Letter 2 Dr. Paul W. Corey


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Letter 2 Dr. Paul W. Corey

  1. 1. Anesthesiology 2008; 109:723–40 To the Editor: The esophageal Doppler is an important part of Perioperative Fluid Management. Doctors Chappell, Jacob, Hofmann-Kiefer, Conzen, and Rehm are to be commended for their excellent paper “A Rational Approach to Perioperative Fluid Management” in Anesthesiology 2008; 109:723–40. I would like to mention some aspects of rational approaches to perioperative fluid management that may be helpful. As we know the intravascular space is not a static one. In addition to fluid shifting out of the intravascular space (type I and type II), which is comprehensively dealt with in this paper, fluid shifting occurs dynamically between various vascular beds. This fluid shifting/shunting can mitigate against and obscure hypovolemia1 posing risks to the vascular beds that are being depleted.2 Additionally the vascular beds themselves can undergo dramatic capacitance changes secondary to anesthetic agents and techniques, various drugs and pathophysiologic states. Given that “the principal goal of Perioperative Fluid Optimization is to optimize cardiac preload” and that the compartments contributing to preload are constantly changing, it is important that the circulation be followed, understood and managed dynamically with continuous, real time objective data. Understanding the hemodynamic condition and making it acceptable in real time helps to determine the amount and time of fluid administration. Not only does the esophageal Doppler enable us to understand and dynamically manage preload conditions, it also enables us to understand and manage left ventricular (LV) contractility and the effect of afterload impedance on LV performance.
  2. 2. Stroke volume optimization via esophageal Doppler-guided fluid boluses not only “seems to” but does improve outcome, not only “in elderly and frail patients”, but across a wide cross section of the adult perioperative population. The evidence base is strong. A technology assessment done by the Agency for Healthcare Research and Quality reviewed over 1600 peer reviewed journals and 346 specific papers and concluded that that “Doppler-guided fluid replacement during surgery leads to a clinically significant reduction in major complications”, that “Doppler-guided fluid replacement during surgery leads to a clinically significant reduction in the total number of complications”, and that “Doppler-monitored fluid replacement leads to a reduction in hospital stay”3. Based on this, Centers for Medicare and Medicaid Services (CMS) determined that use of esophageal Doppler was “reasonable and necessary” and further that its use be covered for “monitoring of cardiac output with the esophageal Doppler for ventilated ICU patients and operative patients requiring fluid optimization”4. CMS subsequently issued instructions to its regional carriers on how to process claims for professional reimbursement for the use of esophageal Doppler5. We are currently receiving payments to monitor and fluid optimize our patients. There are currently not just two, but eight randomized controlled trials that show improved outcomes using esophageal Doppler guided fluid optimization678910111213. These outcomes include decreased length of stay, ICU length of stay, unplanned ICU admissions, use of and doses of vasopressors, lactate levels, interleukin-6 levels, time to bowel sounds, time to taking solid diet, nausea and vomiting and decreases in major complications such as wound infection, pneumonia, respiratory failure, ileus, impaired renal function, and severe PONV.
  3. 3. It is incorrect to conclude, as stated in their paper, “it [Esophageal Doppler-guided fluid boluses] has up until now been compared with only standard fluid handling, which revealed no large differences between the total fluid volume of the two studied groups. (30,42) Accordingly, assuming the worst case, the actual message behind these data could also be that esophageal Doppler- guided fluid overload is superior to uncontrolled fluid overload”. The proper timing of fluid administration needs to be taken into consideration. Certainly if a patient needs a specific amount of volume resuscitation at the beginning of a procedure, giving this amount at the end of the procedure would most likely be of limited benefit and may be deleterious. The total amounts administered may be the same but the outcomes would be, and are, as shown in the randomized controlled trials, different. It is time to stop bringing our patients to recovery areas with acceptable blood pressures and heart rates at best, while totally lacking any measurement or understanding of blood flow and vascular resistance. Knowing all of these factors is essential for proper fluid management and care of our patients and will help minimize overloading the interstitial space and deteriorating the endothelial glycocalyx. Making the esophageal Doppler a part of Perioperative Fluid Management is not only rational, it fixes an astonishing fundamental flaw in our lack of hemodynamic understanding in the 35 million patients that we care for each year in the United States. And most importantly, it will improve their outcomes. Paul W. Corey, MD. San Diego, California
  4. 4. 1 Price HL, Deutsch S, Marshall BE, Stephen GW, Behar MG, Neufeld GR. Hemodynamic and metabolic effects of hemorrhage in man, with particular reference to the splanchnic circulation. Circ Res. 1966; 18(5):469-74. 2 Hamilton-Davies C, Mythen MG, Salmon JB, Jacobson D, Shukla A, Webb AR. Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry. Int Care Med. 1997; 23(3):276-81 3 Agency for Healthcare and Research and Quality. Technology Assessment. Esophageal Doppler Ultrasound-Based Cardiac Output Monitoring for Real-Time Therapeutic Management of Hospitalized Patients. January 16, 2007. 1-120 4 CMS Decision Memo for Ultrasound Diagnostic Procedures Administrative File CAG-00309R, Final Coverage Decision Memorandum for Ultrasound Diagnostic Procedures, May 22, 2007 5 Centers for Medicare and Medicare Services, Pub 100-03 Medicare National Coverage Determinations; Transmittal 76: September 12 2007 6 Mythen M G, Webb A. R. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130:423-429.
  5. 5. 7 Sinclair S, James S, Singer M, Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomized controlled trial BMJ 1997; 315:909-912 8 Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, and Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br. J. Anaesth. 2002; 88: 65-71. 9 Gan TJ , Soppitt A, Maroof M, El-Moalem H, Robertson K M, Moretti E, Dwane P, Glass PSA., Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery. Anesthesiology 2002; 97(4):820-826 Wakeling H. G, McFall M. R, Jenkins C. S, Woods W. G. A, 10 Miles W. F. A, Barclay G. R, and Fleming S. C. Intraoperative esophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery, BJA: British Journal of Anesthesia 2005; 95(5): 634-642. 11 Noblett S. E, Snowden C. P, Shenton B. K, Horgan A. F. Randomized clinical trial assessing the effect of Doppler- optimized fluid management on outcome after elective colorectal resection. BJS 2006; 93(9):1069-1076 12 McKendry M, McGloin H, Saberi D, Caudwell L, Brady A R, Singer M. Randomized controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimization of circulatory status after cardiac surgery. BMJ 2004;329(7460):258. E pub 2004 Chytra I, Pradl R, Bosman R, Pelnar P, Kasal E, Zidkova A. 13 Esophageal Doppler guided fluid management decreases blood
  6. 6. lactate levels in multiple trauma Patients: a randomized controlled trial. Critical Care 2007, 11R24: 1-24