In 1988 Shoemaker developed the first principles of goal directed therapy and its superiority regarding outcome.This concept has been adopted ever since and new perioperative indications such as general, abdominal, cardiac, orthopaedic surgery have evolved. Improved outcome through GDT was proven in several publications.

1. Improve Outcome in Major
Abdominal Surgery with ProAQT
Complications
reduced by
27,7%
Control Group
Study Group
Patients with
Complications
reduced by
41,7%
Control Group
Early goal directed therapy based on radial artery
pulse contour analysis
Less complications especially less infections
Goal directed therapy with PPV, CI and MAP
as target parameters
Individualise your treatment!
Study Group
(1)

2. Goal Directed Therapy (GDT)
– A proven concept for outcome optimisation
In 1988 Shoemaker developed the first principles of goal directed therapy and its superiority regarding
outcome(2). This concept has been adopted ever since and new perioperative indications such as general, abdominal, cardiac, orthopaedic surgery have evolved. Improved outcome through GDT was proven in several
publications.
Benefits of GDT
*
A meta-analysis of Gurgel et al. analysed the impact of
GDT on mortality reduction in high-risk surgeries.
• Over all three defined mortality subgroups: Reduction of mortality by 33% in the GDT group(3).
• Surgical procedures with a mortality from 5% to 20%
in the control group: Reduction of mortality by 35%(4).
reduced
up to
• Surgical procedures with mortality > 20% in the control group: Reduction of mortality by 68%(3).
A meta-analysis of Hamilton et al. and Dalfino et al. analysed the impact of GDT on complications
reduced
by
• In general GDT resulted in a decline of complications
by 56% compared to the control group(5).
• Especially the numbers of infections were reduced
significantly by 60%(6).
A strong cochrane review of Grocott et al. analysed the
impact of GDT on Length of Stay (LoS) (7).
• Postoperative ICU stay: mean reduction by 0.45 days,
reduced
by
• Postoperative hospital stay: mean reduction by 1.16
days
Study or Subgroup
Odds Ratio
M-H, Fixed, 95% CI
Bishop, 1995 (26)
0.38 [0.16, 0.90]
Chytra, 2007(30)
0.69 [0.31, 1.52]
Boyd, 1993 (29)
Fleming, 1992 (32)
Lobo, 2000 (17)
Lobo, 2006 (35)
Lopes, 2007 (36)
Shoemaker, 1998 (4)
Shultz, 1985 (40)
*Forest plot: Comparison of GDT vs.
conventional treatment in surgical
procedures with a mortality > 20%(3)
Odds Ratio
M-H, Fixed, 95% CI
Total (95% CI)
0.21 [0.06, 0.79]
0.41 [0.14, 1.15]
0.19 [0.04, 0.88]
0.22 [0.04, 1.21]
0.29 [0.05, 1.80]
0.07 [0.01, 0.63]
0.07 [0.01, 0.61]
0.32 [0.21, 0.47]
0.1
0.2
0.5
Faverous experimental
1
2
5
10
Faverous control

3. High Risk Abdominal Surgery
Benefits most from GDT
Despite high standards in surgical and
anaesthesiological care in Europe, the
perioperative mortality rate is still higher
than expected(8).
High blood loss (> 20%) and volume shifts during
the procedure can result in hypo- or hypervolaemia
8
6
4
2
0
6,7
Oesophagectomy
•
10
Gastrectomy
Complex procedures with high-risk of intraand post-op complications
11,8
12
Colectomy
Long surgery time (>120 min)
•
14
Mortality [ % ]
•
15,1
16
Mortality rates for procedures in abdominal surgery, 1999 (9)
PulsioFlex – Your navigator in perioperative haemodynamic management
ProAQT
CeVOX
Radial arterial trend monitoring of
Cardiac Index - simply attached to
an arterial line
Central venous oxygen
saturation - simply attached to
a standard CVC
Parameters:
Parameters:
•
Cardiac Output:
CITrend
•
Volume responsiveness:
SVV, PPV
•
Afterload:
SVRI, MAP
•
Cardiac function:
dPmx, CPI
•
Central venous oxygenation
ScvO2
Oxygenation: DO2, VO2, O2ER (ProAQT combined with CeVOX)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Salzwedel C et al., Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative
complications after major abdominal surgery: a multi-center, prospective, randomized study. Crit Care 2013; 17(5): R191.
Shoemaker WC et al., Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988; 94(6): 1176-86.
Gurgel ST & do Nascimento P, Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 2011; 112(6): 1384-91.
Cecconi M et al., Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups. Crit Care 2013; 17(2): 209.
Rhodes A et al., Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 2010; 36(8): 1327-1332.
Dalfino L et al., Haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care 2011; 15(3): R154.
Grocott MP et al., Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. Br J Anaesth 2013; 111: 535-48.
Pearse RM et al., Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012; 380: 1059-1065.
Goodney PP et al., Is Surgery Getting Safer? National Trends in Operative Mortality. J Am Coll Surg 2002; 195: 219-27.

4. Salzwedel Algorithm for Abdominal Surgery
A) Algorithm for initial assessment and treatment
START
PPV < 10%
NO
YES
Define CIopt (at least 2.5)
CI > 2.5
Give volume
STOP
NO
If CI ↓, consider
inotropes
YES
Inotropes
MAP > 65
NO
Vasopressors
B) Algorithm for further intraoperative optimisation
Reassess every 15 min
START
PPV < 10%
NO
YES
CI = CIopt
YES
MAP > 65
Give volume
STOP
NO
NO
If CI ↓, consider
inotropes
Inotropes
YES
Vasopressors
Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure
variation and continuous cardiac index trending reduces postoperative
complications after major abdominal surgery: a multi-center, prospective, randomized study.
Authors
Salzwedel C, Puig J, Carstens A, Bein B, Molnar Z, Kiss K, Hussain A, Belda J, Kirov MY, Sakka SG
and Reuter DA
Centers
University Hospital Hamburg-Eppendorf (DE), University of Valencia (ES), University Hospital SchleswigHolstein Kiel (DE), University of Szeged (HU), Northern State Medical University Arkhangelsk (RU),
Medical Centre Cologne –Merheim (DE)
Journal
Critical Care 2013, 17:R191
Study Type
Multi-center prosepective randomized study
Hypothesis
Goal-directed haemodynamic therapy, based on radial arterial pulse pressure variation and continuous
cardiac index trending reduces complications after major abdominal surgery.
Surgeries
elective abdominal surgery
Inclusion criteria
Expected surgery duration > 120 min or
expected blood loss volume > 20 %,
ASA II or III, arterial line, CVC
Technology
ProAQT Sensor with PulsioFlex Monitor
No of patients
GDT parameters
Study Group (SG)
81
PPV, CI, MAP
Control Group (CG)
79
-
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