Goal-directed therapy:where are the goal postsAnthony Delaney MBBS MSc FACEM FCICMStaff Specialist Malcolm Fisher Intensiv...
A few points to consider What are the goals of early goal directedtherapy? Should all patients have the same goals? How...
So…… What is Early Goal Directed Therapy? O2 saturation Central Venous Pressure Mean Arterial Pressure ScvO2
Should all patients have thesame goals?
Sepsis is a disease of sickpeople Patients with sepsis have comorbidity that willneed to be considered when setting resus...
How do we achieve the goals? SaO2 ≥ 93%Oxygen, PEEP, mechanical ventilation CVP ≥ 8-12 mmHgFluids MAP 60-90 mmHgVaso...
Oxygen saturation text
Oxygen saturation 655 patients randomised to ketamine oretomidate 16% patients had sepsis 2.5% had a cardiac arrest at ...
Central Venous Pressure Determinants:Fluid statusVascular toneCardiac functionIntra-thoracic and intra-abdominal pres...
Positive fluid balance andelevated CVP in septic shock Retrospective analysis of data from VASST 778 patients Analysis ...
Positive fluid balance andelevated CVP in septic shock
Positive fluid balance andelevated CVP in septic shock
 1000 patients with acute lung injury randomisedto conservative or liberal fluid balance Pneumonia and sepsis most commo...
 Nosignificant difference in mortality25.5% v 28.4% Increased ventilator free days14.6 v 12.1 Days out of ICU13.4 v ...
Maintaining CVP with fluids Certainly the potential for mortality andmorbidity associated with excessive fluidadministrat...
Central Venous OxygenSaturation Surrogate for mixed venous oxygen saturation(SvO2) Marker of global adequacy of oxygen d...
Blood transfusion
 30 day mortality 18.7% v 23.3%, p=0.11
 Estimate of OR formortality OR= 1.4795% CI 0.98-2.21P=0.06
So, Patients with sepsis may have comorbidity thatmay make achievement of physiologicalresuscitation goals difficult or u...
 “Before and After” 854 patients with sepsis before 1465 patients after 247 patients 1 year later
 InterventionInstitutional supportLocal championMuliti-disciplinary teamMulti-facted education campaign based on the ...
 I
 15,775 participants from 252 sites Complicated QI project Compliance “goal was achieved within 6 hours” Intervention...
 Jan 2005 to March 2008Hospital mortality 37.0% to 30.8%
So………
Conclusion Be careful about choosing rigid targets forresuscitating septic patients Early Goal Directed Therapy is a com...
Questions??
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?
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Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?

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Anthony Delaney examines the evidence for usefulness of goal directed therapy in the septic patient.

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Anthony Delaney: Goal Directed Therapy – Where are the Goalposts?

  1. 1. Goal-directed therapy:where are the goal postsAnthony Delaney MBBS MSc FACEM FCICMStaff Specialist Malcolm Fisher Intensive Care Unit, Royal NorthShore HospitalSenior Lecturer, Northern Clinical School, Sydney Medical School,University of Sydney
  2. 2. A few points to consider What are the goals of early goal directedtherapy? Should all patients have the same goals? How do you achieve the goals? Does it matter if you score?
  3. 3. So…… What is Early Goal Directed Therapy? O2 saturation Central Venous Pressure Mean Arterial Pressure ScvO2
  4. 4. Should all patients have thesame goals?
  5. 5. Sepsis is a disease of sickpeople Patients with sepsis have comorbidity that willneed to be considered when setting resuscitationgoals But keep in mind….
  6. 6. How do we achieve the goals? SaO2 ≥ 93%Oxygen, PEEP, mechanical ventilation CVP ≥ 8-12 mmHgFluids MAP 60-90 mmHgVasopressors(vasodilators) ScvO2 ≥ 70%BloodDobutamine
  7. 7. Oxygen saturation text
  8. 8. Oxygen saturation 655 patients randomised to ketamine oretomidate 16% patients had sepsis 2.5% had a cardiac arrest at induction
  9. 9. Central Venous Pressure Determinants:Fluid statusVascular toneCardiac functionIntra-thoracic and intra-abdominal pressure
  10. 10. Positive fluid balance andelevated CVP in septic shock Retrospective analysis of data from VASST 778 patients Analysis stratified by quartiles using coxproportional hazards modelsAge, APACHE II score, dose of noradrenaline
  11. 11. Positive fluid balance andelevated CVP in septic shock
  12. 12. Positive fluid balance andelevated CVP in septic shock
  13. 13.  1000 patients with acute lung injury randomisedto conservative or liberal fluid balance Pneumonia and sepsis most common cause 7 day fluid balance -136 ml +/- 491 conservative
  14. 14.  Nosignificant difference in mortality25.5% v 28.4% Increased ventilator free days14.6 v 12.1 Days out of ICU13.4 v 11.2 No difference in other organ dysfnction
  15. 15. Maintaining CVP with fluids Certainly the potential for mortality andmorbidity associated with excessive fluidadministration
  16. 16. Central Venous OxygenSaturation Surrogate for mixed venous oxygen saturation(SvO2) Marker of global adequacy of oxygen deliveryAssuming normal microcirculation, tissue oxygenextraction DO2 = [1.39 x Hb x SaO2 + dissolved O2] xCO
  17. 17. Blood transfusion
  18. 18.  30 day mortality 18.7% v 23.3%, p=0.11
  19. 19.  Estimate of OR formortality OR= 1.4795% CI 0.98-2.21P=0.06
  20. 20. So, Patients with sepsis may have comorbidity thatmay make achievement of physiologicalresuscitation goals difficult or undesirable The treatments required to achieve thephysiological resuscitation goals all havesignificant potential adverse effects Do we need to achieve the physiological goalsto obtain the mortality benefit from early goaldirected therapy?
  21. 21.  “Before and After” 854 patients with sepsis before 1465 patients after 247 patients 1 year later
  22. 22.  InterventionInstitutional supportLocal championMuliti-disciplinary teamMulti-facted education campaign based on the SSCguidelines Powerpoint Posters Pocket cards
  23. 23.  I
  24. 24.  15,775 participants from 252 sites Complicated QI project Compliance “goal was achieved within 6 hours” InterventionSites volunteered for the projectWebsite with educational materialsMeetingsEmail list serverNewsletter
  25. 25.  Jan 2005 to March 2008Hospital mortality 37.0% to 30.8%
  26. 26. So………
  27. 27. Conclusion Be careful about choosing rigid targets forresuscitating septic patients Early Goal Directed Therapy is a complexintervention, and involves more than simplyfollowing a resuscitation recipe Wait a little longer for further high qualityevidence to guide practice in this area
  28. 28. Questions??

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