Critical Care ContinuumAdvances in Critical Care MonitoringIssue No.11, Spring 2011 Scott Seewald, Executive EditorJan M. Headley, RN, BS, EditorTim Patz, Managing Editor

Published by Edwards Lifesciences800-424-3278www.Edwards.com/CriticalCareemail: CriticalCare@Edwards.com

Fewer Complications in High-Risk Surgery

Chinese researchers compared conventional managementwith the use of an intraoperative GDT protocol for fluidoptimization in high-risk patients undergoing abdominal surgery. The GDT protocol included the auto-calibratedFloTrac system in a stroke volume treatment algorithm. Their findings included these benefits for patients in theGDT group, as compared with outcomes in the controlgroup:

■ Fewer patients in the GDT group developed complications: 25% vs 59% in the control group.

■ The total number of complications was reduced in the treatment group: 11 vs 31 in the control group.

■ The median duration of hospital stay was not significantly reduced: 29 days vs 26 days.

Rui Y, Yue Y, Wang J. Intra-operative GDP based on SV during high-risk surgeryreduces postoperative complications. Abs #1370.

SVV Predicts Fluid Responsiveness inPatients Undergoing One-Lung Ventilation

A Japanese study sought to determine the ability of strokevolume variation (SVV) to predict fluid responsiveness inpatients undergoing one-lung ventilation and the impact oftidal volume on that capability. Sixty patients scheduled forpulmonary lobectomy were divided into two groups accord-ing to their tidal volume: high (8 ml/kg) or low (6 ml/kg).

SVV was measured with the FloTrac system. The investiga-tors reported that SVV was able to predict fluid responsive-ness with acceptable levels of sensitivity and specificity inthose patients whose tidal volume was at least 8 ml /kg.

Suehiro K, Okutani R. Stroke volume variation as predictor of fluid responsiveness in patients with one lung ventilation. Abs #989.

Anesthesiologists from around the world heard a number of presentations concerning the increasing use of goal-directedtherapy and monitoring of stroke volume variation in high-risk surgery. Following are highlights from the ASA meeting.

ScvO2 Superior to CI in SVV Correlation

Anesthesiologists in Osaka, Japan, undertook a study to confirm the accuracy of a central venous oximetry catheter(PreSep catheter) in patients undergoing aortic aneurysm surgery. They also examined the correlation between theScvO2 value and cardiac index (CI) and stroke volume varia-tion (SVV) using the FloTrac arterial pressure waveform-basedhemodynamic system. They found that the central venousoximetry catheter provided accurate continuous ScvO2 moni-toring against acute hemodynamic changes. Further, theyreported that the ScvO2 catheter had a stronger correlationwith SVV compared with CI.

Sawai T, Oka M, Nakahira J, et al. Central venous oxygen saturation correlates betterwith stroke volume variation than cardiac index. Abs #635.

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Report from ASAAmerican Society of Anesthesiologists, San Diego, CA, October 10 - 20, 2010

View a PowerPoint presentation onSVV and its clinical application atwww.edwards.com/cccontinuum

GDT Demonstrates Long-Term Survival Benefit

Over the past 30 years, practitioners have developed andrefined numerous methods and protocols aimed at reducingsurgical mortality and morbidity. A recent article reported onoutcomes when preemptive management of hemodynamicswas undertaken in the perioperative period.

A 15-year follow-up study assessed the long-term survival ofhigh-risk surgical patients from a previous randomized con-trolled trial of goal-directed therapy (GDT) in the periopera-tive period. In the original study, post-op patients in the ICUreceived either the best available care at the time or GDTaugmentation of their cardiorespiratory system aimed atachieving global tissue oxygen delivery of 600 ml/(min m2

body surface area). Reduced short-term survival was associ-ated with older age and development of a significant cardiaccomplication in the postoperative period.

The follow-up study demonstrated a long-term survival ben-efit among those who underwent goal-directed resuscitationof their cardiovascular system in the ICU, with more thantwice as many survivors in this group than in the controlgroup after 15 years.

■ Reduced short-term mortality (28 days) in GDT group: 5.7% vs 22.2% in control group, p = 0.015.

■ Increased long-term survival (15 years) in GDT group: 20.7% vs 7.5% in control group, p = 0.09.

Rhodes A, Cecconi M, Hamilton M, et al. Goal-directed therapy in high-risk patients: a 15-year follow-up study. Intensive Care Med. 2010;36(8):1327-32.

GDT Using SVV Credited for ReducedComplications

Investigators at Charles University teaching hospital in theCzech Republic evaluated the influence of fluid optimizationbased on stroke volume variation (SVV) in high-risk patientsundergoing major abdominal surgery. A total of 105patients were randomized to:

■ A control group receiving routine intraoperative care.■ A fluid optimization group (GDT group) guided by

the FloTrac sensor with the goal of maintaining SVV < 10%, using colloid boluses of 3ml/kg.

This study also assessed the influence of SVV-guided fluidtherapy on postoperative morbidity and mortality. Comparedwith the controls, patients in the GDT group showed:

■ Fewer hypotensive events: 2 vs 3.5, p = 0.0001.■ Lower lactate levels after surgery: 1.78 ± 0.83 mmol/l

vs 2.25 ± 1.12 mmol/l, p = 0.0252. ■ Fewer post-op complications: 34 vs 77, p = 0.0066.■ Shorter length of stay: 9 (range 8 -12) vs 10 (8 -19)

days, p = 0.0421.

Also, fewer patients in the GDT group developed complica-tions: 18 (30%) vs 35 (58.3%), p = 0.0033. GDT patientsalso received a significantly greater amount of colloid infusions (1425 ml vs 1000 ml in the control group). Therewere no significant differences in mortality or ICU length of stay.

The authors concluded that “intraoperative hemodynamicoptimization using SVV in high-risk patients undergoingmajor abdominal surgery was associated with improvedhemodynamic stability and reduced serum lactate concentra-tion at the end of surgery.” They added, “GDT using SVV asan end-point was associated with reduced postoperativecomplication rates.”

Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study.Crit Care. 2010; 14 (3):1-15.

“Short-term goal-directed therapy may improve long-term outcomes, in part due to its ability to reduce the number of perioperative complications.”

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In High-Risk Surgery

We would like to hear about your use of SVV forGDT and/or fluid optimization in high-risk surgery.Please e-mail a brief description of your interest-ing case(s) to CriticalCare@Edwards.com. We will contact you regarding writing up andpublishing your report in a subsequent issue ofthe CC Continuum.

How are YOU using SVV in high-risk surgery?

“One of the most probable causes of GDT success is a timely recognition of hemodynamic derangements and prompt intervention for their solution.”

GDT protocols, studies, and otheruseful tools are available atwww.edwards.com/cccontinuum

In the ICU

Edwards LifesciencesOne Edwards WayIrvine, California 92614

For professional use. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Any quotes used in this material are taken from inde-pendent third-party publications and are not intended to imply that such third party reviewed or endorsed any of the products of Edwards Lifesciences. Edwards, EdwardsLifesciences, the stylized E logo, FloTrac and PreSep are trademarks of Edwards Lifesciences Corporation. All other trademarks are property of their respective owners. Dr. Davinder Ramsingh is a paid contributor to the CC Continuum. © 2011 Edwards Lifesciences Corporation. All rights reserved. AR06196

How can you guideyour patient’s fluidtherapy with greaterclarity?See pages 1 & 3.

What’s New on the Web

Organization for Advancing Critical Care Monitoringwww.OACCM.org

Check out these and other free accredited CME programs at www.oaccm.org

The Use of Dynamic Parameters in Perioperative Fluid Management - Gerald Manecke Jr., MD

The Economics of Sepsis - Betsy Gross, RN, BSN, CPCCurrent Trends in Management of Blood Glucose in Type 2 Diabetes Mellitus - Susan Cornell, PharmD, CDE, FAPhA, FAADEMaking the Case for Glycemic Control: Is It a Matter of Tight- ness or Timing? - Barbara “Bobbi” Leeper, MN, RN, CNS, CCRN

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