Oesophageal Doppler Stroke  Volume Optimisation <ul><li>H.G. WAKELING  </li></ul><ul><li>Department of Anaesthesia  </li><...
Worthing
CardioQ Specifications <ul><li>6Kg 4MHz continuous Doppler ultrasound </li></ul><ul><li>Real time aortic blood flow data <...
 
Post operative morbidity Prospective study of 443 major surgery patients <ul><li>Complications Day 5 Day 8 </li></ul><ul><...
Why? <ul><li>Normal intraoperative monitoring of heart rate and blood pressure fails to identify hypovolaemia. </li></ul>
<ul><li>Heart rate </li></ul><ul><li>Mean arterial pressure </li></ul><ul><li>Cardiac Output </li></ul><ul><li>Lactate / P...
25-30% Haemorrhage in Man 2 1 0 1 2 0 1 8 0 1 5 0 9 0 6 0 3 0 B a s e H e a r t r a t e S y s B P T i m e ( m i n u t e s ...
25-30% Haemorrhage in Man Hamilton-Davies et al Intensive Care Med 23(3):276-281,1997 Controlled haemorrhage Re-transfusio...
Circulatory changes during laparotomy Can.J. Anaes 2002 49(3) 302-308 <ul><li>Many reasons for hypovolaemia </li></ul><ul>...
Circulatory changes during laparotomy in rabbits Can.J. Anaes 2002 49(3) 302-308 <ul><li>Spontaneous breathing –  no chang...
Frank Starling Curve Cardiac Function Curve Oesophageal Doppler Monitoring Stroke Volume End-Diastolic Volume    < 10%  ...
Useful Extrasystole
<ul><li>Days in Hospital </li></ul><ul><li>↓ </li></ul><ul><li>↓ </li></ul><ul><li>↓ </li></ul>CABG (Archives of Surg  199...
<ul><li>Would a simple, non-invasive, dynamic, flow-based fluid protocol improve outcome compared with ‘optimal’ controls?...
Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Prospective, double blind RCT </li></ul><ul><li>128 patien...
Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>In addition:- </li></ul><ul><ul><li>Gut permeability inves...
Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Power  0.8 at p=0.05 </li></ul><ul><ul><li>Local and publi...
 
Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Balanced anaesthetic technique </li></ul><ul><ul><li>O 2  ...
Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Surgical and Nursing staff blinded </li></ul><ul><li>Commo...
Patient characteristics     Control Median (IQR) Protocol Median(IQR) Age (years) Mean (sd) 69.6  (10.2) 69.1  (12.3) Phys...
Operative data   Control Median(IQR) Protocol Median(IQR) Blood loss (ml) 500  (975) 500  (700) Per-operative crystalloid ...
Haemodynamic data   Control Median (IQR) Protocol Median(IQR) Stroke Volume  (ml)  p<0.001) 77  (25) 99  (43)   * Cardiac ...
Haemodynamic data   Control Median (IQR) Protocol Median(IQR) CVP overall (mmHg)  13  (5) 14  (5) CVP End of surgery (mmHg...
Post-operative Progress   Control Median (IQR)days Protocol Median (IQR)days Flatus passed 4  (2) 3  (2) Bowels open 5  (2...
Kaplan-Meier Plot
GI Morbidity <ul><li>GI complications </li></ul><ul><ul><li>Control group 29  (45.3%) *  Chi Sq. </li></ul></ul><ul><ul><l...
Serum endotoxin levels
Intestinal Permeability
Mortality <ul><li>30 day mortality 0 </li></ul><ul><li>60 day mortality 1 ( 0.78%) </li></ul><ul><li>Predicted mortality:-...
Total bed occupancy <ul><li>Control group  840 days </li></ul><ul><li>Doppler group  770 days </li></ul><ul><li>Total bed ...
Can you give too much fluid? <ul><li>Brandstrup et al – restricted fluids </li></ul><ul><ul><li>Only healthiest patients r...
Too much fluid? <ul><li>Large saline loads associated with </li></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul...
WORMS <ul><li>Intraoperative Doppler guided fluids are associated with shorter length of hospital stay after major surgery...
IPPV IPPV & PEEP HEAD DOWN Reliable CVP? HEAD UP
Haemodynamic values at start and end of surgery
CVP <ul><li>Bears no relation to blood volume </li></ul><ul><ul><li>Ref.  Baek S, Surgery 1975;78:304-15 </li></ul></ul><u...
Elderly Laparoscopic Gastrectomy <ul><li>10 patients Mean age 80.8 years (75-87) </li></ul><ul><li>Laparoscopic Distal Gas...
Orthopaedic patients <ul><li>Primary Hip replacement </li></ul><ul><li>Elderly slow to mobilise </li></ul><ul><li>Why? </l...
 
 
Summary <ul><li>ODM Simple, non-invasive, inexpensive </li></ul><ul><li>Useful circulatory assessment tool in complex lap....
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Oesophageal Doppler Stroke Volume Optimisation

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"Oesophageal Doppler Stroke Volume Optimisation", a presentation by Wakeling.

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  • Transcript of "Oesophageal Doppler Stroke Volume Optimisation"

    1. 1. Oesophageal Doppler Stroke Volume Optimisation <ul><li>H.G. WAKELING </li></ul><ul><li>Department of Anaesthesia </li></ul><ul><li>Worthing Hospital, West Sussex,UK. </li></ul>
    2. 2. Worthing
    3. 3. CardioQ Specifications <ul><li>6Kg 4MHz continuous Doppler ultrasound </li></ul><ul><li>Real time aortic blood flow data </li></ul><ul><li>12 hour patient probes </li></ul><ul><li>10 day probe </li></ul><ul><li>Validated for patients: 3Kg – 150Kg </li></ul>
    4. 5. Post operative morbidity Prospective study of 443 major surgery patients <ul><li>Complications Day 5 Day 8 </li></ul><ul><li>176 (40%) 109 (25%) </li></ul><ul><li>GI Dysfunction (%) 55 51 </li></ul><ul><li>Renal (%) 26 25 </li></ul><ul><li>Inability to ambulate (%) 22 18 </li></ul><ul><li>Pulmonary (%) 17 24 </li></ul><ul><li>Infection (%) 12 16 </li></ul><ul><li>Wound complication(%) 3 10 </li></ul><ul><li>Cardiovascular (%) 9 15 </li></ul>
    5. 6. Why? <ul><li>Normal intraoperative monitoring of heart rate and blood pressure fails to identify hypovolaemia. </li></ul>
    6. 7. <ul><li>Heart rate </li></ul><ul><li>Mean arterial pressure </li></ul><ul><li>Cardiac Output </li></ul><ul><li>Lactate / Pyruvate ratio </li></ul><ul><li>Splanchnic blood flow </li></ul><ul><li>Splanchnic blood volume </li></ul>11 healthy volunteers. Blood volume reduced by 15-20%. All subjects developed CNS symptoms. Change from baseline - 5% - 6% 0% +7% - 9% - 40%*** Price HL et al. Circulation Research 1966;5:469-474 Covert Compensated Hypovolemia
    7. 8. 25-30% Haemorrhage in Man 2 1 0 1 2 0 1 8 0 1 5 0 9 0 6 0 3 0 B a s e H e a r t r a t e S y s B P T i m e ( m i n u t e s ) 8 0 0 m l 8 0 0 m l Hamilton-Davies et al Intensive Care Med 23(3):276-281,1997 Controlled haemorrhage Re-transfusion 0 2 0 4 0 6 0 8 0 1 0 0 1 2 0 1 4 0 1 6 0
    8. 9. 25-30% Haemorrhage in Man Hamilton-Davies et al Intensive Care Med 23(3):276-281,1997 Controlled haemorrhage Re-transfusion Base 800ml 800ml Gastric pHi 7 . 0 0 7 . 0 5 7 . 1 0 7 . 1 5 7 . 2 0 7 . 2 5 7 . 3 0 7 . 3 5 7 . 4 0 7 . 4 5 T i m e ( m i n u t e s ) a e m o r r h a g e 2 1 0 1 2 0 1 8 0 1 5 0 9 0 6 0 3 0
    9. 10. Circulatory changes during laparotomy Can.J. Anaes 2002 49(3) 302-308 <ul><li>Many reasons for hypovolaemia </li></ul><ul><ul><li>Starvation </li></ul></ul><ul><ul><li>Blood loss </li></ul></ul><ul><ul><li>Open wound </li></ul></ul><ul><li>Splanchnic circulation reduced first </li></ul><ul><li>Changes in regional circulation during laparotomy and ventilation </li></ul>
    10. 11. Circulatory changes during laparotomy in rabbits Can.J. Anaes 2002 49(3) 302-308 <ul><li>Spontaneous breathing – no changes </li></ul><ul><li>IPPV with Zero PEEP - no changes </li></ul><ul><li>Abdomen open, PEEP 12cmH 2 O </li></ul><ul><ul><li>Mean arterial BP reduced </li></ul></ul><ul><ul><li>Hepatic and renal blood flow reduced to less than <10% of starting value; partial recovery at 0 PEEP </li></ul></ul><ul><ul><li>Carotid and aortic flow less than half </li></ul></ul><ul><li>Abdomen closed similar but less marked </li></ul>
    11. 12. Frank Starling Curve Cardiac Function Curve Oesophageal Doppler Monitoring Stroke Volume End-Diastolic Volume  < 10%  > 10%  0%
    12. 13. Useful Extrasystole
    13. 14. <ul><li>Days in Hospital </li></ul><ul><li>↓ </li></ul><ul><li>↓ </li></ul><ul><li>↓ </li></ul>CABG (Archives of Surg 1995 130: 423) #Neck of Femur BMJ 1997;315:909 - 12. Major General Surgery Anesthesiol, 97(4), 820-826, 2002 Optimising stroke volume during surgery
    14. 15. <ul><li>Would a simple, non-invasive, dynamic, flow-based fluid protocol improve outcome compared with ‘optimal’ controls? </li></ul><ul><ul><li>Pre-operative iv fluid </li></ul></ul><ul><ul><li>Full standard monitoring incl. CVP </li></ul></ul><ul><ul><li>Target CVP 12-15mmHg </li></ul></ul>
    15. 16. Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Prospective, double blind RCT </li></ul><ul><li>128 patients, colorectal surgery </li></ul><ul><li>Intervention: Doppler guided colloid fluids </li></ul><ul><li>1 0 outcome measure: Length of stay </li></ul><ul><li>2 0 outcome measure: Time to full diet </li></ul><ul><li>Sponsored by the Department of Health </li></ul><ul><li>R & D Grant SEO252 </li></ul>
    16. 17. Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>In addition:- </li></ul><ul><ul><li>Gut permeability investigated </li></ul></ul><ul><ul><ul><li>Lactulose-mannitol </li></ul></ul></ul><ul><ul><ul><li>Systemic endotoxin </li></ul></ul></ul><ul><ul><li>Systemic inflammatory markers </li></ul></ul><ul><ul><ul><li>IL-6, C reactive protein, </li></ul></ul></ul><ul><ul><li>Quality of recovery and EORTC questionnaires </li></ul></ul>
    17. 18. Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Power 0.8 at p=0.05 </li></ul><ul><ul><li>Local and published data </li></ul></ul><ul><ul><li>1 0 n=58 </li></ul></ul><ul><ul><li>2 0 n=64 </li></ul></ul><ul><li>Control – </li></ul><ul><ul><li>NIBP, ECG, Pulse Oximetry, Capnography </li></ul></ul><ul><ul><li>Central Venous pressure 12 – 15 mmHg </li></ul></ul><ul><li>Intervention – Doppler fluid algorithm </li></ul>
    18. 20. Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Balanced anaesthetic technique </li></ul><ul><ul><li>O 2 / N 2 O / Isoflurane </li></ul></ul><ul><ul><li>Fentanyl 1-2 μg.Kg -1 & Morphine </li></ul></ul><ul><ul><li>Propofol 1.5-3 mg.Kg -1 </li></ul></ul><ul><ul><li>Vecuronium </li></ul></ul><ul><li>Crystalloid given pre-operatively and at anaesthetist’s discretion </li></ul>
    19. 21. Worthing Optimisation Research in Major Surgery (WORMS) <ul><li>Surgical and Nursing staff blinded </li></ul><ul><li>Common patient led recovery pathway </li></ul><ul><li>Fluid prescription on the ward entirely at discretion of surgical team. </li></ul>
    20. 22. Patient characteristics     Control Median (IQR) Protocol Median(IQR) Age (years) Mean (sd) 69.6 (10.2) 69.1 (12.3) Physiological Possum 18 (7.0) 17 (6.5) Operative Possum 16 (9.0) 15.5 (7.0) BMI 26 (7.25) 24.5 (6.75)
    21. 23. Operative data   Control Median(IQR) Protocol Median(IQR) Blood loss (ml) 500 (975) 500 (700) Per-operative crystalloid (ml) 3000 (1187) 3000 (1750) Per-op. colloid * (ml) Range 1500 (0 – 4000) 2000 p<0.001 (500-5000 ) Urine output 1 st 36 hours * 2754 (1453) 3649 (2000) p<0.01
    22. 24. Haemodynamic data   Control Median (IQR) Protocol Median(IQR) Stroke Volume (ml) p<0.001) 77 (25) 99 (43) * Cardiac Output (l.min -1 ) p<0.02 5.6 (2.9) 7.25 (2.37) * Oxygen Delivery (ml.min.m 2 ) p<0.011 445 (200) 535 (229) *
    23. 25. Haemodynamic data   Control Median (IQR) Protocol Median(IQR) CVP overall (mmHg) 13 (5) 14 (5) CVP End of surgery (mmHg) 13 (5.5) 13 (4.5)
    24. 26. Post-operative Progress   Control Median (IQR)days Protocol Median (IQR)days Flatus passed 4 (2) 3 (2) Bowels open 5 (2) 4 (3) Full diet 7 (2) 6 (2) Discharge 11.5 (4.75) 10 (5.75)
    25. 27. Kaplan-Meier Plot
    26. 28. GI Morbidity <ul><li>GI complications </li></ul><ul><ul><li>Control group 29 (45.3%) * Chi Sq. </li></ul></ul><ul><ul><li>Doppler Group 9 (14%) </li></ul></ul><ul><li>Relative Risk (95%CI) </li></ul><ul><ul><li>Control 2.035 ( 1.474, 2.810 ) </li></ul></ul><ul><ul><li>Treatment 0.379 ( 0.209, 0.686 ) </li></ul></ul><ul><li>Risk Ratio 5.3 : 1 </li></ul>
    27. 29. Serum endotoxin levels
    28. 30. Intestinal Permeability
    29. 31. Mortality <ul><li>30 day mortality 0 </li></ul><ul><li>60 day mortality 1 ( 0.78%) </li></ul><ul><li>Predicted mortality:- </li></ul><ul><li>Median values P-POSSUM – 3.3% </li></ul><ul><li>National mortality 7.5% </li></ul>
    30. 32. Total bed occupancy <ul><li>Control group 840 days </li></ul><ul><li>Doppler group 770 days </li></ul><ul><li>Total bed saving 70 days </li></ul>
    31. 33. Can you give too much fluid? <ul><li>Brandstrup et al – restricted fluids </li></ul><ul><ul><li>Only healthiest patients recruited </li></ul></ul><ul><ul><li>Non-individualised protocol </li></ul></ul><ul><ul><li>6000ml N/Saline given to std. group </li></ul></ul><ul><ul><ul><li>(only 5,000ml iv fluid in Doppler group) </li></ul></ul></ul><ul><ul><ul><li>No bowel prep </li></ul></ul></ul><ul><ul><li>N/Saline continued post-op with oral fluid </li></ul></ul><ul><ul><li>4,000ml N/Saline in restricted group – </li></ul></ul><ul><ul><li>Post op aim to keep weight constant. </li></ul></ul>
    32. 34. Too much fluid? <ul><li>Large saline loads associated with </li></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Poorer outcome </li></ul></ul><ul><li>4.7% mortality, plus pulmonary oedema in ASA I and II patients </li></ul><ul><li>So, restricting fluid protected patients from being drowned with Saline </li></ul>
    33. 35. WORMS <ul><li>Intraoperative Doppler guided fluids are associated with shorter length of hospital stay after major surgery even when control group CVP kept between 12 and 15mmHg. </li></ul><ul><li>Why? </li></ul>
    34. 36. IPPV IPPV & PEEP HEAD DOWN Reliable CVP? HEAD UP
    35. 37. Haemodynamic values at start and end of surgery
    36. 38. CVP <ul><li>Bears no relation to blood volume </li></ul><ul><ul><li>Ref. Baek S, Surgery 1975;78:304-15 </li></ul></ul><ul><li>Unreliable readings in theatre </li></ul><ul><li>Unless constantly bolused gives little useful information. </li></ul><ul><li>Associated with significant cost and complications. </li></ul>
    37. 39. Elderly Laparoscopic Gastrectomy <ul><li>10 patients Mean age 80.8 years (75-87) </li></ul><ul><li>Laparoscopic Distal Gastrectomy </li></ul><ul><li>30 day mortality – 0% </li></ul><ul><li>90% 2 year survival </li></ul><ul><li>No HDU requirement </li></ul><ul><li>Doppler fluid management integral to anaesthetic technique </li></ul>
    38. 40. Orthopaedic patients <ul><li>Primary Hip replacement </li></ul><ul><li>Elderly slow to mobilise </li></ul><ul><li>Why? </li></ul>
    39. 43. Summary <ul><li>ODM Simple, non-invasive, inexpensive </li></ul><ul><li>Useful circulatory assessment tool in complex lap. surgery </li></ul><ul><li>Likely to have role in improving orthopaedic recovery </li></ul><ul><li>Intraoperative ODM shortened length of stay compared with CVP managed controls in Colorectal patients: </li></ul><ul><li>Significantly earlier return of gut function </li></ul><ul><li>Significant reduction in post-op. complications </li></ul><ul><li>Significantly better cardiac output and O 2 Delivery </li></ul><ul><li>Significant cost savings. </li></ul><ul><li>Right Volume Right Fluid Right time </li></ul>

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