An algorithmic approach to the very high risk surgical patient

Transcription

1 An algorithmic approach to the very high risk surgical patient Daniel A. Reuter Center of Anesthesiology and Intensive Care Medicine Hamburg-Eppendorf Universiy Medical Center

2 Disclosures: Member of the Medical Advisory Board of Pulsion Medical Systems Scientific collaborations with: Draeger Medical Fresenius Medical B. Braun

3 Why an algorithmic approach? An algorithm is a set of rules that precisely defines a sequence of operations to perform a procedure or to solve a problem.

4 To analyze and to reduce the perioperative risk for the high-risk surgery patient Define the risk of surgery Define the risk of the patient Optimizing preoperative status Define the adequate hemodynamic monitoring Define the adequate hemodynamic management

5 Define the risk of surgery Define the risk of the patient Optimizing preoperative status Define the adequate hemodynamic monitoring Define the adequate hemodynamic management

6 Leitlinien: Defining the ESC risk of / ESA surgery2009

7 Surgical Risk: ESC But

8 Surgical Risk: ESC

9 Surgical Risk: ESC always incorporate the experience of the surgeon!

10 Define the risk of surgery Define the risk of the patient Optimizing preoperative status Define the adequate hemodynamic monitoring Define the adequate hemodynamic management

11 Patient-specific RiskBelastbarkeit

12 Patient-specific Risk Active cardiovascular/pulmonary diseases Functional capacity Clinical risk factors

13 Patient-specific Risk Active cardiovascular disease: Instable coronary syndrome Acute heart insufficiency Significant arrhythmias Symptomatic valvular disease Recent MI (<30d) (ESC Guidelines)

14 Patient-specific Risk Functional capacity (ESC Guidelines)

15 Patient specific risk: Clinical risk factors: Revised Lee Cardiac Risk Index Known CAD Heart insufficiency IDDM Cerebrovascular Diseases Renal insufficiency, creatinine >/= 2mg/dl

16 How to put that in an algorithmic approach?

17 The preoperative algorithmic approach: A Patient-specific Risk B Surgery Specific Risk Action: Further Modifiedevaluation Cardiac Risk by cardiologists: Index (Lee) Active cardiac Disease O CAD (history of MI, AP, coronary artery surgery, pos. ECG O instable Action CB1 coronary extended Physical Beta Blockers: syndrome vascular Activity (arterial) surgery Initiate further evaluation, findings if: History - MI < of 30 percutaneous d O cerebrovascular coronary intervention: diseases (history of stroke, TIA) instable B2 other < 4 APMET procedures / MET non with assessable: increasedc risk, O - Patient on Beta- O Blockers: Diabetes continuation such as: Elective - high O surgery: degree AO intraperitoneal, AP continuation (CCS III-IV) intrathoracic of acetylsalicylic surgery acid (if surgically tolerable), O chronic reanal insufficiency discontinuation stable O A3 O AP + head in B1 of immobilized Clopidogrel + / neck C surgery, patients (check carotis-tea with cardiology): - initiate perioperative O Heart beta-blocker insufficiency therapy, if: O decompensated O O PTCA extended heart without orthopedic insufficiency stent: surgery (NYHA4, newafter symptoms) 14 days O significant And O B1 + signs of Ischemia in stress test (check with cardiology) Consider O O PTCA arrhythmias prostatectomies defining Number further with BMS: of evaluation, the strategy these predictors if: after for (0-5) 30 : ( days perioperative ) - symptomatic O B1/B2 O PTCA bradycardia, + proven high degree CAD, AV-block A2 1 with predictor: Monitoring DES: A1 O/ Management after 365 days! - symptomatic ventricular arrhythmia, new VT O A1 + B1 - supraventricular consider perioperative 2 predictors: arrhythmia with beta-blocker A2 HR > O100 /min therapy, if: O A1 + B2 O severe valvular O B1/B2 dysfunction 3 + Predictors C + A1 A3 O O known CAD CC2 1-2, and no evaluation within the last 2 years : - P mean > 40 mmhg; - valve area < 1 cm² - symptomatic MVS Petzoldt M et al. (2008) Anaesthesist 57:

18 Escalation of Monitoring / Management Complexity / Invasiveness of Monitoring Low intermediate high Risk of Surgery Patient associated Risk Low intermediate high

19 Perioperative hemodynamic optimization: Ratio: Optimizing blood flow: means reaching adequate circulation - ensuring endorgan function - Minimizing complications - leads to improved Outcome

20 Flow is more important than pressure

21 Preload Volume and Parameters of Fluid responsiveness are better than Filling pressures to guide fluid therapy

22 CO Technologies PA Thermodilution Transcardiopulmonary Indicator dilution Pulse contour analysis centrally / calibrated Pulse contour analysis peripherally / uncalibrated Echo / Doppler CNAP / BMeye Bioimpedance Bioreactance

23

24 Our approach: Patient associated risk Low intermediate high Basic Monitoring plus A-line Plus ProAct Basic Monitoring plus A-line/BMeye Basic Monitoring: NIBP, ECG, Pulse Ox, Capno Basic Monitoring plus A-line plus PiCCO andtee Basic Monitoring plus A-line plus ProAct Basic Monitoring plus A-line/BMeye Basic Monitoring plus A-line, plus PiCCO, TEE and PAC Basic Monitoring plus A-line, plus PiCCO andtee Basic Monitoring plus A-line plus ProAct Low intermediate high Risk of Surgery

25 Define the risk of surgery Define the risk of the patient Optimizing preoperative status Define the adequate hemodynamic monitoring Define the adequate hemodynamic management

26 Wherever meaningful: individualized algorithms: The Principle: Preload Flow Perfusion Pressure Heart Rate Avoid Fluid Overload

27 Perioperative algorithms: yes yes yes yes GEDVI > 640 CI > 2.5 MAP > 70 HR > 80 HR < 110 yes OK no yes no no no no EVLWI > 10 no give volume until GEDVI > 640 GEDVI > 800 no EVLWI > 10 no give volume until GEDVI > 800 yes GEDVI > 800 GEDVI > 800 Post-OP Ventilation : 12.6 ± 3.6 h vs ± 4.3 h (p<0.002) no Fit for ICU-discharge : yes25 ± 13 h yes vs. 33 ± 17 yesh (p=0.018) EVLWI > 10 no give volume until GEDVI > 800 yes no EVLWI > 10 no give volume until GEDVI > 800 yes sedation, Hb elevation, pharmacotherapy In case of EVLWI > 12 care for signs of pulmonary edema and give diuretics if necessary give catecholamines until CI > 2.5 give vasopressors until MAP > 70 performe pacing, give chronotropes Goepfert et al.; Intensive Care Med (2007) 33:96 103

28 Heterogeneous Ranges for optimal Preload Preload Flow Perfusion Pressure Heart Rate Avoid Fluid Overload

29 101 Patients When discharged from ICU (neurosurgery) Crit Care Dec 14;13(6):R202.

30 Crit Care Dec 14;13(6):R202.

31 Heterogeneous Ranges for optimal Preload Surgical Sepsis

32 This implies individual target ranges: Laurent Muller et al.; Anesth Analg 2008;107:607 13

33

34 Bottom Line for the high risk surgery patient: Primary goal: efficiently optimizing blood flow Individually tailored management: Patient assessment Assessment of surgical risks Preoperative optimization of patient status Use of monitoring techniques that have proven to be accurate, and where we are experienced in Where appropriate, algorithms with defined goals But individualize the goals!

35 Thank you