Patients with Complications

reduced by

41,7%

Complications reduced by

27,7% 41,7%27,7%

Control Group Control GroupStudy Group Study Group

Early goal directed therapy based on radial artery pulse contour analysis

Less complications especially less infections

Goal directed therapy with PPV, CI and MAP as target parameters

Individualise your treatment!

Improve Outcome in Major Abdominal Surgery with ProAQT

(1)

Goal Directed Therapy (GDT)– A proven concept for outcome optimisation

In 1988 Shoemaker developed the fi rst principles of goal directed therapy and its superiority regarding outcome(2). This concept has been adopted ever since and new perioperative indications such as general, ab-dominal, cardiac, orthopaedic surgery have evolved. Improved outcome through GDT was proven in several publications.

*Forest plot: Comparison of GDT vs. conventional treatment in surgical procedures with a mortality > 20%(3)

Study or Subgroup

Bishop, 1995 (26)Boyd, 1993 (29)Chytra, 2007(30)Fleming, 1992 (32)Lobo, 2000 (17)Lobo, 2006 (35)Lopes, 2007 (36)Shoemaker, 1998 (4)Shultz, 1985 (40)

Total (95% CI)

Odds RatioM-H, Fixed, 95% CI

0.38 [0.16, 0.90]0.21 [0.06, 0.79]0.69 [0.31, 1.52]0.41 [0.14, 1.15]0.19 [0.04, 0.88]0.22 [0.04, 1.21]0.29 [0.05, 1.80]0.07 [0.01, 0.63]0.07 [0.01, 0.61]

0.32 [0.21, 0.47]

Odds RatioM-H, Fixed, 95% CI

0.1 0.2 0.5 1 2 5 10Faverous experimental Faverous control

Benefits of GDT***

reduced up to

A meta-analysis of Gurgel et al. analysed the impact of GDT on mortality reduction in high-risk surgeries.• Over all three defi ned mortality subgroups: Reduc-

tion of mortality by 33% in the GDT group(3). • Surgical procedures with a mortality from 5% to 20%

in the control group: Reduction of mortality by 35%(4).• Surgical procedures with mortality > 20% in the con-

trol group: Reduction of mortality by 68%(3).

reduced by

A meta-analysis of Hamilton et al. and Dalfi no et al. ana-lysed the impact of GDT on complications• In general GDT resulted in a decline of complications

by 56% compared to the control group(5).• Especially the numbers of infections were reduced

signifi cantly by 60%(6).

reduced by

A strong cochrane review of Grocott et al. analysed the impact of GDT on Length of Stay (LoS) (7).• Postoperative ICU stay: mean reduction by 0.45 days,• Postoperative hospital stay: mean reduction by 1.16

days

Despite high standards in surgical and anaesthesiological care in Europe, the perioperative mortality rate is still higher than expected(8).

• Long surgery time (>120 min)

• Complex procedures with high-risk of intra- and post-op complications

• High blood loss (> 20%) and volume shifts during the procedure can result in hypo- or hypervolaemia

High Risk Abdominal Surgery Benefi ts most from GDT

1. Salzwedel C et al., Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Crit Care 2013; 17(5): R191.

2. Shoemaker WC et al., Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988; 94(6): 1176-86.3. Gurgel ST & do Nascimento P, Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 2011; 112(6): 1384-91.4. Cecconi M et al., Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The eff ect on diff erent risk groups. Crit Care 2013; 17(2): 209.5. Rhodes A et al., Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 2010; 36(8): 1327-1332.6. Dalfi no L et al., Haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care 2011; 15(3): R154.7. Grocott MP et al., Perioperative increase in global blood fl ow to explicit defi ned goals and outcomes after surgery: a Cochrane Systematic Review. Br J Anaesth 2013; 111: 535-48.8. Pearse RM et al., Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012; 380: 1059-1065.9. Goodney PP et al., Is Surgery Getting Safer? National Trends in Operative Mortality. J Am Coll Surg 2002; 195: 219-27.

PulsioFlex – Your navigator in perioperative haemodynamic management

Radial arterial trend monitoring of Cardiac Index - simply attached to an arterial line

Central venous oxygen saturation - simply attached to

a standard CVC

Parameters:

• Cardiac Output: CITrend

• Volume responsiveness: SVV, PPV

• Afterload: SVRI, MAP

• Cardiac function: dPmx, CPI

Parameters:

• Central venous oxygenation ScvO2

Oxygenation: DO2, VO2, O2ER (ProAQT combined with CeVOX)

Mortality rates for procedures in abdominal surgery, 1999 (9)

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PULSION Medical Systems SE • Hans-Riedl-Str. 17 • 85622 Feldkirchen, GermanyTel. +49 (0)89 45 99 14-0 • Fax +49 (0)89 45 99 14-18info@pulsion.com • www.PULSION.com PULSION Medical UK, Ltd. • Unit C4, Heathrow Corporate Park, Green Lane • Hounslow Middlesex, TW4 6ER, United Kingdom • Tel. +44 (208) 81 47 97 4 • infoUK@pulsion.com

Salzwedel Algorithm for Abdominal Surgery

Title Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study.

Authors Salzwedel C, Puig J, Carstens A, Bein B, Molnar Z, Kiss K, Hussain A, Belda J, Kirov MY, Sakka SG and Reuter DA

Centers University Hospital Hamburg-Eppendorf (DE), University of Valencia (ES), University Hospital Schleswig-Holstein Kiel (DE), University of Szeged (HU), Northern State Medical University Arkhangelsk (RU), Medical Centre Cologne –Merheim (DE)

Journal Critical Care 2013, 17:R191

Study Type Multi-center prosepective randomized study

Hypothesis Goal-directed haemodynamic therapy, based on radial arterial pulse pressure variation and continuous cardiac index trending reduces complications after major abdominal surgery.

Surgeries elective abdominal surgery

Inclusion criteria Expected surgery duration > 120 min orexpected blood loss volume > 20 %,ASA II or III, arterial line, CVC

Technology ProAQT Sensor with PulsioFlex Monitor

No of patientsGDT parameters

Study Group (SG) 81 PPV, CI, MAP

Control Group (CG) 79 -

Reassess every 15 minSTART

PPV < 10% YES

Give volume

NOCI = CIopt MAP > 65YES

Inotropes

NO

Vasopressors

NO

If CI ↓, consider inotropes

B) Algorithm for further intraoperative optimisation

Define CIopt (at least 2.5)

START

PPV < 10% YES

Give volume

NO

CI > 2.5 MAP > 65YES

Inotropes

NO

Vasopressors

NOIf CI ↓, consider

inotropes

STOP

A) Algorithm for initial assessment and treatment

STOP

YES