Goal Directed Therapy reduces postoperative complications and improves outcome

Fluid optimizationFigure 1 

 

rational of fluid management

Figure 2

 Goal Directed Therapy (GDT) is a term used to describe the use of cardiac output (CO) or similar parameters to perioperatively guide intravenous fluid and inotropic therapy [1].

 

In critical and anesthesiological care, the goal of hemodynamic monitoring is to guide fluid therapy by means of dynamic markers in order to optimize the balance between tissue oxygen supply and demand. Keeping the patient's fluid status in balance between hypo- and hypervolemia (Figure 1) is the most effective way to combat global tissue hypoxia, shock and multi organ failure [2].

 

Monitoring and minimizing PPV by volume loading as well as perioperative increase in oxygen delivery in high risk surgical patients not only improves survival, but also provides an actual and relative cost savings. This may have important implications for the management of these patients and the funding of intensive care[1]. It is suggested that even in medium risk surgery and intermediate care an optimization of fluid management improves medical outcome [3, 4].

 

With the availability of CNAP®-PPV and noninvasive cardiac output with CNAP® HD derived from the CNAP® blood pressure signal using pulsewave analysis it is now possible to tailor fluid requirements more precisely to the needs of the individual patient as the effectiveness of a fluid therapy can now easily be tracked by the highly precise CO trending.

The rationale behind hemodynamic optimization is simple and clear (Figure 2): Goal directed fluid management improves medical outcome and reduces costs at the same time.

 

 

Dynamic Fluid Markers and Cardiac Output

Dynamic variables such as Pulse Pressure Variation (PPV) and/or Stroke Volume Variation (SVV) are predictors of fluid responsiveness in patients under general anesthesia and mechanical ventilation [5, 6, 7, 8]. PPV/SVV indicate if patients appropriately respond to the administration of fluid with an increase in cardiac output, or, if they need to be treated with vasopressive medication, inotropic agents or reduction of depth of anesthesia as a response to a drop in blood pressure. See the simple therapeutic algorithm.

 

According to the British consensus guidelines, patients should receive intravenous fluid to achieve an optimum of stroke volume as this reduces post operative complication rates and duration of hospital stay [1, 3, 9, 10]. See protocols for goal directed therapy

 

  

See also:

 


 

References:

[1] Maxime Cannnesson. (Department of Anesthesiology, University of California, Irvine). Goal Directed Therapy. Conmed Corporation, (Summary of Literature). [http://www.conmed.com/Patient%20Care%20PDF/GDT_Final.pdf]

[2] Bellamy. Wet, dry or something else?. British journal of anaesthesia (2006) vol. 97 (6) pp. 755-7

[3] Hamilton et al. A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients. Anesthesia and analgesia (2010) pp.

[4] Maguire et al. Technical communication: respiratory variation in pulse pressure and plethysmographic waveforms: intraoperative applicability in a North American academic center. Anesthesia and analgesia (2011) vol. 112 (1) pp. 94-6

[5] Marik et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med (2009) vol. 37 (9) pp. 2642-7

[6] Solus-Biguenet et al. Non-invasive prediction of fluid responsiveness during major hepatic surgery. British journal of anaesthesia (2006) vol. 97 (6) pp. 808-16

[7] Cannesson et al.: Assessing the diagnostic accuracy of pulse pressure variation for the prediction of fluid responsiveness: a "grey zone approach". Anesthesiology 2011 Aug 115 (2) 231-41

[8] Michard et al. Clinical use of respiratory changes in arterial pulse pressure to monitor the hemodynamic effects of PEEP. Am J Respir Crit Care Med (1999) vol. 159 (3) pp. 935-9

[9] Powell-Tuck et al. British consensus guidelines on intravenous fluid therapy for adult surgical patients - GIFTASUP.

[10] Cannesson & Mahajan: 2nd Goal Directed Symposium 2012. Hemodynamic optimization in perioperative and critical care medicine: From therapy to practice.