PREVENT COMPLICATIONS IN MAJOR SURGERY

Transcription

1 PREVENT COMPLICATIONS IN MAJOR SURGERY Dept of Anesthesia and ICM (Prof. G. Della Rocca) Azienda Ospedaliero-Universitaria University of Udine. Udine, Italy

2 CLINICAL TRIAL OF SURVIVORS CARDIORESPIRATORY PATTERNS AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS Shoemaker WC, Appel Pl, Waxmax K Crit Care Med 1982;10(6):

3 CLINICAL TRIAL OF SURVIVORS CARDIORESPIRATORY PATTERNS AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS Shoemaker WC, Appel Pl, Waxmax K Crit Care Med 1982;10(6):

4 Critical Care 2006, 10:R81

5 From Jan 1999 to Oct 2004 (70 months) 94 Hosp in UK All surgical procedures (HRG) n = Exclusion criteria: endoscopy day-case surg cardio-thorac neurosurg organ tx obstetrics burns Critical Care 2006, 10:R81

6 Critical Care 2006, 10:R81

7 Critical Care 2006, 10:R81

8 Critical Care 2006, 10:R81

9 Critical Care 2006, 10:R81

10 Critical Care 2006, 10:R81

11 Renal: fluids!!! (fenoldopam?) Infections: sepsis

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14 SVI/DO 2 I RCT, HR surgical patients (n=122 pts) DO 2 I 600 ml min -1 m -2 vs conventional management Cardiac Output (LidCO System) 60 days Critical Care 2005; 9:R

15 Critical Care 2005; 9:R

16 Critical Care 2005; 9:R

17 Critical Care 2005; 9:R

18 Critical Care 2005; 9:R

19 Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery. TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass FTc Anesthesiology 2002; 97:

20 Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery. TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass Anesthesiology 2002 ; 97: 820-6

21 Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery. TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass Anesthesiology 2002 Gan et al. Anesthesiology 2002 ; 97: 820-6

22 SV vs CVP: decreased LOS and complications Wakeling HG et al BJA 2005; 95(5):

23 PERIOP HEMODYNAMIC OPTIMIZATION Preop eval Surgery ICU discharge Hospital discharge High Risk patients definition OPTIMIZATION outcome High risk population Supposed normal goals supranormal goals

24 PERIOP HEMODYNAMIC OPTIMIZATION DO 2 = CO x CaO 2 (DO2 >600 ml/min/m2) (CVP, SV,ABF-FTc, SvO2, Lac, dynamic indexes) (AP, HR, diuresis)

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26 Anesth Analg 2005;100:

27 How should fluid be administered Anesth Analg 2005;100:

28 SUPPOSED NORMAL GOALS

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30 Cardiac surgery

31 Orthopedic surgery

32 Major abdominal surgery

33 n = 32 prospective study Liberal fluid regimen: transiet pulmonary improvement but postop Hypoxiemia tendency to deacrease in morbidity Br J Anesth 2007;99:500-8

34 Br J Anesth 2007;99:500-8

35 Br J Anesth 2007;99:500-8

36 Br J Anesth 2007;99:500-8

37 Retrospective Study n = 41 divided in 2 groups: < 3L vs >3L intraop - Restricted regimen: <LOS (MV?) ICU and Hospital - No difference in morbidity Vasc Endovasc Surg 2008;June 25

38 Vasc Endovasc Surg 2008;June 25

39 n = 100: retrospective study Conclusion: more fluids more complications! Eur J Vasc Endovasc Surg 2007;34:522-7

40 Eur J Vasc Endovasc Surg 2007;34:522-7

41 Intraoperative fluid management during orthotopic liver transplantation RA Schroeder, BH Collins, E Tuttle-Newhall, K Robertson, J Plotkin, LB Johnson, PC Kuo 2 liver transplant centers experience low CVP method vs normal CVP method clinical safety of a low CVP fluid management strategy in patients undergoing Ltx J Cardiothorac Vasc Anesth 2004;18(4):

42 Intraoperative fluid management during orthotopic liver transplantation RA Schroeder, BH Collins, E Tuttle-Newhall, K Robertson, J Plotkin, LB Johnson, PC Kuo despite sussess in lowering blood transfusion requirements in liver resection patients, a low CVP should be avoided in patients undergoing liver transplantation J Cardiothorac Vasc Anesth 2004;18(4):

43 J Cardiothor Vasc Anesth 2008; 22(2):311-4

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46 We aimed to investigate the effects of DO 2 I optimization, with and without dobutamine, on the incidence of perioperative complication in HR surgical patients Lobo SM et al Crit Care 2006; 10:R72 (doi: /cc4913)

47 volume dobutamine Lobo SM et al Crit Care 2006; 10:R72 (doi: /cc4913)

48 dobutamine volume Lobo SM et al Crit Care 2006; 10:R72 (doi: /cc4913)

49 Lobo SM et al Crit Care 2006; 10:R72 (doi: /cc4913)

50 IS SUPRANORMAL DO 2 NECESSARY? Conclusion PAC-guided hemodynamic optimization using dobutamine determines better outcomes, whereas fluids alone increase the incidence of postoperative complications in patients with high risk of perioperative death. Lobo SM et al Crit Care 2006; 10:R72 (doi: /cc4913)

51 Use it only when you need and not only because of protocols.

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56 NIV AND PERIOPERATIVE OPTIMIZATION

57 Incluison criteria: ASA I-II Major abdominal surgery PaO 2 /FiO 2 < hr after extubation Exclusion criteria: Cardiac, Respiratory and Obese patients Recent Major surgery, CT, immunosuppression Acidosis, hipercapnia (CO 2 >50 mmhg) SpO 2 <80 % Hypoalbuminemia, renal insufficiency, anemia, ARDS

58 1 hr after extubation: CTRL group 6 h Venti Mask FiO PROT group 6h CPAP 7.5 cmh 2 O FiO (Helmet) After 6 h 1 h Venti Mask FiO and then: If PaO 2 /FiO 2 < 300 back to the assigned group > 300 stop treatment

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61 PERIOP HEMODYNAMIC OPTIMIZATION Preop eval Surgery ICU discharge Hospital discharge High Risk patients definition OPTIMIZATION outcome High risk population Supposed normal goals supranormal goals Postoperative NIV.

62 Is ICU postoperative care necessary for HR patients? Yes but to optimize and not to monitor..

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64 HEMODYNAMIC OPTIMIZATION Volume/dobutamine/ITBVI (intraop or eary ICU) (No recent MI-ischemia or ß-blocker therapy) Lung protection: EVLWI (early predictor of mortality/late warning system) Fast track anesthesia + NIV (if PaO 2 /FiO 2 <300)

65 Renal protection Lung protection

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67 When? Early!