Making the case for
implementing goal directed
therapy
Bobbi Leeper RN or Kathryn Von Rueden RN
Senior Education Consultants
Edwards Lifesciences
What is the Problem?
• Traditional end-points of resuscitation are often
misleading and inadequate.
• Poor outcomes are due to inability to meet
oxygen demands and development of oxygen
debt.
• Targeting specific hemodynamic and
oxygenation goals improve outcomes.
• Challenges exist to implement goal directed
therapy despite known benefits.
MAP maintained with 15 - 18%
blood loss
• Pressure is determined
by resistance and flow.
P=RxF
• Pressure is not a good
indicator of flow.
• Up to approximately 15 18 % of blood volume
may be lost and pressure
will be maintained by an
increase in resistance.
CVP and PAOP:
Poor Predictors of Fluid Status
• Kumar et al. CCM 2004
• Pressure based indices did not correlate to volume or change
in stroke volume after a fluid bolus.
Pre-fluid bolus
Post fluid bolus
Pre-fluid bolus
Post fluid bolus
Dynamic vs. Static Parameters
Predicting SVI changes >= 5%, CI > 15%
Cannesson 2009 & Michard 1999
Cardiorespiratory Monitoring:
• Optimize the balance between oxygen supply
and demand
• Maximize delivery to enhance oxygen utilization
• Protect against tissue hypoxia
Cardiorespiratory System:
3 Step Process
• Pulmonary Gas
Exchange
– Ventilation
• Oxygen Delivery
– Perfusion
• Systemic Gas
Exchange
– Oxygen Utilization
The Balance
Compensatory Mechanisms
• Maintain Balance between Oxygen Delivery and
Demand
– 1. Increase cardiac output: Heart rate first
– 2. Redistribution of blood flow
– 3. Increase oxygen extraction
Cardiorespiratory Assessment
Oxygen Delivery:
DO2 = CO x CaO2 x 10
= 950 - 1150 ml/min
DO2I = 400 – 500 ml/min/m2
[ CO2 = (1.38 x Hgb x SO2) + (0.0031 x PO2)]
Oxygen Consumption:
VO2 = CO x (CaO2 – CvO2) x 10 =
200 - 250 ml/min
VO2I = 120 – 160 ml/min/m2
Indexed values are multiplied by CI
VO2/ DO2 Relationship:
DO2 = CaO2 x CO x 10
=
1000 ml/min
VO2 = CO x (CaO2 - CvO2) x 10
=
250 ml/min
O2ER = VO2/DO2 = (250/1000)
=
.25
O2ER = Oxygen extraction ratio
Conceptual VO2 / DO2 Relationship
Implications of Oxygen Debt:
Factors Influencing accumulation of Oxygen Debt:




O2 Demand > O2 Consumed = O2 Debt
Decreased oxygen delivery
Decreased cellular extraction
Increased demands
Pay back
Interest
VO2
150
ml/min
O2
Debt
TIME
Timing or Targets?
Rivers Calls for EGDT
EGDT: The Targets
CVP
MAP
ScvO2
Surviving Sepsis Campaign Results
(CCM 2010;38(2))
252 sites, 18 countries, n=15,775
165 sites used (excluded sites with < 20 pts)
Final n=15,022
2 year follow up
Mortality reductions:
7 % Absolute Risk Reduction 37% to 30.8% p=.001
5.4 % Risk Adjusted Decrease
1st 6 hr bundle compliance increased
10.9% to 30.1%
Impact of SSC protocols on LOS &
mortality in septic shock
No
Bundle
With
Bundle
Mortality
57.3 %
37.5 %
Hospital
LOS
41 d
36.2 d
ICU LOS
11 d
8.4 d
N= 384 septic patients vs.
historical control
• Compliance with 6 hr
bundle associated with
reduced mortality
• Achievement of
ScvO2/SvO2 >70%
associated with
improved mortality
Ortega et al: CCM 2010;38:1036-1043
Bundled
care for
severe
sepsis
Barochia AV, et al: Bundled care for severe sepsis: Analysis of clinical trials CCM 2010;38(2)668-678
Timing or Targets or BOTH?
O2ER in High Risk Surgery
• Conclusions: Early
treatment directed to
maintain O2ER at <
27% reduces organ
failures (27 failures
vs. 9 failures, p <
• A prospective, randomized,
0.001) and hospital
controlled multi-center trial.
stay (11.3 3.8 days vs.
13.4 6.1 days, p <
• 135 high-risk major
0.05) of high-risk
abdominal surgery.
surgical patients.
O2ER as a target
Does timing matter?
• Critical illness increases
metabolic demand
• Cardiovascular system
must meet demand to
avoid tissue hypoxia
• Development of tissue
hypoxia correlates with
survival rate
Pay back
VO2
Interest
150
ml/min
O2
Debt
TIME
Kern & Shoemaker CCM 2002
21 Studies Reviewed
Impact of GDT on Mortality
Hamilton, Cecconi, Rhodes , Anesth Analg 2010: accessed on-line 3/17/2011 2010
Goal-directed therapy in high-risk surgical
patients: a 15-year follow-up study
• Alive at 15 yrs:
11(20.7%) EGDT pts vs.
4 (7.5%) control (p=0.09)
• Median survival EGDT
group was increased by
1,107 days (>3yrs)
(1,781 vs. 674 days, p=0.005)
• LT survival associated w/
age, no post-op cardiac
complications, EGDT
Rhodes, A. et al: Intens Care Med. 2010
Lees CC 2009 HRS Algorithm (modified)
Identify high-risk surgical patient
Shoemaker/Boyd criteria, POSSUM
Establish functional capacity
Ensure optimum management of chronic disease and acute physiology
Refer to AHA/ACC Guidelines
Surgery
Institute flow monitoring and goal-directed fluid therapy pre-op and intra-op if possible
Admit to ICU post-op
Institute flow monitoring
Ensure adequate oxygenation and hct
Target oxygen delivery/tissue perfusion goals
DO2I > 600ml/min/M2, CI > 4.5l/min/M2
Fluid until not fluid responsive, add
inodilator if goals not achieved
Maintain monitoring and goals
For up to 8 hours
Making the case for implementing goal
directed therapy
CAUTION: Federal (United States) law restricts this device to sale by or on the order of a
physician. See instructions for use for full prescribing information, including indications,
contraindications, warnings, precautions and adverse events.
Bobbi Leeper and Kathryn Von Rueden are paid consultants of Edwards Lifesciences. Any
quotes used in this material are taken from independent third-party publications and are
not intended to imply that such third party received or endorsed any of the products of
Edwards Lifesciences.
As a member of the Advanced Medical Technology Association ("AdvaMed"), Edwards
Lifesciences strictly adheres to the requirements of the AdvaMed Code of Ethics regarding
interactions with health care professionals. Edwards Lifesciences wishes to disclose that
all speakers, instructors and panel members will receive compensation and reimbursement
of reasonable travel expenses from Edwards Lifesciences for their services in full
compliance with all applicable laws, rules and regulations, including the AdvaMed Code of
Ethics.
Edwards, Edwards Lifesciences, the stylized E logo, FloTrac, Vigileo and PreSep are
trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of
their respective owners. ©2011 Edwards Lifesciences Corporation. All rights reserved.
AR06158