PREVENT COMPLICATIONS IN MAJOR SURGERY

Dept of Anesthesia and ICM

(Prof. G. Della Rocca)

Azienda Ospedaliero-Universitaria

University of Udine. Udine, Italy

Crit Care Med 1982;10(6):398-403

CLINICAL TRIAL OF SURVIVORS’ CARDIORESPIRATORY PATTERNS AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS

Shoemaker WC, Appel Pl, Waxmax K

Crit Care Med 1982;10(6):398-403

CLINICAL TRIAL OF SURVIVORS’ CARDIORESPIRATORY PATTERNS AS THERAPEUTIC GOALS IN CRITICALLY ILL POSTOP PTS

Shoemaker WC, Appel Pl, Waxmax K

Critical Care 2006, 10:R81

Exclusion criteria: endoscopyday-case surgcardio-thoracneurosurgorgan txobstetricsburns

From Jan 1999 to Oct 2004 (70 months)

94 Hosp in UK

All surgical procedures (HRG)

n = 4 117 727

Critical Care 2006, 10:R81

Critical Care 2006, 10:R81

Critical Care 2006, 10:R81

Critical Care 2006, 10:R81

Critical Care 2006, 10:R81

Critical Care 2006, 10:R81

• Renal: fluids!!! (fenoldopam?)

• Infections: sepsis

Critical Care 2005; 9:R687-693

RCT, HR surgical patients (n=122 pts)

DO2I 600 mL min-1 m-2 vs conventional management

Cardiac Output (LidCO System)

60 days

SVI/DO2I

Critical Care 2005; 9:R687-693

Critical Care 2005; 9:R687-693

Critical Care 2005; 9:R687-693

Critical Care 2005; 9:R687-693

Anesthesiology 2002; 97:820-826

Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery.

TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass

FTc

Anesthesiology 2002 ; 97: 820-6

Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery.

TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass

Anesthesiology 2002 – Gan et al.

Anesthesiology 2002 ; 97: 820-6

Goal-directed Intraoperative Fluid Administration Reduces Lenght of Hospital Stay after Major Surgery.

TJ Gan, A Soppitt, M Maroof, H El-Moalem, KM Robertson, E Moretti, P Dawne, PS Glass

Wakeling HG et al BJA 2005; 95(5): 634-42

SV vs CVP:

decreased LOS and complications

Preop eval Surgery ICU discharge Hospital discharge

High Risk patientsdefinition

OPTIMIZATION∆ outcome

High risk population“Supposed” normal goals ≠ “supranormal” goals

PERIOP HEMODYNAMIC OPTIMIZATION

DO2 = CO x CaO2

PERIOP HEMODYNAMIC OPTIMIZATION

(CVP, SV,ABF-FTc, SvO2, Lac, dynamic indexes)

(AP, HR, diuresis)

(DO2 >600 mL/min/m2)

Anesth Analg 2005;100:1093-106

Anesth Analg 2005;100:1093-106

How should fluid be administered

“SUPPOSED” NORMAL GOALS

Cardiac surgeryCardiac surgery

Orthopedic surgeryOrthopedic surgery

Major abdominal surgeryMajor abdominal surgery

Br J Anesth 2007;99:500-8

n = 32 prospective study

Liberal fluid regimen:

transiet pulmonary improvement but postop Hypoxiemia

tendency to deacrease in morbidity

Br J Anesth 2007;99:500-8

Br J Anesth 2007;99:500-8

Br J Anesth 2007;99:500-8

Vasc Endovasc Surg 2008;June 25

Retrospective Study

n = 41 divided in 2 groups: < 3L vs >3L intraop

- Restricted regimen: <LOS (MV?) ICU and Hospital

- No difference in morbidity

Vasc Endovasc Surg 2008;June 25

Eur J Vasc Endovasc Surg 2007;34:522-7

Conclusion: more fluids more complications!

n = 100: retrospective study

Eur J Vasc Endovasc Surg 2007;34:522-7

Intraoperative fluid management duringorthotopic liver transplantation

RA Schroeder, BH Collins, E Tuttle-Newhall, K Robertson, J Plotkin, LB Johnson, PC Kuo

J Cardiothorac Vasc Anesth 2004;18(4): 438-441

2 liver transplant centers experience

low CVP method vs normal CVP method

clinical safety of a low CVP fluid management strategy in

patients undergoing Ltx

J Cardiothorac Vasc Anesth 2004;18(4): 438-441

“despite sussess in lowering blood transfusion requirements in liver

resection patients, a low CVP should be avoided in patients

undergoing liver transplantation”

Intraoperative fluid management duringorthotopic liver transplantation

RA Schroeder, BH Collins, E Tuttle-Newhall, K Robertson, J Plotkin, LB Johnson, PC Kuo

J Cardiothor Vasc Anesth 2008; 22(2):311-4

Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)

“We aimed to investigate the effects of DO2I

optimization,

with and without dobutamine,

on the incidence of perioperative complication

in HR surgical patients”

Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)

dobutaminevolume

Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)

dobutamine

volume

Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)

Lobo SM et al Crit Care 2006; 10:R72 (doi:10.1186/cc4913)

PAC-guided hemodynamic optimization using

dobutamine determines better outcomes,

whereas fluids alone increase the incidence of

postoperative complications in patients with

high risk of perioperative death.

Conclusion

IS SUPRANORMAL DO2 NECESSARY?

Use it only when you need and not only because of protocols….

NIV AND PERIOPERATIVE OPTIMIZATION

Incluison criteria:

ASA I-II

Major abdominal surgery

PaO2/FiO2 < 300 1 hr after extubation

Exclusion criteria:

Cardiac, Respiratory and Obese patients

Recent Major surgery, CT, immunosuppression

Acidosis, hipercapnia (CO2>50 mmHg)

SpO2<80 %

Hypoalbuminemia, renal insufficiency, anemia, ARDS

1 hr after extubation:

CTRL group → 6 h Venti Mask FiO2 0.5

PROT group → 6h CPAP 7.5 cmH2O FiO2 0.5 (Helmet)

After 6 h

1 h Venti Mask FiO2 0.3 and then:

If PaO2/FiO2 < 300→ back to the assigned group

> 300→stop treatment

Preop eval Surgery ICU discharge Hospital discharge

High Risk patientsdefinition

OPTIMIZATION∆ outcome

High risk population“Supposed” normal goals ≠ “supranormal” goals

Postoperative NIV.

PERIOP HEMODYNAMIC OPTIMIZATION

Is ICU postoperative care necessary forHR patients?

Yes but to optimize and not to “monitor” …..

HEMODYNAMIC OPTIMIZATION

Volume/dobutamine/ITBVI (intraop or eary ICU)

(No recent MI-ischemia or ↑ ß-blocker therapy)

Lung protection: EVLWI (early predictor of mortality/latewarning system)

Fast track anesthesia + NIV (if PaO2/FiO2<300)

Renalprotection

Lungprotection

When? Early!