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The influence of PEEP and positioning on central venous pressure and venous hepatic hemodynamics in patients undergoing liver resection. J Clin Monit Comput 2016; 31:1221-1228. [DOI: 10.1007/s10877-016-9970-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022]
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102
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Johnson A, Ahrens T. Stroke volume optimization: the new hemodynamic algorithm. Crit Care Nurse 2016; 35:11-27. [PMID: 25639574 DOI: 10.4037/ccn2015427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Critical care practices have evolved to rely more on physical assessments for monitoring cardiac output and evaluating fluid volume status because these assessments are less invasive and more convenient to use than is a pulmonary artery catheter. Despite this trend, level of consciousness, central venous pressure, urine output, heart rate, and blood pressure remain assessments that are slow to be changed, potentially misleading, and often manifested as late indications of decreased cardiac output. The hemodynamic optimization strategy called stroke volume optimization might provide a proactive guide for clinicians to optimize a patient's status before late indications of a worsening condition occur. The evidence supporting use of the stroke volume optimization algorithm to treat hypovolemia is increasing. Many of the cardiac output monitor technologies today measure stroke volume, as well as the parameters that comprise stroke volume: preload, afterload, and contractility.
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Affiliation(s)
- Alexander Johnson
- Alexander Johnson is a clinical nurse specialist, Central DuPage Hospital, Cadence Health System-Northwestern Medicine, Winfield, Illinois.Thomas Ahrens is a research scientist, Barnes-Jewish Hospital, St Louis, Missouri.
| | - Thomas Ahrens
- Alexander Johnson is a clinical nurse specialist, Central DuPage Hospital, Cadence Health System-Northwestern Medicine, Winfield, Illinois.Thomas Ahrens is a research scientist, Barnes-Jewish Hospital, St Louis, Missouri
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103
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Meng L, Heerdt P. Perioperative goal-directed haemodynamic therapy based on flow parameters: a concept in evolution. Br J Anaesth 2016; 117:iii3-iii17. [DOI: 10.1093/bja/aew363] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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104
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Som A, Maitra S, Bhattacharjee S, Baidya DK. Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials. J Anesth 2016; 31:66-81. [PMID: 27738801 DOI: 10.1007/s00540-016-2261-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/30/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Optimum perioperative fluid administration may improve postoperative outcome after major surgery. This meta-analysis and systematic review has been aimed to determine the effect of dynamic goal directed fluid therapy (GDFT) on postoperative morbidity and mortality in non-cardiac surgical patients. MATERIAL AND METHODS Meta-analysis of published prospective randomized controlled trials where GDFT based on non-invasive flow based hemodynamic measurement has been compared with a standard care. Data from 41 prospective randomized trials have been included in this study. RESULTS Use of GDFT in major surgical patients does not decrease postoperative hospital/30-day mortality (OR 0.70, 95 % CI 0.46-1.08, p = 0.11) length of post-operative hospital stay (SMD -0.14; 95 % CI -0.28, 0.00; p = 0.05) and length of ICU stay (SMD -0.12; 95 % CI -0.28, 0.04; p = 0.14). However, number of patients having at least one postoperative complication is significantly lower with use of GDFT (OR 0.57; 95 % CI 0.43, 0.75; p < 0.0001). Abdominal complications (p = 0.008), wound infection (p = 0.002) and postoperative hypotension (p = 0.04) are also decreased with used of GDFT as opposed to a standard care. Though patients who received GDFT were infused more colloid (p < 0.0001), there is no increased risk of heart failure or pulmonary edema and renal failure. CONCLUSION GDFT in major non- cardiac surgical patients has questionable benefit over a standard care in terms of postoperative mortality, length of hospital stay and length of ICU stay. However, incidence of all complications including wound infection, abdominal complications and postoperative hypotension is reduced.
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Affiliation(s)
- Anirban Som
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Sulagna Bhattacharjee
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
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105
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Grensemann J, Defosse JM, Wieland C, Wild UW, Wappler F, Sakka SG. Comparison of PulsioFlex® uncalibrated pulse contour method and a modified Fick principle with transpulmonary thermodilution measurements in critically ill patients. Anaesth Intensive Care 2016; 44:484-90. [PMID: 27456179 DOI: 10.1177/0310057x1604400407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Monitoring of cardiac index (CI) by uncalibrated pulse contour (PC) methods has been shown to be inaccurate in critically ill patients. We tested accuracy and trending of a new pulse contour method and a modified Fick method using central venous oxygen saturation. We studied 21 critically ill and mechanically ventilated patients (age 20-86 years) monitored by PC (PulsioFlex®) and transpulmonary thermodilution (TPTD, PiCCO2®) as reference. At baseline, reference and PC-derived CI (CIPC) were recorded and CI obtained by Fick's method (FM, CIFICK). After four hours, measurements were performed analogously for trending analysis. CI are given in l/min/m2 as mean±standard deviation. At baseline CITPTD was 3.7±0.7, CIPC 3.8±0.7 and CIFICK 5.2±1.8. After 4 hours, CITPTD was 3.5±0.6, CIPC 3.8±1.2 and CIFICK 4.8±1.7. Mean bias for PC at baseline was -0.1 (limits of agreement [LOA] -1.4 to 1.2) and -0.4 (LOA -2.6 to 1.9) after four hours. Percentage errors (PE) were 34% and 60% respectively. FM revealed a bias of -1.5 (LOA -4.8 to 1.8, PE 74%) at baseline and -1.5 (LOA -4.5 to 1.4, PE 68%) at four hours. With an exclusion window of 10% of mean cardiac index, trending analysis by polar plots showed an angular bias of 5° (radial LOA±57°) for PC and 16° (radial LOA±51°) for FM. Although PC values at baseline were marginally acceptable, both methods fail to yield clinically acceptable absolute values. Likewise, trending ability is not adequate for both methods to be used in critically ill patients.
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Affiliation(s)
- J Grensemann
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Köln; Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J M Defosse
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Köln, Germany
| | - C Wieland
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Köln, Germany
| | - U W Wild
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Köln, Germany
| | - F Wappler
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Köln, Germany
| | - S G Sakka
- Professor and Head of the Operative Intensive Care Unit, Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Köln, Germany
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106
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Tusman G, Groisman I, Maidana GA, Scandurra A, Arca JM, Bohm SH, Suarez-Sipmann F. The Sensitivity and Specificity of Pulmonary Carbon Dioxide Elimination for Noninvasive Assessment of Fluid Responsiveness. Anesth Analg 2016; 122:1404-11. [PMID: 26505574 DOI: 10.1213/ane.0000000000001047] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND We sought to determine whether the response of pulmonary elimination of CO2 (VCO2) to a sudden increase in positive end-expiratory pressure (PEEP) could predict fluid responsiveness and serve as a noninvasive surrogate for cardiac index (CI). METHODS Fifty-two patients undergoing cardiovascular surgery were included in this study. By using a constant-flow ventilation mode, we performed a PEEP challenge of 1-minute increase in PEEP from 5 to 10 cm H2O. At PEEP of 5 cm H2O, patients were preloaded with 500 mL IV saline solution after which a second PEEP challenge was performed. Patients in whom fluid administration increased CI by ≥15% from the individual baseline value were defined as volume responders. Beat-by-beat CI was derived from arterial pulse contour analysis, and breath-by-breath VCO2 data were collected during the protocol. The sensitivity and specificity of VCO2 for detecting the fluid responders according to CI was performed by the receiver operating characteristic curves. RESULTS Twenty-one of 52 patients were identified as fluid responders (40%). The PEEP maneuver before fluid administration decreased CI from 2.65 ± 0.34 to 2.21 ± 0.32 L/min/m (P = 0.0011) and VCO2 from 150 ± 23 to 123 ± 23 mL/min (P = 0.0036) in responders, whereas the changes in CI and VCO2 were not significant in nonresponders. The PEEP challenge after fluid administration induced no significant changes in CI and VCO2, in neither responders nor nonresponders. PEEP-induced decreases in CI and VCO2 before fluid administration were well correlated (r = 0.75, P < 0.0001) but not thereafter. The area under the receiver operating characteristic curves for a PEEP-induced decrease in ΔCI and ΔVCO2 was 0.99, with a 95% confidence interval from 0.96 to 0.99 for ΔCI and from 0.97 to 0.99 for ΔVCO2. During the PEEP challenge, a decrease in VCO2 by 11% predicted fluid responsiveness with a sensitivity of 0.90 (95% confidence interval, 0.87-0.93) and a specificity of 0.95 (95% confidence interval, 0.92-0.98). CONCLUSIONS PEEP-induced changes in VCO2 predicted fluid responsiveness with accuracy in patients undergoing cardiac surgery.
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Affiliation(s)
- Gerardo Tusman
- From the *Department of Anesthesia, Hospital Privado de Comunidad, Mar del Plata, Buenos Aires, Argentina; †Electronic Department, Bioengineering Laboratory, School of Engineering, Mar del Plata University, Mar del Plata, Argentina; ‡Swisstom AG, Landquart, Switzerland; §Department of Surgical Sciences Section of Anesthesiology and Critical Care, Hedenstierna Laboratory, University Hospital, Uppsala Sweden; and ‖CIBERES, CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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107
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Ripollés J, Espinosa A, Martínez‐Hurtado E, Abad‐Gurumeta A, Casans‐Francés R, Fernández‐Pérez C, López‐Timoneda F, Calvo‐Vecino JM. Terapia hemodinâmica alvo‐dirigida no intraoperatório de cirurgia não cardíaca: revisão sistemática e meta‐análise. Rev Bras Anestesiol 2016; 66:513-28. [DOI: 10.1016/j.bjan.2015.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/18/2015] [Indexed: 11/28/2022] Open
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108
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Ripollés J, Espinosa A, Martínez-Hurtado E, Abad-Gurumeta A, Casans-Francés R, Fernández-Pérez C, López-Timoneda F, Calvo-Vecino JM. Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis. Braz J Anesthesiol 2016; 66:513-28. [DOI: 10.1016/j.bjane.2015.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/18/2015] [Indexed: 02/07/2023] Open
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109
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Navarro LHC, Kramer GC. Goal directed hemodynamic therapy: The time to implement is now. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:373-375. [PMID: 27233472 DOI: 10.1016/j.redar.2016.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 03/16/2016] [Accepted: 03/17/2016] [Indexed: 06/05/2023]
Affiliation(s)
- L H C Navarro
- Anesthesiology Department, Botucatu Medical School - UNESP, Botucatu, Sao Paulo, Brazil.
| | - G C Kramer
- Resuscitation Research Laboratory, Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA
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110
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Saugel B, Wagner JY, Scheeren TWL. Cardiac output monitoring: less invasiveness, less accuracy? J Clin Monit Comput 2016; 30:753-755. [DOI: 10.1007/s10877-016-9900-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 06/13/2016] [Indexed: 02/07/2023]
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111
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Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials. Ann Surg 2016; 263:465-76. [PMID: 26445470 PMCID: PMC4741406 DOI: 10.1097/sla.0000000000001366] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives: To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols. Methods: Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality. Results: A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66–0.89, P = 0.0007), hospital length of stay (LOS; mean difference −1.55 days, 95% CI −2.73 to −0.36, P = 0.01), intensive care LOS (mean difference −0.63 days, 95% CI −1.18 to −0.09, P = 0.02), and time to passage of feces (mean difference −0.90 days, 95% CI −1.48 to −0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference −0.63 days, 95% CI −0.94 to −0.32, P < 0.0001) and time to passage of feces (mean difference −1.09 days, 95% CI −2.03 to −0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to −0.84, P = 0.0002) and total hospital LOS (mean difference −2.14, 95% CI −4.15 to −0.13, P = 0.04). Conclusions: GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting.
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112
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Romagnoli S, Zagli G, Tuccinardi G, Tofani L, Chelazzi C, Villa G, Cianchi F, Coratti A, De Gaudio AR, Ricci Z. Postoperative acute kidney injury in high-risk patients undergoing major abdominal surgery. J Crit Care 2016; 35:120-5. [PMID: 27481746 DOI: 10.1016/j.jcrc.2016.05.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/11/2016] [Accepted: 05/12/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE Acute kidney injury (AKI) is a frequent complication in high-risk patients undergoing major surgery and is associated with longer hospital stay, increased risk for nosocomial infection and significantly higher costs. MATERIALS AND METHODS A prospective observational study exploring the incidence of AKI (AKIN classification at any stage) in high-risk patients within 48 hours after major abdominal surgery was conducted. Patients' preoperative characteristics, intraoperative management, and outcome were evaluated for associations with AKI using a logistic regression model. RESULTS Data from 258 patients were analyzed. Thirty-one patients (12%) developed AKI, reaching the AKIN stage 1. No patient reached an AKIN stage higher than 1. AKI patients were older (75.2 vs 70.2 years; P = 0.0113) and had a higher body mass index (26.5 vs 25.1 kg/m(2)). In addition, AKI patients had a significantly longer ICU length of stay (3.4 vs 2.4 days; P= .0017). Creatinine levels of AKI patients increased significantly compared to the preoperative levels at 24 (P= .0486), 48 (P= .0011) and 72 hours (P= .0055), while after 72 hours it showed a downwards trend. At ICU discharge, 28 out of 31 patients (90.3%) recovered preoperative levels. Multivariate analysis identified age (OR 1.088; P= .002) and BMI (OR 1.124; P= .022) as risk factors for AKI development. Moreover, AKI development was an independent risk factor for ICU stays longer than 48 hours (OR 2.561; P= .019). CONCLUSIONS Mild AKI is a not rare complication in high-risk patients undergoing major abdominal surgery. Although in almost the totality of cases, the indicators of renal function recovered to preoperative levels, post-operative AKI represents a primary risk factor for a prolonged ICU stay.
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Affiliation(s)
- Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy; Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Zagli
- Department of Health Science, University of Florence, Florence, Italy; Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Germana Tuccinardi
- Department of Health Science, University of Florence, Florence, Italy; Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy; Clinical Trials Coordinating Center, Istituto Toscano Tumori, Florence, Italy
| | - Cosimo Chelazzi
- Department of Health Science, University of Florence, Florence, Italy; Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gianluca Villa
- Department of Health Science, University of Florence, Florence, Italy; Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Fabio Cianchi
- Unit of General and Endocrine Surgery, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - Angelo Raffaele De Gaudio
- Department of Health Science, University of Florence, Florence, Italy; Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Zaccaria Ricci
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Renner J, Grünewald M, Bein B. Monitoring high-risk patients: minimally invasive and non-invasive possibilities. Best Pract Res Clin Anaesthesiol 2016; 30:201-16. [PMID: 27396807 DOI: 10.1016/j.bpa.2016.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/21/2016] [Accepted: 04/27/2016] [Indexed: 12/19/2022]
Abstract
Over the past decades, there has been considerable progress in the field of less invasive haemodynamic monitoring technologies. Substantial evidence has accumulated, which supports the continuous measurement and optimization of flow-based variables such as stroke volume, that is, cardiac output, in order to prevent occult hypoperfusion and consequently to improve patients' outcome in the perioperative setting. However, there is a striking gap between the developments in haemodynamic monitoring and the increasing evidence to implement defined treatment protocols based on the measured variables, and daily clinical routine. Recent trials have shown that perioperative morbidity and mortality is higher than anticipated. This emphasizes the need for the anaesthesia community to address this issue and promotes the implementation of proven concepts into clinical practice in order to improve patients' outcome, especially in high-risk patients. The advances in minimally invasive and non-invasive monitoring techniques can be seen as a driving force in this respect, as the degree of invasiveness of any monitoring tool determines the frequency of its application, especially in the operating room (OR). From this point of view, we are very confident that some of these minimally invasive and non-invasive haemodynamic monitoring technologies will become an inherent part of our monitoring armamentarium in the OR and in the intensive care unit (ICU).
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Affiliation(s)
- Jochen Renner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
| | - Matthias Grünewald
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
| | - Berthold Bein
- Department of Anaesthesiology and Intensive Care Medicine, Asklepios Klinik St. Georg, Hamburg, Germany.
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Huber W, Fuchs S, Minning A, Küchle C, Braun M, Beitz A, Schultheiss C, Mair S, Phillip V, Schmid S, Schmid RM, Lahmer T. Transpulmonary thermodilution (TPTD) before, during and after Sustained Low Efficiency Dialysis (SLED). A Prospective Study on Feasibility of TPTD and Prediction of Successful Fluid Removal. PLoS One 2016; 11:e0153430. [PMID: 27088612 PMCID: PMC4835077 DOI: 10.1371/journal.pone.0153430] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/29/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common in critically ill patients. AKI requires renal replacement therapy (RRT) in up to 10% of patients. Particularly during connection and fluid removal, RRT frequently impairs haemodyamics which impedes recovery from AKI. Therefore, "acute" connection with prefilled tubing and prolonged periods of RRT including sustained low efficiency dialysis (SLED) has been suggested. Furthermore, advanced haemodynamic monitoring using trans-pulmonary thermodilution (TPTD) and pulse contour analysis (PCA) might help to define appropriate fluid removal goals. OBJECTIVES, METHODS Since data on TPTD to guide RRT are scarce, we investigated the capabilities of TPTD- and PCA-derived parameters to predict feasibility of fluid removal in 51 SLED-sessions (Genius; Fresenius, Germany; blood-flow 150 mL/min) in 32 patients with PiCCO-monitoring (Pulsion Medical Systems, Germany). Furthermore, we sought to validate the reliability of TPTD during RRT and investigated the impact of "acute" connection and of disconnection with re-transfusion on haemodynamics. TPTDs were performed immediately before and after connection as well as disconnection. RESULTS Comparison of cardiac index derived from TPTD (CItd) and PCA (CIpc) before, during and after RRT did not give hints for confounding of TPTD by ongoing RRT. Connection to RRT did not result in relevant changes in haemodynamic parameters including CItd. However, disconnection with re-transfusion of the tubing volume resulted in significant increases in CItd, CIpc, CVP, global end-diastolic volume index GEDVI and cardiac power index CPI. Feasibility of the pre-defined ultrafiltration goal without increasing catecholamines by >10% (primary endpoint) was significantly predicted by baseline CPI (ROC-AUC 0.712; p = 0.010) and CItd (ROC-AUC 0.662; p = 0.049). CONCLUSIONS TPTD is feasible during SLED. "Acute" connection does not substantially impair haemodynamics. Disconnection with re-transfusion increases preload, CI and CPI. The extent of these changes might be used as a "post-RRT volume change" to guide fluid removal during subsequent RRTs. CPI is the most useful marker to guide fluid removal by SLED.
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Affiliation(s)
- Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
- * E-mail:
| | - Stephan Fuchs
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Andreas Minning
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Claudius Küchle
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Marlena Braun
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Analena Beitz
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Caroline Schultheiss
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Sebastian Mair
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Veit Phillip
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Sebastian Schmid
- Klinik für Anaesthesiologie, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
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Fluid therapy in the perioperative setting-a clinical review. J Intensive Care 2016; 4:27. [PMID: 27087980 PMCID: PMC4833950 DOI: 10.1186/s40560-016-0154-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/07/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Perioperative hypovolemia and fluid overload have effects on both complications following surgery and on patient survival. Therefore, the administration of intravenous fluids before, during, and after surgery at the right time and in the right amounts is of great importance. This review aims to analyze the literature concerning perioperative fluid therapy in abdominal surgery and to provide evidence-based recommendations for clinical practice. RESULTS Preoperative oral or intravenous administration of carbohydrate containing fluids has been shown to improve postoperative well-being and muscular strength and to reduce insulin resistance. Hence, the intake of fluid (preferably containing carbohydrates) should be encouraged up to 2 h prior to surgery in order to avoid dehydration. Excessive intravenous fluid administration adds to tissue inflammation and edema formation, thereby compromising tissue healing. During major abdominal surgery a "zero-balance" intraoperative fluid strategy aims at avoiding fluid overload (and comparable to the so-called restrictive approach) as well as goal-directed fluid therapy (GDT). Both proved to significantly reduce postoperative complications when compared to "standard fluid therapy". Trials comparing "restrictive" or zero-balance and GDT have shown equal results, as long as fluid overload is avoided in the GDT group as well (categorized as "zero-balance GDT"). It is possible that high-risk surgical patients, such as those undergoing acute surgery, may benefit from the continuous monitoring of circulatory status that the GDT provides. Data on this group of patients is not available at present, but trials are ongoing. CONCLUSION In elective surgery, the zero-balance approach has shown to reduce postoperative complications and is easily applied for most patients. It is less expensive and simpler than the zero-balance GDT approach and therefore recommended in this review. In outpatient surgery, 1-2 L of balanced crystalloids reduces postoperative nausea and vomiting and improves well-being.
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Hendy A, Bubenek Ş. Pulse waveform hemodynamic monitoring devices: recent advances and the place in goal-directed therapy in cardiac surgical patients. Rom J Anaesth Intensive Care 2016; 23:55-65. [PMID: 28913477 DOI: 10.21454/rjaic.7518.231.wvf] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hemodynamic monitoring has evolved and improved greatly during the past decades as the medical approach has shifted from a static to a functional approach. The technological advances have led to innovating calibrated or not, but minimally invasive and noninvasive devices based on arterial pressure waveform (APW) analysis. This systematic clinical review outlines the physiologic rationale behind these recent technologies. We describe the strengths and the limitations of each method in terms of accuracy and precision of measuring the flow parameters (stroke volume, cardiac output) and dynamic parameters which predict the fluid responsiveness. We also analyzed the place of the APW monitoring devices in goal-directed therapy (GDT) protocols in cardiac surgical patients. According to the data from the three GDT-randomized control trials performed in cardiac surgery (using two types of APW techniques PiCCO and FloTrac/Vigileo), these devices did not demonstrate that they played a role in decreasing mortality, but only decreasing the ventilation time and the ICU and hospital length of stay.
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Affiliation(s)
- Adham Hendy
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
| | - Şerban Bubenek
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
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Fischer MO, Fiant AL, Boutros M, Flais F, Filipov T, Debroczi S, Pasqualini L, Rhanem T, Gérard JL, Guittet L, Hanouz JL, Alves A, Parienti JJ. Perioperative hemodynamic optimization using the photoplethysmography in colorectal surgery (the PANEX3 trial): study protocol for a randomized controlled trial. Trials 2016; 17:159. [PMID: 27004412 PMCID: PMC4804484 DOI: 10.1186/s13063-016-1278-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/02/2016] [Indexed: 11/30/2022] Open
Abstract
Background Photoplethysmography with a digital sensor (ClearSight, Edwards Lifesciences, Irvine, CA, USA) connected to a dedicated monitor (EV 1000, Edwards Lifesciences) was recently proposed for use in performing hemodynamic optimization during surgery. The objective of this study is to evaluate the effect of photoplethysmography on the incidence of postoperative complications compared with the conventional hemodynamic algorithm, which uses mean arterial pressure. Methods/design The hemodynamic optimization using photoplethysmography (PANEX3) trial is a monocentric, randomized, single-blind, controlled, two parallel arm, superiority trial, randomizing 160 patients with an intermediate risk of postoperative complications after colorectal surgery. Informed consent will be obtained from all participants. The hemodynamic optimization is conducted using a specified hemodynamic algorithm either with photoplethysmography (the photoplethysmography group) or with conventional mean arterial pressure (the control group). The anesthesiologist performed a 1:1 randomization the day before surgery using a scratch card, which is available 24/7. The randomization sequence is generated using permutated blocks. Both the patients and surgeons are blinded to the allocation group. The primary outcome is the incidence of at least one postoperative complication during the 30 days following surgery. Two independent experts, who were blinded to the group allocations, validate the complication for each patient using an a priori classification. The secondary outcomes are to study the total number of postoperative complications, the real length of hospital stays, and the postoperative mortality between each group. Discussion The PANEX3 trial is the first randomized controlled study conducted to investigate whether perioperative hemodynamic optimization using photoplethysmography during colorectal surgery could decrease the incidence of patients having at least one postoperative complication. Trial Registration ClinicalTrials.gov Identifier: NCT02343601
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Affiliation(s)
- Marc-Olivier Fischer
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France. .,EA 4650, Université de Caen Basse-Normandie, Esplanade de la Paix, CS 14 032, F-14000, Caen, France.
| | - Anne-Lise Fiant
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Mariam Boutros
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Frédéric Flais
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Tzetan Filipov
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Stéphane Debroczi
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Léa Pasqualini
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Toufiq Rhanem
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Jean-Louis Gérard
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Lydia Guittet
- Department of Public Health, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France.,INSERM1086, Faculty of Medicine, Caen University Hospital, Avenue de la Côte de Nacre, F-14032, Caen, Cedex, France
| | - Jean-Luc Hanouz
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France.,EA 4650, Université de Caen Basse-Normandie, Esplanade de la Paix, CS 14 032, F-14000, Caen, France
| | - Arnaud Alves
- Service de chirurgie digestive, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
| | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14000, Caen, France
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Schmid S, Kapfer B, Heim M, Bogdanski R, Anetsberger A, Blobner M, Jungwirth B. Algorithm-guided goal-directed haemodynamic therapy does not improve renal function after major abdominal surgery compared to good standard clinical care: a prospective randomised trial. Crit Care 2016; 20:50. [PMID: 26951105 PMCID: PMC4782303 DOI: 10.1186/s13054-016-1237-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 02/16/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Acute kidney injury is a common complication after major surgery. In this study, we investigated whether an algorithm-guided goal-directed haemodynamic therapy (GDT) can improve renal outcome compared to good standard clinical care. METHODS A total of 180 patients undergoing major abdominal surgery were prospectively and randomly assigned to one of two groups: in the GDT group, patients were treated with a GDT algorithm using transpulmonary thermodilution while standard care was applied to the control patients. Change in creatinine was studied as the primary end point, postoperative complications as well as 1-year mortality as secondary outcomes. Haemodynamics in GDT and control patients were compared calculating goal-achievement rates. RESULTS Postoperative change in creatinine (18 ± 39 μmol/l (control) vs. 16 ± 42 μmol/l (GDT); mean difference (95 % confidence interval) 1.6 μmol/l (-10 to 13 μmol/l)) was comparable between the GDT and the control group. Postoperative complications and mortality during hospital stay and after 1 year were not influenced by the use of a GDT algorithm. Achievement rates of haemodynamic goals were not higher in the GDT group compared to the already high (>80 %) rates in the control group. Multivariate regression analysis revealed intraoperative hypotension (MAP < 70 mmHg) and postoperative hypovolaemia (GEDI < 640 ml/m(2)) as risk factors for postoperative renal impairment. CONCLUSIONS In this study, GDT was not superior to standard clinical care in order to avoid renal failure after major abdominal surgery. The reason for this finding is most likely the high achievement rate of haemodynamic goals in the control group, which cannot be improved by the GDT algorithm. TRIAL REGISTRATION Clinicaltrials.gov; NCT01035541; registered 17 December 2009.
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Affiliation(s)
- Sebastian Schmid
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Barbara Kapfer
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Markus Heim
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Ralph Bogdanski
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Aida Anetsberger
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Manfred Blobner
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Bettina Jungwirth
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675, Germany.
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Fluid Therapy: Double-Edged Sword during Critical Care? BIOMED RESEARCH INTERNATIONAL 2015; 2015:729075. [PMID: 26798642 PMCID: PMC4700172 DOI: 10.1155/2015/729075] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/25/2015] [Indexed: 12/11/2022]
Abstract
Fluid therapy is still the mainstay of acute care in patients with shock or cardiovascular compromise. However, our understanding of the critically ill pathophysiology has evolved significantly in recent years. The revelation of the glycocalyx layer and subsequent research has redefined the basics of fluids behavior in the circulation. Using less invasive hemodynamic monitoring tools enables us to assess the cardiovascular function in a dynamic perspective. This allows pinpointing even distinct changes induced by treatment, by postural changes, or by interorgan interactions in real time and enables individualized patient management. Regarding fluids as drugs of any other kind led to the need for precise indication, way of administration, and also assessment of side effects. We possess now the evidence that patient centered outcomes may be altered when incorrect time, dose, or type of fluids are administered. In this review, three major features of fluid therapy are discussed: the prediction of fluid responsiveness, potential harms induced by overzealous fluid administration, and finally the problem of protocol-led treatments and their timing.
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Broch O, Carbonell J, Ferrando C, Metzner M, Carstens A, Albrecht M, Gruenewald M, Höcker J, Soro M, Steinfath M, Renner J, Bein B. Accuracy of an autocalibrated pulse contour analysis in cardiac surgery patients: a bi-center clinical trial. BMC Anesthesiol 2015; 15:171. [PMID: 26612072 PMCID: PMC4661938 DOI: 10.1186/s12871-015-0153-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 11/22/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Less-invasive and easy to install monitoring systems for continuous estimation of cardiac index (CI) have gained increasing interest, especially in cardiac surgery patients who often exhibit abrupt haemodynamic changes. The aim of the present study was to compare the accuracy of CI by a new semi-invasive monitoring system with transpulmonary thermodilution before and after cardiopulmonary bypass (CPB). METHODS Sixty-five patients (41 Germany, 24 Spain) scheduled for elective coronary surgery were studied before and after CPB, respectively. Measurements included CI obtained by transpulmonary thermodilution (CITPTD) and autocalibrated semi-invasive pulse contour analysis (CIPFX). Percentage changes of CI were also calculated. RESULTS There was only a poor correlation between CITPTD and CIPFX both before (r (2) = 0.34, p < 0.0001) and after (r (2) = 0.31, p < 0.0001) CPB, with a percentage error (PE) of 62 and 49 %, respectively. Four quadrant plots revealed a concordance rate over 90 % indicating an acceptable correlation of trends between CITPTD and CIPFX before (concordance: 93 %) and after (concordance: 94 %) CPB. In contrast, polar plot analysis showed poor trending before and an acceptable trending ability of changes in CI after CPB. CONCLUSIONS Semi-invasive CI by autocalibrated pulse contour analysis showed a poor ability to estimate CI compared with transpulmonary thermodilution. Furthermore, the new semi-invasive device revealed an acceptable trending ability for haemodynamic changes only after CPB. TRIAL REGISTRATION ClinicalTrials.gov: NCT02312505 Date: 12.03.2012.
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Affiliation(s)
- Ole Broch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105, Kiel, Germany.
| | - Jose Carbonell
- Department of Anaesthesiology and Critical Care, University Hospital Valencia, Avenida Blasco Ibanez 17, 46010, Valencia, Spain
| | - Carlos Ferrando
- Department of Anaesthesiology and Critical Care, University Hospital Valencia, Avenida Blasco Ibanez 17, 46010, Valencia, Spain
| | - Malte Metzner
- Christian-Albrechts-University Kiel, Schleswig-Holstein, Germany
| | - Arne Carstens
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105, Kiel, Germany
| | - Martin Albrecht
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105, Kiel, Germany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105, Kiel, Germany
| | - Jan Höcker
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105, Kiel, Germany
| | - Marina Soro
- Department of Anaesthesiology and Critical Care, University Hospital Valencia, Avenida Blasco Ibanez 17, 46010, Valencia, Spain
| | - Markus Steinfath
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105, Kiel, Germany
| | - Jochen Renner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105, Kiel, Germany
| | - Berthold Bein
- Department of Anaesthesiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
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Sakka SG. Hemodynamic Monitoring in the Critically Ill Patient - Current Status and Perspective. Front Med (Lausanne) 2015; 2:44. [PMID: 26284244 PMCID: PMC4522558 DOI: 10.3389/fmed.2015.00044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/26/2015] [Indexed: 01/20/2023] Open
Abstract
In the critically ill patient, early and effective hemodynamic management including fluid therapy and administration of vasoactive drugs to maintain vital organ perfusion and oxygen delivery is mandatory. Understanding the different approaches in the management of critically ill patients during the resuscitation and further management is essential to initiate adequate context- and time-specific interventions. Treatment of hemodynamic variables to achieve a balance between organ oxygen delivery and consumption is the cornerstone. In general, cardiac output is considered a major determinant of oxygen supply and thus its monitoring is regarded helpful. However, indicators of oxygen requirements are equally necessary to assess adequacy of oxygen supply. Currently, more and more less or even totally non-invasive monitoring systems have been developed and clinically introduced, but require validation in this particular patient population. Cardiac output monitors and surrogates of organ oxygenation only enable to adequately guide management, as patient's outcome is determined by acquisition and interpretation of accurate data, and finally suitable management decisions. This mini-review presents the currently available techniques in the field of hemodynamic monitoring in critically ill patients and briefly summarizes their advantages and limitations.
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Affiliation(s)
- Samir G Sakka
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Center Cologne Merheim, University Witten/Herdecke , Cologne , Germany
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Holder AL, Pinsky MR. Applied physiology at the bedside to drive resuscitation algorithms. J Cardiothorac Vasc Anesth 2015; 28:1642-59. [PMID: 25479921 DOI: 10.1053/j.jvca.2014.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Indexed: 12/25/2022]
Affiliation(s)
- Andre L Holder
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.
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Holder AL, Clermont G. Using what you get: dynamic physiologic signatures of critical illness. Crit Care Clin 2015; 31:133-64. [PMID: 25435482 DOI: 10.1016/j.ccc.2014.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The development and resolution of cardiopulmonary instability take time to become clinically apparent, and the treatments provided take time to have an impact. The characterization of dynamic changes in hemodynamic and metabolic variables is implicit in physiologic signatures. When primary variables are collected with high enough frequency to derive new variables, this data hierarchy can be used to develop physiologic signatures. The creation of physiologic signatures requires no new information; additional knowledge is extracted from data that already exist. It is possible to create physiologic signatures for each stage in the process of clinical decompensation and recovery to improve outcomes.
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Affiliation(s)
- Andre L Holder
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gilles Clermont
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Abstract
Although use of the classic pulmonary artery catheter has declined, several techniques have emerged to estimate cardiac output. Arterial pressure waveform analysis computes cardiac output from the arterial pressure curve. The method of estimating cardiac output for these devices depends on whether they need to be calibrated by an independent measure of cardiac output. Some newer devices have been developed to estimate cardiac output from an arterial curve obtained noninvasively with photoplethysmography, allowing a noninvasive beat-by-beat estimation of cardiac output. This article describes the different devices that perform pressure waveform analysis.
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Affiliation(s)
- Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France; EA4533, Paris-Sud University, 63 rue Gabriel Péri, F-94270 Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France; EA4533, Paris-Sud University, 63 rue Gabriel Péri, F-94270 Le Kremlin-Bicêtre, France
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Joosten A, Alexander B, Cannesson M. Defining goals of resuscitation in the critically ill patient. Crit Care Clin 2015; 31:113-32. [PMID: 25435481 DOI: 10.1016/j.ccc.2014.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There is still no "universal" consensus on an optimal endpoint for goal directed therapy (GDT) in the critically ill patient. As in other areas of medicine, this should help providers to focus on a more "individualized approach" rather than a protocolized approach to ensure proper patient care. Hemodynamic optimization needs more than simply blood pressure, heart rate, central venous pressure and urine output monitoring. It is essential to also monitor flow variables (cardiac output/stroke volume) and dynamic parameters of fluid responsiveness whenever available. This article will provide a review of current and trending approaches of the goals of resuscitation in the critically ill patient.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA; Department of Anesthesiology and Critical Care, Erasme University Hospital, Free University of Brussels, 808 Lennick Road, Brussels 1070, Belgium
| | - Brenton Alexander
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA.
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Cannesson M, Ramsingh D, Rinehart J, Demirjian A, Vu T, Vakharia S, Imagawa D, Yu Z, Greenfield S, Kain Z. Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study. Crit Care 2015; 19:261. [PMID: 26088649 PMCID: PMC4512146 DOI: 10.1186/s13054-015-0945-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/07/2015] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention. METHODS This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database). RESULTS In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1-13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7-9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6-16) days to 7 (5-11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18% (95% confidence interval 9-27%). The incidence of NSQIP complications decreased from 39% to 25% (p = 0.04). CONCLUSION These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries. TRIAL REGISTRATION Clinicaltrials.gov NCT02057653. Registered 17 December 2013.
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Affiliation(s)
- Maxime Cannesson
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
- Health Policy Research Institute, University of California, Irvine, CA, USA.
| | - Davinder Ramsingh
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Aram Demirjian
- Department of Surgery, University of California, Irvine, CA, USA.
| | - Trung Vu
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Shermeen Vakharia
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - David Imagawa
- Department of Surgery, University of California, Irvine, CA, USA.
| | - Zhaoxia Yu
- Department of Statistics, University of California, Irvine, CA, USA.
| | - Sheldon Greenfield
- Health Policy Research Institute, University of California, Irvine, CA, USA.
| | - Zeev Kain
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
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Haas SA, Saugel B, Trepte CJ, Reuter DA. [Goal-directed hemodynamic therapy: Concepts, indications and risks]. Anaesthesist 2015; 64:494-505. [PMID: 26081011 DOI: 10.1007/s00101-015-0035-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Goal-directed hemodynamic therapy is becoming increasingly more interesting for anesthesiologists and intensive care physicians. Meta-analyses of studies evaluating perioperative therapy algorithms demonstrated a reduction of postoperative morbidity compared to the previous clinical practices. In this review article the basic concepts of goal-directed hemodynamic therapy and the principles of previously employed therapy algorithms are described and discussed. Furthermore, the questions of how these therapy strategies can be transferred into daily clinical practice and whether these therapeutic approaches might even bear risks for patients are elucidated.
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Affiliation(s)
- S A Haas
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland,
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Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial. BMC Anesthesiol 2015; 15:82. [PMID: 26041437 PMCID: PMC4453106 DOI: 10.1186/s12871-015-0064-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 05/23/2015] [Indexed: 12/21/2022] Open
Abstract
Background Major abdominal surgery is associated with significant risk of morbidity and mortality in the perioperative period. Optimising intraoperative fluid administration may result in improved outcomes. Our aim was to compare the effects of central venous pressure (CVP), and central venous oxygen saturation (ScvO2)-assisted fluid therapy on postoperative complications in patients undergoing high risk surgery. Methods Patients undergoing elective major abdominal surgery were randomised into control and ScvO2 groups. The target level of mean arterial pressure (MAP) was ≥ 60 mmHg in both groups. In cases of MAP < 60 mmHg patients received either a fluid or vasopressor bolus according to the CVP < 8 mmHg in the control group. In the ScvO2 group, in addition to the MAP, an ScvO2 of <75 % or a >3 % decrease indicated need for intervention, regardless of the actual MAP. Data are presented as mean ± standard deviation or median (interquartile range). Results We observed a lower number of patients with complications in the ScvO2 group compared to the control group, however it did not reach statistical significance (ScvO2 group: 10 vs. control group: 19; p = 0.07). Patients in the ScvO2 group (n = 38) received more colloids compared to the control group (n = 41) [279(161) vs. 107(250) ml/h; p < 0.001]. Both groups received similar amounts of crystalloid (1126 ± 471 vs. 1049 ± 431 ml/h; p = 0.46) and norepinephrine [37(107) vs. 18(73) mcg/h; p = 0.84]. Despite similar blood loss in both groups, the ScvO2 group received more blood transfusions (63 % vs. 37 %; p = 0.018). More patients in the control group had a postoperative PaO2/FiO2 < 200 mmHg (23 vs. 10, p < 0.01). Twenty eight day survival was significantly higher in the ScvO2 group (37/38 vs. 33/41 p = 0.018). Conclusion ScvO2-assisted intraoperative haemodynamic support provided some benefits, including significantly better postoperative oxygenation and 28 day survival rate, compared to CVP-assisted therapy without a significant effect on postoperative complications during major abdominal surgery. Trial registration ClinicalTrials.gov NCT02337010.
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Stens J, de Wolf SP, van der Zwan RJ, Koning NJ, Dekker NA, Hering JP, Boer C. Microcirculatory Perfusion During Different Perioperative Hemodynamic Strategies. Microcirculation 2015; 22:267-75. [DOI: 10.1111/micc.12194] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/11/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Jurre Stens
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Steven P. de Wolf
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - René J. van der Zwan
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Nick J. Koning
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Nicole A.M. Dekker
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | | | - Christa Boer
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
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Molnár Z. Individualized goal directed perioperative care - the way to go! Front Med (Lausanne) 2015; 2:22. [PMID: 25905104 PMCID: PMC4389568 DOI: 10.3389/fmed.2015.00022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/21/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Zsolt Molnár
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
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Redondo Calvo FJ, Bejarano Ramirez N, Uña Orejon R, Villazala Garcia R, Yuste Peña AS, Belda FJ. Elevated Extravascular Lung Water Index (ELWI) as a Predictor of Failure of Continuous Positive Airway Pressure Via Helmet (Helmet-CPAP) in Patients With Acute Respiratory Failure After Major Surgery. Arch Bronconeumol 2015; 51:558-63. [PMID: 25907235 DOI: 10.1016/j.arbres.2015.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/06/2015] [Accepted: 01/16/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION NIV is increasingly used for prevention and treatment of respiratory complications and failure. Some of them are admitted to the PACU with advanced hemodynamic monitors which allow quantification of Extravascular Lung Water (EVLW) by transpulmonary thermodilution technique (TPTD) and Pulmonary Vascular Permeability (PVP) providing information on lung edema. AIM The objective of this study was to ascertain if EVLW Index and PVP Index may predict failure (intubation) or success (non-intubation) in patients developing acute respiratory failure (ARF) in the postoperative period following major abdominal surgery, where the first line of treatment was non-invasive continuous positive airway pressure via a helmet. METHODS Hemodynamic variables, EVLWI and PVPI were monitored with a transpulmonary thermodilution hemodynamic monitor device (PiCCO™) before and after the application of CPAP. RESULTS Avoidance of intubation was observed in 66% of patients with Helmet-CPAP. In these patients after the first hour of application of CPAP, PaO2/FiO2 ratio significantly increased (303.33±65.2 vs. 141.6±14.6, P<.01). Before starting Helmet-CPAP values of EVLWI and PVPI were significantly lower in non-intubated patients (EVLWI 8.6±1.08 vs. 11.8±0.99ml/kg IBW, P<.01 and PVPI 1.7±0.56 vs. 3.0±0.88, P<.01). An optimal cut-off value for EVLWI was established at 9.5, and at 2.45 for PVPI (sensitivity of 0.7; specificity of 0.9, P<.01). CONCLUSION In this type of patient the physiological parameters that predict the failure of Helmet-CPAP with the greatest accuracy were the value of the EVLWI and PVPI before Helmet-CPAP institution and the PaO2/FiO2 ratio and the respiratory rate after one hour of CPAP.
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Affiliation(s)
| | | | - Rafael Uña Orejon
- Servicio de Anestesiología y Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - Ruben Villazala Garcia
- Servicio de Anestesiología y Medicina Intensiva, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Ana Sofia Yuste Peña
- Servicio de Anestesiología y Medicina Intensiva, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Francisco Javier Belda
- Servicio de Anestesiología y Medicina Intensiva, Hospital Clínico Universitario de Valencia, Valencia, España
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Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond) 2015; 4:3. [PMID: 25897397 PMCID: PMC4403901 DOI: 10.1186/s13741-015-0014-z] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Perioperative fluid therapy remains a highly debated topic. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo- or hyperperfusion. Relative to perioperative fluid therapy, three inescapable conclusions exist: overhydration is bad, underhydration is bad, and what we assume about the fluid status of our patients may be incorrect. There is wide variability of practice, both between individuals and institutions. The aims of this paper are to clearly define the risks and benefits of fluid choices within the perioperative space, to describe current evidence-based methodologies for their administration, and ultimately to reduce the variability with which perioperative fluids are administered. METHODS Based on the abovementioned acknowledgements, a group of 72 researchers, well known within the field of fluid resuscitation, were invited, via email, to attend a meeting that was held in Chicago in 2011 to discuss perioperative fluid therapy. From the 72 invitees, 14 researchers representing 7 countries attended, and thus, the international Fluid Optimization Group (FOG) came into existence. These researches, working collaboratively, have reviewed the data from 162 different fluid resuscitation papers including both operative and intensive care unit populations. This manuscript is the result of 3 years of evidence-based, discussions, analysis, and synthesis of the currently known risks and benefits of individual fluids and the best methods for administering them. RESULTS The results of this review paper provide an overview of the components of an effective perioperative fluid administration plan and address both the physiologic principles and outcomes of fluid administration. CONCLUSIONS We recommend that both perioperative fluid choice and therapy be individualized. Patients should receive fluid therapy guided by predefined physiologic targets. Specifically, fluids should be administered when patients require augmentation of their perfusion and are also volume responsive. This paper provides a general approach to fluid therapy and practical recommendations.
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Goal-Directed Fluid Therapy Using Stroke Volume Variation for Resuscitation after Low Central Venous Pressure-Assisted Liver Resection: A Randomized Clinical Trial. J Am Coll Surg 2015. [PMID: 26206652 DOI: 10.1016/j.jamcollsurg.2015.03.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal perioperative fluid resuscitation strategy for liver resections remains undefined. Goal-directed therapy (GDT) embodies a number of physiologic strategies to achieve an ideal fluid balance and avoid the consequences of over- or under-resuscitation. STUDY DESIGN In a prospective randomized trial, patients undergoing liver resection were randomized to GDT using stroke volume variation as an end point or to standard perioperative resuscitation. Primary outcomes measure was 30-day morbidity. RESULTS Between 2012 and 2014, one hundred and thirty-five patients were randomized (GDT: n = 69; standard perioperative resuscitation: n = 66). Median age was 57 years and 56% were male. Metastatic disease comprised 81% of patients. Overall (35% GDT vs 36% standard perioperative resuscitation; p = 0.86) and grade 3 morbidity (28% GDT vs 18% standard perioperative resuscitation; p = 0.22) were equivalent. Patients in the GDT arm received less intraoperative fluid (mean 2.0 L GDT vs 2.9 L standard perioperative resuscitation; p < 0.001). Perioperative transfusions were required in 4% (6% GDT vs 2% standard perioperative resuscitation; p = 0.37) and boluses in the postanesthesia care unit were administered to 24% (29% GDT vs 20% standard perioperative resuscitation; p = 0.23). Mortality rate was 1% (2 of 135 patients; both in GDT). On multivariable analysis, male sex, age, combined procedures, higher intraoperative fluid volume, and fluid boluses in the postanesthesia care unit were associated with higher 30-day morbidity. CONCLUSIONS Stroke volume variation-guided GDT is safe in patients undergoing liver resection and led to less intraoperative fluid. Although the incidence of postoperative complications was similar in both arms, lower intraoperative resuscitation volume was independently associated with decreased postoperative morbidity in the entire cohort. Future studies should target extensive resections and identify patients receiving large resuscitation volumes, as this population is more likely to benefit from this technique.
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MacDonald N, Ahmad T, Mohr O, Kirk-Bayley J, Moppett I, Hinds C, Pearse R. Dynamic preload markers to predict fluid responsiveness during and after major gastrointestinal surgery: an observational substudy of the OPTIMISE trial. Br J Anaesth 2015; 114:598-604. [DOI: 10.1093/bja/aeu398] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Closed-loop assisted versus manual goal-directed fluid therapy during high-risk abdominal surgery: a case-control study with propensity matching. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:94. [PMID: 25888403 PMCID: PMC4372998 DOI: 10.1186/s13054-015-0827-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 02/19/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare the results with those for matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload-independent state, defined as percentage of case time with stroke volume variation less than or equal to 12%. METHODS Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team, and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment, each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias. RESULTS A total of 40 patients were enrolled, 5 were ultimately excluded and 25 matched pairs were selected from among the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95 ± 6% of case time versus 87 ± 14%, P =0.008). There was no difference in case mean or final stroke volume index (45 ± 10 versus 43 ± 9 and 45 ± 11 versus 42 ± 11, respectively) or mean arterial pressure (79 ± 8 versus 83 ± 9). Case end heart rate was significantly lower in the closed-loop assisted group (77 ± 10 versus 88 ± 13, P =0.003). CONCLUSION In this case-control study with propensity matching, clinician use of closed-loop assistance resulted in a greater portion of case time spent in a preload-independent state throughout surgery compared with manual delivery of goal-directed fluid therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02020863. Registered 19 December 2013.
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Fischer MO, Dechanet F, du Cheyron D, Gérard JL, Hanouz JL, Fellahi JL. Evaluation of the knowledge base of French intensivists and anaesthesiologists as concerns the interpretation of respiratory arterial pulse pressure variation. Anaesth Crit Care Pain Med 2015; 34:29-34. [PMID: 25829312 DOI: 10.1016/j.accpm.2014.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/26/2014] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aims of the study were to assess the knowledge of intensivists and/or anaesthesiologists concerning respiratory arterial pulse pressure variation (PPV) and to define the criteria used to indicate a fluid challenge. STUDY DESIGN A prospective observational study. PATIENTS AND METHODS Intensivists and anaesthesiologists from one region of France were evaluated for their knowledge about the prerequisites (continuous arterial pressure monitoring, regular sinus rhythm, mechanical ventilation without spontaneous breathing) and confounding factors shifting the threshold value of PPV (low tidal volume, decreased pulmonary compliance, low heart rate/respiratory rate ratio, right ventricular dysfunction, and/or intra-abdominal hypertension) using clinical vignettes. Criteria used by physicians to indicate a fluid challenge were also collected. RESULTS One hundred and forty-five physicians were included in the study. Among them, 87 (60%) knew prerequisites but none of them had full knowledge of all confounding factors. Criteria used to perform a fluid challenge were mainly PPV and the passive leg-raising test for the residents and PPV, blood pressure, oliguria and hydric balance for the qualified physicians. CONCLUSIONS PPV was widely employed to indicate a fluid challenge and 60% of the physicians knew the prerequisites. However, the physicians did not correctly interpret all confounding factors.
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Affiliation(s)
- Marc-Olivier Fischer
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, Université de Caen Basse-Normandie, esplanade de la Paix, CS 14 032, 14000 Caen, France.
| | - Fabien Dechanet
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Damien du Cheyron
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Jean-Louis Gérard
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Jean-Luc Hanouz
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, Université de Caen Basse-Normandie, esplanade de la Paix, CS 14 032, 14000 Caen, France
| | - Jean-Luc Fellahi
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, Université de Caen Basse-Normandie, esplanade de la Paix, CS 14 032, 14000 Caen, France
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Michard F, Benes J. (Bright) future of dynamic parameters is in the operating theatre. Br J Anaesth 2015; 113:519. [PMID: 25135895 DOI: 10.1093/bja/aeu283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Ripollés Melchor J, Espinosa A. [Goal directed fluid therapy controversies in non-cardiac surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:477-480. [PMID: 25284819 DOI: 10.1016/j.redar.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 06/03/2023]
Affiliation(s)
- J Ripollés Melchor
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Leonor, Madrid, España.
| | - A Espinosa
- Department of Anesthesia, Blekinge County Council Hospital, Karlskrona, Suecia
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Benes J, Giglio M, Brienza N, Michard F. The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:584. [PMID: 25348900 PMCID: PMC4234857 DOI: 10.1186/s13054-014-0584-z] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 10/09/2014] [Indexed: 12/21/2022]
Abstract
Introduction Dynamic predictors of fluid responsiveness, namely systolic pressure variation, pulse pressure variation, stroke volume variation and pleth variability index have been shown to be useful to identify in advance patients who will respond to a fluid load by a significant increase in stroke volume and cardiac output. As a result, they are increasingly used to guide fluid therapy. Several randomized controlled trials have tested the ability of goal-directed fluid therapy (GDFT) based on dynamic parameters (GDFTdyn) to improve post-surgical outcome. These studies have yielded conflicting results. Therefore, we performed this meta-analysis to investigate whether the use of GDFTdyn is associated with a decrease in post-surgical morbidity. Methods A systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through September 2013 was conducted. Data synthesis was obtained by using odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) by random-effects model. Results In total, 14 studies met the inclusion criteria (961 participants). Post-operative morbidity was reduced by GDFTdyn (OR 0.51; CI 0.34 to 0.75; P <0.001). This effect was related to a significant reduction in infectious (OR 0.45; CI 0.27 to 0.74; P = 0.002), cardiovascular (OR 0.55; CI 0.36 to 0.82; P = 0.004) and abdominal (OR 0.56; CI 0.37 to 0.86; P = 0.008) complications. It was associated with a significant decrease in ICU length of stay (WMD −0.75 days; CI −1.37 to −0.12; P = 0.02). Conclusions In surgical patients, we found that GDFTdyn decreased post-surgical morbidity and ICU length of stay. Because of the heterogeneity of studies analyzed, large prospective clinical trials would be useful to confirm our findings. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0584-z) contains supplementary material, which is available to authorized users.
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Montenij L, de Waal E, Frank M, van Beest P, de Wit A, Kruitwagen C, Buhre W, Scheeren T. Influence of early goal-directed therapy using arterial waveform analysis on major complications after high-risk abdominal surgery: study protocol for a multicenter randomized controlled superiority trial. Trials 2014; 15:360. [PMID: 25227114 PMCID: PMC4175278 DOI: 10.1186/1745-6215-15-360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/28/2014] [Indexed: 01/20/2023] Open
Abstract
Background Early goal-directed therapy refers to the use of predefined hemodynamic goals to optimize tissue oxygen delivery in critically ill patients. Its application in high-risk abdominal surgery is, however, hindered by safety concerns and practical limitations of perioperative hemodynamic monitoring. Arterial waveform analysis provides an easy, minimally invasive alternative to conventional monitoring techniques, and could be valuable in early goal-directed strategies. We therefore investigate the effects of early goal-directed therapy using arterial waveform analysis on complications, quality of life and healthcare costs after high-risk abdominal surgery. Methods/Design In this multicenter, randomized, controlled superiority trial, 542 patients scheduled for elective, high-risk abdominal surgery will be included. Patients are allocated to standard care (control group) or early goal-directed therapy (intervention group) using a randomization procedure stratified by center and type of surgery. In the control group, standard perioperative hemodynamic monitoring is applied. In the intervention group, early goal-directed therapy is added to standard care, based on continuous monitoring of cardiac output with arterial waveform analysis. A treatment algorithm is used as guidance for fluid and inotropic therapy to maintain cardiac output above a preset, age-dependent target value. The primary outcome measure is a combined endpoint of major complications in the first 30 days after the operation, including mortality. Secondary endpoints are length of stay in the hospital, length of stay in the intensive care or post-anesthesia care unit, the number of minor complications, quality of life, cost-effectiveness and one-year mortality and morbidity. Discussion Before the start of the study, hemodynamic optimization by early goal-directed therapy with arterial waveform analysis had only been investigated in small, single-center studies, including minor complications as primary endpoint. Moreover, these studies did not include quality of life, healthcare costs, and long-term outcome in their analysis. As a result, the definitive role of arterial waveform analysis in the perioperative hemodynamic assessment and care for high-risk surgical patients is unknown, which gave rise to the present trial. Patient inclusion started in May 2012 and is expected to end in 2016. Trial registration This trial was registered in the Dutch Trial Register (registration number NTR3380) on 3 April 2012. Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-360) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Eric de Waal
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Saugel B, Reuter D. III. Are we ready for the age of non-invasive haemodynamic monitoring? Br J Anaesth 2014; 113:340-3. [DOI: 10.1093/bja/aeu145] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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142
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Perioperative hemodynamic optimization: a revised approach. J Clin Anesth 2014; 26:500-5. [DOI: 10.1016/j.jclinane.2014.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 01/22/2023]
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143
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Suehiro K, Joosten A, Alexander B, Cannesson M. Guiding Goal-Directed Therapy. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0074-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Della Rocca G, Vetrugno L, Tripi G, Deana C, Barbariol F, Pompei L. Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperative approach? BMC Anesthesiol 2014; 14:62. [PMID: 25104915 PMCID: PMC4124502 DOI: 10.1186/1471-2253-14-62] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/14/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Fluid management in the perioperative period has been extensively studied but, despite that, "the right amount" still remains uncertain. The purpose of this paper is to summarize the state of the art of intraoperative fluid approach today. DISCUSSION In the current medical literature there are only heterogeneous viewpoints that gives the idea of how confusing the situation is. The approach to the intraoperative fluid management is complex and it should be based on human physiology and the current evidence. SUMMARY An intraoperative restrictive fluid approach in major surgery may be beneficial while Goal-directed Therapy should be superior to the liberal fluid strategy. Finally, we propose a rational approach currently used at our institution.
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Affiliation(s)
- Giorgio Della Rocca
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Luigi Vetrugno
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Gabriella Tripi
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Cristian Deana
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Federico Barbariol
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
| | - Livia Pompei
- Dipartimento di Scienze Mediche Sperimentali e Cliniche, University of Udine, University of Udine, 33100 Udine, Italy
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NÉMETH M, TÁNCZOS K, DEMETER G, ÉRCES D, KASZAKI J, MIKOR A, MOLNÁR Z. Central venous oxygen saturation and carbon dioxide gap as resuscitation targets in a hemorrhagic shock. Acta Anaesthesiol Scand 2014; 58:611-9. [PMID: 24641618 DOI: 10.1111/aas.12312] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Fluid resuscitation is still a major challenge. We aimed to describe changes in central venous oxygen saturation (ScvO2 ) and venous-to-arterial carbon dioxide gap (dCO2 ) during an experimental stroke volume (SV) index (SVI)-guided hemorrhage and fluid resuscitation model in pigs. METHODS Twelve anesthetized, mechanically ventilated pigs were bled till baseline SVI (Tbsl ) dropped by 50% (T0 ), thereafter fluid resuscitation was performed with balanced crystalloid in four steps until initial SVI was reached (T4 ). Statistical analysis was performed with Statistical Program for Social Sciences version 18.0; data are expressed as mean ± standard deviation. RESULTS After bleeding, ScvO2 dropped (Tbsl = 78 ± 7 vs. T0 = 61 ± 5% P < 0.05) and oxygen extraction ratio increased (Tbsl = 0.20 ± 0.07 vs. T0 = 0.36 ± 0.05, P < 0.05). By T4 the ScvO2 normalized, but on average it remained 5% lower than at Tbsl (T4 = 73 ± 9% P < 0.05) and oxygen extraction also remained higher as compared with Tbsl (T4 = 0.24 ± 0.09 P = 0.001). ScvO2 showed significant correlation with SVI (r = 0.564, P < 0.001). dCO2 increased during hypovolemia (Tbsl :5.3 ± 2.0 vs. T0 :9.6 ± 2.3 mmHg, P = 0.001), then returned to normal by T4 = 5.1 ± 2.6 mmHg, and it also showed significant correlation with SVI (R = -0.591, P < 0.001) and oxygen extraction (R = 0.735, P < 0.001). CONCLUSIONS In this SV-guided bleeding and fluid resuscitation model, both ScvO2 and dCO2 correlated well with changes in SV, but only the dCO2 returned to its baseline, normal value, while ScvO2 remained significantly lower than at baseline. These results suggest that dCO2 may be a good hemodynamic endpoint of resuscitation, while ScvO2 is not strictly a hemodynamic parameter, but rather an indicator of the balance between oxygen delivery and consumption.
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Affiliation(s)
- M. NÉMETH
- Department of Anaesthesiology and Intensive Therapy; University of Szeged; Szeged Hungary
| | - K. TÁNCZOS
- Department of Anaesthesiology and Intensive Therapy; University of Szeged; Szeged Hungary
| | - G. DEMETER
- Department of Anaesthesiology and Intensive Therapy; University of Szeged; Szeged Hungary
| | - D. ÉRCES
- Institute of Surgical Research; University of Szeged; Szeged Hungary
| | - J. KASZAKI
- Institute of Surgical Research; University of Szeged; Szeged Hungary
| | - A. MIKOR
- Department of Anaesthesiology and Intensive Therapy; University of Szeged; Szeged Hungary
| | - Z. MOLNÁR
- Department of Anaesthesiology and Intensive Therapy; University of Szeged; Szeged Hungary
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Tánczos K, Németh M, Molnár Z. The multimodal concept of hemodynamic stabilization. Front Public Health 2014; 2:34. [PMID: 24818123 PMCID: PMC4012216 DOI: 10.3389/fpubh.2014.00034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 04/01/2014] [Indexed: 11/13/2022] Open
Abstract
Hemodynamic instability often leads to hypoperfusion, which has a significant impact on outcome in both medical and surgical patients. Measures to detect and treat tissue hypoperfusion early by correcting the imbalance between oxygen delivery and consumption is of particular importance. There are several studies targeting different hemodynamic endpoints in order to investigate the effects of goal-directed therapy on outcome. A so-called multimodal concept putting several variables in context follows simple logic and may provide a broader picture. Furthermore, rather than treating population based "normal" values of certain indices, this concept can be translated into the individualized patient care to reach adequate oxygen supply and tissue oxygenation in order to avoid under, or over resuscitation, which are equally harmful. The purpose of this review is to give an overview of current data providing the basis of this a multimodal, individualized approach of hemodynamic monitoring and treatment.
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Affiliation(s)
- Krisztián Tánczos
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Márton Németh
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Zsolt Molnár
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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