Haemodynamic Control in Fast-Track Surgery. CardioQ


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Haemodynamic Control in Fast-Track Surgery. CardioQ

  1. 1. <ul><li>HAEMODYNAMIC CONTROL IN FAST-TRACK SURGERY. CARDIOQ </li></ul>Manuel Núñez Debén Division of Anesthesiology and Reanimation Meixoeiro Hospital. Vigo
  2. 2. Anesthetic protocol Fast-track surgery <ul><li>1.- Preoperative. Selected patients </li></ul><ul><li>2.-.Anesthetic Technique. </li></ul><ul><li>Regional anesthesia and multimodal techniques. </li></ul><ul><li>3.- Drug Control. </li></ul><ul><li>Minimize ileus and PONV. </li></ul><ul><li>4.- Overall measurement of support: </li></ul><ul><li>* Temperature and blood glucose control </li></ul><ul><li>*Food and early ambulation </li></ul><ul><li>* Liquid Control intake </li></ul>The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care. Anesth Analg 2007;104:1380 –96
  3. 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 <ul><li>Preoperative Hydration a : </li></ul><ul><li>Avoid prolonged fasting </li></ul><ul><li>Preoperative fluids </li></ul><ul><ul><li> Catabolic response </li></ul></ul><ul><ul><li> Insuline resistance </li></ul></ul><ul><li>Liquid restriction b : </li></ul><ul><li>(intra and postoperative) </li></ul><ul><li> Interstitial edema </li></ul><ul><li> Postoperative morbidity </li></ul><ul><li> Hospital stay </li></ul>
  4. 4. <ul><li>Objective: IV fluid therapy that does not change body weight reduces the </li></ul><ul><li>morbidity after colorectal surgery 1 </li></ul><ul><li>Basic monitoring: </li></ul><ul><ul><li>Arterial Blood pressure </li></ul></ul><ul><ul><li>Heart rate </li></ul></ul><ul><ul><li>Diuresis </li></ul></ul><ul><ul><li>Known limitations: </li></ul></ul><ul><ul><li>Difficult diagnosis of hemodynamic changes, especially when they act on compensation mechanisms (peripheral blood and splenic sequestration) that are associated with increased morbidity 2 </li></ul></ul>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. 5. CARDIOQ <ul><li>Esophageal Echo-doppler. Measures blood flow in a downstream portion of aorta by an esophageal probe. </li></ul><ul><li>Graphic image in forms of speed /time. </li></ul><ul><li>Hemodynamic data &quot; beat by beat &quot; in Intraoperative * </li></ul><ul><li>*Cardiac Output (CO), Stroke Volume (SV), Heart Rate (HR), preload, afterload, contractility. </li></ul><ul><li>Reliable obtained data (Correlation > 80%) </li></ul><ul><li>Easy placement. Similar to a NGT </li></ul>*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. 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. 7. Wave of bad placement probe Heart Signal Venous signal
  8. 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. 9. Pathological waves Decreased afterload:  (PV & FTc) <ul><li>Compensated Hypovolaemia: </li></ul><ul><li>FTc.  PV </li></ul><ul><li>CO & SV. </li></ul><ul><li>Compensatory tachycardia </li></ul>Increased afterload:  (FTc, PV, CO & SV)
  10. 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 <ul><li>Maintenance: </li></ul><ul><li>Hartmann solution 5cc/kg/h </li></ul><ul><li>Hb>8 gr/dl </li></ul><ul><li>Bolos 200 cc colloids </li></ul><ul><li>According to algorithm </li></ul>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. 11. Limitations: <ul><li>Aortic area calculation by nomogram without specific measurement. </li></ul><ul><li>Software calculation for the loss of ventricular volume of supra-aortic branches </li></ul><ul><li>Turbulent aortic flow may alter results </li></ul><ul><li>Poor positioning or mobilization can cause false readings later. </li></ul><ul><li>Anesthetic drugs may alter their use </li></ul><ul><li>Basically reduced to mechanical ventilation. </li></ul><ul><ul><ul><li>CORRELATION > 80% WITH THERMODILUTION METHODS </li></ul></ul></ul><ul><li>Contraindications: </li></ul><ul><li>Esophageal Neoplasms </li></ul><ul><li>Coagulopathies </li></ul><ul><li>Esophagitis </li></ul><ul><li>Esophageal varices </li></ul><ul><li>Pathology oropharyngeal / esophageal. </li></ul>