The Cochrane Collaboration and South African Cochrane Centre (SACC)
Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in...
Transcript of Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in...
![Page 1: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/1.jpg)
Perioperative Goal
Directed TherapyImproving the Quality of
Care for Our Surgical Patients
DESIRÉE CHAPPELL, CRNA
ERAS TEAM LEAD
NORTON AUDUBON HOSPITAL, LOUISVILLE, KY
![Page 2: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/2.jpg)
Disclosure
Edwards Lifesciences, Speakers Bureau
American Society for Enhanced Recovery,
Board of Directors
![Page 3: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/3.jpg)
Overview
Perioperative Goal Directed Therapy (PGDT)
Enhanced Recovery (ER)
The Norton Audubon Experience
CRNA opportunities within Enhanced Surgical Recovery Programs
![Page 4: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/4.jpg)
Goal of
Intraoperative
Fluid
Management
Maintain
Intravascular Fluid Volume
LV Filling Pressures
BP/CO
Oxygen Delivery
Manage
Preoperative Status
Surgical Considerations
Postoperative Needs
![Page 5: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/5.jpg)
1 liter
Normal
Saline
![Page 6: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/6.jpg)
Prowle, J. R. et al. Nat. Rev. Nephrol. 6, 107–115 (2010)
Fluid Administration Gone WRONG
![Page 7: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/7.jpg)
![Page 8: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/8.jpg)
![Page 9: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/9.jpg)
SWEET
SPOT
![Page 10: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/10.jpg)
Traditional
Fluid Therapy
Vital Signs
Dogma/ Clinicians
Crude Markers
of
Hypovolemia
• BP
• HR
• UOP
• EBL
![Page 11: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/11.jpg)
Blood Pressure =
Late Indicator
Assumption:
MAP=CO
If BP = CO
If BP = CO
1,2Hamilton et al, ICM 1997Pressure FLOW
![Page 12: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/12.jpg)
Traditional
Fluid Therapy
Provider Variability
Vital Signs
Dogma/ Clinicians
![Page 13: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/13.jpg)
Variability of
Providers
50%Patients
4-10 ml/kg/hr
50%Patients
Outside Range
The strongest predictor of corrected crystalloid infusion was the anesthesia providers regardless of patient factors.
Lillot BJA 2014
![Page 14: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/14.jpg)
Colon
Surgery• Significant
Variability in DOS fluid admin
• Variability leads to poor outcomes
Perioperative Fluid Utilization Variability and Association
With OutcomesConsiderations for Enhanced Recovery Efforts in Sample US Surgical
PopulationsJulie K.M. Thacker, MD, William K. Mountford, PhD,y Frank R. Ernst, PharmD, MS,z
Michelle R. Krukas, MA,z and Michael (Monty) G. Mythen, MBBS, MD, FRCA, FFICM, FCAI (Hon)Annals of Surgery 2015
![Page 15: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/15.jpg)
Conventional
Stolting et. al. Basics of Anesthesia, 5th ed. Elsevier - China, p. 349, 200
Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005; 103: 419-28 7
Restrictive
Perioperative Goal-Directed Therapy
Str
oke
Vo
lum
e
Preload
Evolution of Fluid Management
Liberal
Frank-Starling Curve
![Page 16: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/16.jpg)
GOAL Directed Fluid Therapy
ABP
Continuous NON/MINinvasive
CO
Cardiac Output/ Index
SV
Stroke Volume/ Index
SVV
Strove Volume Variation (SVV)
![Page 17: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/17.jpg)
Parameters of
FLOW
![Page 18: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/18.jpg)
Cardiac Output/ Index
![Page 19: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/19.jpg)
Stroke Volume
![Page 20: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/20.jpg)
Stroke Volume
Variation
A calculated percentage of
variation between the Stroke
Volumes…
![Page 21: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/21.jpg)
Preload
Stroke
Volume
0
SVV > 13%
Journal of Cardiothoracic and Vascular
Anesthesia, Vol 24, No 3 (June), 2010: pp
487-497
Fluid Bolus
Preload
Dependence
Optimization
J.Bloomstone M.D. 2011
High Resp
Variation= Fluid
responsiveness
Low Resp
Variation=
Decreased Fluid
responsiveness
SVV < 13%
![Page 22: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/22.jpg)
Limitations of SVV
pontaneous Ventilation
idal Volume (<8cc/Kg)
pen Chest
neumoperitoneum
ustained Cardiac Arrhythmias
![Page 23: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/23.jpg)
Kuper et al BMJ. 2011; 342:d3016
Nice/Kuper
Protocol
![Page 24: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/24.jpg)
WHO?
ASA 1•Procedure Specific
ASA2/3
•Procedure Specific
•NON Invasive
ASA>4
•Procedure Specific
•Critical State
•NON⇾ Min-Invasive
ALL Surgical
Patients!Degree of
intervention-
Pathway/Patient
dependent
![Page 25: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/25.jpg)
WHEN
PreOPOptimization
IntraOP
Pre/Post Incision
Post Op Rescue/ Tx
![Page 26: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/26.jpg)
Real –Time Hemo-
Dynamic Data
Clinical Judgement
Fluid Therapy Protocols
ACTION
Perioperative Goal Directed Therapy
• Cont BP
• CO
• SV
• SVV
• Knowledge
• Experience
• Evidenced
Based
![Page 27: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/27.jpg)
Simulator
![Page 28: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/28.jpg)
Simulator
![Page 29: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/29.jpg)
Simulator
![Page 30: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/30.jpg)
Simulator
![Page 31: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/31.jpg)
Don’t Get Caught
up in the
“NUMBERS”
![Page 32: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/32.jpg)
Knowledge and
Experience
![Page 33: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/33.jpg)
Optimization using GDFT
![Page 34: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/34.jpg)
PGDT Reduces Complications
![Page 35: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/35.jpg)
Evidence
:
30+ positive RCTs 14+ meta-analyses
Reduction by1-2(avg. days)
in Length of Stay
32-55% reduction in Post-Surgical Complications
1-2
30+ positive RCTs
14+ meta-analyses1 Hamilton M, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical
patients. Anesth Analg. 2011;112(6):1392-1402 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. BJA, 2013.3 Corcoran et al. Perioperative Fluid Management Strategies in Major Surgery: A Stratified Meta-Analysis. Society of Critical Care Anesthesiologists. 2012 ; 114 (3)
![Page 36: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/36.jpg)
PGDTReduces Complications
Reduces Variance
Improves Outcomes
Successful Recovery
![Page 37: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/37.jpg)
The Norton Audubon
ExperienceERAS IMPLEMENTATION OVER 2 YEARS
![Page 38: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/38.jpg)
![Page 39: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/39.jpg)
Background
![Page 40: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/40.jpg)
Baseline 2014
Measure
Average Std
dev
# Discharges
Length of
Stay11.13
7.69 159
Measure
Average Std
dev
# Discharges
Variable
Direct Cost
$10,72
9
$8,590159
Clinical Effectiveness ERAS Report –
Colorectal ProceduresBaseline 2014/ Improvement 2015-2016
Improvement
2015
Improvement
2016
Average per patient Std dev #
Discharges
Average per patient Std dev #
Discharges
Length of Stay 5.143.68 66
6.24.45 69
Average per patient Std dev #
Discharges
Average per patient Std dev #
Discharges
Variable
Direct Cost
$6,261$2,951 66
$7,087$4,780 69
![Page 41: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/41.jpg)
Variable Direct Cost Buckets
![Page 42: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/42.jpg)
Norton Audubon Results
Reduction
LOSReduction
V/D
COSTS
![Page 43: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/43.jpg)
CRNAs role in
PGDT InitiativeHOW CRNAS IMPROVE INTRAOPERATIVE CARE
![Page 44: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/44.jpg)
CRNAs
leading the
PGDT/ER
Movement
CRNAs
As
Ambassadors
Care ProvidersFacilitators
Educators Active Participants
![Page 45: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/45.jpg)
![Page 46: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/46.jpg)
Where to Begin
Lit. review
Current Practice?
Ask for DATA
![Page 47: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/47.jpg)
The Face of
ESR
![Page 48: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/48.jpg)
Enhanced Surgical Recovery
in your Practice
Change is
ConstantPGDT = ESR
Standard
Of Care
CRNAs as Leaders
ESR =
BEST PRACTICE!
![Page 49: Perioperative Goal Directed TherapyMar 09, 2017 · 2 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane](https://reader033.fdocuments.us/reader033/viewer/2022050220/5f65f91ab20ecf37f25566d7/html5/thumbnails/49.jpg)
Enhanced Surgical Recovery
in your Practice
Change is
ConstantPGDT = ESR Standard
Of Care
CRNAs as Leaders
ESR = BEST PRACTICE!