Team Alignment Presentation

Hemodynamic Optimization through Perioperative Goal-Directed Therapy

Why and How?Why and How?

Dr XHospital Y

• Paid consultant for Edwards Lifesciences• Affiliation• Other (as appropriate)

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Disclosures

WHY?3

• Complications are not exceptions

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Hemodynamic Optimization: Why?

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Infection— Pneumonia— Urinary tract infection— Superficial wound infection— Deep wound infection— Organ-space wound infection— Systemic sepsis or septic shock

Gastro-intestinal— Nausea and vomiting— Ileus (paralytic or functional)— Acute bowel obstruction— Anastomotic leak— Gastro-intestinal hypertension— Hepatic dysfunction— Pancreatitis

Respiratory— Prolonged mechanical ventilation (>48h)— Unplanned intubation or reintubation— Respiratory failure or ARDS— Pleural effusion

Renal— Renal insufficiency (increase in creatinine levels or decrease in urine output)— Renal failure (requiring dialysis)

Cardiovascular— Deep venous thrombosis— Pulmonary embolism— Myocardial infraction— Hypotension— Arrhythmia— Cardiogenic pulmonary edema— Cardiogenic shock— Infarction of GI track— Distal ischemia— Cardiac arrest (exclusive of death)

Neuro— Stroke or cerebro-vascular accident— Coma— Altered mental status or cognitive dysfunction or

delirium

Hemato— Bleeding requiring transfusion— Anemia— Coagulopathy

Other— Vascular graft of flap failure— Wound dehiscence— Peripheral nerve injury— Pneumothorax

Most Common Post-Surgical Complications

http://www.patient.co.uk/doctor/common-postoperative-complications

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• 84,730 inpatients• General or vascular surgery• NSQIP database (designed to record

post-surgical complications until day 30)

Variation in Hospital Mortality Associated with Inpatient Surgery.

Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, M.D., M.P.H.

N Engl J Med 2009

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NSQIP Complications M = Major m = minor

Infection M— Pneumonia m— Urinary tract infection m— Superficial wound infection M— Deep wound infection M— Organ-space wound infection M— Systemic sepsis or septic shock

Gastro-intestinal— Nausea and vomiting— Ileus (paralytic or functional)— Acute bowel obstruction— Anastomotic leak— Gastro-intestinal hypertension— Hepatic dysfunction— Pancreatitis

Respiratory M— Prolonged mechanical ventilation (>48h) M— Unplanned intubation or reintubation

— Respiratory failure or ARDS— Pleural effusion

Renalm — Renal insufficiency (increase in creatinine levels

or decrease in urine output) M— Renal failure (requiring dialysis)

Cardiovascular m— Deep venous thrombosis M— Pulmonary embolism M— Myocardial infraction

— Hypotension— Arrhythmia— Cardiogenic pulmonary edema— Cardiogenic shock— Infarction of GI track— Distal ischemia— Cardiac arrest (exclusive of death)

Neuro M— Stroke or cerebro-vascular accident

— Coma— Altered mental status or cognitive dysfunction or delirium

Hemato M— Bleeding requiring transfusion

— Anemia— Coagulopathy

Other M— Vascular graft of flap failure M— Wound dehiscence

— Peripheral nerve injury— Pneumothorax

http://www.patient.co.uk/doctor/common-postoperative-complications

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• Complication rate was 24.6-26.9%• Major complication rate was 16.2-18.2%

Variation in Hospital Mortality Associated with Inpatient Surgery.

Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, M.D., M.P.H.

N Engl J Med 2009

129,233 casesComplication rates depend on the surgical procedure

Surgery Morbidity rate %

Esophagectomy 55.1

Pelvic exenteration 45.0

Pancreatectomy 34.9

Colectomy 28.9

Gastrectomy 28.7

Liver resection 27

Prioritizing Quality Improvement in General Surgery.

Schilling et al. J Am Coll Surg. 2008; 207:698–704.

129,546 casesComplication rates depend on the patient

Risk factor Odd ratio

ASA 4/5 vs 1/2 1.9

ASA 3 vs 1/2 1.5

Dyspnea at rest vs. none 1.4

History of COPD 1.3

Dyspnea with minimal exertion vs. none

1.2

Successful Implementation of the Department of Veterans Affairs’ NSQIP in the Private

Sector: The Patient Safety in Surgery Study. Khuri et al. Ann Surg 2008

• Complications are not exceptions• Complications are costly

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Hemodynamic Optimization: Why?

Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012

Extra cost $

$6358$12802

$42790

2250 Patients Undergoing General and Vascular Surgery

Synergistic Implications of Multiple Postoperative Outcomes.

Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D.

Am J Med Quality 2012

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All Complications(6 Studies)

Acute Kidney Injury(4 Studies) Surgical Site Infections(7 Studies)Hosp Assoc Pneumonia (8 Studies)Urinary Tract Infection(5 Studies)Major GI Complications(4 Studies)

Minor GI Complications(3 Studies)

$42,790$4,278

$22,023$2,590

$27,969$2,425

$64,544$3,237

$12,828$767

$77,483$6,214

$8,296$5,412

Complications Have a Cost

Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012

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All Complications(6 Studies)

Acute Kidney Injury(4 Studies) Surgical Site Infections(7 Studies)Hosp Assoc Pneumonia (8 Studies)Urinary Tract Infection(5 Studies)Major GI Complications(4 Studies)

Minor GI Complications(3 Studies)

$42,790$4,278

$22,023$2,590

$27,969$2,425

$64,544$3,237

$12,828$767

$77,483$6,214

$8,296$5,412

Wide range!

Complications Have a Cost

Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012

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All Complications(6 Studies)

Acute Kidney Injury(4 Studies) Surgical Site Infections(7 Studies)Hosp Assoc Pneumonia (8 Studies)Urinary Tract Infection(5 Studies)Major GI Complications(4 Studies)

Minor GI Complications(3 Studies)

$42,790$4,278

$22,023$2,590

$27,969$2,425

$64,544$3,237

$12,828$767

$77,483$6,214

$8,296$5,412

Reliable?

Complications Have a Cost

Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012

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More Reliable Approach

Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012

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+ $18,000

2250 Patients Undergoing General and Vascular Surgery

Synergistic Implications of Multiple Postoperative Outcomes.

Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D.

Am J Med Quality 2012

Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012

• Complications are not exceptions• Complications are costly• Complications are responsible for

prolonged LOS and readmissions

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Hemodynamic Optimization: Why?

Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012

19Number of Postoperative Events

Mar

gina

l Len

gth

of S

tay

Synergistic Implications of Multiple Postoperative Outcomes.

Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail Ortenzi, RN, BSN, and Peter W. Dillon, M.D.

Am J Med Quality 2012

12,767 colectomiesAverage excess LOS for adverse events = 9.8 days

Prioritizing Quality Improvement in General Surgery.

Schilling et al. J Am Coll Surg. 2008; 207:698–704.

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Association Between Occurrence of a Postoperative Complication and Readmission.

Implications for Quality Improvement and Cost SavingsElise H. Lawson, M.D. MSHS, Bruce Lee Hall, M.D. Ph.D, MBA, Rachel Louie, MS,

Susan L. Ettner, Ph.D., David S. Zingmond, M.D., Ph.D, Lein Han, Ph.D, Michael Rapp, M.D., JD and Clifford Y. Ko, M.D. MS, MSHS

Ann Surg 2013

• Complications are not exceptions• Complications are costly• Complications are responsible for

prolonged LOS and readmissions• Complications affect long-term survival

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Hemodynamic Optimization: Why?

Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications. Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D., Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program Ann Surg 2005

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• 105,951 surgical patients (GI, vasc, hip)• 8 year follow-up

Determinants of Long-Term Survival After Major Surgery and the Adverse Effect

of Postoperative Complications.Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D.,Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program

Ann Surg 2005

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• « The most important determinant of decreased postoperative survival was the occurrence, within 30 days postop, of any complication »

Determinants of Long-Term Survival After Major Surgery and the Adverse Effect

of Postoperative Complications.Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D.,Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program

Ann Surg 2005

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• « The most important determinant of decreased postoperative survival was the occurrence, within 30 days postop, of any complication »

• « Independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69% »

Determinants of Long-Term Survival After Major Surgery and the Adverse Effect

of Postoperative Complications.Shukri F. Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D.,Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program

Ann Surg 2005

• Complications are not exceptions• Complications are costly• Complications are responsible for

prolonged LOS and readmissions• Complications affect long-term survival• Hemodynamic Optimization through

PGDT is a KEY to prevent post-surgical complications

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Hemodynamic Optimization: Why?

Data on file.

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• Patho-physiology

Hemodynamic Optimization through PGDT is KEY

Data on file.

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• Low preload, low cardiac output, low blood pressure, low perfusion• Arrhythmia (hypovolemia)

• GI dysfunction (hypoperfusion)

• Postoperative ileus, PONV• Upper GI bleeding• Anastomotic leak

• Infectious complication (tissue hypoperfusion)

• Acute renal insufficiency or failure (decreased renal blood flow)2002; 89: 622-632.

Effects of Low Volume Fluid Administration

Data on file.

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• Pulmonary edema, prolonged mechanical ventilation• GI dysfunction

• Abdominal compartment syndrome• Ileus• Anastomotic leak

• Hemodilution and coagulopathy002; 89: 622-632.

Effects of High Volume Fluid Administration

Data on file.

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Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290Editorial by M. C. Bellamy

Where Do We Want to Be?

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TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

32

TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

HOW DO YOU KNOW?

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TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

CVP?

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

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A Low CVP Does Not Mean Your Patient Needs Fluid

Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis

and a Plea for Some Common Sense.Paul E. Marik, M.D., FCCM, Rodrigo Cavallazzi, M.D.

Crit Care Med 2013; 41:1774-1781

REVIEW ARTICLES

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A Low CVP Does Not Mean Your Patient Needs Fluid

Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis

and a Plea for Some Common Sense.Paul E. Marik, M.D., FCCM, Rodrigo Cavallazzi, M.D.

Crit Care Med 2013; 41:1774-1781

REVIEW ARTICLES

CONCLUSION: There are no data to support the widespread practice of using central venous pressure to guide the fluid therapy. This approach to fluid resuscitation should be abandoned.

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TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

Blood Pressure?

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

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Can Changes in Arterial Pressure be Used to Detect Changes in Cardiac Output During Volume

Expansion in the Perioperative Period?Yannick Le Manach, M.D., Ph.D., Christoph K. Hofer, M.D., Ph.D.

Jean-Jacques Lehot, M.D., Ph.D., Benoit Vallet, M.D., Ph.D., Jean-Pierre Goarin, M.D.Benoit Tavernier, M.D., Ph.D., Maxime Cannesson, M.D., Ph.D.

Anesthesiology 2013

PERIOPERATIVE MEDICINE

Changes in Blood Pressure do not Reflect Changes in Blood Flow

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PERIOPERATIVE MEDICINE

NO!

Can Changes in Arterial Pressure be Used to Detect Changes in Cardiac Output During Volume

Expansion in the Perioperative Period?Yannick Le Manach, M.D., Ph.D., Christoph K. Hofer, M.D., Ph.D.

Jean-Jacques Lehot, M.D., Ph.D., Benoit Vallet, M.D., Ph.D., Jean-Pierre Goarin, M.D.Benoit Tavernier, M.D., Ph.D., Maxime Cannesson, M.D., Ph.D.

Anesthesiology 2013

PERIOPERATIVE MEDICINE

Changes in Blood Pressure do not Reflect Changes in Blood Flow

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TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

HOW DO YOU KNOW?

Preload

Stroke Volume

Frank-Starling relationship between preload and stroke volume

Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290

Preload

Stroke Volume

TARGET ZONE

Frank-Starling relationship between preload and stroke volume

Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290

Preload

Stroke Volume

TARGET ZONEHYPO HYPER

Frank-Starling relationship between preload and stroke volume

Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290

Preload

Stroke Volume

∆P = fluid-induced increase in preload

∆SV >> 10% ∆SV > 10%

∆SV < 10%

HYPO HYPER

The Stroke Volume Optimization Strategy

Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290

Preload

Stroke Volume

SVV >> 10%

SVV > 10% SVV < 10%

The Stroke Volume Optimization Strategy

Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290

Preload

Stroke Volume

SVV >> 10%

SVV > 10% SVV < 10%

HYPO HYPER

The Stroke Volume Optimization Strategy

Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290

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TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

HOW DO YOU KNOW?

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

47

TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

Flow parameters!

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

48

TARGET ZONE

Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study

SVV to preditct fluid responsiveness

SV/CO to assess the effects of fluid

Where Do We Want to Be?

Wet, Dry or Something Else?British Journal of Anaesthesia 97 (6): 755-7 (2006)

Doi:10.1093/bja/ae1290

• Plug and play techniques• Non-operator dependent• Stroke Volume (SV) and Cardiac output (CO)• Stroke Volume Variation (SVV) = reliable

predictor of fluid responsiveness• Option for patients with an A-line =

Arterial Pressure –based Cardiac Output• Option for patients without an A-line =

Arterial Pulse Contour Analysis49

Monitoring Flow Parameters is Easywith Pulse Contour Methods

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• Patho-physiology• Outcome studies

Hemodynamic Optimization through PGDT is KEY

Evidence-Based Medicine: Using a Hemodynamic Protocol with Specific Goals

(Perioperative Goal-Directed Therapy) Based on Flow Measurements is Useful

N.I.C.E. (NHS) Protocol - National institute for health and clinical excellence / national health system (NHS) Perioperative Goal-Directed Therapy protocol

• > 30 positive RCTs• Several meta-analyses• Several QIPs

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Superiority of Hemodynamic Optimization Over Standard Fluid Management

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Reduction in Average odd or risk ratio (confidence interval)

Author (reference)

Acute kidney injury 0.64 (0.50-0.83) 0.71 (0.57-0.90)0.67 (0.46-0.98)

Brienza (9)Grocott (13)

Corcoran (14)

Minor GI complications 0.29 (0.17-0.50) Giglio (10)

Minor GI complications 0.42 (0.27-0.65) Giglio (10)

Surgical site infection 0.58 (0.46-0.74)0.65 (0.50-0.84)

Dalfino (11)Grocott (13)

Urinary tract infection 0.44 (0.22-0.88) Dalfino (11)

Pneumonia 0.71 (0.55-0.92)0.74 (0.57-0.96)

Dalfino (11)Corcoran (14)

Respiratory failure 0.51 (0.28-0.93) Grocott (13)

Total morbidity rate 0.44 (0.35-0.55)0.68 (0.58-0.80)

Hamilton (12)Grocott (13)

Clinical Benefits of Hemodynamic Optimization Over Standard Fluid Management

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Reduction in Average odd or risk ratio (confidence interval)

Author (reference)

Hospital length of stay 1.16 (0.43-1.89)1.95 (0.57-0.90)

Grocott (13)Corcoran (14)

Effects of Hemodynamic Optimization on HLOS

• Highly selected patients• Extra-resources• Hawthorne effect

Main RCTs Limitations

Hamilton2010; Dalfino2011; Giglio2009; Corcoran2012; Grocott2013; Brienza2009

RCTs Are Not Real Life

RCT QIP

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Period 1 Period 2

Now Comparative Evaluation

Data collection 1From an e-database(mortality, ICU LOS, HLOS, morbidity)

Data collection 2From an e-database(mortality, ICU LOS, HLOS, morbidity)

ImplementationTreatment protocol

Before-After Comparison

Perioperative hemodynamic therapy: quality improvement programs should help to resolve our uncertainty Frederic Michard*1, Maxime Cannesson2 and Benoit Vallet3 Michard et al. Critical Care 2011, 15:445 http://ccforum.com/content/15/5/445

Quality Improvement ReportKuper et al.

BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016

Age Control (n=658) Intervention (n=649)≤60 196 (29.8) 237 (36.5)

61-70 175 (26.6) 167 (25.7)

≥71 287 (43.6) 245 (37.8)

Surgical specialty:

Colorectal 339 (51.5) 355 (54.7)

Gynecological 4 (0.6) 9 (1.4)

Orthopaedic 139 (21.1) 133 (20.5)

Kidney or pancreas transplant 48 (7.3) 33 (5.1)

Upper gastrointestinal 79 (12.0) 55 (8.5)

Urology 21 (3.2) 45 (6.9)

Vascular 28 (12.6) 19 (2.9)

Mean (SD) POSSUM score 34.3 (8.3) 34.0 (8.5)

ASA physical status grade: 83 (12.6) 108 (16.6)

1

2 299 (45.4) 313 (48.2)

3 247(37.5) 185 (28.5)

4 26 (4.0) 41 (6.3)

5 1 (0.2) 1 (0.2)

Mode of surgery:

Urgent or emergency 201(30.5) 177 (27.3)

Elective or scheduled 457 (69.5) 472 (72.7)Quality Improvement Report Kuper et al. BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016

Hemodynamic Optimization Protocol

N.I.C.E. (NHS) Protocol - National institute for health and clinical excellence / national health system (NHS) Perioperative Goal-Directed Therapy protocol

Control InterventionPatient group No Mean (SD) stay No Mean (SD) stay P valueTotal 658 18.7 (24.4) 649 15.1 (16.7) 0.002

Derby 201 10.9 (10.7) 201 8.4 (7.3) 0.007

Manchester 232 25.5 (34.8) 224 19.8 (23.2) 0.043

Whittington 255 15.7 (13.4) 224 13.4 (12.7) 0.108

Postoperative 658 17.2 (24.0) 649 13.6 (15.9) 0.001

HLOS Reduction

Quality Improvement Report Kuper et al. BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016

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UC Irvine QI Program

Permission obtained from Dr. Cannesson to utilize this information.

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Pre Implementation (n=128)

Post Implementation (n=116)

Full ERAS package application 8% 62%

Intraoperative fluid administration 10 ml/kg/h 7 ml/kg/h

Surgery duration 456 min 422 min

Estimated blood loss 550 ml 440 ml

LOS ICU 2.5 days 1.6 days

LOS hospital 12.2 days 9.5 days

Blood transfusion 45% 35%

PRBC per patient transfused 4.4 units 2.7 units

Initial Experience

UC Irvine QI Program

Permission obtained from Dr. Cannesson to utilize this information.

65

UC Irvine QI Program

Permission obtained from Dr. Cannesson to utilize this information.

66

• Patho-physiology• Outcome studies• Recommendations and guidelines

Hemodynamic Optimization through PGDT is KEY

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Perioperative fluid management: ConsensusStatement from the enhanced recovery partnership

Perioperative Medicine 2012

CONSENSUS STATEMENT OPEN ACCESS

2012: Enhanced Recovery Partnership

The Enhanced Recovery Partnership recommends the use of intra-operative fluid management technologies to enhance treatment with the aim of avoiding both hypovolaemia and fluid excess. This should be decided on a case-by-case basis adheringto local guidelines in the context of NICE recommendations, national guidelines and the Innovation, Health and Wealth Review.

Individualized Goal-Directed Fluid Therapy

Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012

The use of intra-operative fluid management technologies are recommended from the ouset in the following types of cases:

• Major surgery with a 30 day mortality rate of > 1%.• Major surgery with an anticipated blood loss of greater

than 500 ml.• Major intra-abdominal surgery.• Intermediate surgery (30 day mortality > 0.5%) in high

risk patients (age > 80 years, history of LVF, MI, CVA or peropheral arterial disease).

• Unexpected blood loss and/or fluid loss requiring > 2 litres of fluid replacement.

The Enhanced Recovery Partnership recommends that all Anaesthetists caring for patients undergoing intermediate or major surgery should have cardiac

output measuring technologies immediately available and be trained to use them.

Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012

Bristish Consensus Guidelines on Intravenous Fluid Therapy for

Adult Surgical PatientsGIFTASUP

Jeremy Powell-Tuck (chair)1, Peter Goslin2, Dileep N. Lobo1,3 , Simon P. Allison1, Gordon L. Carlson3,4, Marcus Gore3 , Andrew J. Lewington5, Rupert M. Pearse6 , Monty G. Mythen6

On behalf of 1BAPEN Medical - a core group of BAPEN, 2 the Associaton for Clinical Biochemistry, 3the Association of Surgeons of Great Britain and Ireland,4the Society of Academic and Research Surgery, 5the Renal Association and 6 the Intensive Care Society.

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GIFTASUP

In patients undergoing some forms of orthopaedic and abdominal surgery, intraoperative treatment with intravenous fluid to achive an optimal value of stroke volume should be used where possible as this may reduce postoperative complication

rates and duration of hospital stay.Orthopaedic surgery: Evidence level 1b 28, 33

Abdominal surgery: Evidence level 1a30-32,34,48-50

RECOMMENDATION 13

Intraoperative Fluid Management

Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERSA®)

Society RecommendationsU.O. Gustafsson • M. J. Scott • W. Schwenek • N. Demartines • D. Roulin •

N.Francis • C.E. McNaught • J. MacFie • A.S. Liberman • M. Soop •A. Hill • R. H. Kennedy • D.N. Lobo • K. Fearon • O. Ljungqvist

Word J Surg (2013) 37:259-284DOI 10.1007/s00268-012-1772-0

Item Recommendation Evidence level Recommendation grade

Perioperative fluid management

Patients should receive intraoperative fluids(colloids and crystalloids) guided by flow measurements to optimse cardiac output

Balanced crystalloids: High Flowmeasurement in open surgery: High

Strong

• Complications are not exceptions• Complications are costly• Complications are responsible for

prolonged LOS and readmissions• Complications affect long-term survival• Hemodynamic optimization through

Perioperative Goal-Directed Therapy decreases post-surgical complications and hospital LOS

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You Know Why?

Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERSA®) Society Recommendations U.O. Gustafsson • M. J. Scott • W. Schwenek • N. Demartines • D. Roulin • N.Francis • C.E. McNaught • J. MacFie • A.S. Liberman • M. Soop • Hill • R. H. Kennedy • D.N. Lobo • K. Fearon • O. Ljungqvist Word J Surg (2013) 37:259-284 DOI 10.1007/s00268-012-1772-0

HOW?74

• Assess• Align• Apply• Measure

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Hemodynamic Optimization Program

• Select one or several surgical procedures where a benefit has been established and hence is also expected in your institution

76

Assess

77

Surgical procedure ICD9 codesEsophagectomy 42.40, 42.41, 42.42, 43.99

Gastrectomy 43.5, 43.6, 43.7, 43.81, 43.89, 43.99

Partial hepatectomy 50.22, 50.3

Pancreatectomy and pancreaticoduodenectomy

52.51-52.53, 52.59, 52.6, 52.7

Colectomy 45.71-45.76, 45.79, 45.81-45.83, 48.41, 48.69

Resection of rectum 48.50-48.52, 48.59, 48.61-48.65, 48.69

Total cystectomy 57.71, 57.79

Femur & hip fracture repair 79.15, 79.25, 79.35, 79.85

Hip replacement 81.51-81.53

Abdominal aortic aneurysm 38.44

Aorto-iliac and peripheral bypass 39.25, 39.29

Surgical procedures, with corresponding ICD codes, part of positiverandomized controlled trials demonstrating the value of perioperative

hemodynamic optimization.

• Select one or several surgical procedures where a benefit has been established and hence is also expected in your institution

• You can (but do not have to) restrict the implementation to a subgroup of patients who have a higher risk to develop complications (eg patients with specific co-morbidities or patients with ASA score > I or patients older than 65 yrs) 78

Assess

• Assess the current morbidity rate using a list of complications and/or assess the current hospital length of stay.

79

Assess

80

Infection— Pneumonia— Urinary tract infection— Superficial wound infection— Deep wound infection— Organ-space wound infection— Systemic sepsis or septic shock

Gastro-intestinal— Nausea and vomiting— Ileus (paralytic or functional)— Acute bowel obstruction— Anastomotic leak— Gastro-intestinal hypertension— Hepatic dysfunction— Pancreatitis

Respiratory— Prolonged mechanical ventilation (>48h)— Unplanned intubation or reintubation— Respiratory failure or ARDS— Pleural effusion

Renal— Renal insufficiency (increase in creatinine levels

or decrease in urine output)— Renal failure (requiring dialysis)

Cardiovascular— Deep venous thrombosis— Pulmonary embolism— Myocardial infraction— Hypotension— Arrhythmia— Cardiogenic pulmonary edema— Cardiogenic shock— Infarction of GI track— Distal ischemia— Cardiac arrest (exclusive of death)

Neuro— Stroke or cerebro-vascular accident— Coma— Altered mental status or cognitive dysfunction or

delirium

Hemato— Bleeding requiring transfusion— Anemia— Coagulopathy

Other— Vascular graft of flap failure— Wound dehiscence— Peripheral nerve injury— Pneumothorax

Most Common Post-Surgical Complications

http://www.patient.co.uk/doctor/common-postoperative-complications

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Morbidity Rate = 30%

No complicationn=140

1+complicationn=60

Colorectaln=200

• Predict the clinical benefits of our hemodynamic optimization program

82

Assess

83

Reduction in Average odd or risk ratio (confidence interval)

Author (reference)

Acute kidney injury 0.64 (0.50-0.83) 0.71 (0.57-0.90)0.67 (0.46-0.98)

Brienza (9)Grocott (13)

Corcoran (14)

Minor GI complications 0.29 (0.17-0.50) Giglio (10)

Minor GI complications 0.42 (0.27-0.65) Giglio (10)

Surgical site infection 0.58 (0.46-0.74)0.65 (0.50-0.84)

Dalfino (11)Grocott (13)

Urinary tract infection 0.44 (0.22-0.88) Dalfino (11)

Pneumonia 0.71 (0.55-0.92)0.74 (0.57-0.96)

Dalfino (11)Corcoran (14)

Respiratory failure 0.51 (0.28-0.93) Grocott (13)

Total morbidity rate 0.44 (0.35-0.55)0.68 (0.58-0.80)

Hamilton (12)Grocott (13)

Clinical Benefits of Hemodynamic Optimization Over Standard Fluid Management

1+complicationn=21-33

No complicationn=167-179

Colorectaln=200

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Last Year Next YearHemodynamic Optimization

Odd Ratio

Future Morbidity Rate 10.5-16.5% (Example)

No complicationn=140

1+complicationn=60

Colorectaln=200

• Predict the economic benefits of our hemodynamic optimization program

85

Assess

86

Cost $2.10M

No complicationn=140

Cost $1.92M

1+complicationn=60

Colorectaln=200

Total cost = $4.02M

Assess (Example)

Cost $2.10M

Cost/patient$15K

No complicationn=140

Cost $1.92M

Cost/patient$32K

1+complicationn=60

Colorectaln=200

87

Total cost = $4.02M

Extra cost/patient w/ 1+compl.= $17K

Assess (Example)

Total cost$672-1056K

1+complicationn=21-33

Total cost$2.51-2.69M

No complicationn=167-179

Colorectaln=200

Cost $2.10M

Cost/patient$15K

No complicationn=140

Cost $1.92M

Cost/patient$32K

1+complicationn=60

Colorectaln=200

88

Total cost = $4.02M

Extra cost/patient w/ 1+compl.= $17K

Last Year Next YearHemodynamic Optimization

Odd Ratio

Total cost = $3.36-3.57M

Savings/patient = $2,250-3,300

Total savings = $450-660K

Assess (Example)

• Build a team. Your core team should be lead by a champion and include at least one representative of the surgical team, of the anesthesia team, of the anesthesia assistant (AA) and/or certified registered nurse anesthetist (CRNA) team, as well as your quality officer.

89

Align

• Choose a treatment protocol. One of your first tasks will be to select the most appropriate hemodynamic optimization protocol for the surgical population you have selected. Several protocols have been shown to be effective

90

Align

91

• Stroke Volume (SV) optimization with fluid

• Oxygen Delivery Index (iDO2) optimization with fluid and inotropes

• Pulse Pressure Variation (PPV) or Stroke Volume Variation (SVV) optimization with fluid

This summary describes the three main perioperative GDT strategies which have been successfully used in clinical studies or quality improvement programs to decrease

postoperative morbidity and length of stay:

Kuper2011, Cecconi 2011, and Ramsingh 2012 

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Kuper2011, Cecconi 2011, and Ramsingh 2012 

• Choose a product. Most hemodynamic optimization protocols are based on the monitoring of flow parameters and/or dynamic predictors of fluid responsiveness.

93

Align

• Train. All anesthesiologists and AA/CRNA who will ensure hemodynamic optimization must be trained

94

Apply

• Ensure optimal compliance. Compliance to guidelines and recommendations is often suboptimal. To ensure hemodynamic optimization protocols are followed properly several actions and tools are useful:

95

Apply

• SOP. Defining hemodynamic optimization through Perioperative Goal-Directed Therapy as an official and new Standard Operating Procedure (SOP) for hemodynamic management in your department.

96

Apply

• Surgical Safety Checklist. Adding a single item to the current “Sign In” section of the surgical safety checklist, such as “the patient’s eligibility for hemodynamic optimization has been considered”

97

Apply

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.

Before induction of anaesthesia Before skin incision Before patient leaves operating room

Surgical Safety Checklist

Before induction of anaesthesia Before skin incision Before patient leaves operating room

Patient’s eligibility for hemodynamic optimization has been considered

Surgical Safety Checklist

• Compliance tools. Tools designed to quantify and track compliance to a specific hemodynamic optimization / PGDT protocol (SV optimization with fluid).

100

Apply

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Example of Compliance Tool

• Electronic data recording. Downloading hemodynamic parameters.

102

Apply

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Example of SVV e-Recording

Total cost$672-1056K

1+complicationn=21-33

Total cost$2.51-2.69M

No complicationn=167-179

Colorectaln=200

Cost $2.10M

Cost/patient$15K

No complicationn=140

Cost $1.92M

Cost/patient$32K

1+complicationn=60

Colorectaln=200

104

Total cost = $4.02M

Extra cost/patient w/ 1+compl.= $17K

Last Year Next YearHemodynamic Optimization

Odd Ratio

Total cost = $3.36-3.57M

Savings/patient = $2,250-3,300

Total savings = $450-660K

Measure (Example)

• Assess• Align• Apply• Measure

105

Hemodynamic Optimization Pro

• Retrieved from: http://www.patient.co.uk/doctor/common-postoperative-complications• Variation in Hospital Mortality Associated with Inpatient Surgery. Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B.

Dimick, M.D., M.P.H. N Engl J Med 2009• Prioritizing Quality Improvement in General Surgery. Schilling et al. J Am Coll Surg. 2008; 207:698–704.• Synergistic Implications of Multiple Postoperative Outcomes. Melissa M. Boltz, DO, Christopher S. Hollenbeak, Ph.D., Gail

Ortenzi, RN, BSN, and Peter W. Dillon, M.D. Am J Med Quality 2012• Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications. Shukri F.

Khuri, M.D., William G. Henderson, Ph.D., Ralph G. DePalma, M.D., Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, M.D., SM and the Participants in the VA National Surgical Quality Improvement Program Ann Surg 2005

• Association Between Occurrence of a Postoperative Complication and Readmission Implications for Quality Improvement and Cost Savings Elise H. Lawson, M.D. MSHS, Bruce Lee Hall, M.D. Ph.D, MBA, Rachel Louie, MS, Susan L. Ettner, Ph.D., David S. Zingmond, M.D., Ph.D, Lein Han, Ph.D, Michael Rapp, M.D., JD and Clifford Y. Ko, M.D. MS, MSHS Ann Surg 2013

• Can Changes in Arterial Pressure be Used to Detect Changes in Cardiac Output During Volume Expansion in the Perioperative Period? Yannick Le Manach, M.D., Ph.D., Christoph K. Hofer, M.D., Ph.D. Jean-Jacques Lehot, M.D., Ph.D., Benoit Vallet, M.D., Ph.D., Jean-Pierre Goarin, M.D. Benoit Tavernier, M.D., Ph.D., Maxime Cannesson, M.D., Ph.D. Anesthesiology 2013

• Wet, Dry or Something Else? British Journal of Anaesthesia 97 (6): 755-7 (2006) Doi:10.1093/bja/ae1290 Editorial by M. C. Bellamy

• Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense. Paul E. Marik, M.D., FCCM, Rodrigo Cavallazzi, M.D. Crit Care Med 2013; 41:1774-1781

• N.I.C.E. (NHS) Protocol - National institute for health and clinical excellence / national health system (NHS) Perioperative Goal-Directed Therapy protocol

• Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012• Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERSA®) Society

Recommendations U.O. Gustafsson • M. J. Scott • W. Schwenek • N. Demartines • D. Roulin • N.Francis • C.E. McNaught • J. MacFie • A.S. Liberman • M. Soop • Hill • R. H. Kennedy • D.N. Lobo • K. Fearon • O. Ljungqvist Word J Surg (2013) 37:259-284 DOI 10.1007/s00268-012-1772-0

References

• Enhanced Recovery Pathways Optimize Health Outcomes and Resource Utilization: A Meta-Analysis of Randomized Controlled Trials in Colorectal Surgery. Michel Adamina M.D., PD, Henrik Kehlet, M.D. Ph.D., George A. Tomlinson, Anthony J. Senagore, M.D. MS, MBA, and Conor P. Delaney, M.D. MCh, Ph.D., Cleveland, OH; St Gallen, Switzerland; Copenhagen, Denmark; Toronto, Ontario, Canada; and Los Angeles, CA Surgery 2011

• Quality Improvement Report Kuper et al. BMJ 2011;342:d3016 doi: 10.1136/bmj.d3016

• Perioperative fluid management: Consensus Statement from the enhanced recovery partnership Perioperative Medicine 2012

• Bristish Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients .Jeremy Powell-Tuck (chair)1, Peter Goslin2, Dileep N. Lobo1,3 , Simon P. Allison1, Gordon L. Carlson3,4, Marcus Gore3 , Andrew J. Lewington5, Rupert M. Pearse6 , Monty G. Mythen6 On behalf of 1BAPEN Medical - a core group of BAPEN, 2 the Associaton for Clinical Biochemistry, 3the Association of Surgeon Great Britain and Ireland,4the Society of Academic and Research Surgery, 5the Renal Association and 6 the Intensive Care Society.

References

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Thank you!

Hemodynamic Optimization through Perioperative Goal-Directed Therapy

Why and How?

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