University of Groningen Goal-oriented hemodynamic treatment in high-risk surgical patients Sonneveld, Johan Pieter Cornelis IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2005 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Sonneveld, J. P. C. (2005). Goal-oriented hemodynamic treatment in high-risk surgical patients s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 10-02-2018
RIJKSUNIVERSITEIT GRONINGEN Goal-oriented Hemodynamic Treatment in High-risk Surgical Patients Proefschrift ter verkrijging van het doctoraat in de Medische Wetenschappen aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus, dr. F. Zwarts, in het openbaar te verdedigen op woensdag 12 oktober 2005 om 14:45 uur door Johan Pieter Cornelis Sonneveld geboren op 27 januari 1966 te Doornspijk
Promotor: Copromotor: Prof. Dr. J.M.K.H. Wierda Dr. V. Fidler Beoordelingscommissie: Prof. Dr. L.P.H.J. Aarts Prof. Dr. J. Damen Prof. Dr. J. Klein ISBN: 90-367-2339-6
Paranimfen: Dr. P.J. van den Berg Drs. T.J. Elbertsen Financial support for the publication of this thesis by the Foundation for Experimental Anesthesiology and Clinical Pharmacology (Groningen, The Netherlands) is gratefully acknowledged. =VQ^MZ[Q\a5MLQKIT+MV\MZ/ZWVQVOMV This research was supported by the University Medical Center Groningen, University of Groningen, the Netherlands. Copyright 2005 by J.P.C. Sonneveld. All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission from the author. Printed by: Stichting Drukkerij C. Regenboog, Groningen
&RQWHQWV Introduction Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Introductory chapter. Oxygen uptake, transport and utilization, and the role of hemodynamic treatment on outcome; aims of the study. Pulmonary Artery Guided Treatment of Hemodynamics in High-risk Surgical (Trauma) Patients Undergoing Major Noncardiac Surgery. Perioperative pre-shock states, their clinical consequences and strategies to prevent and treat them - an overview of the literature up to 1996. Preoperative Goal-oriented Hemodynamic Treatment (Tune-up) in High-risk Surgical Patients; an Open, Randomized Controlled Clinical Trial in the period 1996-1998. Clinical Pathway of High-risk Surgical Patients Undergoing Elective, Major Noncardiac Surgery and Scheduled for Postoperative ICUadmission - a descriptive cohort study 1996-1998 in the University Hospital Groningen. Costs Related to Preoperative Goal Oriented Hemodynamic Treatment (Tune-up) at the Intensive Care Unit of High-risk Surgical Patients. Preoperative Goal Oriented Hemodynamic Treatment of High Risk Surgical Patients Undergoing Major Noncardiac Surgery. An overview of the literature 1998-2005. Goal Oriented Hemodynamic Treatment (GOHT) in Patients Undergoing Major Surgery. Conclusions and Perspectives in the Context of Perioperative Medicine. 1 5 41 61 83 97 127 Summary and Conclusions 141 Samenvatting en conclusies 149 Dankwoord 159 Curriculum Vitae 163
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,QWURGXFWLRQ Homeostasis under normal physiologic conditions is maintained by aerobic metabolism. The cardiopulmonary system provides oxygen delivery from the environment into the body, to every single cell, to maintain aerobic metabolism. Figure 1. From the British Medical Journal 1998, volume 317, pages 1302-1306 1, with permission from the BMJ Publishing Group. The oxygen transport (oxygen delivery) and utilization (oxygen consumption) in an adult of approximately 75 kilograms, having a cardiac output (Qt) of 5 L/min and breathing air at standard barometric pressure (PiO 2 dry) are schematically summarized in figure 1. 1-3 Oxygen (O 2 ) is extracted from the environment and bound in the red cells by hemoglobin (Hb). The arterial circulation carries the oxygenated red blood cells to the tissues. The circulatory system splits in a fine capillary network in the peripheral tissues. The difference in oxygen tension drives the oxygen from the blood through the capillary endothelium and cell barriers into the cells. In the cell oxygen is used by mitochondria, the so-called energy factories of the cell, to maintain aerobic homeostasis. At the level of organs the metabolic rate may vary extensively, dependent on the state of activity. The cardiopulmonary system has a large capacity to increase oxygen delivery to maintain aerobic metabolism under (patho)physiologic conditions. The balance is maintained as long as the amount of Hb, the rate of perfusion and minute volume of ventilation allow a sufficient delivery of oxygen to the tissues (figure 1). However, this system may be overcharged and consequently the oxygen delivery may fail to supply sufficiently for aerobic metabolism. A temporary oxygen debt may develop that needs to be counterbalanced to prevent an ongoing anaerobic metabolism. Pathophysiologic conditions at any level of oxygen transfer may interfere with the distribution to and utilization of oxygen in the tissues. The duration and severity of an oxygen deficiency may result in damage, dysfunction, and ultimately failure or death of cells or even tissues. High values of Qt, oxygen delivery and oxygen consumption correlate with the rate of survival in critically ill (postoperative) patients.
,QWURGXFWLRQ Figure 2. From the British Medical Journal 1998, volume 317, pages 1302-1306 1, with permission from the BMJ Publishing Group. During the seventies and the eighties of the twentieth century, the relation of oxygen delivery and consumption in critically ill patients was found to be significantly different compared to healthy individuals (dotted line in figure 2). It was argued that insufficient oxygen supply to the tissues played a key role in the development of multi organ failure (MOF) and death ( oxygen dependency ). The earlier observed high values of oxygen transport and utilization, found in surviving critically ill patients, were hypothesized to improve outcome in specific patient categories. The hypothesis was tested in multiple clinical trials of critically ill patients, including surgical patients. Regarding the value of striving for so-called supranormal values of Qt, oxygen delivery and oxygen consumption, firm conclusions were difficult to make since various types of patients had been included in these trials. Some authors advocated hemodynamic treatment as a preventive treatment in noncardiac so-called high-risk surgical patients. However, none of these studies compared the standard preoperative work-up of patients with the proposed additional hemodynamic treatment to be performed at the intensive care unit (ICU). We therefore designed a randomized controlled trial of preoperative goaloriented hemodynamic treatment (GOHT) on high-risk surgical patients, to study whether a reduction in complication rate could be achieved. We compared the usual preoperative preparation on the ward with GOHT at the ICU. The primary aim of the main study is to demonstrate a reduction of perioperative morbidity by preoperative hemodynamic treatment in noncardiac major surgery. Secondly, it was hypothesized that a reduction in complication rate may reduce the length of stay (LOS) at the ICU and in the hospital. Additionally we compared the two trial groups with a group of patients that was eligible for the trial but did not participate in it for logistic or personal reasons. A critical review of the outcome of the literature before, during and after the study puts our study in the perspective of clinical relevant settings of past and current practices.
,QWURGXFWLRQ Reference List 1. Treacher DF, Leach RM: Oxygen transport-1. Basic principles. BMJ 1998; 317: 1302-6 2. Leach RM, Treacher DF: Oxygen transport-2. Tissue hypoxia. BMJ 1998; 317: 1370-3 3. Leach RM, Treacher DF: The pulmonary physician in critical care * 2: oxygen delivery and consumption in the critically ill. Thorax 2002; 57: 170-7