PACT module High risk surgical patient. Intensive Care Training Program Radboud University Medical Centre Nijmegen

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1 PACT module High risk surgical patient Intensive Care Training Program Radboud University Medical Centre Nijmegen

2 Intravascular volume effect of Ringer s lactate Double-tracer BV measurement Blood 1097 ± 285 ml Ringer s 3430 ± 806 ml Volume effect Ringer s 17 ± 10% Double-tracer BV measurement 245 ± 64 ml Volume effect Albumin 20% 184 ± 63% Double-tracer BV measurement Jacob M. Crit Care 2012;16:R86

3 Volume effect literature Jacob M. Crit Care 2012;16:R86

$Sudden death Refractory shock Bleeding Undertermined 22,8% 5$ 0 ICU mortality 30 D mortality 60 D mortality 90 D mortality

4 High risk surgery N = 587 Mortality (%) MOF Sudden death Refractory shock Bleeding Undertermined 22,8% 5 0 ICU mortality 30 D mortality 60 D mortality 90 D mortality 2,5% 6,8% 14,9% 53,0% Lobo SM. Anesth Analg epup ehead of print

5 Independent risk factors on day of ICU admission Lobo SM. Anesth Analg epup ehead of print

6 Identify high-risk surgical patient Shoemaker/ Boyd criteria P-POSSUM Optimum management of chronic disease ACC/AHA guidelines Surgery with flow monitoring and GDT Optimal volume dopexamine or dobutamine Postoperative ICU with GDT SaO2 > 95% Hb > 6 mmol DO2 & VO2 goals DO2 > 600 CI > 4.5 SvO2 > 70% Lees N. Crit Care 2009;13:231 Maintain monitoring and goals for 8 hours

7 Pre-operative risk Cardiac Revised cardiac risk index Stress echocardiography General Shoemaker criteria POSSUM score Anaerobic threshold

8 Revised cardiac risk index High risk surgery Previous history of cardiac ischemia Previous history of congestive heart failure Previous history of TIA or CVA Use of insulin Creatinin > 150 μmol/l

9 Revised cardiac risk index Class Risk-factor Incidence (%)

10 Shoemaker criteria Cardiopulmonary disease (NYH 3 en 4) Acute severe blood loss (> 8 E) Age > 70 and limited physiological reserve Sepsis Respiratory insufficiency Acute abdomen with hemodynamic instability Acute renal insufficiency End-stage vascular disease including the aorta Oncologic surgery (oesophagus, stomach, pancreas)

11 Anaerobic threshold 50 Mortality (%) Anaerobic threshold < 11 ml/kg/min Anaerobic threshold > 11 ml/kg/min Anaerobic threshold < 11 ml/kg/min + ischemia ECG Anaerobic threshold > 11 ml/kg/min + ischemia ECG Older P. Chest 1993

12 Preventive measures Hemodynamic optimisation β-blockade Statins

13 Kern JW. Crit Care Med 2002;30:

14 Pulmonary artery catheter N = ,0 Control AP catheter 9,7 7,5 7,7 7,8 7,4 5,0 2,5 0 4,3 3,4 0,9 0 Mortality MI Renal insufficiency Pulmonary embolus Sandham JD. N Engl J Med 2003

Outcome measure Control group GDT group P-value No. with complications 41 (68%) 27 (44%) 0.007 No. of complications 90 43 0.001 Median LOS (d) 14 (11-27) 11 (7-15) 0.

15 Outcome measure Control group GDT group P-value No. with complications 41 (68%) 27 (44%) No. of complications Median LOS (d) 14 (11-27) 11 (7-15) Mean LOS (d) Duration ICU stay (h) 45 (25-99) 43 (24-102) 0.82 Mortality (28 D) 7 (11.7%) 6 (9.7%) 0.78 Mortality (60 D) 9 (15%) 7 (11.3%) 0.59 Pearse R. Crit Care 2005;9:R

16 GDT and cardiac events Outcome measure Control group GDT group P-value Arrythmia 9 5 ns Acute heart failure 4 4 ns Myocardial infarction 3 0 ns Stroke 1 2 ns Severe sepsis/shock 9 1 < 0.01 Pearse RM. BMJ Cardiovasc Disord 2007;7:10

17 ScvO2 a useful parameter? Cut off 65% Pearse R. Crit Care 2005;9:R

ScvO2 a useful parameter? Parameter High ScvO2 Low ScvO2 P-value Number 64 53 ns Age 66 ± 12 69 ± 11 0.40 p-possum 37.8 ± 7.4 39.0 ± 7.5 0.39 APACHE II 9.8 ± 4.3 9.0 ± 3.9 0.

18 ScvO2 a useful parameter? Parameter High ScvO2 Low ScvO2 P-value Number ns Age 66 ± ± p-possum 37.8 ± ± APACHE II 9.8 ± ± LOS 12 (9-15) 14 (9-25) < 0.01 Complications (no. pat.) 29 (45%) 35 (66%) 0.03 Complications (per pat.) 0.8 ± ± Mortality 7 (11%) 4 (7%) 0.54 Pearse R. Crit Care 2005;9:R

19 ScvO2 a useful parameter? Crit Care 2006;10:R158

20 ScvO2 a useful parameter? Optimal ScvO2 73% Postoperative complications We need a prospective RCT Crit Care 2006;10:R158

21 Microcirculation

22 β-blockade Placebo B-blockade 30, , % 15,0 % 10 7, M mortality 2 Y Mortality 0 0 Non-fatal MI Cardiac death Mangano DT. N Engl J Med 1996 Polderman D. N Engl J Med 1999

23 β-blockade % Placebo N = 103 Days (median) Metoprolol *** 0 Cardiac morbidity Infrarenal vascular surgery 0 LOS Brady AR. J Vasc Surg 2005

24 Devereaux DJ. BMJ 2005;331:

25 Major perioperative events Bradycardia

26 β-blockade in DM patients undergoing major non-cardiac surgery Juul AB. BMJ 2006;332:1482

28 POISE Study Group. Lancet 2008;371:

29 Guidelines Implement a run-in phase for perioperative beta blockade for at least 7 days Target heart rate of 60 bpm - avoid hypotension Continu beta-blockers if already on this therapy

30 Perioperative statins Useful in carotid endarterectomy Useful in abdominal aortic aneurysm Useful in peripheral artery disease Although definite proof is not yet available it is reasonable to prescribe statins in patients with non-cardiac vascular surgery Stalenhoef AFH. J Vasc Surg 2009;49:

31 Identify high-risk patient Shoemaker criteria Anaerobic threshold P-POSSUM Analyse according AHA Revised CRI Dobutamine Stress Test Risk stratification Optimal medical therapy Hemodynamic optimisation β-blockade + hemodynamic optimisation Pears RM. Crit Care 2004

32 Local protocol Minimal 2 high-risk factors ScvO2 central parameter (> 70% or 3% ) Preoperative TTE Volume therapy, milrinon Prevention of volume overload Continue preoperative β-blockade Statin in non-cardiac vascular surgery

33 Acute limb ischemia Sudden decrease in limb perfusion threatening viability 1.5/10.000/year Six P s - paresthesia, pain, pallor, pulselessness, poikilothermia, paralysis No collaterals - urgent revascularization usually necessary - 10 to 15% amputation Thrombosis - embolism - dissection - trauma

34 Acute limb ischemia Creager MA. N Engl J Med 2012;366:

35 Strategy IV heparin to minimize thrombus propagation Stage I & IIa - additional imaging IIb - catheter-directed thrombolysis/or III - no imaging/revascularization

37 Stenosis Occlusion proximal superficial femoral artery Focal occlusion right popliteal artery Self-expanding stent

38 Endovascular revascularization Multi-side-hole catheter with thrombolytic agent into the thrombus Clinical and angiographic control during infusion Alteplase - reteplase - tenecteplase for hours Satisfactory in 75-92% - GP IIb/IIIa RA accelerates reperfusion but not outcome

39 Endovascular revascularization Major hemorrhage 6-9% Benefit of newer percutaneous mechanical devices unclear

Surgical revascularization Thromboembolectomy, bypass surgery, endarterectomy Special problem - thrombosis of popliteal aneurysm - frequent

40 Surgical revascularization Thromboembolectomy, bypass surgery, endarterectomy Special problem - thrombosis of popliteal aneurysm - frequent amputation due to concomitant diffuse thromboembolic occlusion of all 3 major runoff vessels - flow restoration of runoff vessel before aneurysm exclusion

41 Treatment Catheter directed thrombolysis Surgery Viable or marginally threatened limb Occlusion < 2 weeks duration Thrombosis of synthetic graft Thrombosis of occluded stent One identifiable runoff vessel Immediately threatened limb Symptoms of occlusion > 2 weeks

42 Reperfusion injury Severe pain, hypoesthesia, weakness of affected limb, myoglobinuria and elevated CK Especially anterior compartment of the leg - Motor: dorsiflexion of foot - sensory: dorsum of foot and first web space Compartment pressure > 30 mmhg

Algorithm for Managing Acute Lower Extremity Ischemia. Peter A. Schneider, MD Honolulu, Hawaii

Algorithm for Managing Acute Lower Extremity Ischemia Peter A. Schneider, MD Honolulu, Hawaii Disclosure Peter A. Schneider, MD... I have the following potential conflicts of interest to report: Consulting: