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Haemodynamic Control in Fast-Track Surgery. CardioQ

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  • 1.
    • HAEMODYNAMIC CONTROL IN FAST-TRACK SURGERY. CARDIOQ
    Manuel Núñez Debén Division of Anesthesiology and Reanimation Meixoeiro Hospital. Vigo
  • 2. Anesthetic protocol Fast-track surgery
    • 1.- Preoperative. Selected patients
    • 2.-.Anesthetic Technique.
    • Regional anesthesia and multimodal techniques.
    • 3.- Drug Control.
    • Minimize ileus and PONV.
    • 4.- Overall measurement of support:
    • * Temperature and blood glucose control
    • *Food and early ambulation
    • * Liquid Control intake
    The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care. Anesth Analg 2007;104:1380 –96
  • 3. Strict monitoring of fluid intake: a Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy Hausel J, Nygren J, Thorell A, et al.. Br J Surg 2005;92:415–21. b A Rational Approach to Perioperative Fluid Management. Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. Anesthesiology. 2008 Oct;109(4):723-40 Fluid intake control
    • Preoperative Hydration a :
    • Avoid prolonged fasting
    • Preoperative fluids
      •  Catabolic response
      •  Insuline resistance
    • Liquid restriction b :
    • (intra and postoperative)
    •  Interstitial edema
    •  Postoperative morbidity
    •  Hospital stay
  • 4.
    • Objective: IV fluid therapy that does not change body weight reduces the
    • morbidity after colorectal surgery 1
    • Basic monitoring:
      • Arterial Blood pressure
      • Heart rate
      • Diuresis
      • Known limitations:
      • Difficult diagnosis of hemodynamic changes, especially when they act on compensation mechanisms (peripheral blood and splenic sequestration) that are associated with increased morbidity 2
    1 Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on posoperative complications: comparasion of two Periopertive fluid regimens. A randomized assessor-blinded multicentre trial. Ann Surg. 2003;238:641-8 2 Chan VWS, Peng PWH, Kaszas Z, et al. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery. Clinical outcome and cost. Anesth Analg 2001;93:1181– 4 Strict monitoring of fluid intake: ARTERIAL PRESSURE = (FLOW x RESISTANCE) Preload Contractility
  • 5. CARDIOQ
    • Esophageal Echo-doppler. Measures blood flow in a downstream portion of aorta by an esophageal probe.
    • Graphic image in forms of speed /time.
    • Hemodynamic data " beat by beat " in Intraoperative *
    • *Cardiac Output (CO), Stroke Volume (SV), Heart Rate (HR), preload, afterload, contractility.
    • Reliable obtained data (Correlation > 80%)
    • Easy placement. Similar to a NGT
    *Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. G. MacKay, K. Fearon, A. McConnachie , M. G. Serpell , R. G. Molloy , P. J. O'Dwyer. Br J Surg 2006; 93:1469-74.
  • 6. Corrected Flow Time (FTc) 330 – 360 milliseconds Peak Velocity (PV) 20 years 90 – 120 cm/sec 40 years 80 – 110 cm/sec 60 years 60 – 90 cm/sec 80 years 40 – 70 cm/sec FTc . Directly proportional to preload and inversely proportional to SVR PV y Mean Acceleration are markers of contractility and afterload I.V. (both decreasing with increasing afterload and vice versa) NORMAL VALUE
  • 7. Wave of bad placement probe Heart Signal Venous signal
  • 8. Pathological waves Hypovolaemia: FTc  . PV  CO  . HR  SV  Hypovolaemia + 200 cc fluid: FTc improved. Base wave  GC & VS improved Hypovolaemia + 400 cc fluid: FTc improved. Base wave  
  • 9. Pathological waves Decreased afterload:  (PV & FTc)
    • Compensated Hypovolaemia:
    • FTc.  PV
    • CO & SV.
    • Compensatory tachycardia
    Increased afterload:  (FTc, PV, CO & SV)
  • 10. NO YES OTHER THERAPIES AS APPROPRIATE e.g. NO • DILATORS (± MORE FLUID) IF LOW FTc, LOW PV & BP ACCEPTABLE • INOTROPES IF LOW PV & LOW BP • VASOPRESSORS IF HIGH FTc, HIGH SV, LOW BP YES NO NO MONITOR SV, FTc Treatment Algorithm suggested by Prof. Mervyn Singer UCL London. Deltex Medical 9051-5361 Issue 1
    • Maintenance:
    • Hartmann solution 5cc/kg/h
    • Hb>8 gr/dl
    • Bolos 200 cc colloids
    • According to algorithm
    SV (& FTc) INCREASE > 10%? ORGAN HYPOPERFUSION? HYPOTENSION? CIRCULATORY OPTIMISATION? 200 ML FLUID CHALLENGE OVER 10 MINS STILL COMPROMISED? (e.g. LOW BP, OLIGURIA) PATIENT LOSING FLUID AT RATE EXCEEDING INPUT?
  • 11. Limitations:
    • Aortic area calculation by nomogram without specific measurement.
    • Software calculation for the loss of ventricular volume of supra-aortic branches
    • Turbulent aortic flow may alter results
    • Poor positioning or mobilization can cause false readings later.
    • Anesthetic drugs may alter their use
    • Basically reduced to mechanical ventilation.
        • CORRELATION > 80% WITH THERMODILUTION METHODS
    • Contraindications:
    • Esophageal Neoplasms
    • Coagulopathies
    • Esophagitis
    • Esophageal varices
    • Pathology oropharyngeal / esophageal.