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Perioperative Goal Directed Hemodynamic Therapy Implementation

Experience at UC Irvine

Maxime Cannesson MD PhD

PROFESSOR

Director Clinical Research & Cardiac Anesthesia

Department of Anesthesiology & Perioperative Care University of California Irvine

Conflicts of Interest

Consultant for: Edwards Lifesciences Masimo Corp. ConMed Covidien Philips Medical System Draeger gauss surgical Founder: Sironis Research Grant: Foundation for Anesthesia Education and Research Center for Health and Quality Innovation (University of California) Masimo Corp Edwards Lifesciences

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HEALTHCARE QUALITY

Q

ualit

y of

Car

e

Time

System A

Average

Standard Deviation

Ideal

System B

High Reliability Organization

M Cannesson - ASA 2013

Cannesson M. Pulse Pressure Variation and Goal Directed Therapy J Cardiothorac Vasc Anesth 2009

Conceptual Framework

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Anesthesia Analgesia 2011

In order for NHS hospitals to be eligible for any CQUIN quality incentive payments in 2013/14, which equate to 2.5% of their standard NHS revenues, hospitals must: "Demonstrate to commissioners that 2013/14 trajectories for the technology [Intra-Operative Fluid Management] are in place which are consistent with National Technology Assessment Centre (NTAC) guidance."

January 2013

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Demonstrate...

Soon we will have to

“The perioperative surgical home model would pioneer the role of anesthesiologists acting to coordinate the services provided by other health care professionals during the perioperative period. Such a model may, if executed correctly, help to manage the full spectrum of surgical episodes, reduce costly complications and improve the efficiency of care” ASA Committee on Future Health Care Models

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The Problems Today

Factors Influencing Total Crystalloid Administration During Abdominal Surgery: A Retrospective Multicenter Analysis Lilot M, Ehrenfeld J, Lee C, Rothman B, Cannesson M, Rinehart J.

Anesthesiology 2013 (In Press)

! 5,813 abdominal surgeries ! 234 Anesthesia providers ! University of California Irvine ! Vanderbildt University ! 2 years period of time

BEFORE IMPLEMENTATION OF GUIDELINES FOR FLUID MANAGEMENT

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This  variability  is  not  readily  explained  by  pa3ent  or  surgical  factors  and  appears  to  be  largely  a  result  of  random  fluctua3ons  in  prac3ce  from  provider-‐to-‐provider  and  even  within  providers  

from  case-‐to-‐case.

Lilot  M,  Ehrenfeld  J,  Lee  C,  Rothman  B,  Cannesson  M,  Rinehart  J.  Anesthesiology  2013  (In  Press)

Cannesson et al. Crit Care 2011

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Anesthesia & Analgesia 2012

The Problems today

!   Lack of Standardization in the way fluid management is conducted during surgery

!   Poor Compliance with Best evidence / Best Practices

!   Even when solutions exist, they are often applied inconsistently and / or too late

!   How do we Demonstrate that best evidence / best practices have been applied?

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How to Create the Culture of Change? Our experience at UC Irvine

SURGICAL

HOME

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How to Create TEAM WORK Our experience at UC Irvine

Department Leadesrhip Chairman & Vice Chair for Quality

Hospital Leadesrhip Chief Medical Officer

Administration

Group of Team Leaders

Surgery

Nursing

Residents

ICU

Patients

IT People

Billing

Techs

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How to Create Knowledge Our experience at UC Irvine

Devellopment of a Curriculum Mandatory for ALL Residents, CRNAs & Attendings

Online Training Bedside Training by the Team Leaders

Pre Test Post Test

Intranet

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Anesthesia Information Management System

Timeline

Baseline Evaluation

1 year

Training

3 months

Program

1 Year

Pre Test

Knowledge

Post Test

Knowledge

Type of Surgery

- Pancreatic

- Liver

- Cancer debulking

Historical - Prospective Study

Quasi experimental Design

IRB approval HS# 2011-8140 UCI

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!!

!!

The Future of perioperative fluid management

Automated Fluid Management Systems

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Closed-Loop Fluid Administration Compared to Anesthesiologist Management for Hemodynamic Optimization and Resuscitation During Surgery: An In Vivo Study!Joseph Rinehart, Christine Lee, Cecila Canales, Allen Kong, Zeev Kain, Maxime Cannesson!Anesthesia Analgesia 2013

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Closed-Loop Fluid Administration Compared to Anesthesiologist Management for Hemodynamic Optimization and Resuscitation During Surgery: An In Vivo Study!Joseph Rinehart, Christine Lee, Cecila Canales, Allen Kong, Zeev Kain, Maxime Cannesson!Anesthesia Analgesia 2013

Fully closed-loop fluid administration during aorto-bifemoral bypass

Engineering studies

Animal Studies

Human Pilot Study (12 patients)

First Clinical Study (40 vs 40 patients)

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Conclusions

•  Hemodynamic Optimization Impacts Postoperative Outcome+++ •  The challenge is to ease the implementation of this approach at the bedside •  Education, technology, and a system based approach can facilitate this

implementation

•  Automated fluid management systems can also facilitate this implementation and Guarantee compliance

•  A systematic implementation can improve patients outcome