This document discusses non-invasive guided goal-directed therapy (GDT) for hemodynamic monitoring and optimization. It describes using a bedside monitor to continuously and non-invasively estimate cardiac output and stroke volume based on pulse wave transit time analysis of ECG and pulse oximetry signals. The method is calibrated using intermittent non-invasive blood pressure readings. Studies show this approach can guide fluid administration and help achieve hemodynamic goals like those used in invasive GDT protocols to improve outcomes. The document provides details on set up, use, and limitations of this non-invasive GDT method for perioperative hemodynamic optimization.

1. Non-Invasive Guided GDT
Suraphong Lorsomradee, MD.,PhD.
Associate Professor, Division of Cardiac Anesthesia,
Chiang Mai University Hospital
THAILAND
GDT EducASIA: Simple Bedside Monitor

2. Dynamic Clinical Monitoring

3. Lorsomradee, et al:
J Cardiothorac Vasc Anesth.
Aug;21(5):492-6, 2007
Change in Position
Leg Elevation

4. Lorsomradee, et al:
Anaesthesia.
Oct;62(10):979-83, 2007
Vasoconstrictor

5. PEEP & Preload
Lorsomradee, et al:
J Cardiothorac Vasc Anesth.
Aug 21(5):492-6., 2007

6. Painful Surgical Stimuli
Sternotomy SuctionSomatic PainWound dressing IntubationRetractor Other

7. Myocardial
ischemia
Cell death
Myocardial
dysfunction
Myocardial
stunning
reperfusion
no
reperfusion
Sublethal
Reperfusion injury
Delayed
Reperfusion injury
Early lethal
Reperfusion injury
Cell death
during
reperfusion
These factors may interfere myocardial perfusion and aggravate perioperative myocardial
ischemia , lethal reperfusion injury and irreversible cell death.

8. CardioprotectionPrevention of myocardial ischemia has traditionally focused on maintaining
Myocardial oxygen balance
Heart rate
contractility
afterload
CBF: normal region
CBF: ischemic region
subendocardium
Ischemia
Beta-blocker
Alpha2 agonist
Ca-channel blocker

9. Introduction
Physical Findings (Non-specific)
Clinical signs of hypovolemia are neither sensitive nor specific in the critically ill patient.
Increased sympathetic tone
- Tachycardia, hyperpnea,
- Diaphoresis
Decrease organ perfusion
- Decrease urine output, ileus,
- Altered sensorium,
- Lactic acidosis
- Hypotension occurs late

10. blood pressure
Bloodvolume
blood pressure
Bloodvolume Pain
Hypertension
Emotional
Shock
Hypotension
Deep sedation
BP
BP

11. SV
HR
Vascular tone
Blood Viscosity
Invasive BP Monitoring

12. Arterial Pulse Cardiac Output
(APCO)
Transesophageal Echocardiography
(TEE)
Thermodilution
(Swan-Ganz)
Cardiac Output

13. Non-invasive Blood Pressure (NIBP)
Electrocardiography (ECG)
Pulse Oximetry (SpO2)
Routine
Non-Invasive Monitor

14. ECG-SpO2 Estimated
Continuous Cardiac Output

15. PEP(Pre-ejection Period)
Reflects cardiac contractility
PEP ↓ ⇒ SV ↑
PWTT1
Reflects Blood Pressure
PWTT1 ↓ ⇒ SV ↑
PWTT2
Reflects SVR
PWTT2 ↓ ⇒ SV ↑
PWTT ↓
SV ↑

16. ↑ Contractility
PWTT ↓ SV ↑
↑ SVR
PWTT ↑ SV ↓

17. Inverse Correlation between PWTT and SV
-8
-6
-4
-2
0
2
4
-100 -80 -60 -40 -20 0 20 40 60 80 100
ΔPWTT[ｍｓ]
ΔSV[cc]
y=-0.0511*x-0.876
r=-0.71(p<0.001)
n=560
Animal Experiment: Correlation between
the change of PWTT and SV since the
starting time (Sugo. et. al. IEEE, 1998)
Positive inotropic:
Dobutamine
Negative inotropic:
Propranolol/pentobarbital
Vasoconstriction:
Phenylephrine
Vasodilation:
Nitroglycerin
Hypovolemia:
Removal/ transfusion of blood

18. Accuracy Evaluation
Multicenter Study
esCCO system v.s. ICO (thermodilution)
No. of Patient=213 No. of Data=541
Average of difference
between esCCO and ICO=0.08(L), σ=1.07

19. esCCO Set up & Calibration

20. Non-invasive Blood Pressure (NIBP)
Electrocardiography (ECG)
Pulse Oximetry (SpO2)
PWTT ~ SV
Non-Invasive Cardiac Output

21. • ECG Electrode: Avoid hair or reused
• Site of ECG: Respiratory rate (RR)
• Signal Interferance: Electrocauterization
ECG
Reliability

22. SpO2
Reliability
• SpO2 Interferance : Nail polish, etc
: Motion
• Sensor Position: Hand or foot? (PWTT longer)
• Perfusion Index (PI): Adult > 1 %
Pediatric > 0.7 %

23. Perfusion Index (PI)
Adult > 1 %
Pediatric > 0.7 %

24. Perfusion Index (PI)
Reliability
• Perfusion Index (PI): Adult > 1 %
Pediatric > 0.7 %
• Interferance: Cold or Vasoconstriction
NIBP measurement

25. • Patient Setting
• Calibration
PWTT

26. esCO = K × (α × PWTT + β) × HR
α is an experimental constant,
β is calculated based on Pulse-Pressure of IBP or NIBP,
K is calculated based on a given CO value.*
esSV

27. Bedside Monitor

29. Trend Graph esCCO,APCO

30. Trend Graph
PWTTV,NK_PPV,Vigileo_SVV
NK_PPV
Vigileo_SVV
PWTTV

31. Tips and Tricks
Hemodynamic Monitoring
• Trend
• Change after intervention
• Titration

32. Response to increase
cardiac load obtained
by leg elevation
The ability of the
heart to improve its
performance via
Frank-Starling
mechanism
Anesth Analg 2006;103:289 –96

33. SevofluranePropofol
Anesthetic Induced Physiological Change
Length-dependent Regulation of Myocardial Function Anesthesiology 2001;95:357-63
Both technique: Passive leg elevation or Frank-Starring mechanism
are preserved in perioperative period.

34. DesfluranePropofol
Anesthetic Induced Physiological Change
Length-dependent Regulation of Myocardial Function Anesthesiology 2001;95:357-63
Both technique: Passive leg elevation or Frank-Starring mechanism
are preserved in perioperative period.

35. Fluid Challenge
CCO esCCO

36. “Fluid Challenge Test”
PGDT Treatment Protocol

37. UK NHS/
NICE Protocol
(Kuper)
Kuper M, Gold SJ, Callow C, et
al. BMJ. 2011;342:d3016.
Sample
PGDT
Treatment
Protocol

38. Estimated Stroke Volume
esSV
“Fluid Challenge Test”

39. Estimated Stroke Volume
esSV

40. Estimated Stroke Volume
esSV
30
48
56
64
72
80 84

41. Estimated Stroke Volume
esSV

42. Complications from Unguided Hemodynamic Optimisation

43. Bellamy MC. Br J Anaesth. 2006;97:755-757.
Complications
Volume Load
OPTIMAL
Edema
Organ dysfunction
Adverse outcome
Hypoperfusion
Organ dysfunction
Adverse outcome
OverloadedHypovolemic
Optimal Volume Administration
(and the impact of excessive and insufficient administration)

44. Evolution of Fluid Management
The “Conventional” approach
is trying to predict the amount of volume /
fluids needed based upon a the duration and
severity of a particular procedure
Stolting et. al. Basics of Anesthesia, 5th ed. Elsevier - China, p. 349, 200
Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005; 103: 419-28 7
The “Restrictive” fluid approach is
based on minimizing fluids based on Blood
Pressure
“Goal-Directed Therapy” approach considers
optimizing volume / fluids via the Frank Starling Curve and individualizing to
goals

45. Early Goal-directed Therapy
Supplemental oxygen ± endotracheal
intubation and mechanical ventilation
Central venous and
arterial catheterization
CVP
Crystalloid
Colloid
<8 mm Hg
MAP
8-12 mm Hg
Vasoactive agents
<65 mm Hg
>90 mm Hg
ScvO2
≥65 and ≤90 mm Hg
Goals
achieve
d
≥70%
Hospital admission
Yes
No
Sedation and/or
paralysis
(if intubated)
Transfusion of red cells to
hematocrit ≥30%
<70%
Inotropic agents
<70%
≥70%
Rivers et al NEJM 2001;345:1368
Volume
Pressor
Inotrope

46. StaticCardiac filling pressure
Marik P E et al. Chest 2008;134:172-178Osman D. Crit Care Med 2007; 37:64-8
Preload ≠ Fluid Responsiveness
CVP
SVV & PPV
Dynamic

47. SVVStroke Volume Variation
Pulse Pressure VariationPPV
Preload

48. SVV
PPV
10-15%
PVI
15-20%

49. Fluid Challenge
SVV esSVV

51. SVV ≥ 12 % SVV < 12 %
200 ml fluid
challenge over 5
min
Measure and record
Cardiac index (CI)
CI > 2.5 CI ≤ 2.5
Start dopamine
And titration
Until CI > 2.5
GDT group
Measure and record
SVV
Give
vasopressors
No
MAP ≥ 65
mmHg
Yes
A comparison of return of gastrointestinal function between
perioperative goal-directed therapy and traditional fluid
therapy in major abdominal surgery patients
: A prospective randomized
controlled study

52. Control GDT p Value
Age (y) 54 ± 10 58 ± 13 0.402
Body mass index (kg/m2) 21 ± 2 22 ± 3 0.097
ASA Classification 2 ± 0 2 ± 0
Operation time (min) 244 ± 97 282 ± 123 0.519
Total blood loss (ml) 850 ± 1409 900 ± 667 0.930
Fluid replacement
- Crystalloid (ml) 3144 ± 4097 1807 ± 696 0.351
- Colloid (ml) 1163 ± 650 879 ± 488 0.874
- PRC (ml) 765 ± 644 572 ± 357 0.161
- FFP (ml) 912 ± 863 755 ± 228 0.119
- Total (ml) 4135 ± 5636 3080 ± 1266 0.617
Lactate (mmol/L)
- Preoperative 1.34 ± 0.45 1.51 ± 0.68 0.560
- Postoperative 4.74 ± 3.89 3.57 ± 1.37 0.481
Return of bowel function (d) 3.0 ± 1.4 0.8 ± 0.6 0.031*
Length of stay in hospital (d) 14.0 ± 7.7 13.1 ± 6.1 0.799
A comparison of return of gastrointestinal function between perioperative goal-
directed therapy and traditional fluid therapy in major abdominal surgery patients
: A prospective randomized controlled study

53. Control
GDT

62. PVI ≥ 17 % PVI < 17 %
200 ml fluid
challenge over 5
min
Estimated Cardiac index
esCCI
esCCI > 2.5 esCCI ≤ 2.5
Start dopamine
And titration
Until esCCI > 2.5
GDT group
Measure and record
PVI
Give
vasopressors
No
MAP ≥ 65
mmHg
Yes
A comparison of return of gastrointestinal function between
perioperative goal-directed therapy and traditional fluid
therapy in major abdominal surgery patients
: A prospective randomized
controlled study
University Hospital

63. Control
PVI guided GDT

64. Secondary Care Hospital

66. Control (n=50) GDT (n=50) significance
Operation time (hr) 120.74 (±96.09) 115 (±60.27) 0.721
Blood loss (ml) 196.32 (±195.86) 297.20 (±425.50) 0.131
IV type (0.9% NaCl) 50 (100%) 50 (100%) 0.656
IV fluid (ml) 1,256.00 (±1290.61) 1,809 (±1047.43) 0.021*
delta lactate 13.99 (±11.97) 12.95 (±12.13) 0.668
Urine output (ml) 70 (±73.76) 98.62 (±68.87) 0.048*
Return of bowel sound
(hr) 98.66 (±33.37) 67.40 (±22.25) 0.000*
Soft diet (hr) 157.68 (±46.62) 110.18 (±25.61) 0.000*
Length of stay (day) 12.90 (±6.91) 9.68 (±2.88) 0.003*
Cost of treatment
(Baht)
94,518.07
(±75313.11)
54,667.25
(±23358.44) 0.023*
Secondary Care Hospital

67. ●
●●
●
●
●
●
●
●
●
●
●
= [(38 - 17) x 80] / 1.2
= 1400 dyn.s/cm5
SVR = [(MAP-CVP) x 80] / CO

69. Cardiac
Output
Stroke Volume
Contractility
AfterloadPreload
Heart Rate
MacrocirculationMicrocirculation
By optimizing the Cardiac function, Volume, and Vessel tone…we can optimize
the Macrocirculation … then we focus more into the microcirculation

72. = [(1.39 x Hb x SaO2)+(0.003 x PaO2)] x CI x 10
= [(1.39 x 6.2 x 0.97)+(0.003 x 100)] x 2.3 x 10
= 199.1 ml O2/min/m2
DO2I = CaO2 x CI x 10

74. The End
Thank you for
your attention