Making the case for implementing goal directed

therapy Bobbi Leeper RN or Kathryn Von Rueden RN

Senior Education Consultants Edwards Lifesciences

What is the Problem?

• Traditional end-points of resuscitation are often misleading and inadequate.

• Poor outcomes are due to inability to meet oxygen demands and development of oxygen debt.

• Targeting specific hemodynamic and oxygenation goals improve outcomes.

• Challenges exist to implement goal directed therapy despite known benefits.

MAP maintained with 15 - 18% blood loss

• Pressure is determined by resistance and flow. P = R x F

• Pressure is not a good indicator of flow.

• Up to approximately 15 -18 % of blood volume may be lost and pressure will be maintained by an increase in resistance.

CVP and PAOP: Poor Predictors of Fluid Status

• Kumar et al. CCM 2004• Pressure based indices did not correlate to volume or change

in stroke volume after a fluid bolus.

Pre-fluid bolus Post fluid bolus Pre-fluid bolus Post fluid bolus

Dynamic vs. Static Parameters

Predicting SVI changes >= 5%, CI > 15%Cannesson 2009 & Michard 1999

Cardiorespiratory Monitoring:

• Optimize the balance between oxygen supply and demand

• Maximize delivery to enhance oxygen utilization• Protect against tissue hypoxia

Cardiorespiratory System: 3 Step Process

• Pulmonary Gas Exchange– Ventilation

• Oxygen Delivery– Perfusion

• Systemic Gas Exchange– Oxygen Utilization

The Balance

Compensatory Mechanisms

• Maintain Balance between Oxygen Delivery and Demand– 1. Increase cardiac output: Heart rate first – 2. Redistribution of blood flow– 3. Increase oxygen extraction

Cardiorespiratory Assessment Oxygen Delivery: DO2 = CO x CaO2 x 10 = 950 - 1150 ml/minDO2I = 400 – 500 ml/min/m2

[ CO2 = (1.38 x Hgb x SO2) + (0.0031 x PO2)]

Oxygen Consumption: VO2 = CO x (CaO2 – CvO2) x 10 =

200 - 250 ml/minVO2I = 120 – 160 ml/min/m2

Indexed values are multiplied by CI

VO2/ DO2 Relationship:

DO2 = CaO2 x CO x 10 = 1000 ml/min

VO2 = CO x (CaO2 - CvO2) x 10 = 250 ml/min

O2ER = VO2/DO2 = (250/1000)= .25

O2ER = Oxygen extraction ratio

Conceptual VO2 / DO2 Relationship

Implications of Oxygen Debt:Factors Influencing accumulation of Oxygen Debt: O2 Demand > O2 Consumed = O2 Debt Decreased oxygen delivery Decreased cellular extraction Increased demands

VO2

TIME

O2

Pay back Interest150

ml/min Debt

Timing or Targets?

Rivers Calls for EGDT

EGDT: The Targets

CVP

MAP

ScvO2

Surviving Sepsis Campaign Results (CCM 2010;38(2))

252 sites, 18 countries, n=15,775165 sites used (excluded sites with < 20 pts)

Final n=15,022

2 year follow up Mortality reductions:

7 % Absolute Risk Reduction 37% to 30.8% p=.0015.4 % Risk Adjusted Decrease

1st 6 hr bundle compliance increased10.9% to 30.1%

Impact of SSC protocols on LOS & mortality in septic shock

N= 384 septic patients vs. historical control

• Compliance with 6 hr bundle associated with reduced mortality

• Achievement of ScvO2/SvO2 >70% associated with improved mortality

Ortega et al: CCM 2010;38:1036-1043

No Bundle

With Bundle

Mortality 57.3 % 37.5 %

Hospital LOS

41 d 36.2 d

ICU LOS 11 d 8.4 d

Barochia AV, et al: Bundled care for severe sepsis: Analysis of clinical trials CCM 2010;38(2)668-678

Bundled care for severe sepsis

Timing or Targets or BOTH?

O2ER in High Risk Surgery • Conclusions: Early

treatment directed to maintain O2ER at < 27% reduces organ failures (27 failures vs. 9 failures, p < 0.001) and hospital stay (11.3 3.8 days vs. 13.4 6.1 days, p < 0.05) of high-risk surgical patients.

• A prospective, randomized, controlled multi-center trial.

• 135 high-risk major abdominal surgery.

O2ER as a target

Does timing matter?

• Critical illness increases metabolic demand

• Cardiovascular system must meet demand to avoid tissue hypoxia

• Development of tissue hypoxia correlates with survival rate

VO2

TIME

O2 Debt

Pay back Interest

150 ml/min

Kern & Shoemaker CCM 2002 21 Studies Reviewed

Impact of GDT on MortalityHamilton, Cecconi, Rhodes , Anesth Analg 2010: accessed on-line 3/17/2011 2010

Goal-directed therapy in high-risk surgicalpatients: a 15-year follow-up study

• Alive at 15 yrs:11(20.7%) EGDT pts vs. 4 (7.5%) control (p=0.09)

• Median survival EGDTgroup was increased by 1,107 days (>3yrs)(1,781 vs. 674 days, p=0.005)

• LT survival associated w/ age, no post-op cardiac complications, EGDT

Rhodes, A. et al: Intens Care Med. 2010

Lees CC 2009 HRS Algorithm (modified)

SurgeryInstitute flow monitoring and goal-directed fluid therapy pre-op and intra-op if possible

Ensure optimum management of chronic disease and acute physiology Refer to AHA/ACC Guidelines

Identify high-risk surgical patientShoemaker/Boyd criteria, POSSUM Establish functional capacity

Maintain monitoring and goalsFor up to 8 hours

Target oxygen delivery/tissue perfusion goalsDO2I > 600ml/min/M2, CI > 4.5l/min/M2 Fluid until not fluid responsive, add

inodilator if goals not achieved

Admit to ICU post-opInstitute flow monitoring Ensure adequate oxygenation and hct

Making the case for implementing goal directed therapy

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Bobbi Leeper and Kathryn Von Rueden are paid consultants of Edwards Lifesciences. Any quotes used in this material are taken from independent third-party publications and are not intended to imply that such third party received or endorsed any of the products of Edwards Lifesciences.

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