Haemodynamic Optimisation

Riding the Wave

Dr Laurence WeinbergAnaesthetist, Department of Anaesthesia, Austin Hospital

Senior Fellow, Department of Surgery, University of Melbourne

Declarations• Edwards Lifesciences Fluid Advisory Board• Baxter National Fluid Advisory Board• Pancare Foundation Scientific Board

“We need to understand our own outcomes before we can

make a difference”George Bernard Shaw

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“Austin,You've Got a Problem”

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Haemodynamic truth

?

Diagnostic and Haemodynamic Monitoring tools

NOT Therapeutic Interventions

“No DEVICE can improve patient-centered outcomes UNLESS

it is coupled to a treatment that improves outcome”

Modified from M. Pinsky, J.L. Vincent

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Treatments save lives NOT

Monitors

BUT WE HAVE TO MAKE A DECISION

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• All patients ERAS; n= 65Hypothesis• ?SS-GDT + ERAS vs. ERAS alone

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ERAS only (n=50) SS-DGT + ERAS (n=15) P-value

ASA, Age, Comorbidities NS

Duration Sx (median) 6.5 hours 8.0 hours 0.001

Intra-operative IV fluids (median) 4250 ml 3000 ml NS

Fluid balance Day 1 (median) 1363 ml 1418 ml NS

Fluid balance Day 2 (median) 278 ml 353 ml NS

Fluid balance Day 3 (median) 100 ml 170 ml NS

Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS

Mann-Whitney test

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ERAS only (n=50) SS-DGT + ERAS (n=15) P-value

ASA, Age, Comorbidities NS

Duration Sx (median) 6.5 hours 8.0 hours 0.001

Intra-operative IV fluids (median) 4250 ml 3000 ml NS

Fluid balance Day 1 (median) 1363 ml 1418 ml NS

Fluid balance Day 2 (median) 278 ml 353 ml NS

Fluid balance Day 3 (median) 100 ml 170 ml NS

Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS

Mann-Whitney test

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ERAS only (n=50) SS-DGT + ERAS (n=15) P-value

ASA, Age, Comorbidities NS

Duration Sx (median) 6.5 hours 8.0 hours 0.001

Intra-operative IV fluids (median) 4250 ml 3000 ml NS

Fluid balance Day 1 (median) 1363 ml 1418 ml NS

Fluid balance Day 2 (median) 278 ml 353 ml NS

Fluid balance Day 3 (median) 100 ml 170 ml NS

Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS

Mann-Whitney test

Complications

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Complics No Complics0

1020304050607080

GDT + ERASERAS

P = 0.0295% CI: 1.3 to 16OR: 4.5

% of patients

How do we use the information from the

device?

Optimize outcomes“Goal Directed Therapy" setting a haemodynamic goal

and fitting the patient to the goal

Who is having a specific operation!!!

“Haemodynamic Optimisation" i.e. looking at the patient and fitting the goal to the patient

Purpose AHDM

• Assess circulatory performance• Determine if CO is consistent with keeping

tissue O2 demand

AND IF NOT……………….

Purpose AHDM

To determine what components of the haemodynamic profile need to adjusted

to re-establish consumption-demand balance

Pinsky & Payen. Functional haemodynamic monitoring, 2004; 1-4Pinsky & Payen, Crit Care 2005; 9: 566

Haemodynamic truth

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Restoration of MAP may not restore microcirculation

i.e. Pressure is NOT flow

Pressure ≠ Flow

Haemodynamic truth

There is no normal cardiac output

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• Adequate to meet the metabolic demands

• Inadequate to meet metabolic demands

AHDM: Proven OutcomesUsing a treatment protocol with haemodynamic monitoring (consistently) leads to improved clinical outcomes.

BUT WHAT PROTOCOL?

Two Goal Directed Protocol Philosophies

Give fluid, observe response, continue to give fluid and other therapies until target achieved

SV Max(Fluid First)

Haemodynamic Stability

(Observe First)Measure deterioration of clinical condition, titrate therapy using a variety of parameters

Variations:• Different “trigger” parameters: SVV, CO/CI,

DO2, SvO2 / ScvO2, CVP (declining)• Different philosophies on degree of treatment

Typical SV-Max ProtocolMonitor SV

SV increase > 10%

Monitor SV

250 ml fluid over 10 minutes

SV decrease > 10%Yes

BJA 2005; 5: 634-642

Is the patient haemodynamically stable?

Do Nothing Yes No

Is the patient preload-responsive?

Yes No Yes No

Volume bolusAdd Vasopressor

Volume bolus Add Vasopressor Add Inotrope

Yes No

Reassess the patient

Is the patient hypotensive and have reduced vasomotor tone?

Haemodynamic Stability Protocol

Haemodynamic Stability Protocol

Haemodynamic Stability Protocol

MAP

≥65 mmHg with NOR

And

<90 mmHg with nitrates

SVV

≤10 >10

CI<2.5 CI≥2.5

Dobu/Adr3

Or

nitrates

≤2 Fluidboluses1

SVV ≤ 10 SVV>10

Fluid2

ScvO2>70%

If not

Hgb>10

(Transusionof RBC)

Haemodynamic Stability Protocol

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Major surgery

Prolonged surgery

Preload dependent optimization

concept

Increased cardiac function

Normal cardiac function

Decreased cardiac function

Preload

Frank-Starling Curve Stroke Volume Cardiac Output Cardiac Index Mixed Venous % Lactate TOE

Stro

ke

Volu

me

How to measure flow

IS THE PUMP

WORKING?

Stro

ke V

olum

e

Increased cardiac function

Normal cardiac function

Decreased cardiac function

Preload

Frank-Starling Curve

IS THE TANK FULL??

Str

ok

e V

olu

me

Increased cardiac function

Normal cardiac function

Decreased cardiac function

Preload

Frank-Starling Curve

1. An indication of fluid responsiveness

AND

2. A method of verifying that fluid is beneficial to the patient’s status

BOTH DIMENSIONS

ARE NECESSARY

TO OPTIMIZE FLUID

STATUS

120 mmHg

40 mmHg

Arterial Pressure

PPmax

PPmin

PPmax - PPmin

(PPmax + PPmin) /2∆PP =

Am J Respir Crit Care Med 2000; 162:134-138

Threshold PPV > 13 %

PPV or SVV equals

Volume responsive

PPV or SVV equals

Give more fluid

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Effects of vasoconstrictors on the heart? Raises left afterload -> decreases SV/CO? Releases blood from peripheral to central veins ->

increase CVP and CO

SV

SVPreload

Preload dependent

Phenylephrine increases preload

and therefore increases CO

SV

SVPreload

Preload independent

Phenylephrine No increase in

stroke volume. No increase in CO,

increase in afterload

ConclusionA threshold PPV value of 16.4% allowed discrimination between phenylephrine-

induced increase in SV and phenylephrine-induced decrease in SV

(94% sensitivity; 100% specificity).

Stroke Volume Variation in Hepatic Resection: A Replacement for Standard Central Venous PressureAnn Surg Oncol. 2013 Oct 23.

Results: 40 patients: CVP of -1 to 1 correlated to a SVV of 18-21 (R2 = 0.85, p < 0.001)

Conclusion: SVV safely as an alternative to CVP monitoring equivalent outcomes.

Surgical & Anaesthesia Goals During Major Liver Resection

Mobilisation & Control of inflow and outflow Resection Phase

Surgical - Blood loss from major hepatic veins or IVC- Pringle manoeuvre (total inflow occlusion of PV & HA) = decrease of CO

by 20-30% = CVS compromise- Total hepatic vascular occlusion (tumours close to IVC): occlusion

supra & infrahepatic IVC & hepatic pedicle = up to 60% decrease in CO

Anaesthesia considerations to reduce portal pressures• Fluid restriction• Reverse trendelenberg • Venodilatation• Venesection• Autologous normovolaemic haemodilution• Diuretics • Low CVP• Monitoring of CO or SvO2 to optimise oxygen delivery

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SV Increases > 10%

Do nothing

MAP

Cardiac Index

Inodilator

Low Normal/High

<20% Baseline

VasoconstrictorB-Blocker /

antihypertensive/diuretic

High/Normal High/Normal

Cardiac Index

Inotrope

FLUID Challenge 250 mL

Within 20% baseline

> 20% baseline

Decrease /stop vasoconstrictorAdequate anaesthesia?Adequate analgesia?Adequate muscle relaxation?

Cardiac Index

Low

Inodilator/Vasodilator

Low

Yes

Assess volume responsiveness

Re-assess Volume Responsiveness

Optimal oxygen delivery?Heart rate optimized?Adequate oxygenation? Correct severe anaemia?Correct hypothermia?

Dissection & Liver Resection

- Fluid restriction- Reverse trendelenberg- Venodilatation to reduce hepatic pressure - Venesection & autologous haemodilution- Low PEEP- Low dose vasopressor

< 25% > 25%

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Surgical & Anaesthesia Goals During Major Liver Resection

Confirmation of haemostasis & closure

Anaesthesia considerations - restoration of circulating blood volume• Return of autologous blood• Normalise CVP/SVV• Avoid hypervolaemia• Monitoring of CO or SvO2 to

optimise oxygen delivery

Surgical- Argon Beam to hepatic veins - Coagulation & fibrin glues- Haemostasis/control of bleeding

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SV Increases > 10%

Do nothing

MAP

Cardiac Index

Inodilator

Low Normal/High

<20% Baseline

Vasoconstrictor

Optimal oxygen delivery?Heart rate optimized?Adequate oxygenation? Correct severe anaemia?Correct hypothermia?

B-Blocker / antihypertensive/di

uretic

High/Normal High/Normal

Cardiac Index

Inotrope

FLUID Challenge 250 mL

Within 20% baseline

> 20% baseline Decrease /stop vasoconstrictorAdequate anaesthesia?Adequate analgesia?Adequate muscle relaxation?

Cardiac Index

Low

Inodilator/Vasodilator

Low

> 20%< 20%

Yes

Major pancreatic surgery

Assess volume responsiveness

Re-assess Volume Responsiveness

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• All patients ERAS; n= 129Hypothesis• SS-GDT + ERAS vs. ERAS alone

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ERAS only (n=25) SS-GDT + ERAS (n=104) P-value

Resection volumes 375 g 450 g NS

Duration Sx (median) 4.3 hours 6.0 hours 0.0001

Intra-operative IV fluids (median) 3000 ml (1375-4000) 3000 ml (2000-3738) NS

Fluid balance Day 1 (median) 3000 ml (2200-4000) 3054 ml ( 2050-4133) NS

Length of stay (median) 6.6 days (IQR: 5.5-9) 7 days (IQR: 5.7-11) NS

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ERAS only (n=25) SS-DGT + ERAS (n=104) P-value

Resection volumes 450 g 375 g 0.24

Duration Sx (median) 4.3 hours 6.0 hours 0.0001

Intra-operative IV fluids (median) 3000 ml (1375-4000) 3000 ml (2000-3738) NS

Fluid balance Day 1 (median) 3000 ml (2200-4000) 3054 ml ( 2050-4133) NS

Length of stay (median) 7 days (IQR: 5.7-11) 6.6 days (IQR: 5.5-9) NS

Complications

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Complics No Complics0

1020304050607080

GDT + ERASERAS

P = 0.4795% CI: 0.2 to 1.7OR: 0.6

% of patients

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Stroke Volume Variation (%) - all patients

Time (standardised)

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“The proposed algorithm of DGT induced some patients the additional

application of inotropes”Safety needs to be

clarified?

• 22 RCT’s reporting CVS complications• 2129 patients• DGT: reduction in CVS complications• Subgroup analysis (supra-normal DO2 : most

benefit from GDT83

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“GDT better than liberal fluid therapy, but whether GDT is superior to a restrictive fluid

strategy remains uncertain”

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Concluding thoughts• Consensus: advanced haemodynamic monitoring is better than not

monitoring• AHDM: diagnostic and haemodynamic monitoring tools: NOT

therapeutic interventions• Consensus: goals are needed!• Approaching consensus that protocols (reproducible care practices)

are better than no protocols, but still some dissenting opinions.• Individualize treatment for certain operations

Thank you