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  • Benoit Benoit ValletVallet

    PlePle ddAnesthAnesthsiesie RRanimationanimationHpitalHpital HuriezHuriez

    CHRU de Lille CHRU de Lille -- [email protected]@chru--lille.frlille.fr

    Lille 25 mars 2010

    La Goal-Directed

    Therapy

    prvient-ellede linsuffisance rnale postopratoire ?

  • Conflit dIntrt Consultant pour Edwards Lifesciences

  • Dfinir linsuffisance rnale ?

  • RIFLE criteria for Acute Kidney Injury (AKI) Bellomo et al Crit Care 2004;8:R20412

    ESRD End-stage renal disease

    GFR >25% orcreatinine 1.5

    or creatinine

    >

    15 mg/L

    UO < 0.5 mL/kg/h6 h

    UO < 0.5 mL/kg/h12 h

    GFR >50% or

    creatinine 2or creatinine

    >

    20 mg/L

    Persistent ARF = complete loss of renal function > 4 weeks

    UO < 0.3mL/kg/h24 h or anuria 12 h

    GFR >75% or

    creatinine 3 orcreatinine

    >

    40 mg/Lor acute

    > 5 mg/L Olig

    uria

    Risk

    Injury

    Failure

    Loss

    Highsensitivity

    Highspecificity

    Creatinine

    criteria Urine output criteria

    Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group

    Normal creatinineMan: 7-13.5 mg/LWoman: 5-12 mg/L

  • Vs RIFLE criteria, the AKIN criteria do not materially improve the sensitivity, robustnessor predictive ability of the definition and classification of AKI in the first 24 h after ICU admission

  • Development and Validation of an AKI Risk Index for Patients Undergoing General Surgery

    Results from a national data set Kheterpal S et al. Anesthesiology 2009;110:505-15

    Outcome data from general surgery procedures performed in 121 US medical centers (2005-2006)

    152,244 operations reviewed;75,952 met the inclusion criteria; and 762 (1.0%) were complicated by AKI

    (increase in serum creatinine

    >20 mg/L

    or ARF necessitating dialysis)

    The primary outcome was AKI within 30 days 30-day mortality among patients with and without AKI was compared

    11 independent preoperative predictors: >56 yr - male emergency surgery - intraperitoneal surgery, diabetes - active congestive heart failure ascites - hypertension mild or moderate preoperative renal insufficiency

    Patients with six or more risk factors had a 9% incidence of AKI Patients experiencing AKI had an 8x increase in 30-day mortality

  • GlomerularGlomerular filtration rate (GFR) is affected byfiltration rate (GFR) is affected byhydrostatic and osmotic pressurehydrostatic and osmotic pressure

  • Solut de remplissage et risque rnal ?

  • Type de Solut de Remplissage et Risque Rnal Schortgen F, Girou E, Deye N, Brochard L; CRYCO Study Group

    Intensive Care Med 2008;34:2157-68

  • InflammationInflammation

  • Endothelium InjuryEndothelium Injury Kidney FunctionKidney Function

  • Quest-ce que la Goal-Directed Therapy (GDT) ?

  • En simplifiant

    lextrme

    : la GDT applique le principe de Frank et Starling

  • RemplissageRemplissage

    Volumedjectionsystolique

    (VES)

    Prcharge

    ventriculaire

    En simplifiant

    lextrme : la GDT applique le principe de Frank et Starling

    RRserveserve

    de de prprchargecharge= = rrpondeurpondeur

    Pas de Pas de rrserveserve

    de de prprchargecharge= = non non rrpondeurpondeur

    RemplissageRemplissage

  • PreloadPreload

    SVSV

    Reserve of Reserve of preload = fluid preload = fluid responsiveresponsive

    Non fluid responsiveNon fluid responsive

    GoalGoal--Directed Therapy : Detecting patients who will be able to turn fDirected Therapy : Detecting patients who will be able to turn fluid luid loading into a significant increase in SV (loading into a significant increase in SV (Fluid responsiveFluid responsive) )

    Oesophageal Doppler Guided Fluid Management

  • De nombreuses tudes ont dmontr que la maximalisation du VES amliorait le pronostic des patients

    Mythen et al. Arch Surg 1995Sinclair et al. BMJ 1997Venn et al. Br J Anaesth 2002Gan et al. Anesthesiology 2002Conway et al. Anaesthesia 2002Wakeling HG et al. Br J Anaesth 2005Noblett SE et al. Br J Surg 2006

    DURING HIGH-RISK SURGERY

  • De nombreuses tudes ont dmontr que la maximalisation du VES amliorait le pronostic des patients

    Mythen et al. Arch Surg 1995Sinclair et al. BMJ 1997Venn et al. Br J Anaesth 2002Gan et al. Anesthesiology 2002Conway et al. Anaesthesia 2002Wakeling HG et al. Br J Anaesth 2005Noblett SE et al. Br J Surg 2006

    DURING HIGH-RISK SURGERY

  • 100 pts ASA 1-3 Major elective surgery + anticipated blood loss >500mL Volume expansion Doppler-guided vs control Continuous crystalloid infusion 5mL/kg/h

    Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery

    Gan TJ et al. Anesthesiology 2002;97:820-6

  • Acute renal dysfunction

    4% vs 8%

    Hospital stay:

    5 +

    3 vs 7 +

    3 days

    Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery

    Gan TJ et al. Anesthesiology 2002;97:820-6

    100 pts ASA 1-3 Major elective surgery + anticipated blood loss >500mL Volume expansion Doppler-guided vs control Continuous crystalloid infusion 5mL/kg/h

  • Acute renal dysfunction

    4% vs 8%

    Hospital stay:

    5 +

    3 vs 7 +

    3 days

    Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery

    Gan TJ et al. Anesthesiology 2002;97:820-6

    100 pts ASA 1-3 Major elective surgery + anticipated blood loss >500mL Volume expansion Doppler-guided vs control Continuous crystalloid infusion 5mL/kg/h

  • Intraoperative

    Oesophageal

    Doppler Guided Fluid ManagementShortens Postoperative Hospital Stay after

    Major Bowel SurgeryWakeling et al. Brit J Anaest 2005;95:634-42

    GDT-Doppler patients:- Larger volume of iv colloids than controls (median 2000 vs 1500 mL, P

  • En simplifiant

    lextrme : la GDT applique le principe de Frank et Starling

  • En simplifiant

    lextrme : la GDT applique le principe de Frank et Starling

    Est-ce suffisant ?

  • InterventionFluidRBC

    dobutamineto maintainO2 ER < 27%(

    ScvO2

    > 73% since ScvO2

    1 -

    EO2

    ) during surgery and the post-operative period (24h)

    135 patientsElective major abdominalsurgery or abdominalaortic surgery(ASAIII; n = 94)

    NormalNormal>73 %>73 %

    LowLow95%)((increased Oincreased O22

    ERER))

    SaOSaO22LowLow

    (hypoxemia)(hypoxemia)

    FluidFluidchallenge,challenge,

    RBCRBC

    CVPCVP

    HypovolemiaHypovolemiaMyocardialMyocardialdysfunctiondysfunction

    DobutamineDobutamine

    CVP10 mmHg

    Goal-Directed Intraoperative

    Therapy Reduces Morbidityand Length of Hospital Stay in High-Risk Surgical Patients

    Donati et al. Chest 2007;132:181724

  • 44.1%2.6+4.0g/kg/min

    4.5%0.4+2.2g/kg/min

    Goal-Directed Intraoperative

    Therapy Reduces Morbidityand Length of Hospital Stay in High-Risk Surgical Patients

    Donati et al. Chest 2007;132:181724

  • Goal-Directed Intraoperative

    Therapy Reduces Morbidityand Length of Hospital Stay in High-Risk Surgical Patients

    Donati et al. Chest 2007;132:181724

  • En simplifiant

    lextrme : la GDT applique le principe de Frank et Starling

  • En simplifiant

    lextrme : la GDT applique le principe de Frank et Starling

    La GDT pourrait tre avantageusement complmentepar un paramtre

    global

    dutilisation de lO2

    chez les patients les plus

    risque

  • En simplifiant

    lextrme : la GDT applique le principe de Frank et Starling

    La GDT pourrait tre avantageusement complmentepar un paramtre

    global

    dutilisation de lO2

    chez les patients les plus

    risque

    Quelles sont les preuves ?

  • Perioperative hemodynamic optimization or goal-directed therapy refers to the perioperative monitoring and manipulation of physiologic hemodynamic parameters by means of fluids, red blood cells, and inotropic drugs

    With the aim to reach values of cardiac output and oxygen delivery to face the increase in oxygen demand and to prevent organ failure

  • 20 studies4,220 patients

    13 as high quality studies

    9 enrolled high-risk patients

    Sensitivity analysis combining:- Grade R of RIFLE classification- Stage 1 of AKIN classification- SCr>20 mg/L, increase>50%or by 5 mg/L or need of RRT,disregarding urine output

  • 5.4% 8.3%

  • 6.1% 9.2%

  • 7.3% 11.2%

  • Un effet de la GDT sur dautres organes ?

  • 16 randomized controlled trials (3410 participants)

    GI complications

    were ranked as major

    (required radiological or surgical intervention or life-threatening condition) or minor

    (no or

    only pharmacological treatment required)

    Major GI complications were significantly reduced by GDT when compared with a control group (OR, 0.42; 95% CI, 0.27-0.65)

    Minor GI complications were also significantly decreased in the GDT group (OR, 0.29; 95% CI, 0.17-0.50)

    Treatment did not reduce hepatic injury rate (OR, 0.54; 95% CI, 0.19-1.55)

    Goal-Directed Haemodynamic Therapy and Gastrointestinal Complications in Major Surgery: A Meta-Analysis of Randomized Controlled Trials

    Giglio MT, Marucci M, Testini M, Brienza N Br J Anaesth. 2009 Nov;103(5):637-46

  • Quels outils au quotidien ?

  • Intellivue, Philips

    Flotrac/Vigileo, Edwards

    PiCCO plus, Pulsion

    S/5, GE

    Monitorage Automatis

    et Invasif (KT artriel) de la Rponse au Remplissage

  • Plateau

    PFaible PPV

    Portio

    n acs

    enda

    nte

    Prcharge

    (P)

    VES

    P =

    modifications cycliques de prchargeinduites par la ventilation mcanique

    Large PPV20.5%

    4.5%

    REMPLISSAGEREMPLISSAGE

    PPPPmaxmax

    --

    PPPPminmin

    ((PPPPmaxmax

    ++

    PPPPminmin

    ) /2) /2PPV =PPV =

  • Critical Care 2006Critical Care 2006Control Intervention

  • Critical Care 2006Critical Care 2006

    http://ccforum.com/content/11/5/R100/figure/F4?highres=y

  • PVI/SpO2 , Masimo

    Finometer, Finapres

    CNAP, CNS

    Monitorage Automatis

    et Non Invasif de la Rponse au Remplissage ?

  • 54 fluid challengesmajor hepatic surgery

    PPVartPPVart

    12.512.5

    PPVfinaPPVfina

    1414

  • Adapted

    from

    Cannesson

    M. et al. Br

    J Anesth

    2008;101:200-6

    A PVI >14% before

    volume expansion discriminatedbetween

    responders

    and non-responderswith

    81% sensitivity

    and 100% specificity

  • Non-invasive Prediction of Fluid Responsiveness

  • PAni

    PAi

    Pairway

    Monnet X, Dres M, Ferr A, Bleibtreu A, Richard C, Teboul JLESICM 2009 poster # 0293

    Respiratory variation and invasive estimation of arterial pressure

  • Pulse pressure variation and stroke volume variation: from

    flying

    blind

    to flying

    right?Cannesson M, Vallet B, Michard F. Br J Anaesth 2009;103:896-7

  • La Goal-Directed Therapy (GDT) prvient-elle de linsuffisance rnale postopratoire ?

    Oui (vraisemblablement) quand la GDT: Est dbute en pr ou per-opratoire Est ralise chez les patients risque:

    Sujet g et/ou avec comorbidits (diabte, HTA, cardiopathie) Chirurgie durgence ou intrapritonale Prsentant une instabilit hmodynamique propratoire

    Est ralise par le remplissage et lutilisation dinotropes Le choix du type de solut de remplissage doit faire lobjet

    dtudes complmentaires Dans la mtaanalyse de Brienza et al. (CCM 2009), la mortalit

    est rduite par la GDT (OR 0.50; CI 0.310.80; p = 0.004), quoique lhtrognit statistique soit importante

    Il apparat raisonable didentifier en per-opratoire les patients (selon la chirurgie envisage) qui doivent bnficier de la GDT pour choisir le monitorage le plus adapt la conduite du traitement

    Diapositive numro 1Conflit dIntrtDiapositive numro 3RIFLE criteria for Acute Kidney Injury (AKI)Bellomo et al Crit Care 2004;8:R20412Diapositive numro 5Development and Validation of an AKI Risk Indexfor Patients Undergoing General SurgeryResults from a national data set Kheterpal S et al. Anesthesiology 2009;110:505-15Diapositive numro 7Diapositive numro 8Type de Solut de Remplissage et Risque RnalSchortgen F, Girou E, Deye N, Brochard L; CRYCO Study GroupIntensive Care Med 2008;34:2157-68 Diapositive numro 10Diapositive numro 11Diapositive numro 12Diapositive numro 13Diapositive numro 14Diapositive numro 15Diapositive numro 16Diapositive numro 17Diapositive numro 18Diapositive numro 19Diapositive numro 20Diapositive numro 21Diapositive numro 22Diapositive numro 23Diapositive numro 24Diapositive numro 25Diapositive numro 26Diapositive numro 27Diapositive numro 28Diapositive numro 29Diapositive numro 30Diapositive numro 31Diapositive numro 32Diapositive numro 33Diapositive numro 34Diapositive numro 35Diapositive numro 36Goal-Directed Haemodynamic Therapy and Gastrointestinal Complications in Major Surgery: A Meta-Analysis of Randomized Controlled TrialsGiglio MT, Marucci M, Testini M, Brienza NBr J Anaesth. 2009 Nov;103(5):637-46Diapositive numro 38Monitorage Automatis et Invasif(KT artriel) de la Rponse au Remplissage Diapositive numro 40Diapositive numro 41Diapositive numro 42Diapositive numro 43Diapositive numro 44Diapositive numro 45Diapositive numro 46Diapositive numro 47Monitorage Automatis et Non Invasif de la Rponse au Remplissage ? Diapositive numro 49Diapositive numro 50Diapositive numro 51Diapositive numro 52Diapositive numro 53La Goal-Directed Therapy (GDT) prvient-ellede linsuffisance rnale postopratoire ?