Financial Disclosures
Perioperative Goal Directed Therapy
Modern Approach to Fluid Management:
Physiological Background and Evidence
Air Liquide
Bayer
Biosyn
Edwards
Orion
Prostrakran
Schering
Prof. Dr. Steffen Rex
Department of Anesthesiology, University Hospitals Leuven
Department of Cardiovascular Sciences, KU Leuven
Belgium
[email protected]
Perioperative Goal Directed Therapy
Why?
Anesthesia-related mortality
Perioperative Goal Directed Therapy
Why?
Perioperative mortality
~ 1:100.000
Bainbridge D. et al.
Perioperative and anaesthetic-related mortality in developed and developing
countries: a systematic review and meta-analysis.
Lancet 2012; 380: 1075–81
Perioperative Goal Directed Therapy
Pearse R. et al.
Mortality after surgery in Europe:
a 7 day cohort study.
Lancet 2012; 380: 1059–65
Perioperative Goal Directed Therapy
1
Why do patients die perioperatively?
Most Common Post-Surgical Complications
Why?
Perioperative mortality
Leading causes of death
Germany, 2011
91
22
01
Gastro-intestinal
— Nausea and vomiting
— Ileus (paralytic or functional)
— Acute bowel obstruction
— Anastomotic leak
— Gastro-intestinal hypertension
— Hepatic dysfunction
— Pancreatitis
60
200000
0
Total
Cardiovascular
diseases
Malignancies
Respiratory
diseases
1000000
0
Statistisches Bundesamt,
Wiesbaden 2013,
www.destatis.de
95
46
Total
Cardiovascular Malignancies
diseases
Perioperative
deaths
9
Neuro
— Stroke or cerebro-vascular accident
— Coma
— Altered mental status or cognitive dysfunction or
delirium
Respiratory
— Prolonged mechanical ventilation (>48h)
— Unplanned intubation or reintubation
— Respiratory failure or ARDS
— Pleural effusion
Hematology
— Bleeding requiring transfusion
— Anemia
— Coagulopathy
01
60
200000
18
15
91
22
33
In-hospital mortality 2.5%
22
400000
7,387,816 in-patient
surgical procedures
34
600000
852328
800000
Cardiovascular
— Deep venous thrombosis
— Pulmonary embolism
— Myocardial infarction
— Hypotension
— Arrhythmia
— Cardiogenic pulmonary edema
— Cardiogenic shock
— Infarction of GI track
— Distal ischemia
— Cardiac arrest (exclusive of death)
9
22
400000
34
600000
Infection
— Pneumonia
— Urinary tract infection
— Superficial wound infection
— Deep wound infection
— Organ-space infection
— Sepsis or septic shock
33
852328
800000
15
1000000
Respiratory
diseases
Renal
— Renal insufficiency (increase in creatinine levels
or decrease in urine output)
— Renal failure (requiring dialysis)
Other
— Vascular graft of flap failure
— Wound dehiscence
— Peripheral nerve injury
— Pneumothorax
http://www.patient.co.uk/doctor/common-postoperative-complications
Ghaferi et al. Variation in hospital mortality associated with inpatient surgery. New Engl J Med 2009
Perioperative Goal Directed Therapy
Why do patients die perioperatively?
Post-Surgical Complications: Frequency
Perioperative Goal Directed Therapy
Why?
Post-Surgical Complications: Predictability
Complication rates depend on the
surgical procedure
• 
N = 84,730
• 
American College of Surgeons National
Surgical Quality Improvement Program
Surgery
Morbidity rate %
Esophagectomy
55.1
• 
Complication rate: 24.6 - 26.9%
Pelvic exenteration
45.0
• 
Major complication rate: 16.2 - 18.2%
Pancreatectomy
34.9
• 
Mortality from major complications:
12.5% - 21.4%
Colectomy
28.9
Gastrectomy
28.7
Ghaferi A. et al.
Variation in hospital mortality associated with inpatient surgery.
N Engl J Med 2009;361:1368-75
Perioperative Goal Directed Therapy
N= 129,233
Schilling P et al.
Prioritizing Quality Improvement in General Surgery.
J Am Coll Surg. 2008; 207:698–704.
Liver resection
27
Perioperative Goal Directed Therapy
2
Why?
Post-Surgical Complications: Predictability
Why?
Post-Surgical Complications: Predictability
Complication rates depend on the patient
Risk factor
N= 129,546
Odds ratio
ASA 4/5 vs 1/2
1.9
ASA 3 vs 1/2
1.5
Dyspnea at rest vs. none
1.4
History of COPD
1.3
Dyspnea with minimal exertion
vs. none
1.2
Khuri S et al.
Successful Implementation of the Department of Veterans Affairs’
NSQIP in the Private Sector: The Patient Safety in Surgery Study.
Ann Surg. 2008 Aug;248(2):329-36.
Pearse R. et al.
Mortality after surgery in Europe:
a 7 day cohort study.
Lancet 2012; 380: 1059–65
Perioperative Goal Directed Therapy
Perioperative Goal Directed Therapy
Boltz et al.
Table 3. Multivariate Linear Regression Analysis of Length of Stay Associated With Postoperative Events
Postoperative Event
Why?
Post-Surgical Complications: Costs
$18,000
average extra cost for treating a patient with one or
more post-surgical complications
2250 Patients
Undergoing General and Vascular Surgery
Extra costs may include:
•  Treatment (e.g., antibiotics,
reintervention, anticoagulation)
•  Laboratory tests
•  Diagnostics
•  Prolonged hospital length of
stay
•  Increased readmissions
•  Decreased patient throughput
Boltz M. et al.
Synergistic Implications of Multiple Postoperative Outcomes.
Am J Med Qual. 2012 Sep-Oct;27(5):383-90.
Perioperative Goal Directed Therapy
Events, n (%)
Cardiac arrest requiring CPR
5 (0.22)
Cerebrovascular accident
1 (0.04)
Transfusion requirement
3 (0.13)
Intubated >48 hours
9 (0.40)
Other cardiac occurrence
3 (0.13)
Other wound occurrence
12 (0.53)
Graft/prosthesis failure
8 (0.36)
Other occurrence
12 (0.53)
Wound dehiscence
6 (0.27)
Surgical site infection
86 (3.80)
Myocardial infarction
2 (0.09)
Venous thromboembolism
21 (0.93)
Urinary tract infection
16 (0.71)
Renal insufficiency
2 (0.09)
700
Schilling et al
Improving Quality of Care in General Surgery
J Am Coll Surg
Sepsis
17 (0.76)
Pneumonia
8 (0.36)
Ventilator dependence
6 (0.27)
Septic shock
4 (0.18)
Table 1. Relative Contribution of 36 Procedures to Adverse Events and Excess Length of Stay in General Surgery, American
Acute renal failure with hemodialysis
4 (0.18)
College of Surgeons – National Surgery Quality Improvement Program, 2005–2006
Postoperative events = 2
104 (4.62)
Average
excess
Proportion
Postoperative events = 3+
127 (5.64) of
Procedures
Proportion of
length of stay
all excess
% of
Adverse eventAbbreviations:
all adverse
for adverse
CPR, cardiopulmonary
resuscitation. length of
Procedure
n
total
rate, %
events, %
event, d
stay, %
Why?
Post-Surgical Complications: Length of stay
95% Confidence
Marginal
Effect, days
Lower
Upper
−3.90
−1.31
−0.96
0.19
0.22
0.87
0.98
1.54
2.07
2.14
2.15
2.45
3.02
3.67
4.94
6.95
8.81
10.62
11.78
5.18
11.01
−4.98
−7.47
−4.77
−2.58
−4.64
−1.80
−2.34
−1.41
−2.41
0.93
−5.75
−0.08
−0.07
−5.70
1.24
0.57
0.17
−1.14
−0.73
3.65
8.81
−2.83
4.84
2.86
2.96
5.08
3.53
4.30
4.49
6.54
3.34
10.06
4.99
6.10
13.04
8.64
13.34
17.46
22.39
24.29
6.71
13.21
1. Colectomy ! colostomy
12,767 9.9
28.9
24.3
9.8
23.5
2. Small intestine resection
3,576 2.8
32.9
7.7
13.9
10.6
3. Cholecystectomy/inpatient
11,718 9.1
7.5
5.7
8.7
4.9
Schilling
P et hernia
al.
4. Ventral
repair
7,477 5.8
10.1
4.9
6.3
3.1
Prioritizing Quality Improvement in General Surgery.
Pancreatectomy
1,927 1.5
34.9
4.4
6.8
3.0
J5.Am
Coll Surg. 2008; 207:698–704.
6. Appendectomy
9,016 7.0
7.2
4.3
4.4
1.9
7. Bariatric procedures
6,167 4.8
8.3
3.4
3.7
1.2
8. Proctectomy ! colectomy ! anastomosis
1,402 1.1
31.5
2.9
6.2
1.8
9. Lysis of adhesions
1,323 1.0
23.1
2.0
10.5
2.1
10. Liver resection
1,045 0.8
27.0
1.9
8.8
1.6
11. Mastectomy/simple, radical, or
subcutaneous
4,313 3.3
5.6
1.6
0.9
0.1
12. Cholecystectomy/outpatient
12,258 9.5
1.8
1.5
0.9
0.1
13. Gastrectomy/total or partial
731 0.6
28.7
1.4
11.8
1.6
14. Lumpectomy ! axillary lymph node
dissection
10,270 7.9
2.0
1.4
1.2
0.2
Undergoing
15. Gastrorrhaphy/perforation or bleeding ulcer 2250
451 Patients
0.3
40.6
1.2
16.1
1.9
and0.2Vascular
Surgery 1.0
16. Suture small or large bowel perforation General
301
49.5
12.5
1.2
17. Fundoplasty or paraesophageal hernia repair
1,871 1.4
7.9 Boltz M. et al. 1.0
10.7
1.0
18. Esophagectomy/total or near total
254 of0.2
55.1 Outcomes. 0.9
11.6
1.1
Synergistic Implications
Multiple Postoperative
Am J Med
19. Splenectomy/total or partial
659
0.5Qual. 2012 Sep-Oct;27(5):383-90.
20.2
0.9
13.2
1.1
20. Gastrojejunostomy
381 0.3
34.9
0.9
10.6
0.9
Figure 1. Cumulative
length of19.5
stay and cumulative 1.6
cost of postoperative events
Perioperative
21. All fistula repairs
362 0.3Goal Directed
34.0 Therapy
0.8
22. Inguinal or femoral hernia repair/inpatient
1,452 1.1
7.7
0.7
6.1
0.4
23. Inguinal or femoral hernia repair/outpatient
9,509 7.4
1.1
0.7
0.2
0.01
24. Above- or below-knee amputation
307 0.2
31.3
0.6
9.2Downloaded from ajm.sagepub.com
0.6 at KU Leuven University Library on November 21, 2014
25. Debridement for necrotizing soft tissue
infection
222 0.2
43.2
0.6
20.5
1.3
26. Bilioenteric anastomosis
278 0.2
33.5
0.6
8.9
0.5
27. Drain peritoneal abscess/not appendiceal
188 0.1
47.3
0.6
17.5
1.0
28. Debride pancreas
128 0.1
69.5
0.6
26.6
1.5
29. Thyroidectomy/total or subtotal
5,192 4.0
1.7
0.6
3.8
0.2
30. Excision of intraabdominal or
retroperitoneal tumor
429 0.3
18.4
0.5
9.0
0.5
31. Parathyroidectomy
2,521 2.0
2.1
0.3
5.5
0.2
32. Vagotomy and other gastric procedures
655 0.5
6.7
0.3
10.0
0.3
33. Adrenalectomy
480 0.4
8.5
0.3
12.2
0.3
34. Reduction of volvulus, intussusception, or
hernia by laparotomy
138 0.1
22.5
0.2
12.6
0.3
35. Pelvic exenteration
40 0.03
45.0
0.1
11.1
0.1
36. Toe or foot amputation
33 0.02
39.4
0.1
2.5
0.02
DISCUSSION
We found that a small number of operations account for a
disproportionate share of morbidity, mortality, and excess
length of stay in general surgery. Colectomy registered the
greatest share of adverse events followed by small intestine
resection, inpatient cholecystectomy, ventral hernia repair,
and pancreatic resection. These procedures account for a
large proportion of overall adverse events because they are
frequently performed, associated with high baseline risk, or
both. Baseline risks, as for the latter, are no doubt a func-
3
PERIOPERATIVE MEDICINE
Ø  Postoperative
complications:
Most significant
independent risk factor
for readmission
Ø  Any post-surgical
complication increases
the risk of readmission
by a factor of four
Why?
Post-Surgical Complications: Long-term survival
HR for mortality
Why?
Post-Surgical Complications: Re-Admission
Relationship between Intraoperative Mean
Arterial Pressure and Clinical Outcomes after
Noncardiac Surgery
Toward an Empirical Definition of Hypotension
.JDIBFM8BMTI.%1IJMJQ+%FWFSFBVY.%1I%p"NJU9(BSH.%1I%q
"OESFB,VS[.%f"MQBSTMBO5VSBO.%║3FJU[F/3PETFUI.%+BDFL$ZXJOT
-FIBOB5IBCBOF1I%pp%BOJFM*4FTTMFS.%qq
[odds ratio: 4.20;
95% CI: 2.89–6.13]
Kassin M et al.
Risk Factors for 30-Day Hospital Readmission
among General Surgery Patients.
J Am Coll Surg 2012;215:322–330.
ABSTRACT
Moonesinghe SR et al.
Survival after postoperative morbidity: a longitudinal observational cohort study
British Journal of Anaesthesia 113 (6): 977–84 (2014).
Perioperative Goal Directed Therapy
What We Already Know about This
t 6OEFSTUBOEJOH JOUSBPQFSBUJWF FWFOUT UI
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Perioperative Goal Directed Therapy
Background: Intraoperative hypotension may contribute
to postoperative acute kidney injury (AKI) and myocardial
injury, but what blood pressures are unsafe is unclear. The
authors evaluated the association between the intraoperative
What This Article Tells Us That Is N
t 5IJTSFUSPTQFDUJWFBOBMZTJTFYBNJOFENFB
EFUFSNJOF QSFEJDUPST PG QPTUPQFSBUJWF N
JUZJOOPODBSEJBDTVSHJDBMQBUJFOUTJOBEB
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UBUJPOTPGSFUSPTQFDUJWFBOBMZTFTNVTUCF
* Assistant Professor, Departments of Medicine, and Clinical
Epidemiology and Biostatistics, McMaster University, Hamilton,
Ontario, Canada. † Associate Professor, Departments of Medicine,
and Clinical Epidemiology and Biostatistics, and the Population
Health Research Institute, McMaster University, Hamilton Health
Sciences, Hamilton, Ontario, Canada. ‡ Professor, Departments of
Medicine, and Epidemiology and Biostatistics, Western University, London, Ontario, Canada. § Professor, ║ Associate Professor, ‡‡ Professor and Department Chair, Department of Outcomes
Research, ** Assistant Professor, Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland,
Ohio. # Research Fellow, Department of Anesthesia, University of
KwaZulu-Natal, Durban, South Africa, and Department of Clinical
Epidemiology and Biostatistics, McMaster University. †† Professor,
Department of Clinical Epidemiology and Biostatistics, McMaster
University.
Received from the Departments of Medicine, and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario,
Canada. Submitted for publication September 13, 2012. Accepted
for publication May 22, 2013. Dr. Walsh is supported by a New
Investigator Award from the Kidney Research Scientist Core Education and National Training program funded by the Canadian
Institutes of Health Research, Kidney Foundation of Canada and
Canadian Society of Nephrology (Montreal, Quebec, Canada). Dr.
Devereaux is supported by a Career Investigator Award from the
Heart and Stroke Foundation of Ontario (Ottawa, Ontario, Canada).
Dr. Garg is supported by a Clinician Scientist Award from the Canadian Institutes of Health Research (Ottawa, Ontario, Canada). The
authors declare no competing interests.
Address correspondence to Dr. Walsh: Nephrology and Transplantation, Marian Wing, St. Joseph’s Hospital, 50 Charlton Avenue
E, Hamilton, Ontario, Canada L8N 4A6. [email protected].
This article may be accessed for personal use at no charge through
the Journal Web site, www.anesthesiology.org.
mean arterial pressure (MAP) and the ris
cardial injury.
Methods: The authors obtained peri
33,330 noncardiac surgeries at the Clev
The authors evaluated the association bet
MAP from less than 55 to 75 mmHg and
and myocardial injury to determine the
where risk is increased. The authors then
ciation between the duration below this
outcomes adjusting for potential confou
Results: AKI and myocardial injury d
(7.4%) and 770 (2.3%) surgeries, resp
threshold where the risk for both outc
Post-Surgical Complications:
How to avoid?
•  Perioperative mortality/morbidity is still
inacceptably high
•  Complications are not exceptions
•  Complications are costly
•  Complications are responsible for prolonged
LOS and readmissions
•  Complications affect long-term survival
Perioperative Goal Directed Therapy
◇ 5IJT BSUJDMF JT GFBUVSFE JO i5IJT .POUI
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#SBEZ , )PHVF $8 +S *OUSBPQFSBUJWF I
UJFOUPVUDPNF%PFTPOFTJ[FmUBMM "/
o
Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott
Williams & Wilkins."OFTUIFTJPMPHZ
"OFTUIFTJPMPHZ7t/P
MAP <55 mmHg.
507
n = 33.330
Perioperative Goal Directed Therapy
4
Post-Surgical Complications:
How to avoid?
Morbidityñ
HOW
Morbidityñ
YOU
O
D
Bundgaard-Nielsen M. et al.
‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy –
a critical assessment of the evidence.
Acta Anaesthesiol Scand 2009; 53: 843–851
Identification of the target zone:
Trial and error?
W?
O
N
K
TARGET ZONE
Michard F.
Predicting Fluid Responsiveness in ICU Patients. A Critical Analysis of the Evidence
CHEST 2002; 121:2000–2008
Perioperative Goal Directed Therapy
Perioperative Goal Directed Therapy
1144
HABICHER ET AL
Fig 1. Relationship between perioperatively administered fluid
volume and postoperative morbidity, and factors influencing the
shift of the curve (arrow). Boxes indicate the risk of complications
associated with deviation from normovolemia. SIRS, systemic inflammatory response syndrome; PONV, postoperative nausea and
vomiting. (Reprinted with permission.12)
mary, these studies suggest individualized goal-directed volume management as a promising approach to improve outcome in cardiac surgical patients.
HOW TO MONITOR GOAL-DIRECTED THERAPY IN
CARDIAC SURGERY
Pressure-Based Parameters
Adequate fluid loading is a prerequisite for hemodynamic
optimization of surgical patients. This is especially true for
cardiac patients in whom alterations in the cardiac performance
curve caused by underlying cardiac disease limit their tolerance
to hyper- or hypovolemia. The estimation of volume status
using clinical parameters alone is not sufficient for the early
recognition of fluid deficiency or overload to implement targeted treatment.24 Thus, volume status imbalances frequently
are not recognized at all or are recognized too late, with drastic
consequences for the hemodynamic stability of these patients.24,25 To date, filling pressures have been the standard
approach in clinical practice to assess the hemodynamics and
the volume status. Still, international guidelines use filling
pressures as a resuscitation endpoint.26 A recent survey of
cardiosurgical ICU specialists showed that CVP is used for
monitoring volume therapy 87% of the time followed by MAP
with 84% and PCWP with 30%.27
The limitations of pressure-based parameters, which are influenced by cardiac compliance, intra-abdominal pressure, airway pressure, pulmonary vascular resistance, and cardiac pathologies such as tricuspid regurgitation and congestive heart
failure, increasingly have been recognized.28 Only 1 study by
Bennett-Guerrero et al29 concluded that a PCWP !10 mmHg
could serve as a predictor for an increase in stroke volume after
fluid challenge with a sensitivity of 68% and a specificity of
79%. In this study, 19 patients undergoing primary coronary
artery bypass graft (CABG) surgery were included. After the
induction of anesthesia, a bolus of 250 mL of 6% hydroxyethylstarch (HES) was administered. The patient was classified as
a responder when the stroke volume increased by more than
10% after the fluid challenge. The responders had a significantly lower PCWP than nonresponders. In all other studies,
these results could not be reproduced. A study by Wiesenack et
al30 compared the single transpulmonary thermodilution technique with pressure-based parameters by PAC as an indicator
for cardiac preload. In patients undergoing CABG surgery,
hypovolemia was evaluated by a CVP !10 mmHg and PCWP
!12 mmHg. A fluid challenge was performed with 7 mL/kg of
6% HES. The measurement after fluid loading showed significant increases of CVP and PCWP, but this increase did not
Identification of the target zone:
Fixed volume regimen?
Identification of the target zone:
Static preload parameters (CVP, volumetry) ?
only observed 50 times (54%). Overall,
the fluid responsiveness was poorly predicted by a PAOP of !12 mm Hg: sensitivity, 77% (95% CI, 65– 87%); specificity,
51% (95% CI, 40 – 62%); PPV, 54%;
NPV, 74%.
„Restrictive fluid management“:
Pre-Infusion
•  reduced morbidity in
gastrointestinal surgery
•  Open questions:
§  Effects in other surgical
disciplines?
Fig 2. Rates of postoperative major GI complications for each of the
studies with ORs and 95% CIs. The
studies were divided into 2 subgroups defined as high risk of bias
and low risk of bias. The pooled OR
and 95% CI are shown as the total.
The size of the box at the point estimate of the OR gives a visual representation of the weighting of the
study. The diamond represents the
point estimate of the pooled OR and
the length of the diamond is proportionate to the CI. (Reprinted with permission.16)
§  What
Combination of Central Venous
Pressure and PAOP
is restrictive?
Figure 2. Individual values (open circles) and mean " SD (closed circles) of pre-infusion central venous
pressure (CVP) (both expressed in millimeters of mercury) in responders (R) and nonresponders (NR).
ΔCI > 15%
Osman D. et al.
Cardiac filling pressures are not appropriate to predict
hemodynamic response to volume challenge.
Crit Care Med 2007; 35:64–68
ΔCI < 15%
From our data, 8 mm Hg of central
venous pressure and 11 mm Hg of PAOP
were the optimal threshold values. If a
patient had a central venous pressure of
!8 mm Hg and a PAOP of !11 mm Hg,
he or she was likely to be responder, with
a sensitivity of 35%, a specificity of 71%,
a PPV of 54%, and a NPV of 63%.
Combination of Cardiac Filling
Pressures and SVI
Central Venous Pressure and SVI. The
significance of central venous pressure to
predict a hemodynamic response to volume
in patients with low SVI (!30 mL·m$2)
was evaluated in that population (condition
observed in 61 instances). The area under
the ROC curve was only 0.54 (95% CI,
Perioperative Goal Directed Therapy0.40 – 0.67%). When a pre-infusion central
venous pressure of !8 mm Hg was associated with a low SVI (!30 mL·m$2), the
positive prediction was higher than in the
Figure 3. Individual values (open circles) and mean " SD (closed circles) of pre-infusion pulmonary
overall population but still unsatisfactory:
artery occlusion pressure (PAOP) (both expressed in millimeters of mercury) in responders (R) and
sensitivity, 38%; specificity, 63%; PPV,
nonresponders (NR).
61%; NPV, 39%.
PAOP and SVI. The value of PAOP to
geted in spontaneous breathing patients PAOP
predict a hemodynamic response to voland a central venous pressure of 12 mm Hg
ume in patients with a low SVI (!30
The pre-infusion PAOP was significantly mL·m$2) was also evaluated. The area
in mechanically ventilated patients. In our
study, because all patients received me- lower in responders than in nonresponders under the ROC curve was only 0.59 (95%
chanical ventilation, we also tested this (10 " 4 vs. 11 " 4 mm Hg, p ! .05), but a CI, 0.45– 0.72%). When a pre-infusion
value. A pre-infusion central venous pres- large overlap of individual values was ob- PAOP of !12 mm Hg was associated with
sure of !12 mm Hg was observed 114 served between the groups (Fig. 3).
an SVI of !30 mL·m$2, the positive preThe area under the ROC curve was diction of volume responsiveness was
times (76%). For those patients, fluid responsiveness was observed only 53 times only 0.63 (95% CI, 0.55– 0.70) and was higher but still poor: sensitivity, 78%;
(46%). Overall, fluid responsiveness was not statistically greater than that gener- specificity, 46%; PPV, 69%; NPV, 58%.
poorly predicted by a central venous pres- ated for central venous pressure: differsure of !12 mm Hg: sensitivity, 82% (95% ence between areas, 0.053 (95% CI, 0.01– DISCUSSION
CI, 70 –90%); specificity, 28% (95% CI, 19 – 0.12; p # .12).
Our study demonstrates that in septic
The optimal threshold value was 11 mm
39%); PPV, 47%; NPV, 67%.
The prediction was still poor for a very Hg. A pre-infusion PAOP value of !11 mm patients receiving mechanical ventilation,
low value of central venous pressure (!5 Hg predicted fluid responsiveness with a cardiac filling pressures are poor predictors
mm Hg): sensitivity, 23%; specificity, sensitivity of 77% (95% CI, 65– 87%), a of fluid responsiveness, even when each fill80%; PPV, 47%; NPV, 58%. However, specificity of 51% (95% CI, 40 – 62%), ing pressure was interpreted in combination with the knowledge of the other filling
these latter findings must be cautiously a PPV of 54%, and a NPV of 74%.
In the updated guidelines of the Amer- pressure or with SVI. Therefore, we defiinterpreted because the condition of central venous pressure of !5 mm Hg was ican College of Critical Care (2), a PAOP nitely believe that the use of PAOP or cenrelatively rare (only 23 times), probably of !12 mm Hg was recommended to be tral venous pressure as targets for volume
because our patients had been resusci- targeted. A pre-infusion PAOP of !12 resuscitation in patients with sepsis must
tated before the insertion of the pulmo- mm Hg was observed 92 times (61%). For be discouraged. Accordingly, targeting volthose patients, fluid responsiveness was ume therapy to a central venous pressure
nary artery catheter.
Marik P. et al.
Dynamic changes in arterial waveform derived
variables and fluid responsiveness in
mechanically ventilated patients: A systematic
review of the literature.
Crit Care Med 2009; 37:2642–2647
Bundgaard-Nielsen M. et al.
‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy –
a critical assessment of the evidence.
Acta Anaesthesiol Scand 2009; 53: 843–851
Perioperative Goal Directed Therapy
66
Crit Care Med 2007 Vol. 35, No. 1
5
Identification of the target zone:
Blood pressure?
Identification of the target zone:
How?
279
!
es
ic
d
in
d
te
la
e
-r
w
lo to progressive hypovolaemia
f
Fig. 1 The haemodynamic response
r
in healthy volunteers. T baseline,
end of bleed, T prior to retransfusion. p value = significance
of bleed relative to basefo ofT end
line as derived usingo
g repeated measures ANOVA
d
ul
venousopressure monitoring has already been demonRetransfusion
h to be an unreliable indicator of volume status in
strated
s
conditions
of increased vascular tone, such as high catee
states or post-surgical hypothermia [13]. In
Wcholamine
addition to this, central catheter placement is not with279
0
Perioperative Goal Directed Therapy
1
Fig. 2 The tonometric response to progressiv
healthy volunteers. T 0 baseline, T 1 end of ble
transfusion. p value = significance of end of ble
line as derived using repeated measures ANOV
trointestinal intramucosal : arterial CO2 gap als
fall after removal of first aliquot of blood
2
been fatal. One possible explanation fo
the heart rate to compensate for the fa
ume is that the subject did not demonstr
autonomic response. However, there wa
Withdrawal of 25%
subject’s medical history to make us sus
of blood volume
disease. The oesophageal Doppler has
be sensitive to changes in left ventricula
has not been compared to other techniq
Hamilton-Davies
C. et al.
trathoracic
blood volume or transthorac
out morbidity [14].
Comparison of commonly used clinical indicators of
tion of preload changes. It is possible
In spite of the mean rise in hearthypovolaemia
rate of with
17 %,
in no tonometry.
gastrointestinal
subject did the absolute rate constitute Intensive
a clinically
Care Med sig(1997) 23:niques
276–281 may offer earlier warning of re
nificant tachycardia. Subject 6 showed no change in but further investigation is needed.
Perioperative Goal Directed Therapy
Base excess and lactate measuremen
blood pressure until more than 30 % of his blood volFig. 2 The tonometric
to pressure
progressivefell
hypovolaemia
in the acute hypovolaemic state
cation of
ume had been removed,
at which response
point the
healthy
volunteers.
T 0 baseline,
T 1 end of
bleed, T 2 prior
to re- indicating that the time course
probably
dramatically over
seconds,
requiring
immediate
retranstransfusion. p value = significance of end of bleed relative to basecome
abnormal is longer than the peri
fusion. Prior toline
thisaspoint,
the
subject
stated
that
he
had
derived using repeated measures ANOVA. Tonometric gasCurrent theory points to the gut as the
no symptoms of
hypovolaemia,
despite
the
trointestinal
intramucosal
: arterial
COalterations
2 gap also shows significant
fall2 after
of first
aliquot
gapremoval
and the
noted
fallofinblood
stroke vol- fer hypoperfusion as a result of acute h
in pHi and PCO
Fig. 1 The haemodynamic response to progressive hypovolaemia
ume. Had this situation occurred in the face of rapid on- 16, 17]. If lactate production or localised
in healthy volunteers. T 0 baseline, T 1 end of bleed, T 2 prior to reFig. 2to
The
tonometric
response to
progressive
hypovolaemia
in
going
surgical
bleeding,
the
outcome
may well
have in this region, it will be subjected to a
transfusion. p value = significance of end of bleed relative
baseline as derived using repeated measures ANOVA
healthy volunteers. T 0 baseline, T 1 end of bleed, T 2 prior to retransfusion. p value
= significance
of end of
bleed relative
to basebeen
fatal. One
possible
explanation
for this failure of
line as derived using repeated measures ANOVA. Tonometric gasthe heart rate to compensate for the fall in stroke voltrointestinal intramucosal : arterial CO2 gap also shows significant
thatofthe
subject did not demonstrate a reasonable
fall after removal ume
of firstis
aliquot
blood
Fig. 1 The haemodynamic response to progressive hypovolaemia
venous pressure monitoring has already been demonin healthy volunteers. T 0 baseline, T 1 end of bleed, T 2 prior to restratedp value
to be
an unreliable
oftovolume
status in
transfusion.
= significance
of end ofindicator
bleed relative
baseline conditions
as derived usingof
repeated
measures
ANOVA tone, such as high cateincreased
vascular
autonomic response. However, there was nothing in the
subject’s medical history to make us suspect autonomic
oesophageal
Doppler
been fatal. Onedisease.
possible The
explanation
for this failure
of has been shown to
the[13].
heartIn
rate to
forchanges
the fall ininstroke
volbecompensate
sensitive to
left ventricular
filling [15] but
cholamine states or post-surgical hypothermia
that the has
subject
not demonstrate
reasonable
notdidbeen
comparedato
other techniques, such as inaddition to this, central catheter placement is ume
not iswithHowever,
therevolume
was nothing
in the
venous
pressure monitoring
trathoracic
blood
or transthoracic
echo in detecout morbidity
[14]. has already been demon- autonomic response.
strated to be an unreliable indicator of volume status in subject’s medical history to make us suspect autonomic
tion of preload
is possible
that these techIn spite
of thevascular
mean rise
heart
rate
of 17disease.
%, in no
The oesophageal
Dopplerchanges.
has been It
shown
to
conditions
of increased
tone,in
such
as high
catemay
offer earlier
subjectstates
did the
absolute rate
constitute
clinically
sig- to niques
be sensitive
changes in
left ventricular
fillingwarning
[15] but of reduced preload,
cholamine
or post-surgical
hypothermia
[13].a In
has not been
to other
techniques, is
such
as inaddition
to this,
central catheter
placement
is not withbut further
investigation
needed.
nificant
tachycardia.
Subject
6 showed
no change
in compared
trathoracic
or transthoracic
echo in
detecoutblood
morbidity
[14].
Base excess
and lactate
measurements
gave no indipressure
until more than 30 % of his blood
vol-blood volume
tion of preload
changes.
is possible
that these tech- state of the subjects,
In
spite
of the
mean
rise in heart
rate of point
17 %, in
nopressure
ofItthe
acute hypovolaemic
ume
had
been
removed,
at which
the
fell cation
subject did the absolute rate constitute a clinically sig- niques may offer earlier warning of reduced preload,
probably
indicating
that
the
time
course for these to bedramatically
over
seconds,
requiring
immediate
retransnificant tachycardia. Subject 6 showed no change in but further investigation is needed.
abnormal
is longer
the period of the study.
fusion.
Prior
tomore
this point,
subject
stated
he had
excesscome
and lactate
measurements
gavethan
no indiblood
pressure
until
than 30the
% of
his blood
vol- thatBase
Current
theory points
the
gut as the first area to sufsymptoms
of hypovolaemia,
cation of the acute
hypovolaemic
state oftothe
subjects,
umeno
had
been removed,
at which point thedespite
pressure the
fell alterations
that the time course
these to
dramatically
overPCO
seconds,
requiring immediate retrans- probably indicating
fer hypoperfusion
as aforresult
ofbeacute hypovolaemia [8,
in pHi and
2 gap and the noted fall in stroke volis 17].
longer
the production
period of the or
study.
fusion.
Prior
to this
the subject
statedinthat
had ofcome
ume.
Had
thispoint,
situation
occurred
theheface
rapidabnormal
on- 16,
If than
lactate
localised acidosis occurs
no symptoms of hypovolaemia, despite the alterations Current theory points to the gut as the first area to sufgoing
thefall
outcome
have in this
region,
it will
be subjected
and the noted
in stroke may
vol- well
fer hypoperfusion
as a result
of acute
hypovolaemia
[8, to a large dilutional
in pHi
and surgical
PCO gapbleeding,
2
ume. Had this situation occurred in the face of rapid ongoing surgical bleeding, the outcome may well have
Identification of the target zone:
The importance of flow
16, 17]. If lactate production or localised acidosis occurs
in this region, it will be subjected to a large dilutional
Identification of the target zone:
The Frank Starling Curve
Stroke Volume
Preload-independent,
i.e. volume-unresponsive
HYPO
TARGET
Preload-dependent,
i.e. volume responsive
HYPER
DO2 = CO · caO2
= HR · SV · caO2
Perioperative Goal Directed Therapy
Preload
Perioperative Goal Directed Therapy
6
Identification of the target zone:
The Frank Starling Curve
Identification of the target zone:
Stroke volume optimization
Normovolemia is achieved
when the individual patient
is no longer volumeresponsive
à Further volume fails to
improve SV
CVP
N.I.C.E. (NHS) Protocol - National institute for health and
clinical excellence / national health system (NHS)
Perioperative Goal-Directed Therapy Protocol
Kuper M. et al.
Intraoperative fluid management guided by oesophageal
Doppler monitoring.
BMJ 2011;342:d3016
Bentzer J. et al.
Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids?
JAMA. 2016;316(12):1298-1309
Perioperative Goal Directed Therapy
Identification of the target zone:
Stroke volume optimization - Laparoscopy
Perioperative Goal Directed Therapy
Identification of the target zone:
Ventilation induced arterial pressure variations
PPmax
PPmin
PPV = (PPmax - PPmin) / PPmean
SVmax
Brandstrup B. et al.
Which goal for fluid therapy during colorectal surgery is
followed by the best outcome: near-maximal stroke volume or
zero fluid balance?
British Journal of Anaesthesia 109 (2): 191–9 (2012)
Perioperative Goal Directed Therapy
SVmean
SVmin
Bentzer J. et al.
Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids?
JAMA. 2016;316(12):1298-1309
SVV = (SVmax - SVmin) / SVmean
Perioperative Goal Directed Therapy
7
Identification of the target zone:
Identification of the target zone:
Ventilation induced arterial pressure variations
Ventilation induced arterial pressure variations
SV
PP
Volume unresponsive
d
c
b
Volume responsive
a
A
B
C
D
Ventilation-induced cyclic changes in preload
Preload
Perioperative Goal Directed Therapy
Identification of the target zone:
SVV/PPV - Limitations
Salzwedel C. et al.
Perioperative goal-directed hemodynamic therapy based on radial
arterial pulse pressure variation and continuous cardiac index
trending reduces postoperative complications after major abdominal
surgery: a multi-center, prospective, randomized study.
Critical Care 2013, 17:R191
Perioperative Goal Directed Therapy
Identification of the target zone:
Diagnostic accuracy
•  SOS
OR
he
•  Spontaneous ventilation
t
t in
•  Open chest-conditions
en
s
•  Sustained cardiac arrhythmias
e
r
tp
•  Low tidal volumes
no
e
•  High respiratory rate
r
sa
•  PHT/RV dysfunction (Pulsus
on paradoxus)
i
t
•  Vasoconstriction (êaortic
ita compliance)
im
•  Children (échest
e l wall compliance, éaortic compliance)
s
e laparoscopy) (êchest wall compliance)
•  High IAP
th(IAH,
of values?, grey zone 9-13%
•  Cut-off
y
n
Ma(14-25% of the patients are within this zone)
•  Alternative: Passive leg raising
Bentzer J. et al.
Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids?
JAMA. 2016;316(12):1298-1309
Perioperative Goal Directed Therapy
Perioperative Goal Directed Therapy
8
Identification of the target zone:
How to measure SV?
Identification of the target zone:
How to measure SV?
Pulmonary Artery Catheter
Less invasive CO-monitors
VolumeView
Hofer CK, Rex S., et al.
Update on minimally invasive hemodynamic
monitoring in thoracic anesthesia.
Curr Opin Anesthesiol 2014, 27
PiCCO
FloTrac™-Vigileo
LiDCO
less-invasive
Perioperative Goal Directed Therapy
And so what?
Esophageal
Doppler
minimally-invasive
ClearSight
non-invasive
Perioperative Goal Directed Therapy
PGDT:
Mortality
N = 734
N = 106
Pearse R. et al.
Effect of a Perioperative, Cardiac Output–Guided
Hemodynamic Therapy Algorithm on Outcomes
Following Major Gastrointestinal Surgery.
A Randomized Clinical Trial and Systematic Review.
JAMA. 2014 Jun 4;311(21):2181-90
Fig. 1 Kaplan–Meier survival analysis of patients grouped accordRhodes A et al.
ing to study arm (protocol or control)
Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study
Intensive Care Med (2010) 36:1327–1332
Perioperative Goal Directed Therapy
Perioperative Goal Directed
Therapywere well balanced in terms of baseline
two groups
demographics, operation type and numbers, and specific
high-risk criteria. There were similar proportions of protocol and control patients who underwent vascular surgery
(57 vs. 52%, p = 0.70) and major abdominal surgery
(32 vs. 37%, p = 0.69). Of particular note, both groups
also contained a similar number of patients undergoing
high-risk emergency procedures (40 vs. 31%, p = 0.42).
More details of the original study can be found in the
Electronic Supplementary Material.
674 days, HR 1.8 (95% CI 1.2–2.8)
over 3 years (Table 1).
Data were also analyzed for all pa
control) together. The development
complication had a profound impact o
When split into those with and withou
was a significant survival advantage f
develop a perioperative complication
HR 2.0 (95% CI 1.3–3.0), p \ 0.0001]
complications there were no survivor
and for those with cardiovascular co
3,000 days (Fig. 2). Patients in the co
nificantly longer survival if they avoi
the perioperative period [median su
116 days, HR 5.0 (2.6–9.9), p \ 0.00
not the case for the protocol patients [
HR 1.0 (0.6–1.9), p = 0.42] (Fig. 3).
The following factors were sig
with survival on univariate analysis
area, baseline postoperative APACHE
development of a postoperative co
surgery performed, and postoperati
delivery index (ESM Fig. 1). On
analysis using a Cox regression plot
ables remained independently assoc
age [HR 1.04 (1.02–1.07), p \ 0.00
0.61 (0.4–0.9), p = 0.02], and devel
cant cardiac postoperative complica
6.6), p \ 0.0001] (ESM Fig. 2).
Survival analysis from 28 days post
Survival analysis from randomization
In this long-term follow-up study, outcome data were
available on 106 out of the original 107 patients (99%),
with 1 patient from the control group being lost to followup. For further analysis there were therefore 53 patients in
each study arm. At 15 years post randomization there
were 11 (20.7%) patients alive in the protocol group and 4
(7.5%) in the control group (p = 0.09). The survival
curves for the 15 years following randomization showed a
significantly improved survival for protocol patients
(p = 0.005) (Fig. 1). The median survival for the protocol
group patients was increased by 1,107 days [1,781 vs.
Fifteen patients died during the firs
randomization. At 28 days, data w
patients in the protocol group and f
group. At 15 years, 11 (22%) pati
group and 4 (10%) in the control g
(p = 0.11). The protocol group
although nonsignificantly, increased s
median survival of the protocol grou
controls was increased from 1,409 to
(95% CI 0.9–2.3), p = 0.18].
The development of a significant
28 days of randomization had a maj
term survival. Patients with a com
Table 1 Outcome data described as median survival in days together with the HR and its 95% confidence inte
Protocol
Control
Survival from randomization
1,781
Survival from 28 days post randomization
1,836
No complication
674
1,409
Complication
Survival from randomization
542
1,993
9
HR
9
1.811
1.433
HR
1
0
95%
1.96
1.3
PGDT:
Morbidity
PGDT:
Morbidity: Not only volume!
N = 3024
Preemptive Hemodynamic Intervention
Table 2. Subgroup Analysis for Mortality
Subgroup
Monitor
ODM
PAFC
Othera
Therapy
Fluids
Fluids and
inotropes
Goals
CI/DO2
FTc/SV
Otherb
Resuscitation
target
Supranormal
Normal
No. of studies
No. of patients
Control group mortality
Odds ratio (95% CI)
9
15
5
894
3511
400
28/448 (6%)
179/1739 (10%)
17/198 (9%)
0.75 (0.41–1.37)
0.35 (0.19–0.65)*
0.61 (0.27–1.35)
10
19
700
4105
16/350 (5%)
208/2035 (10%)
0.44 (0.19–1.06)
0.47 (0.29–0.76)*
17
9
3
3350
894
561
183/1657 (11%)
28/448 (6%)
13/280 (5%)
0.38 (0.21–0.68)*
0.75 (0.41–1.37)
0.43 (0.15–1.19)
8
21
0.29 (0.18–0.47)
0.86 (0.66–1.13)
89/346 (26%)
135/2039 (7%)
0.29 (0.18–0.47)*
0.86 (0.66–1.13)
ODM ! esophageal Doppler monitoring; PAFC ! pulmonary artery flotation catheter; CI ! cardiac index; DO2 ! oxygen delivery; FTc ! corrected flow time; SV !
stroke volume.
a
PiCCOplus, CVP/A line, DX2020, FloTrac, LidCOplus.
b
Oxygen extraction ratio, pulse pressure variation, SV̇O2, and lactate.
*Statistically significant.
Hamilton M. et al.
A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to
Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients.
Anesth Analg 2011;112:1392–402
Pearse R. et al.
Effect of a Perioperative, Cardiac Output–Guided
Hemodynamic Therapy Algorithm on Outcomes
Following Major Gastrointestinal Surgery.
A Randomized Clinical Trial and Systematic Review.
JAMA. 2014 Jun 4;311(21):2181-90
Salzwedel C. et al.
Perioperative goal-directed hemodynamic therapy based on radial
arterial pulse pressure variation and continuous cardiac index
trending reduces postoperative complications after major abdominal
surgery: a multi-center, prospective, randomized study.
Critical Care 2013, 17:R191
Perioperative Goal Directed Therapy
Figure 3. Effects of preemptive hemodynamic intervention in protocol group versus control on complication rate. M-H !
Mantel-Haenszel.
Perioperative Goal Directed Therapy
OR of 0.48 [0.33– 0.78]; P ! 0.0002) (Fig. 2). Subgroup
analysis of the mortality end point revealed that mortality
was reduced in those studies using a pulmonary artery
catheter (OR 0.35 [0.19 – 0.65]; P ! 0.001), for fluids and
inotropes as opposed to IV fluids alone (OR 0.47
[0.29 – 0.76]; P ! 0.002), cardiac index or oxygen delivery as
the end point (OR 0.38 [0.21– 0.68]; P ! 0.001), and studies
using a supranormal resuscitation target (OR 0.29
[0.18 – 0.47]; P ! 0.00001) (Table 2).
Morbidity
Twenty-three of the 29 studies reported the number of
patients with complications as an end point. Meta-analysis
of these studies (Fig. 3) demonstrated a significant reduction in the overall complication rate (OR 0.43 [0.34 – 0.53];
P " 0.00,001) and a significant reduction across all of the 4
subgroups assessed (Table 3).
1396
PGDT:
Safety
www.anesthesia-analgesia.org
Trial Quality
The quality of the individual studies as assessed by the Jadad
score is presented in Table 4. It is apparent that very few of the
studies were performed in a double-blind manner and nearly
all were done in a single center. Figure 4 shows an OR plot of
mortality split by quality. The higher quality studies (with a
Jadad score !3) fail to show a significant reduction in mortality, as opposed to lower quality studies that do. The effect of
quality on morbidity is shown in Figure 5. In contrast to
mortality, there is a significant reduction in morbidity irrespective of trial quality. The point estimate of effect is similar for the
2 groups but the CI for the lower quality studies is wider.
Time-Dependent Analysis
Figure 6 shows a graph of the apparent decline in controlgroup mortality over time, with recent studies demonstrating lower mortality rates. Figure 7 shows an approximate
ANESTHESIA & ANALGESIA
PGDT:
Length of stay
N = 2129
Standardized mean difference:
−1.14 days
(95 CI: −1.45 to −0.85)
Perioperative Goal Directed Therapy
Perioperative Goal Directed Therapy
10
PGDT:
Costs
PGDT:
Guidelines
N = 75,140
Morbidity rate: 11.2%
Patients with
complications
Patients without
complications
p
In-hospital
mortality
12.4%
1.4%
<0.001
Hospital LOS
20.5 ± 20.1 d
8.1 ± 7.1d
<0.001
Direct costs
$47,284 ± 49,170
$17,408 ± 15,612
<0.001
With PDGT:
•  projected decrease of complications by 8.0 - 9.3%
•  gross costs savings of $43 M- $73 M for the study population
•  gross costs savings of $569 - $970 per patient
The Enhanced Recovery Partnership recommends that all Anaesthetists caring for
patients undergoing intermediate or major surgery should have cardiac output
measuring technologies immediately available and be trained to use them.
The use of intra-operative fluid management technologies are recommended from the
outset in the following types of cases:
§  Major surgery with a 30 day mortality rate of >1%.
§  Major surgery with and anticipated blood loss of greater than 500 ml.
§  Major intra-abdominal surgery.
§  Intermediate surgery (30 day mortality>0.5%) in high risk patients (age>80 years, history of
LVF, MI, CVA or peripheral arterial disease).
§  Unexpected blood loss and/or fluid loss requiring >2 litres of fluid replacement.
§  Patients with ongoing evidence of hypovolaemia and or tissue hypoperfusion (e.g. persistent
lactic acidosis).
Perioperative Goal Directed Therapy
PGDT:
Guidelines
Perioperative Goal Directed Therapy
PGDT:
Guidelines
Intra operative fluid management
Recommendation 13
In patients undergoing some forms of orthopaedic and abdominal
surgery, intraoperative treatment with intravenous fluid to achieve
an optimal value of stroke volume should be used where possible
as this may reduce postoperative complication rates and duration of
hospital stay.
„The CardioQ-ODM should be considered for use in
patients undergoing major or high-risk surgery or other
surgical patients in whom a clinician would consider using
invasive cardiovascular monitoring.
Orthopaedic surgery: Evidence level 1b
This will include patients undergoing major or high-risk
surgery or highrisk patients undergoing intermediate-risk
surgery.”
Patients undergoing non-elective major abdominal or orthopaedic
surgery should receive intravenous fluid to achieve an optimal
value of stroke volume during and for the first eight hours after
surgery. This may be supplemented by a low dose dopexamine
infusion.
NICE: CardioQ-ODM oesophageal doppler monitor: Medical Technology guidance 3. National Institute for
Health and Clinical Excellent, March 2011.
http://www.nice.org.uk/nicemedia/live/13312/52624/52624.pdf
Perioperative Goal Directed Therapy
Abdominal surgery: Evidence level 1a
Recommendation 14
Evidence level 1b
Perioperative Goal Directed Therapy
11
PGDT:
Guidelines
Perioperative hemodynamic optimization:
Summary
•  Perioperative mortality/morbidity is still inacceptably high
• 
• 
• 
• 
Complications are not exceptions
Complications are costly
Complications are responsible for prolonged LOS and readmissions
Complications affect long-term survival
•  Improvement in outcome requires a bundle of therapeutic measures
•  Perioperative Goal-Directed Therapy
4.1.2. Recommandations et argumentaire
Chez les patients chirurgicaux considérés « à haut risque », il est recommandé de titrer
le remplissage vasculaire peropératoire en se guidant sur une mesure du volume
d’éjection systolique (VES) dans le but de réduire la morbidité postopératoire, la durée
de séjour hospitalier, et le délai de reprise d’une alimentation orale des patients de
chirurgie digestive.
GRADE 1+.
Perioperative Goal Directed Therapy
• 
• 
• 
• 
• 
• 
• 
is a key element
optimizes fluid status in the individual patient using SV-measurements
reduces morbidity and hospital LOS
can be focused on high-risk patients (which are easy to identify)
requires a treatment protocol
re-imbursement?
implementation?
Perioperative Goal Directed Therapy
Thank you very much for your attention
Perioperative Goal Directed Therapy
12