Pulse Contour Analysis: Riding the Wave
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Dr. Laurence Weinberg discusses haemodynamic optimization in surgical patients, emphasizing the need for understanding outcomes before implementing therapies. The document outlines the importance of goal-directed therapy and advanced haemodynamic monitoring to tailor fluid and medication interventions based on individual patient needs. It presents protocols for optimizing patient care, highlighting evidence for improved outcomes associated with systematic monitoring and treatment strategies.
Pulse Contour Analysis: Riding the Wave
- 1. Haemodynamic Optimisation Riding the Wave Dr Laurence Weinberg Anaesthetist, Department of Anaesthesia, Austin Hospital Senior Fellow, Department of Surgery, University of Melbourne
- 2. Declarations • Edwards Lifesciences Fluid Advisory Board • Baxter National Fluid Advisory Board • Pancare Foundation Scientific Board
- 3. “We need to understand our own outcomes before we can make a difference” George Bernard Shaw
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- 6. “Austin, You've Got a Problem” 6
- 9. Diagnostic and Haemodynamic Monitoring tools NOT Therapeutic Interventions
- 10. “No DEVICE can improve patient-centered outcomes UNLESS Treatments save lives it is coupled to a treatment that NOT improves outcome” Monitors Modified from M. Pinsky, J.L. Vincent 10
- 11. BUT WE HAVE TO MAKE A DECISION
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- 25. • All patients ERAS; n= 65 Hypothesis • ?SS-GDT + ERAS vs. ERAS alone 25
- 26. 26 ERAS only (n=50) SS-DGT + ERAS (n=15) P-value ASA, Age, Comorbidities NS Duration Sx (median) 6.5 hours 8.0 hours 0.001 Intra-operative IV fluids (median) 4250 ml 3000 ml NS Fluid balance Day 1 (median) 1363 ml 1418 ml NS Fluid balance Day 2 (median) 278 ml 353 ml NS Fluid balance Day 3 (median) 100 ml 170 ml NS Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS Mann-Whitney test
- 27. 27 ERAS only (n=50) SS-DGT + ERAS (n=15) P-value ASA, Age, Comorbidities NS Duration Sx (median) 6.5 hours 8.0 hours 0.001 Intra-operative IV fluids (median) 4250 ml 3000 ml NS Fluid balance Day 1 (median) 1363 ml 1418 ml NS Fluid balance Day 2 (median) 278 ml 353 ml NS Fluid balance Day 3 (median) 100 ml 170 ml NS Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS Mann-Whitney test
- 28. 28 ERAS only (n=50) SS-DGT + ERAS (n=15) P-value ASA, Age, Comorbidities NS Duration Sx (median) 6.5 hours 8.0 hours 0.001 Intra-operative IV fluids (median) 4250 ml 3000 ml NS Fluid balance Day 1 (median) 1363 ml 1418 ml NS Fluid balance Day 2 (median) 278 ml 353 ml NS Fluid balance Day 3 (median) 100 ml 170 ml NS Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS Mann-Whitney test
- 29. Complications 29 80 70 60 50 40 30 20 10 0 Complics No Complics GDT + ERAS ERAS P = 0.02 95% CI: 1.3 to 16 OR: 4.5 % of patients
- 31. How do we use the information from the device?
- 32. Optimize outcomes “Goal Directed Therapy" setting a haemodynamic goal and fitting the patient to the goal “Haemodynamic Optimisation" i.e. looking at the patient and fitting the goal to the patient Who is having a specific operation!!!
- 33. Purpose AHDM • Assess circulatory performance • Determine if CO is consistent with keeping tissue O2 demand
- 34. Purpose AHDM To determine what components of the haemodynamic profile need to adjusted to re-establish consumption-demand balance Pinsky & Payen. Functional haemodynamic monitoring, 2004; 1-4 Pinsky & Payen, Crit Care 2005; 9: 566
- 35. Haemodynamic truth Restoration of MAP may not restore microcirculation i.e. Pressure is NOT flow 35
- 36. Pressure ≠ Flow
- 37. Haemodynamic truth There is no normal cardiac output • Adequate to meet the metabolic demands • Inadequate to meet metabolic demands 37
- 38. AHDM: Proven Outcomes Using a treatment protocol with haemodynamic monitoring (consistently) leads to improved clinical outcomes. BUT WHAT PROTOCOL?
- 39. Two Goal Directed Protocol Philosophies SV Max (Fluid First) Give fluid, observe response, continue to give fluid and other therapies until target achieved Haemodynamic Stability (Observe First) Measure deterioration of clinical condition, titrate therapy using a variety of parameters Variations: • Different “trigger” parameters: SVV, CO/CI, DO2, SvO2 / ScvO2, CVP (declining) • Different philosophies on degree of treatment
- 40. Typical SV-Max Protocol Monitor SV 250 ml fluid over 10 minutes SV increase > 10% Yes SV decrease > 10% Monitor SV
- 42. BJA 2005; 5: 634-642
- 44. Haemodynamic Stability Protocol Is the patient haemodynamically stable? Do Nothing Yes No Is the patient preload-responsive? Yes No Is the patient hypotensive and have reduced vasomotor tone? Yes No Yes No Volume bolus Add Vasopressor Volume bolus Add Vasopressor Add Inotrope Reassess the patient
- 47. Haemodynamic Stability Protocol MAP ≥65 mmHg with NOR And <90 mmHg with nitrates SVV ≤10 >10 CI<2.5 CI≥2.5 Dobu/ Adr3 Or nitrates ≤2 Fluid boluses1 SVV ≤ 10 SVV>10 Fluid2 ScvO2>70% If not Hgb>10 (Transusion of RBC)
- 48. 48 Major surgery
- 50. Preload dependent optimization concept
- 51. Increased cardiac function Normal cardiac function Decreased cardiac function How to measure flow Frank-Starling Curve Preload Stroke Volume Cardiac Output Cardiac Index Mixed Venous % Lactate TOE Stroke Volume IS THE PUMP WORKING?
- 52. Stroke Volume Increased cardiac function Normal cardiac function Decreased cardiac function Frank-Starling Curve Preload IS THE TANK FULL??
- 53. Frank-Starling Curve Stroke Volume Increased cardiac function Normal cardiac function Decreased cardiac function Preload BOTH DIMENSIONS ARE NECESSARY TO OPTIMIZE FLUID STATUS 1. An indication of fluid responsiveness AND 2. A method of verifying that fluid is beneficial to the patient’s status
- 54. 120 mmHg 40 mmHg PPmax Arterial Pressure PPmin PPmax - PPmin (PPmax +PPmin) /2 ΔPP = Am J Respir Crit Care Med 2000; 162:134-138 Threshold PPV > 13 %
- 55. PPV or SVV equals Volume responsive
- 56. PPV or SVV equals Give more fluid
- 59. Effects of vasoconstrictors on the heart ? Raises left afterload -> decreases SV/CO ? Releases blood from peripheral to central veins -> increase CVP and CO
- 60. SV PreSlVoad Preload dependent Phenylephrine increases preload and therefore increases CO
- 61. Preload independent SV PreSlVoad Phenylephrine No increase in stroke volume. No increase in CO, increase in afterload
- 63. Conclusion A threshold PPV value of 16.4% allowed discrimination between phenylephrine-induced increase in SV and phenylephrine-induced decrease in SV (94% sensitivity; 100% specificity).
- 64. Stroke Volume Variation in Hepatic Resection: A Replacement for Standard Central Venous Pressure Ann Surg Oncol. 2013 Oct 23. Results: 40 patients: CVP of -1 to 1 correlated to a SVV of 18-21 (R2 = 0.85, p < 0.001) Conclusion: SVV safely as an alternative to CVP monitoring equivalent outcomes.
- 65. Surgical & Anaesthesia Goals During Major Liver Resection Mobilisation & Control of inflow and outflow Resection Phase Surgical - Blood loss from major hepatic veins or IVC - Pringle manoeuvre (total inflow occlusion of PV & HA) = decrease of CO by 20-30% = CVS compromise - Total hepatic vascular occlusion (tumours close to IVC): occlusion supra & infrahepatic IVC & hepatic pedicle = up to 60% decrease in CO Anaesthesia considerations to reduce portal pressures • Fluid restriction • Reverse trendelenberg • Venodilatation • Venesection • Autologous normovolaemic haemodilution • Diuretics • Low CVP • Monitoring of CO or SvO2 to optimise oxygen delivery 65
- 66. FLUID Challenge 250 mL SV Increases > 10% Dissection & Liver Resection - Fluid restriction - Reverse trendelenberg - Venodilatation to reduce hepatic pressure - Venesection & autologous haemodilution - Low PEEP - Low dose vasopressor Low Normal/High Do nothing MAP Cardiac Index Inodilator <20% Baseline High/Normal High/Normal Vasoconstrictor B-Blocker / antihypertensive/ diuretic Cardiac Index Inotrope Within 20% baseline > 20% baseline Decrease /stop vasoconstrictor Adequate anaesthesia? Adequate analgesia? Adequate muscle relaxation? Cardiac Index Low Low Inodilator/ Vasodilator Yes Assess volume responsiveness Re-assess Volume Responsiveness Optimal oxygen delivery? Heart rate optimized? Adequate oxygenation? Correct severe anaemia? Correct hypothermia? < 25% > 25%
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- 69. Surgical & Anaesthesia Goals During Major Liver Resection Confirmation of haemostasis & closure Surgical - Argon Beam to hepatic veins - Coagulation & fibrin glues - Haemostasis/control of bleeding Anaesthesia considerations - restoration of circulating blood volume • Return of autologous blood • Normalise CVP/SVV • Avoid hypervolaemia • Monitoring of CO or SvO2 to optimise oxygen delivery 69
- 73. FLUID Challenge 250 mL SV Increases > 10% Low Normal/High Do nothing MAP Cardiac Index Inodilator <20% Baseline High/Normal High/Normal Vasoconstrictor Optimal oxygen delivery? Heart rate optimized? Adequate oxygenation? Correct severe anaemia? Correct hypothermia? B-Blocker / antihypertensive/di uretic Cardiac Index Inotrope Within 20% baseline > 20% baseline Decrease /stop vasoconstrictor Adequate anaesthesia? Adequate analgesia? Adequate muscle relaxation? Cardiac Index Low Low Inodilator/ Vasodilator < 20% > 20% Yes Major pancreatic surgery Assess volume responsiveness Re-assess Volume Responsiveness
- 74. 74 • All patients ERAS; n= 129 Hypothesis • SS-GDT + ERAS vs. ERAS alone
- 75. 75 ERAS only (n=25) SS-GDT + ERAS (n=104) P-value Resection volumes 375 g 450 g NS Duration Sx (median) 4.3 hours 6.0 hours 0.0001 Intra-operative IV fluids (median) 3000 ml (1375-4000) 3000 ml (2000-3738) NS Fluid balance Day 1 (median) 3000 ml (2200-4000) 3054 ml ( 2050-4133) NS Length of stay (median) 6.6 days (IQR: 5.5-9) 7 days (IQR: 5.7-11) NS
- 76. 76 ERAS only (n=25) SS-DGT + ERAS (n=104) P-value Resection volumes 450 g 375 g 0.24 Duration Sx (median) 4.3 hours 6.0 hours 0.0001 Intra-operative IV fluids (median) 3000 ml (1375-4000) 3000 ml (2000-3738) NS Fluid balance Day 1 (median) 3000 ml (2200-4000) 3054 ml ( 2050-4133) NS Length of stay (median) 7 days (IQR: 5.7-11) 6.6 days (IQR: 5.5-9) NS
- 77. Complications 77 80 70 60 50 40 30 20 10 0 Complics No Complics GDT + ERAS ERAS P = 0.47 95% CI: 0.2 to 1.7 OR: 0.6 % of patients
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- 80. 80 40 35 30 25 20 15 10 5 0 Stroke Volume Variation (%) - all patients Time (standardised)
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- 82. 82 “The proposed algorithm of DGT induced some patients the additional application of inotropes” Safety needs to be clarified?
- 83. • 22 RCT’s reporting CVS complications • 2129 patients • DGT: reduction in CVS complications • Subgroup analysis (supra-normal DO2 : most benefit from GDT 83
- 84. 84 “GDT better than liberal fluid therapy, but whether GDT is superior to a restrictive fluid strategy remains uncertain”
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- 88. Concluding thoughts • Consensus: advanced haemodynamic monitoring is better than not monitoring • AHDM: diagnostic and haemodynamic monitoring tools: NOT therapeutic interventions • Consensus: goals are needed! • Approaching consensus that protocols (reproducible care practices) are better than no protocols, but still some dissenting opinions. • Individualize treatment for certain operations
- 89. Thank you