Non invasive guided gdt
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This document discusses non-invasive guided goal-directed therapy (GDT) for hemodynamic monitoring and optimization. It describes using a bedside monitor to continuously and non-invasively estimate cardiac output and stroke volume based on pulse wave transit time analysis of ECG and pulse oximetry signals. The method is calibrated using intermittent non-invasive blood pressure readings. Studies show this approach can guide fluid administration and help achieve hemodynamic goals like those used in invasive GDT protocols to improve outcomes. The document provides details on set up, use, and limitations of this non-invasive GDT method for perioperative hemodynamic optimization.
![Inverse Correlation between PWTT and SV
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ΔPWTT[ｍｓ]
ΔSV[cc]
y=-0.0511*x-0.876
r=-0.71(p<0.001)
n=560
Animal Experiment: Correlation between
the change of PWTT and SV since the
starting time (Sugo. et. al. IEEE, 1998)
Positive inotropic:
Dobutamine
Negative inotropic:
Propranolol/pentobarbital
Vasoconstriction:
Phenylephrine
Vasodilation:
Nitroglycerin
Hypovolemia:
Removal/ transfusion of blood](https://image.slidesharecdn.com/non-invasiveguidedgdt-190122163310/85/Non-invasive-guided-gdt-17-320.jpg)
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= [(38 - 17) x 80] / 1.2
= 1400 dyn.s/cm5
SVR = [(MAP-CVP) x 80] / CO](https://image.slidesharecdn.com/non-invasiveguidedgdt-190122163310/85/Non-invasive-guided-gdt-67-320.jpg)
![= [(1.39 x Hb x SaO2)+(0.003 x PaO2)] x CI x 10
= [(1.39 x 6.2 x 0.97)+(0.003 x 100)] x 2.3 x 10
= 199.1 ml O2/min/m2
DO2I = CaO2 x CI x 10](https://image.slidesharecdn.com/non-invasiveguidedgdt-190122163310/85/Non-invasive-guided-gdt-72-320.jpg)
Non invasive guided gdt
- 1. Non-Invasive Guided GDT Suraphong Lorsomradee, MD.,PhD. Associate Professor, Division of Cardiac Anesthesia, Chiang Mai University Hospital THAILAND GDT EducASIA: Simple Bedside Monitor
- 3. Lorsomradee, et al: J Cardiothorac Vasc Anesth. Aug;21(5):492-6, 2007 Change in Position Leg Elevation
- 4. Lorsomradee, et al: Anaesthesia. Oct;62(10):979-83, 2007 Vasoconstrictor
- 5. PEEP & Preload Lorsomradee, et al: J Cardiothorac Vasc Anesth. Aug 21(5):492-6., 2007
- 6. Painful Surgical Stimuli Sternotomy SuctionSomatic PainWound dressing IntubationRetractor Other
- 7. Myocardial ischemia Cell death Myocardial dysfunction Myocardial stunning reperfusion no reperfusion Sublethal Reperfusion injury Delayed Reperfusion injury Early lethal Reperfusion injury Cell death during reperfusion These factors may interfere myocardial perfusion and aggravate perioperative myocardial ischemia , lethal reperfusion injury and irreversible cell death.
- 8. CardioprotectionPrevention of myocardial ischemia has traditionally focused on maintaining Myocardial oxygen balance Heart rate contractility afterload CBF: normal region CBF: ischemic region subendocardium Ischemia Beta-blocker Alpha2 agonist Ca-channel blocker
- 9. Introduction Physical Findings (Non-specific) Clinical signs of hypovolemia are neither sensitive nor specific in the critically ill patient. Increased sympathetic tone - Tachycardia, hyperpnea, - Diaphoresis Decrease organ perfusion - Decrease urine output, ileus, - Altered sensorium, - Lactic acidosis - Hypotension occurs late
- 10. blood pressure Bloodvolume blood pressure Bloodvolume Pain Hypertension Emotional Shock Hypotension Deep sedation BP BP
- 11. SV HR Vascular tone Blood Viscosity Invasive BP Monitoring
- 12. Arterial Pulse Cardiac Output (APCO) Transesophageal Echocardiography (TEE) Thermodilution (Swan-Ganz) Cardiac Output
- 13. Non-invasive Blood Pressure (NIBP) Electrocardiography (ECG) Pulse Oximetry (SpO2) Routine Non-Invasive Monitor
- 14. ECG-SpO2 Estimated Continuous Cardiac Output
- 15. PEP(Pre-ejection Period) Reflects cardiac contractility PEP ↓ ⇒ SV ↑ PWTT1 Reflects Blood Pressure PWTT1 ↓ ⇒ SV ↑ PWTT2 Reflects SVR PWTT2 ↓ ⇒ SV ↑ PWTT ↓ SV ↑
- 16. ↑ Contractility PWTT ↓ SV ↑ ↑ SVR PWTT ↑ SV ↓
- 17. Inverse Correlation between PWTT and SV -8 -6 -4 -2 0 2 4 -100 -80 -60 -40 -20 0 20 40 60 80 100 ΔPWTT[ｍｓ] ΔSV[cc] y=-0.0511*x-0.876 r=-0.71(p<0.001) n=560 Animal Experiment: Correlation between the change of PWTT and SV since the starting time (Sugo. et. al. IEEE, 1998) Positive inotropic: Dobutamine Negative inotropic: Propranolol/pentobarbital Vasoconstriction: Phenylephrine Vasodilation: Nitroglycerin Hypovolemia: Removal/ transfusion of blood
- 18. Accuracy Evaluation Multicenter Study esCCO system v.s. ICO (thermodilution) No. of Patient=213 No. of Data=541 Average of difference between esCCO and ICO=0.08(L), σ=1.07
- 19. esCCO Set up & Calibration
- 20. Non-invasive Blood Pressure (NIBP) Electrocardiography (ECG) Pulse Oximetry (SpO2) PWTT ~ SV Non-Invasive Cardiac Output
- 21. • ECG Electrode: Avoid hair or reused • Site of ECG: Respiratory rate (RR) • Signal Interferance: Electrocauterization ECG Reliability
- 22. SpO2 Reliability • SpO2 Interferance : Nail polish, etc : Motion • Sensor Position: Hand or foot? (PWTT longer) • Perfusion Index (PI): Adult > 1 % Pediatric > 0.7 %
- 23. Perfusion Index (PI) Adult > 1 % Pediatric > 0.7 %
- 24. Perfusion Index (PI) Reliability • Perfusion Index (PI): Adult > 1 % Pediatric > 0.7 % • Interferance: Cold or Vasoconstriction NIBP measurement
- 25. • Patient Setting • Calibration PWTT
- 26. esCO = K × (α × PWTT + β) × HR α is an experimental constant, β is calculated based on Pulse-Pressure of IBP or NIBP, K is calculated based on a given CO value.* esSV
- 27. Bedside Monitor
- 31. Tips and Tricks Hemodynamic Monitoring • Trend • Change after intervention • Titration
- 32. Response to increase cardiac load obtained by leg elevation The ability of the heart to improve its performance via Frank-Starling mechanism Anesth Analg 2006;103:289 –96
- 33. SevofluranePropofol Anesthetic Induced Physiological Change Length-dependent Regulation of Myocardial Function Anesthesiology 2001;95:357-63 Both technique: Passive leg elevation or Frank-Starring mechanism are preserved in perioperative period.
- 34. DesfluranePropofol Anesthetic Induced Physiological Change Length-dependent Regulation of Myocardial Function Anesthesiology 2001;95:357-63 Both technique: Passive leg elevation or Frank-Starring mechanism are preserved in perioperative period.
- 36. “Fluid Challenge Test” PGDT Treatment Protocol
- 37. UK NHS/ NICE Protocol (Kuper) Kuper M, Gold SJ, Callow C, et al. BMJ. 2011;342:d3016. Sample PGDT Treatment Protocol
- 38. Estimated Stroke Volume esSV “Fluid Challenge Test”
- 42. Complications from Unguided Hemodynamic Optimisation
- 43. Bellamy MC. Br J Anaesth. 2006;97:755-757. Complications Volume Load OPTIMAL Edema Organ dysfunction Adverse outcome Hypoperfusion Organ dysfunction Adverse outcome OverloadedHypovolemic Optimal Volume Administration (and the impact of excessive and insufficient administration)
- 44. Evolution of Fluid Management The “Conventional” approach is trying to predict the amount of volume / fluids needed based upon a the duration and severity of a particular procedure Stolting et. al. Basics of Anesthesia, 5th ed. Elsevier - China, p. 349, 200 Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005; 103: 419-28 7 The “Restrictive” fluid approach is based on minimizing fluids based on Blood Pressure “Goal-Directed Therapy” approach considers optimizing volume / fluids via the Frank Starling Curve and individualizing to goals
- 45. Early Goal-directed Therapy Supplemental oxygen ± endotracheal intubation and mechanical ventilation Central venous and arterial catheterization CVP Crystalloid Colloid <8 mm Hg MAP 8-12 mm Hg Vasoactive agents <65 mm Hg >90 mm Hg ScvO2 ≥65 and ≤90 mm Hg Goals achieve d ≥70% Hospital admission Yes No Sedation and/or paralysis (if intubated) Transfusion of red cells to hematocrit ≥30% <70% Inotropic agents <70% ≥70% Rivers et al NEJM 2001;345:1368 Volume Pressor Inotrope
- 46. StaticCardiac filling pressure Marik P E et al. Chest 2008;134:172-178Osman D. Crit Care Med 2007; 37:64-8 Preload ≠ Fluid Responsiveness CVP SVV & PPV Dynamic
- 47. SVVStroke Volume Variation Pulse Pressure VariationPPV Preload
- 51. SVV ≥ 12 % SVV < 12 % 200 ml fluid challenge over 5 min Measure and record Cardiac index (CI) CI > 2.5 CI ≤ 2.5 Start dopamine And titration Until CI > 2.5 GDT group Measure and record SVV Give vasopressors No MAP ≥ 65 mmHg Yes A comparison of return of gastrointestinal function between perioperative goal-directed therapy and traditional fluid therapy in major abdominal surgery patients : A prospective randomized controlled study
- 52. Control GDT p Value Age (y) 54 ± 10 58 ± 13 0.402 Body mass index (kg/m2) 21 ± 2 22 ± 3 0.097 ASA Classification 2 ± 0 2 ± 0 Operation time (min) 244 ± 97 282 ± 123 0.519 Total blood loss (ml) 850 ± 1409 900 ± 667 0.930 Fluid replacement - Crystalloid (ml) 3144 ± 4097 1807 ± 696 0.351 - Colloid (ml) 1163 ± 650 879 ± 488 0.874 - PRC (ml) 765 ± 644 572 ± 357 0.161 - FFP (ml) 912 ± 863 755 ± 228 0.119 - Total (ml) 4135 ± 5636 3080 ± 1266 0.617 Lactate (mmol/L) - Preoperative 1.34 ± 0.45 1.51 ± 0.68 0.560 - Postoperative 4.74 ± 3.89 3.57 ± 1.37 0.481 Return of bowel function (d) 3.0 ± 1.4 0.8 ± 0.6 0.031* Length of stay in hospital (d) 14.0 ± 7.7 13.1 ± 6.1 0.799 A comparison of return of gastrointestinal function between perioperative goal- directed therapy and traditional fluid therapy in major abdominal surgery patients : A prospective randomized controlled study
- 53. Control GDT
- 62. PVI ≥ 17 % PVI < 17 % 200 ml fluid challenge over 5 min Estimated Cardiac index esCCI esCCI > 2.5 esCCI ≤ 2.5 Start dopamine And titration Until esCCI > 2.5 GDT group Measure and record PVI Give vasopressors No MAP ≥ 65 mmHg Yes A comparison of return of gastrointestinal function between perioperative goal-directed therapy and traditional fluid therapy in major abdominal surgery patients : A prospective randomized controlled study University Hospital
- 66. Control (n=50) GDT (n=50) significance Operation time (hr) 120.74 (±96.09) 115 (±60.27) 0.721 Blood loss (ml) 196.32 (±195.86) 297.20 (±425.50) 0.131 IV type (0.9% NaCl) 50 (100%) 50 (100%) 0.656 IV fluid (ml) 1,256.00 (±1290.61) 1,809 (±1047.43) 0.021* delta lactate 13.99 (±11.97) 12.95 (±12.13) 0.668 Urine output (ml) 70 (±73.76) 98.62 (±68.87) 0.048* Return of bowel sound (hr) 98.66 (±33.37) 67.40 (±22.25) 0.000* Soft diet (hr) 157.68 (±46.62) 110.18 (±25.61) 0.000* Length of stay (day) 12.90 (±6.91) 9.68 (±2.88) 0.003* Cost of treatment (Baht) 94,518.07 (±75313.11) 54,667.25 (±23358.44) 0.023* Secondary Care Hospital
- 67. ● ●● ● ● ● ● ● ● ● ● ● = [(38 - 17) x 80] / 1.2 = 1400 dyn.s/cm5 SVR = [(MAP-CVP) x 80] / CO
- 69. Cardiac Output Stroke Volume Contractility AfterloadPreload Heart Rate MacrocirculationMicrocirculation By optimizing the Cardiac function, Volume, and Vessel tone…we can optimize the Macrocirculation … then we focus more into the microcirculation
- 72. = [(1.39 x Hb x SaO2)+(0.003 x PaO2)] x CI x 10 = [(1.39 x 6.2 x 0.97)+(0.003 x 100)] x 2.3 x 10 = 199.1 ml O2/min/m2 DO2I = CaO2 x CI x 10
- 74. The End Thank you for your attention