U N I V E R S I T Ä T S M E D I Z I N B E R L I N

1. Goal directedperioperativemonitoring Univ.-Prof. Dr. Michael Sander Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin Campus Charité Mitte, Campus Virchow-Klinikum Charité - Universitätsmedizin Berlin U N I V E R S I T Ä T S M E D I Z I N B E R L I N

2. Disclosure Research grants or royalties for lectures: • Edwards Life Science • Fresenius Medical • The Medicines Company • Pulsion Medical Systems

3. Educational objective • Goal-directed perioperative monitoring • Why? • Who? • What? • How?

4. AGENDA • Risks in the OR • Parameters • Blood pressure • Venoussaturation • Dynamic parametersofcirculation • Conclusion

5. Old people – a challenge for the future Jeanne Louise Calment * February, 21th 1875 in Arles, France; † August, 4th 1997

6. Old people – a challenge for the future Jeanne Louise Calment * February, 21th 1875 in Arles, France; † August, 4th 1997

7. part in % over 65 years old over 80 years old men women Percentage of older people increases Amount of older people over 65/80 years of entire population

8. Demographic change- a challenge for the future - Siewert, U. et al. (2010). Deutsches Ärzteblatt international, 107(18), 328–334.

9. European Surgical Outcome Study • Results • Inclusionof 46.539 patients • 1.855 patientsdied(in-hospital mortality 4%) • Conclusion • Strategiestominimiserisk • Methods • 7 day cohort study • Time of recruitment: 4.4.2011 to 11.4.2011 • Multi center study (498 centers in Europe) • Patients • Inclusion of all „non cardiac-surgery“ patients (elective and not elective) • Primary endpoint • hospital mortality (maximum follow-up 60 days) Pearse, R. et al. (2012). Lancet, 380(9847), 1059–1065.

10. Improving our care “Now, here, you see, it takes all the running you can do to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!”

11. Patient safety- risk reduction strategy - • Risks on patient side: • Age • Pre-existing conditions • Heart and circulation • Anaemia • Genetic • ... individual goal-directed therapy • Risk in surgery: • Type of surgery • Blood loss • Emergency vs. elective • ... • Structural risk: • Checklists • Monitoring • Education • Standardized paths • for treatments • SOP Sander, M. (2013) Perioperatives Risiko. DIVI Jahrbuch 2012/2013 ISBN: 978-3-941468-84-9

12. Patient safety- risk reduction strategy - • Risks on patientside: • Age • Pre-existingconditions • Heart andcirculation • Anaemia • Genetic • ... individual goal-directed therapy hemodynamic management • Risk in surgery: • Type ofsurgery • Blood loss • Emergency vs. elective • ... • Structuralrisk: • Checklists • Monitoring • Education • Standardizedpaths • fortreatments • SOP Sander, M. (2013) Perioperatives Risiko. DIVI Jahrbuch 2012/2013 ISBN: 978-3-941468-84-9

13. Fluid management and morbidity morbidity Risks  • Hypoperfusion • SIRS • Sepsis • MOV Risks  • Edema • Ileus • PONV • Pulmonary dysf. hypovolaemia normovolaemia hypervolaemia Habicher, M., Sander, M. (2011). Journal of Cardiothoracic and Vascular Anesthesia, 25(6), 1141–1153.

14. Fluid management and morbidity Method: randomised controlled multi center studyl, N=172, median (range) colonic surgery - restrictive vs. liberal liquid management morbidity restrictive (n=69) ↔ liberal (n=72) Fluid at the day of surgery: 5388 ml (2700–11083) complications postop: 44 patients (51%) Fluid at the day of surgery: 2740 ml (1100 – 8050), p<0,01 complications postop: 28 patients (33%), p=0,01 hypovolaemia normovolaemia hypervolaemia Brandstrup, B. et al. (2003). Annals of Surgery, 238(5), 641–648.

15. Fluid management and morbidity Method: randomised controlled double blind intervention study, N=32, median (range) colonic surgery - restrictive vs. liberal liquid management morbidity restrictiv (n=16) ↔ liberal (n=16) Fluid intraop: 1640 ml (935–2250), p<0,01 Complications postop: 6 patients with 18 complications, 38%, p=0,01 Fluid intraop: 5050 ml (3563–8050) complications postop: 1 patients with 1 complication (6%) hypovolaemia normovolaemia hypervolaemia Holte, K. et al. (2007). British Journal of Anaesthesia, 99(4), 500–508.

16. Individualized hemodynamic goal-directed therapy morbidity restrictive ↔ liberal pre-existingcondition Typ ofintervention Preoplossofblood Preoppreload Epiduralanaesthesia ... individualized hemodynamic management hypovolaemia normovolaemia hypervolaemia Habicher, M., Sander, M. (2011). Journal of Cardiothoracic and Vascular Anesthesia, 25(6), 1141–1153.

17. Classics

18. Supranormal DO2 Shoemaker et al. Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients. Chest (1992) vol. 102 (1) pp. 208-15

19. Adequate oxygen suply consumption supply

20. Does DO2 increases VO2 ? No ! Yes ! Shibutani K. Crit Care Med 1983

21. Does DO2 increases VO2 ? Sharma, V. K., & Dellinger, R. P. (2003). The International Sepsis Forum’s frontiers in sepsis: high cardiac output should not be maintained in severe sepsis. Critical care (London, England), 7(4), 272. doi:10.1186/cc2350

22. Oxygen supply: DO2 • simplified fomula = DO2 = CO X (Hgb X 1.34 X Sa02) X 10

23. Oxygen Delivery: What are the components? Oxygen Delivery DO2 Cardiac Output Stroke volume CaO2 Preload Afterload Contractility Heart rate PaO2 SaO2 CVP PCWP PVR SVR Ejection fraction Synchrony Hct

24. Implementation into practice? Monitoring of circulation: „It was fatal for the development of our understanding of circulation, that blood flow is relatively difficult to measure, whereas blood pressure is easily measured: This is the reason why the blood pressure meter has gained such a fascinating influence, although most organs do not need pressure, but blood flow. Jarisch A. (1928). Deutsche Medizinische Wochenschrift

25. To the question: “Do you believe that your current hemodynamic management could be improved?” 86.5 % of ASA respondents and 98.1 % of ESA respondents (p < 0.001) answered Yes. Cannesson et al. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Critical care (London, England) (2011) vol. 15 (4) pp. R197

26. Cannesson et al. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Critical care (London, England) (2011) vol. 15 (4) pp. R197

27. Parameters for individualized hemodynamic therapy ? stroke volume central venous pressure pulse pressure variation central venous saturation arterial pressure echocardiography Most frequent answers: „which parameters do you use to manage for hemodynamic and volume management“? Data in percent, n = 62 Kastrup, M., Sander, M. et al. (2013). Acta Anaesthesiologica Scandinavica, 57(2), 206–213.

28. Pressure Arterial pressure and central venous pressure for rmanagement of circulation therapy

29. Marik, P. E., & Cavallazzi, R. (2013). Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Critical Care Medicine, 41(7), 1774–1781. doi:10.1097/CCM.0b013e31828a25fd

30. Does CVP predict fluid responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense • There are no data to support the widespread prac- tice of using central venous pressure to guide fluid therapy. This approach to fluid resuscitation should be abandoned. (Crit Care Med 2013; 41:1774–1781) Marik, P. E., & Cavallazzi, R. (2013). Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Critical Care Medicine, 41(7), 1774–1781. doi:10.1097/CCM.0b013e31828a25fd

31. venous saturation

32. Physiology – Oxygen transport Hemoglobin Hemoglobin Hemoglobin Hemoglobin Hemoglobin O2 O2 O2 Lung Tissue CO2 CO2

33. Venous oximetry Venous saturation in balance between: • VenöseSättigungenzeigen die Balance zwischen: • Herzzeitvolumen • ArterielleSättigung • Hämoglobingehalt • Sauerstoffverbrauch cardiac output arterial saturation hemoglobin oxygen consumption

34. A low ScvO2 in the perioperative setting is associated with a higher risk of postoperative complications

35. Review van Beest, P., Wietasch, G., Scheeren, T., Spronk, P., & Kuiper, M. (2011). Clinical review: use of venous oxygen saturations as a goal - a yet unfinished puzzle. Critical care (London, England), 15(5), 232. doi:10.1186/cc10351

36. Limitations

37. Problems with interpretation of ScvO2 • A lowScvO2indicates that something is wrong, but not what is wrong nor what needs to be done (fluids? inotropics?) But, • If O2ER is reduced - especially in high risk surgery patients - normal and high ScvO2 does not guarantee that perfusion is adequate and that the patient has an ideal state of volume

38. Pathophysiology of oxygen transport Hämoglobin Hemoglobin Hemoglobin Hämoglobin O2 O2 O2 Lung Tissue CO2 CO2

39. Hemodynamic monitoring

40. Outcome und Monitoring-Device Grocott, M. P., et al. (2012). Cochrane database of systematic reviews, 11, CD004082.

41. 388 criticallyillandhemodynamic instabil patients in 3 european ICUs Randomization: 1.minimal invasive CO Monitoring 2. no CO Monitoring Takala, J. et al.(2011) Crit Care. Jun 15;15(3):R148.

42. TherapeuticInterventions: Hemodynamicstabilization: Study group Control Takala, J. et al.(2011) Crit Care. Jun 15;15(3):R148.

43. Perioperative Optimization • 85 patientswithelectivecolectomy • Fluid restrictiongroup (n=43) • 1500ml crystalloids intraoperative • 500ml colloids (Gelofusine) accordingto • heart rate, bloodpressure, urineproduction • Blood loss 1:1 substitutionwithcolloids • transfusion <10 g/dl respect. < 7g/dl • GDFT group (n=42) • 1500ml crystalloids • colloidsaccordingtoflowchart • Blood loss 1:1 substitutionwithcolloids • transfusion <10 g/dl respect. < 7g/dl Srinivasa, S. et al. (2013) British Journal of Surgery; 100: 66–74

44. Perioperative Optimization No difference in outcome Srinivasa, S. et al. (2013) British Journal of Surgery; 100: 66–74

45. Most importantly, one must never forget that it is not the monitoring itself that can improve outcomes but the changes in therapy guided by the data obtained. Vincent, J-L. et al. (2011) Critical Care 15:229.

46. Goal directed hemodynamic monitoring AND therapy

48. Functional hemodynamics- stroke volume, PPV, SVV and TOE vs. CVP - methods: metaanalyse of 29 studies, N=685 patients statistics:ROC analyses (AUC; 95% - CI; increase SVI, CI) Stroke volume optimization and functional hemodynamic parameters are very suitable for individualized management of hemodynamic therapy. Marik, P. et al. (2009). Critical Care Medicine, 37(9), 2642–2647.

49. Individualized hemodynamic treatment strategies Individualized optimization of hemodynmaic reduces incidence of complications as well as length of hospital stay of patients undergoing surgery Grocott, M. P., et al. (2012). Cochrane database of systematic reviews, 11, CD004082.

50. Conclusion • Hemodynmic monitoring • Alone does not change outcome • Individualized hemodynamic treatment strategies • Do have an impact on patient outcome • „One size does not fit all“ – Individualized approach for hemodynmamic management • Goals of treatment are not static parameters (MAP, CVP, ScvO2) • Goals of treament are functional parameters, i.e. stroke volume optimization, pulse pressure variation and stroke volume variation • Perspective • International guidelines • Clinical implementation  patient safety 