PERIOPERATIVE OPTIMIZATION

OF THEHIGH-RISK SURGICAL

PATIENT

IntroductionPeri Operative Risk of death in genral surgery is < 1%Not widly practised b/c

Lack of knowledge in applying current available toolsLack of experience with the practicalities of peri

optimization

This article increase our awareness of How & When to utilize monitoring equipment to achieve optimal result.

Introduction cont…

Perioperative risk of death after general

surgery is less than 1% but some time upto

33%

Clinical acumen and Observation allow us to

predict the high risk cases

Normal physiology during surgery

During Surgery increase metabolic demand

Increase CO

Increase oxygen delivery

Oxygen Debt But Sometime could not increase Oxygen

delivery adequately

OXYGEN DEBT

Magnitude and length of O2 Debt associated

with increase incidence of complication

oxygen debt cont…

• Should be paid back

within 8 Hr Never paid

Complication Cell Dysfunction / Death

Physiological parameter for optimization

Cardiac index ( CI) > 4.5 litre/min /m2

oxygen delivery (DO2I) > 600 ml /min /m2

oxygen consumption(VO2 I) > 170 ml /min/ m2

Suboptimal value of CI,DO2,VO2

Tissue hypoxia

Uneven Vascular constriction

Uneven microcirculatory blood flow

to vascular bed

Mythen and Webb, showed;

60% patient have gut hypoperfusion

triggering of the systemic inflammatory response

Organ Failure

dfdfdf

Morbidity & Death

Identifying the patient who will benefit

Many scoring systems can quantify the risk

Goldman and colleagues cardiac risk index high

risk of mortality in patients with cardiac disease

ASA score is widely accepted as part of

preoperative assessment

Patients:- high risk

Current /previous severe, cardio-respiratory ds

Acute abdominal catastrophe with

haemodynamic instability

Acute renal failure

Severe multiple trauma

Cont…..Evidence of limited physiological reserve in one

/more vital organs in elderly patients more

than 70 yr

Shock

Acute respiratory failure

Septic shock

Surgery: the high-risk

Colorectal, vascular,a intra-abdominal surgery

Trauma surgery involving more than two body cavities or intraperitoneal soiling with bowel contents

Prolonged surgery (>11/2 h)

Emergency surgery

Physiological principles of optimization

Cardiac index ( CI) > 4.5 litre/min /m2

oxygen delivery (DO2I) > 600 ml /min /m2

oxygen consumption(VO2 I) > 170 ml /min/ m2

This last one can’t be altered So not a goal for therapy

CI & DO2 depends on

Cardiac output(HR x Stroke vol.) Cardiac index =

Body surface area

DO2 = CI x (Oxygen content of arterial blood)

= CI x (1.34 x Hb x arterial saturation SaO2)

Optimum O2 delivery obtained by

Manipulation of-

By using---Heart Rate Inotropes

Stroke Vol. FluidHb Blood transfusionO2 Saturation Oxygen

How to perform optimization

Cardiovascular monitors that may be used for goal-directed therapy

---Pulmonary artery catheter

NICO ---Oesophageal Doppler monitor

---Lithium dilution CO (LiDCOplus

---Pulse contour CO (PiCCO)

---Bioelectrical impedance

cardiography and cardiac USG

Pulmonary artery catheter

Recently Use DecreaseParameter obtained is

-- CVP

--Cardiac output

--Cardiac index --SvO2

--DO2 Still It is gold Standard For CV Monitoring

Perioptimization using PAC CI

DO2I> 4.5 litre/min /m2 < 4.5 litre/min /m2

> 600 ml /min /m2 < 600 ml /min /m2

No Further goal-

directed therapy

Cont.. On next page

<4.5,<600…. Cont…

Increase IV Fluid therapy to Pulm. Artery

occlusion pressure of 12-16 mm of Hg

Maintain Hb 8-10 Gm/dL If Decrease BT

Saturation 95% If Saturation Fall O2

Still < 600 ml/mi/m2 Inotrope/inodilator

eg.DOPEXAMINE

Maintain This goal directed therapy

In immediate post operative periodUntill base deficit and lactate level return to

normal

AIM

Mixed Venous saturation is above 70%

Other Cardiovascular monitor1.Oesophageal Doppler monitor:-

Measure Flow velocity In Descinding thoracic

aorta

Can produce estimate of Stroke vol.,CO;

FTc Systolic flow time index of preload

(Normal range 330-360 ms)

FTcFTc < 350 ms Suggest hypovolimia 3ml/kg

in 5-10 min

After Fluid Thrapy of Same patient

Fuid therapy

Stroke Vol.=/ Stroke vol. By 10%

& FTc < 350 ms & FTc > 350 ms

Repeat 3 ml /kg Repeat Untill No

in 5-10 min increase in SV

FTc > 400 ms

No fluid till FTc/SV Decrease by 10%

Cont…

2.Lithium dilution CO (LiDCOplus):-

- Lithium injected iv(C/P)

- Lithium sensor attached to standard arterial line

gives contineous data

-- CO

-- Stroke vol.

-- Stroke Vol. variation

-- Pulse Pressure variability

-- Contineous D O2I

CI Lithium dilution CO Monitor

First trimester pregnancy

Lithium therapy

More suited for post operative period

3. Pulse contour CO (PiCCO):-

Use

-Pulse counter waveform

-Thermodilution technique

large Atery Thermo dilution catheter

(Femoral Brachial Axilarry)

PiCCO Gives,

---- Beat To Beat SV

---- Contineous CO

----SVV

Show ----Global End Diastolic Vol.

Cardiac ---- Intra Thoracic Blood vol.

Preload

---- Extra Vascular lung water

Perioptimization Practical approach

Same Starting Point Fluid loading

Same End Point Adequate O2 Delivery

Post operative Ward Nurses Start

Intra operative Anaesthetist goal directed therapy

Pre optimization Not possible then Intra and post Operative optimization

Post Operative start within 1st post op hr

CONCLUSION

IT IS THE FLUID NOT THE MONITOR MAKE THE DIFFERENCE Partialy correct

NOT ONLY FLUID BUTFLOW IS IMPORTANT