Perioperative Goal Directed Therapy Improving the Quality of Care for Our Surgical Patients

Transcription

1 Perioperative Goal Directed Therapy Improving the Quality of Care for Our Surgical Patients DESIRÉE CHAPPELL, CRNA ERAS TEAM LEAD NORTON AUDUBON HOSPITAL, LOUISVILLE, KY

2 Disclosure Edwards Lifesciences, Speakers Bureau American Society for Enhanced Recovery, Board of Directors

3 Overview Perioperative Goal Directed Therapy (PGDT) Enhanced Recovery (ER) The Norton Audubon Experience CRNA opportunities within Enhanced Surgical Recovery Programs

4 Goal of Intraoperative Fluid Management Maintain Intravascular Fluid Volume LV Filling Pressures Manage Preoperative Status Surgical Considerations BP/CO Postoperative Needs Oxygen Delivery

5 1 liter Normal Saline

6 Fluid Administration Gone WRONG Prowle, J. R. et al. Nat. Rev. Nephrol. 6, (2010)

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9 SWEET SPOT

10 Traditional Fluid Therapy Dogma/ Clinicians Vital Signs Crude Markers of Hypovolemia BP HR UOP EBL

11 Blood Pressure = Late Indicator Assumption: MAP=CO If BP = CO If BP = CO Pressure FLOW Hamilton 1,2 et al, ICM 1997

12 Traditional Fluid Therapy Dogma/ Clinicians Vital Signs Provider Variability

13 Variability of Providers 50% Patients 4-10 ml/kg/hr 50% Patients Outside Range The strongest predictor of corrected crystalloid infusion was the anesthesia providers regardless of patient factors. Lillot BJA 2014

14 Perioperative Fluid Utilization Variability and Association With Outcomes Considerations for Enhanced Recovery Efforts in Sample US Surgical Populations Julie K.M. Thacker, MD, William K. Mountford, PhD,y Frank R. Ernst, PharmD, MS,z Michelle R. Krukas, MA,z and Michael (Monty) G. Mythen, MBBS, MD, FRCA, FFICM, FCAI (Hon) Annals of Surgery 2015 Colon Surgery Significant Variability in DOS fluid admin Variability leads to poor outcomes

15 Stroke Volume Evolution of Fluid Management Conventional Liberal Restrictive Perioperative Goal-Directed Therapy Frank-Starling Curve Preload Stolting et. al. Basics of Anesthesia, 5th ed. Elsevier - China, p. 349, 200 Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005; 103:

16 GOAL Directed Fluid Therapy ABP Continuous NON/MINinvasive CO Cardiac Output/ Index SV Stroke Volume/ Index SVV Strove Volume Variation (SVV)

17 Parameters of FLOW

18 Cardiac Output/ Index

19 Stroke Volume

20 Stroke Volume Variation A calculated percentage of variation between the Stroke Volumes

21 Preload Dependence Optimization Stroke Volume 0 Fluid Bolus High Resp Variation= Fluid responsiveness SVV > 13% Preload Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 3 (June), 2010: pp SVV < 13% Low Resp Variation= Decreased Fluid responsiveness J.Bloomstone M.D. 2011

22 Limitations of SVV pontaneous Ventilation idal Volume (<8cc/Kg) pen Chest neumoperitoneum ustained Cardiac Arrhythmias

23 Nice/Kuper Protocol Kuper et al BMJ. 2011; 342:d3016

24 WHO? ALL Surgical Patients! Degree of intervention- Pathway/Patient dependent ASA 1 ASA2/3 ASA>4 Procedure Specific Procedure Specific NON Invasive Procedure Specific Critical State NON Min-Invasive

25 WHEN PreOP Optimization IntraOP Pre/Post Incision Post Op Rescue/ Tx

26 Perioperative Goal Directed Therapy Real Time Hemo- Dynamic Data Clinical Judgement Fluid Therapy Protocols ACTION Cont BP CO SV SVV Knowledge Experience Evidenced Based

27 Simulator

28 Simulator

29 Simulator

30 Simulator

31 Don t Get Caught up in the NUMBERS

32 Knowledge and Experience

33 Optimization using GDFT

34 PGDT Reduces Complications

35 Evidence 30+ positive RCTs 14+ meta-analyses : 32-55% reduction in Post-Surgical Complications positive RCTs Reduction by1-2(avg. days) 14+ meta-analyses in Length of Stay 1 Hamilton M, Cecconi M, Rhodes A. 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(6): Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. BJA, Corcoran et al. Perioperative Fluid Management Strategies in Major Surgery: A Stratified Meta-Analysis. Society of Critical Care Anesthesiologists ; 114 (3)

36 PGDT Reduces Complications Reduces Variance Improves Outcomes Successful Recovery

37 The Norton Audubon Experience ERAS IMPLEMENTATION OVER 2 YEARS

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39 Background

40 Clinical Effectiveness ERAS Report Colorectal Procedures Baseline 2014/ Improvement Measure Length of Stay Measure Variable Direct Cost Improvement 2015 Baseline 2014 Average per Average patient Std dev Std # # Discharges dev Discharges Length of Stay Variable Average $10,72 9 Std dev 159 # Discharges $8,590 Average per patient Std dev # Discharges $6,261 $2, Improvement 2016 Average per patient Std dev # Discharges Average per patient Std dev # Discharges $7,087 $4, Direct Cost

41 Variable Direct Cost Buckets

42 Norton Audubon Results Reduction LOS Reduction V/D COSTS

43 CRNAs role in PGDT Initiative HOW CRNAS IMPROVE INTRAOPERATIVE CARE

44 CRNAs leading the PGDT/ER Movement Educators CRNAs As Ambassadors Active Participants Facilitators Care Providers

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46 Where to Begin Lit. review Current Practice? Ask for DATA

47 The Face of ESR

48 Enhanced Surgical Recovery in your Practice Change is Constant PGDT = ESR Standard Of Care CRNAs as Leaders ESR = BEST PRACTICE!

49 Enhanced Surgical Recovery in your Practice Change is Constant PGDT = ESR Standard Of Care CRNAs as Leaders ESR = BEST PRACTICE!