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
Disclosures: Member of the Medical Advisory Board of Pulsion Medical Systems Scientific collaborations with: Draeger Medical Fresenius Medical B. Braun
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.
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
Define the risk of surgery Define the risk of the patient Optimizing preoperative status Define the adequate hemodynamic monitoring Define the adequate hemodynamic management
Leitlinien: Defining the ESC risk of / ESA surgery2009
Surgical Risk: ESC But
Surgical Risk: ESC
Surgical Risk: ESC always incorporate the experience of the surgeon!
Define the risk of surgery Define the risk of the patient Optimizing preoperative status Define the adequate hemodynamic monitoring Define the adequate hemodynamic management
Patient-specific RiskBelastbarkeit
Patient-specific Risk Active cardiovascular/pulmonary diseases Functional capacity Clinical risk factors
Patient-specific Risk Active cardiovascular disease: Instable coronary syndrome Acute heart insufficiency Significant arrhythmias Symptomatic valvular disease Recent MI (<30d) (ESC Guidelines)
Patient-specific Risk Functional capacity (ESC Guidelines)
Patient specific risk: Clinical risk factors: Revised Lee Cardiac Risk Index Known CAD Heart insufficiency IDDM Cerebrovascular Diseases Renal insufficiency, creatinine >/= 2mg/dl
How to put that in an algorithmic approach?
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: 655-669
Escalation of Monitoring / Management Complexity / Invasiveness of Monitoring Low intermediate high Risk of Surgery Patient associated Risk Low intermediate high
Perioperative hemodynamic optimization: Ratio: Optimizing blood flow: means reaching adequate circulation - ensuring endorgan function - Minimizing complications - leads to improved Outcome
Flow is more important than pressure
Preload Volume and Parameters of Fluid responsiveness are better than Filling pressures to guide fluid therapy
CO Technologies PA Thermodilution Transcardiopulmonary Indicator dilution Pulse contour analysis centrally / calibrated Pulse contour analysis peripherally / uncalibrated Echo / Doppler CNAP / BMeye Bioimpedance Bioreactance
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
Define the risk of surgery Define the risk of the patient Optimizing preoperative status Define the adequate hemodynamic monitoring Define the adequate hemodynamic management
Wherever meaningful: individualized algorithms: The Principle: Preload Flow Perfusion Pressure Heart Rate Avoid Fluid Overload
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. 15.4 ± 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
Heterogeneous Ranges for optimal Preload Preload Flow Perfusion Pressure Heart Rate Avoid Fluid Overload
101 Patients When discharged from ICU (neurosurgery) Crit Care. 2009 Dec 14;13(6):R202.
Crit Care. 2009 Dec 14;13(6):R202.
Heterogeneous Ranges for optimal Preload Surgical Sepsis
This implies individual target ranges: Laurent Muller et al.; Anesth Analg 2008;107:607 13
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!
Thank you