Conquer the random number generator. Lawrence Weinberg's guide to modern haemodynamic monitoring devices.

1. Haemodynamic
Optimisation
Riding the Wave
Dr Laurence Weinberg
Anaesthetist, Department of Anaesthesia, Austin Hospital
Senior Fellow, Department of Surgery, University of Melbourne

2. Declarations
• Edwards Lifesciences Fluid Advisory Board
• Baxter National Fluid Advisory Board
• Pancare Foundation Scientific Board

3. “We need to understand our
own outcomes before we can
make a difference”
George Bernard Shaw

4. 4 4

5. 5 5

6. “Austin,
You've Got a Problem”
6

7. Haemodynamic truth

9. Diagnostic and Haemodynamic
Monitoring tools
NOT
Therapeutic Interventions

10. “No DEVICE can improve patient-centered
outcomes UNLESS
Treatments save lives
it is coupled to a treatment that
NOT
improves outcome”
Monitors
Modified from M. Pinsky, J.L. Vincent
10

11. BUT WE HAVE TO MAKE A
DECISION

12. 12

13. 13

14. 14

15. 15

16. 16

17. 17

18. 18

19. 19

20. 20
v

21. 21

22. 22

23. 23

24. 24

25. • All patients ERAS; n= 65
Hypothesis
• ?SS-GDT + ERAS vs. ERAS alone
25

26. 26
ERAS only (n=50) SS-DGT + ERAS (n=15) P-value
ASA, Age, Comorbidities NS
Duration Sx (median) 6.5 hours 8.0 hours 0.001
Intra-operative IV fluids (median) 4250 ml 3000 ml NS
Fluid balance Day 1 (median) 1363 ml 1418 ml NS
Fluid balance Day 2 (median) 278 ml 353 ml NS
Fluid balance Day 3 (median) 100 ml 170 ml NS
Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS
Mann-Whitney test

27. 27
ERAS only (n=50) SS-DGT + ERAS (n=15) P-value
ASA, Age, Comorbidities NS
Duration Sx (median) 6.5 hours 8.0 hours 0.001
Intra-operative IV fluids (median) 4250 ml 3000 ml NS
Fluid balance Day 1 (median) 1363 ml 1418 ml NS
Fluid balance Day 2 (median) 278 ml 353 ml NS
Fluid balance Day 3 (median) 100 ml 170 ml NS
Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS
Mann-Whitney test

28. 28
ERAS only (n=50) SS-DGT + ERAS (n=15) P-value
ASA, Age, Comorbidities NS
Duration Sx (median) 6.5 hours 8.0 hours 0.001
Intra-operative IV fluids (median) 4250 ml 3000 ml NS
Fluid balance Day 1 (median) 1363 ml 1418 ml NS
Fluid balance Day 2 (median) 278 ml 353 ml NS
Fluid balance Day 3 (median) 100 ml 170 ml NS
Length of stay (median) 10 days (IQR: 7-14) 10 days (IQR: 9-13) NS
Mann-Whitney test

29. Complications
29
80
70
60
50
40
30
20
10
0
Complics No Complics
GDT + ERAS
ERAS
P = 0.02
95% CI: 1.3 to 16
OR: 4.5
% of
patients

31. How do we use the
information from the
device?

32. Optimize outcomes
“Goal Directed Therapy" setting a haemodynamic goal
and fitting the patient to the goal
“Haemodynamic Optimisation" i.e. looking at
the patient and fitting the goal to the patient
Who is having a specific
operation!!!

33. Purpose AHDM
• Assess circulatory performance
• Determine if CO is consistent with keeping
tissue O2 demand

34. Purpose AHDM
To determine what components of the
haemodynamic profile need to adjusted
to re-establish consumption-demand
balance
Pinsky & Payen. Functional haemodynamic monitoring, 2004; 1-4
Pinsky & Payen, Crit Care 2005; 9: 566

35. Haemodynamic truth
Restoration of MAP may not restore
microcirculation
i.e. Pressure is NOT flow
35

36. Pressure ≠ Flow

37. Haemodynamic truth
There is no normal cardiac output
• Adequate to meet the metabolic demands
• Inadequate to meet metabolic demands
37

38. AHDM: Proven Outcomes
Using a treatment protocol with haemodynamic monitoring
(consistently) leads to improved clinical outcomes.
BUT WHAT PROTOCOL?

39. Two Goal Directed Protocol
Philosophies
SV Max
(Fluid First)
Give fluid, observe response, continue to give
fluid and other therapies until target achieved
Haemodynamic
Stability
(Observe First)
Measure deterioration of clinical condition, titrate
therapy using a variety of parameters
Variations:
• Different “trigger” parameters: SVV, CO/CI, DO2,
SvO2 / ScvO2, CVP (declining)
• Different philosophies on degree of treatment

40. Typical SV-Max Protocol
Monitor SV
250 ml fluid over 10 minutes
SV increase > 10%
Yes SV decrease > 10%
Monitor SV

42. BJA 2005; 5: 634-642

44. Haemodynamic Stability Protocol
Is the patient haemodynamically stable?
Do Nothing Yes No
Is the patient preload-responsive?
Yes No
Is the patient hypotensive and have reduced vasomotor tone?
Yes No Yes No
Volume bolus
Add Vasopressor
Volume bolus Add Vasopressor Add Inotrope
Reassess the patient

45. Haemodynamic Stability Protocol

46. Haemodynamic Stability Protocol

47. Haemodynamic Stability Protocol
MAP
≥65 mmHg
with NOR
And
<90 mmHg
with nitrates
SVV
≤10 >10
CI<2.5 CI≥2.5
Dobu/
Adr3
Or
nitrates
≤2 Fluid
boluses1
SVV ≤ 10 SVV>10
Fluid2
ScvO2>70%
If not
Hgb>10
(Transusion
of RBC)

48. 48
Major surgery

49. Prolonged surgery

50. Preload dependent
optimization concept

51. Increased cardiac function
Normal cardiac function
Decreased cardiac function
How to measure flow
Frank-Starling Curve
Preload
 Stroke Volume
 Cardiac Output
 Cardiac Index
 Mixed Venous %
 Lactate
 TOE
Stroke
Volume
IS THE PUMP
WORKING?

52. Stroke Volume
Increased cardiac function
Normal cardiac function
Decreased cardiac function
Frank-Starling Curve
Preload
IS THE TANK FULL??

53. Frank-Starling Curve
Stroke Volume
Increased cardiac function
Normal cardiac function
Decreased cardiac function
Preload
BOTH DIMENSIONS
ARE NECESSARY
TO OPTIMIZE FLUID
STATUS
1. An indication of fluid
responsiveness
AND
2. A method of verifying
that fluid is beneficial
to the patient’s status

54. 120 mmHg
40 mmHg
PPmax
Arterial Pressure
PPmin
PPmax - PPmin
(PPmax +PPmin) /2
ΔPP =
Am J Respir Crit Care Med 2000; 162:134-138
Threshold PPV > 13 %

55. PPV or SVV
equals
Volume responsive

56. PPV or SVV
equals
Give more fluid

59. Effects of vasoconstrictors on the heart
? Raises left afterload -> decreases SV/CO
? Releases blood from peripheral to central veins ->
increase CVP and CO

60. SV
PreSlVoad
Preload dependent
Phenylephrine
increases preload
and therefore
increases CO

61. Preload independent
SV
PreSlVoad
Phenylephrine
No increase in
stroke volume. No
increase in CO,
increase in
afterload

63. Conclusion
A threshold PPV value of 16.4% allowed
discrimination between phenylephrine-induced
increase in SV and
phenylephrine-induced decrease in SV
(94% sensitivity; 100% specificity).

64. Stroke Volume Variation in Hepatic Resection:
A Replacement for Standard Central Venous Pressure
Ann Surg Oncol. 2013 Oct 23.
Results: 40 patients: CVP of -1 to 1 correlated to a SVV of 18-21
(R2 = 0.85, p < 0.001)
Conclusion: SVV safely as an alternative to CVP monitoring
equivalent outcomes.

65. Surgical & Anaesthesia Goals During Major Liver Resection
Mobilisation & Control of
inflow and outflow
Resection Phase
Surgical
- Blood loss from major hepatic veins or IVC
- Pringle manoeuvre (total inflow occlusion of PV & HA) = decrease of CO
by 20-30% = CVS compromise
- Total hepatic vascular occlusion (tumours close to IVC): occlusion supra
& infrahepatic IVC & hepatic pedicle = up to 60% decrease in CO
Anaesthesia considerations to reduce portal pressures
• Fluid restriction
• Reverse trendelenberg
• Venodilatation
• Venesection
• Autologous normovolaemic haemodilution
• Diuretics
• Low CVP
• Monitoring of CO or SvO2 to optimise oxygen delivery
65

66. FLUID Challenge 250 mL
SV Increases > 10%
Dissection &
Liver Resection
- Fluid restriction
- Reverse trendelenberg
- Venodilatation to reduce hepatic pressure
- Venesection & autologous haemodilution
- Low PEEP
- Low dose vasopressor
Low Normal/High
Do nothing
MAP
Cardiac Index
Inodilator
<20% Baseline
High/Normal High/Normal
Vasoconstrictor
B-Blocker /
antihypertensive/
diuretic
Cardiac Index
Inotrope
Within 20%
baseline
> 20% baseline
Decrease /stop vasoconstrictor
Adequate anaesthesia?
Adequate analgesia?
Adequate muscle relaxation?
Cardiac Index
Low
Low
Inodilator/
Vasodilator
Yes
Assess volume
responsiveness
Re-assess Volume Responsiveness
Optimal oxygen delivery?
Heart rate optimized?
Adequate oxygenation?
Correct severe anaemia?
Correct hypothermia?
< 25% > 25%

67. 67

69. Surgical & Anaesthesia Goals During Major Liver Resection
Confirmation of haemostasis &
closure
Surgical
- Argon Beam to hepatic veins
- Coagulation & fibrin glues
- Haemostasis/control of bleeding
Anaesthesia considerations -
restoration of circulating blood
volume
• Return of autologous blood
• Normalise CVP/SVV
• Avoid hypervolaemia
• Monitoring of CO or SvO2 to
optimise oxygen delivery
69

73. FLUID Challenge 250 mL
SV Increases > 10%
Low Normal/High
Do nothing
MAP
Cardiac Index
Inodilator
<20% Baseline
High/Normal High/Normal
Vasoconstrictor
Optimal oxygen delivery?
Heart rate optimized?
Adequate oxygenation?
Correct severe anaemia?
Correct hypothermia?
B-Blocker /
antihypertensive/di
uretic
Cardiac Index
Inotrope
Within 20%
baseline
> 20% baseline Decrease /stop vasoconstrictor
Adequate anaesthesia?
Adequate analgesia?
Adequate muscle relaxation?
Cardiac Index
Low
Low
Inodilator/
Vasodilator
< 20% > 20%
Yes
Major pancreatic
surgery
Assess volume
responsiveness
Re-assess Volume Responsiveness

74. 74
• All patients ERAS; n= 129
Hypothesis
• SS-GDT + ERAS vs. ERAS alone

75. 75
ERAS only (n=25) SS-GDT + ERAS (n=104) P-value
Resection volumes 375 g 450 g NS
Duration Sx (median) 4.3 hours 6.0 hours 0.0001
Intra-operative IV fluids (median) 3000 ml (1375-4000) 3000 ml (2000-3738) NS
Fluid balance Day 1 (median) 3000 ml (2200-4000) 3054 ml ( 2050-4133) NS
Length of stay (median) 6.6 days (IQR: 5.5-9) 7 days (IQR: 5.7-11) NS

76. 76
ERAS only (n=25) SS-DGT + ERAS (n=104) P-value
Resection volumes 450 g 375 g 0.24
Duration Sx (median) 4.3 hours 6.0 hours 0.0001
Intra-operative IV fluids (median) 3000 ml (1375-4000) 3000 ml (2000-3738) NS
Fluid balance Day 1 (median) 3000 ml (2200-4000) 3054 ml ( 2050-4133) NS
Length of stay (median) 7 days (IQR: 5.7-11) 6.6 days (IQR: 5.5-9) NS

77. Complications
77
80
70
60
50
40
30
20
10
0
Complics No Complics
GDT + ERAS
ERAS
P = 0.47
95% CI: 0.2 to 1.7
OR: 0.6
% of
patients

78. 78

79. 79

80. 80
40
35
30
25
20
15
10
5
0
Stroke Volume Variation (%) - all patients
Time (standardised)

81. 81

82. 82
“The proposed algorithm
of DGT induced some
patients the additional
application of inotropes”
Safety needs to be
clarified?

83. • 22 RCT’s reporting CVS complications
• 2129 patients
• DGT: reduction in CVS complications
• Subgroup analysis (supra-normal DO2 : most
benefit from GDT
83

84. 84
“GDT better than liberal fluid therapy, but
whether GDT is superior to a restrictive fluid
strategy remains uncertain”

85. 85

86. 86

87. 87

88. Concluding thoughts
• Consensus: advanced haemodynamic monitoring is better than not
monitoring
• AHDM: diagnostic and haemodynamic monitoring tools: NOT
therapeutic interventions
• Consensus: goals are needed!
• Approaching consensus that protocols (reproducible care practices)
are better than no protocols, but still some dissenting opinions.
• Individualize treatment for certain operations

89. Thank you