Edwards Critical Care Education Perioperative Goal-Directed Therapy Protocol Summary Issue Date: March 2013
Evidence-based, Perioperative Goal-Directed Therapy (PGDT) protocols Note: This protocol summary is designed to help inform clinicians of key published protocols used to guide hemodynamic monitoring in high-risk surgery. It is not intended to recommend a specific protocol, but to guide hemodynamic optimization through Perioperative Goal-Directed Therapy protocols that have been shown to reduce the number of peri- and postoperative complications, and improve patient outcomes. 1-3 These protocols represent individual strategies to help physicians either titrate or tailor fluid therapy in an individual patient or clinical situation. Since every case is different, physicians must weigh the risks and benefits of initiating any specific protocol. Please refer to Edwards Critical Care Education at Edwards.com/ccEducation for updates and additional information. Issue Date: March 2013 Considering a protocol The following algorithm is provided to help you select the most appropriate Perioperative Goal-Directed Therapy (PGDT) protocol for your patient. Your selection deserves careful consideration. Is my patient at risk* of developing post-op complications? Consider PGDT Any limitation to the use of SVV? Conventional care (eg BP, CVP, HR, urine output) Use an SV-based treatment protocol (NHS, Cecconi) Use an SVV-based treatment protocol (Benes, Ping, Ramsingh) *At risk because of comorbidities or the surgical procedure itself. Limitations to the use of SVV: Spontaneous breathing, tidal volume <7 ml/kg, open chest, atrial fibrillation, right ventricular failure, and laproscopic surgery. Abbreviations: BP: Blood Pressure; CVP: Central Venous Pressure; HR: Heart Rate; SV: Stroke Volume; SVV: Stroke Volume Variation. 2 3
Benes Protocol 1 Randomized controlled trial Undergoing elective abdominal surgery >2 h with expected blood loss >1000 ml Measure and record SVV, Cl One or more of the following: Ischemic heart disease or severe heart dysfunction, moderate to severe chronic obstructive pulmonary disease, aged 70+, ASA III or more SVV 10% and CVP <15 mm Hg Repeat monitoring of SVV, Cl during next 5 minutes Central Venous Pressure, Stroke Volume Variation, Cardiac Index Fluid (Colloid), Dobutamine Decrease in 30-day postoperative complications (56%), decrease in hospital length of stay (10%) Colloid bolus 3 ml/kg over 5 minutes CVP rise 3 mm Hg Dobutamine infusion to reach Cl 2.5 l/min/m 2 SVV <10% and no change or decrease of Cl Cl <2.5 l/min/m 2 Abbreviations: CI: Cardiac Index; CVP: Central Venous Pressure; SVV: Stroke Volume Variation. 4 5
Cecconi Protocol 2 Randomized controlled trial Undergoing elective total hip replacement under regional anesthesia Keep: SaO 2 >95% Hb >8 mg/dl Achieve SV max and then target DO 2 I to 600 ml/min*m 2 250 ml HES bolus HR <100 bpm MAP between 60 and 100 mm Hg ASA II Stroke Volume, Oxygen Delivery Fluid (Colloid), Dobutamine Decrease in postoperative complications (20%) Increase of SV >10% or blood loss >250 ml during fluid challenge SV stable >20 min See oxygen delivery DO 2 I 600 ml/min*m 2 Dobutamine: Increase by 3 mcg/kg*min Decrease or STOP if HR >100 bpm or signs of cardiac ischemia Check every 10 minutes If DO 2 I falls below 600 ml/min*m 2, restart algorithm Abbreviations: DO 2 I: Oxygen Delivery Index; Hb: Hemoglobin; HES: Hydroxyethyl Starch; HR: Heart Rate; MAP: Mean Arterial Pressure; SaO 2 : Oxygen Saturation; SV: Stroke Volume. 6 Resuscitation to achieve a DO 2 I value of 600 is presented as a goal and not intended to be a hard target. This protocol is intended as guidance, and healthcare professionals should use sound clinical judgment and individualize therapy to each specific patient care situation. Modified from Cecconi, et al. Crit Care. 2011;15:R132. Based upon Shoemaker 3 protocol. 7
NHS-NICE/Kuper Protocol 4-13 Quality improvement program (before-after comparison) Undergoing emergency and elective abdominal, orthopedic, gynecologic, urologic, and vascular surgery Three cohorts of patients aged 60, 61-71, and 71 years with ASA >I Measure SV 200-250 ml fluid over 5-10 minutes Stroke Volume SV increase >10%? Fluid 3.7-day decrease in hospital length of stay (25%) Monitor SV for clinical signs of fluid loss SV reduction >10% Abbreviation: SV: Stroke Volume. 8 9
Ping Protocol 14 Randomized controlled trial Undergoing radical gastrectomy, colon cancer resection, rectal cancer, and Whipple surgery Maintain SVV 11%-13% ASA I or ASA II Fluid to maintain the patient in the range Stroke Volume Variation Fluid HR <50 beats/min BP drops >30% from baseline Faster recovery time to normal diet (16%), decrease in hospital length of stay (19%) Atropine.05 mg Ephedrine 6 mg Abbreviations: BP: Blood Pressure; HR: Heart Rate; SVV: Stroke Volume Variation. 10 11
Ramsingh Protocol 15 Randomized, single-blinded controlled trial GDT Group (ventilate 8 ml/kg) Undergoing major abdominal surgery, urologic, gastrointestinal or gynecologic cancer resection, and Whipple surgery P-POSSUM mean predicted mortality rate of 1.4* SVV >12% Monitor SVV and CO Stroke Volume Variation Fluid (Colloid) 250 ml Albumin bolus (may repeat to max of 20 ml/kg) Faster return of GI function (3 vs 4 days), faster return of PO intake (4 vs 5 days), and a 2.5-day decrease in hospital length of stay (33%) SVV >12% >20 ml/kg Albumin? Crystalloid 3:1 replacement (consider PRBCs, monitor ABGs) * No differences other than age were statistically significant. P-POSSUM scores predicted mortality and showed no difference between the groups. Abbreviations: ABGs: Arterial Blood Gases; CO: Cardiac Output; P-POSSUM: Portsmouth Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke Volume Variation. 12 13
Donati Protocol 16 Multicenter randomized controlled trial Pre-op (T0): Arterial and central venous line Check SaO 2 ScvO 2 calculate O 2 ER Undergoing elective abdominal extensive surgery or abdominal aortic surgery Group A Group B ASA II Intra-op (T1): O 2 ER (hourly) Standard management (MAP, urine output, CVP) Central Venous Pressure, Oxygen Extraction Ratio Fluid (Colloid), Dobutamine 27% >27% Decrease in postoperative complications (60%), decrease in hospital length of stay (16%) No change (or decrease Dobutamine) CVP or SVV CVP <10 cm H 2 O or SVV > 12% CVP >10 cm H 2 O or SVV < 12% Fluid challenge Colloids (when Hb >10 g/dl) PBC (when Hb <10 g/dl) If O 2 ER still >27% Dobutamine Post-op (T2): Similar management to intra-op Checks of O 2 ER at the end of anesthesia, 0.5, 1, 2, and 6 hours, and day +1 Abbreviations: CVP: Central Venous Pressure; Hb: Hemoglobin; MAP: Mean Arterial Pressure; O 2 ER: Oxygen Extraction Ratio; Modified Donati Protocol: Donati A, et al. Chest. 2007;132:1817-1824. SaO 2 : Oxygen Saturation; ScvO 2 : Central Venous Oxygen Saturation. O 2 ER is estimated based on use of ScvO 2. 14 15
References 1. Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14(3):R118. 2. Cecconi M, Fasano N, Langiano N, et al. Goal directed haemodynamic therapy during elective total hip arthrosplasty under regional anaesthesia. Crit Care. 2011;15(3):R132. 3. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176-1186. 4. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hyperperfusion during cardiac surgery. Arch Surg. 1995;130(4):423-429. 5. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315(7113):909-912. 6. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88(1):65-71. 7. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97(4):820-826. 8. Conway D, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57(9):845-849. 9. McKendry M, McGloin H, Saberi D, Caudwell L, Brady A, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):258. 10. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler-guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95(5):634-642. 11. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93(9):1069-1076. 12. Chytra I, Pradl R, Bosman R, Pelnár P, Kasal E, Zidková A. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care. 2007;11(1):R24. 13. Kuper M, Gold SJ, Callow C, et al. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ. 2011;342:d3016. 14. Ping W, Hong-Wei W, Tai-Di Z. Effect of stroke volume variabilityguided intraoperative fluid restriction on gastrointestinal functional recovery [published online ahead of print]. Hepatogastroenterology. 2012;59(120). doi:10.5754/hge12283. 15. Ramsingh DS, Sanghvi C, Gamboa J, Cannesson M, Applegate RL 2nd. Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial [published December 2012]. J Clin Monit Comput. doi: 10.1007/s10877-012-9422-5. 16. Donati A, Loggi S, Preiser JC, et al. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest. 2007;132(6):1817-1824. 16 17
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