Ping, Ramsingh)
*At risk because of comorbidities or the surgical procedure itself.† Limitations to the use of SVV: Spontaneous breathing, tidal volume <7 ml/kg, open chest, atrial fibrillation, right ventricular failure, and laproscopic surgery.
2 3
Abbreviations: BP: Blood Pressure; CVP: Central Venous Pressure; HR: Heart Rate; SV: Stroke Volume; SVV: Stroke Volume Variation.
OvErviEw
Randomized controlled trial
Undergoing elective abdominal surgery >2 h with expected blood loss >1000 ml
One or more of the following: Ischemic heart disease or severe heart dysfunction, moderate to severe chronic obstructive pulmonary disease, aged 70+, ASA III or more
Central Venous Pressure, Stroke Volume Variation, Cardiac Index
Fluid (Colloid), Dobutamine
Decrease in 30-day postoperative complications (56%), decrease in hospital length of stay (10%)
Benes Protocol1
NO
NO
NO
YES
YES
NONO
NONO
NONO
YES
YES
YES
SVV ≥10%and CVP <15 mm Hg
Colloid bolus 3 ml/kgover 5 minutes
CVP rise ≤3 mm Hg
SVV <10% andno change or decrease of Cl
Dobutamine infusion toreach Cl ≥2.5 l/min/m2
Cl <2.5 l/min/m2
Measure and record SVV, Cl
Repeat monitoring of SVV, Clduring next 5 minutes
NONO
YES
EnD PRoToCol
Study Design
Patient Population
Inclusion Criteria
Target Parameters
4 5
Intervention
Primary Outcomes
Abbreviations: CI: Cardiac Index; CVP: Central Venous Pressure; SVV: Stroke Volume Variation.
Randomized controlled trial
Undergoing elective total hip replacement under regional anesthesia
ASA II
Stroke Volume, Oxygen Delivery
Fluid (Colloid), Dobutamine
Decrease in postoperative complications (20%)
Cecconi Protocol2
OvErviEw
Study Design
Patient Population
Intervention
InclusionCriteria
6
Target Parameters
Primary Outcomes
Abbreviations: Do2I: Oxygen Delivery Index; Hb: Hemoglobin; HES: Hydroxyethyl Starch; HR: Heart Rate; MAP: Mean Arterial Pressure; Sao2: Oxygen Saturation; SV: Stroke Volume.
NO
YES
NONONO
NONO
NONO
YES
YES
YES
Check every 10 minutesIf DO2I falls below 600 ml/min*m2, restart algorithm
Achieve SV max and then target DO2I to 600 ml/min*m2
Keep:• SaO2 >95%• Hb >8 mg/dl
• HR <100 bpm• MAP between 60 and 100 mm Hg
250 ml HES bolus
See oxygen delivery
Dobutamine:Increase by 3 mcg/kg*minDecrease or STOP if HR >100 bpm or signs of cardiac ischemia
SV stable
>20 min
Increase of SV >10% or blood loss >250 ml
during fluid challenge
DO2I†
≥600 ml/min*m2
EnD PRoToCol
† Resuscitation to achieve a DO2I value of 600 is presented as a goal and not intended to be a hard target. This protocol is intended as guidance, and healthcare professionals should use sound clinical judgment and individualize therapy to each specific patient care situation.
Modified from Cecconi, et al. Crit Care. 2011;15:R132. Based upon Shoemaker3 protocol.
7
NO YES
YES
NONONO
NONO
YES
YES
Measure SV
200-250 ml fluid over 5-10 minutes
SV reduction >10%
Monitor SV for clinical signs of fluid loss
SV increase >10%?
NHS-NiCE/Kuper Protocol4-13
Study Design
Patient Population
Intervention
InclusionCriteria
Quality improvement program (before-after comparison)
Undergoing emergency and elective abdominal, orthopedic, gynecologic, urologic, and vascular surgery
Three cohorts of patients aged ≤60, 61-71, and ≥71 years with ASA >I
Stroke Volume
Fluid
3.7-day decrease in hospital length of stay (25%)
EnD PRoToCol
OvErviEw
8 9
Target Parameters
Primary Outcomes
Abbreviation: SV: Stroke Volume.
Randomized controlled trial
Undergoing radical gastrectomy, colon cancer resection, rectal cancer, and Whipple surgery
ASA I or ASA II
Stroke Volume Variation
Fluid
Faster recovery time to normal diet (16%), decrease in hospital length of stay (19%)
OvErviEw
Ping Protocol14
NONO
YES YES
Fluid to maintain the patient in the range
Maintain SVV11%-13%
BP drops >30%from baseline
Atropine .05 mg
HR <50 beats/min
Ephedrine 6 mg
EnD PRoToCol
Study Design
TargetParameters
Intervention
InclusionCriteria
10 11
Patient Population
Primary Outcomes
Abbreviations: BP: Blood Pressure; HR: Heart Rate; SVV: Stroke Volume Variation.
ramsingh Protocol15
NONO
YES
YES
GDT Group(ventilate 8 ml/kg)
>20 ml/kg Albumin?
250 ml Albumin bolus(may repeat to max of 20 ml/kg)
SVV >12% Monitor SVV and CO
SVV >12%
NONO
NONO
YESCrystalloid 3:1 replacement
(consider PRBCs, monitor ABGs)
EnD PRoToCol
Randomized, single-blinded controlled trial
Undergoing major abdominal surgery, urologic, gastrointestinal or gynecologic cancer resection, and Whipple surgery
P-POSSUM mean predicted mortality rate of 1.4*
Stroke Volume Variation
Fluid (Colloid)
Faster return of GI function (3 vs 4 days), faster return of PO intake (4 vs 5 days), and a 2.5-day decrease in hospital length of stay (33%)
OvErviEw
Study Design
TargetParameters
Intervention
InclusionCriteria
12 13
Patient Population
Primary Outcomes
Abbreviations: ABGs: Arterial Blood Gases; Co: Cardiac Output; P-PoSSUM: Portsmouth Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke Volume Variation.
* No differences other than age were statistically significant. P-POSSUM scores predicted mortality and showed no difference between the groups.
Donati Protocol16
Pre-op (T0):
Post-op (T2):
Intra-op (T1):
Fluid challenge• Colloids (when Hb >10 g/dl)• PBC (when Hb <10 g/dl)If O2ER† still >27%
CVP <10 cm H2Oor SVV > 12%
CVP >10 cm H2Oor SVV < 12%
CVP or SVV
O2ER† (hourly)
Group A Group B
Arterial and central venous lineCheck SaO2—ScvO2—calculate O2ER†
Similar management to intra-opChecks of O2ER† at the end of anesthesia, 0.5, 1, 2, and 6 hours, and day +1
Standard management(MAP, urine output, CVP)
≤27% >27%
No change(or decrease Dobutamine)
Dobutamine
EnD PRoToCol
Multicenter randomized controlled trial
Undergoing elective abdominal extensive surgery or abdominal aortic surgery
ASA II
Central Venous Pressure, Oxygen Extraction Ratio
Fluid (Colloid), Dobutamine
Decrease in postoperative complications (60%), decrease in hospital length of stay (16%)
OvErviEw
Study Design
TargetParameters
Intervention
InclusionCriteria
14 15
Patient Population
Primary Outcomes
Abbreviations: CVP: Central Venous Pressure; Hb: Hemoglobin; MAP: Mean Arterial Pressure; o2ER: Oxygen Extraction Ratio; Sao2: Oxygen Saturation; Scvo2: Central Venous Oxygen Saturation.
Modified Donati Protocol: Donati A, et al. Chest. 2007;132:1817-1824. †O2ER is estimated based on use of ScvO2.
References
1. Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14(3):R118.
2. Cecconi M, Fasano N, Langiano N, et al. Goal directed haemodynamic therapy during elective total hip arthrosplasty under regional anaesthesia. Crit Care. 2011;15(3):R132.
3. 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):1176-1186.
4. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hyperperfusion during cardiac surgery. Arch Surg. 1995;130(4):423-429.
5. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315(7113):909-912.
6. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88(1):65-71.
7. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97(4):820-826.
8. Conway D, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57(9):845-849.
9. McKendry M, McGloin H, Saberi D, Caudwell L, Brady A, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):258.
10. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler-guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95(5):634-642.
11. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93(9):1069-1076.
12. Chytra I, Pradl R, Bosman R, Pelnár P, Kasal E, Zidková A. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care. 2007;11(1):R24.
13. Kuper M, Gold SJ, Callow C, et al. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ. 2011;342:d3016.
14. Ping W, Hong-Wei W, Tai-Di Z. Effect of stroke volume variability- guided intraoperative fluid restriction on gastrointestinal functional recovery [published online ahead of print]. Hepatogastroenterology. 2012;59(120). doi:10.5754/hge12283.
15. Ramsingh DS, Sanghvi C, Gamboa J, Cannesson M, Applegate RL 2nd. Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial [published December 2012]. J Clin Monit Comput. doi: 10.1007/s10877-012-9422-5.
16. Donati A, Loggi S, Preiser JC, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132(6):1817-1824.
16 17
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