perioptimization of high risk surgical patient
TRANSCRIPT
PERIOPERATIVE OPTIMIZATION
OF THEHIGH-RISK SURGICAL
PATIENT
IntroductionPeri Operative Risk of death in genral surgery is < 1%Not widly practised b/c
Lack of knowledge in applying current available toolsLack of experience with the practicalities of peri
optimization
This article increase our awareness of How & When to utilize monitoring equipment to achieve optimal result.
Introduction cont…
Perioperative risk of death after general
surgery is less than 1% but some time upto
33%
Clinical acumen and Observation allow us to
predict the high risk cases
Normal physiology during surgery
During Surgery increase metabolic demand
Increase CO
Increase oxygen delivery
Oxygen Debt But Sometime could not increase Oxygen
delivery adequately
OXYGEN DEBT
Magnitude and length of O2 Debt associated
with increase incidence of complication
oxygen debt cont…
• Should be paid back
within 8 Hr Never paid
Complication Cell Dysfunction / Death
Physiological parameter for optimization
Cardiac index ( CI) > 4.5 litre/min /m2
oxygen delivery (DO2I) > 600 ml /min /m2
oxygen consumption(VO2 I) > 170 ml /min/ m2
Suboptimal value of CI,DO2,VO2
Tissue hypoxia
Uneven Vascular constriction
Uneven microcirculatory blood flow
to vascular bed
Mythen and Webb, showed;
60% patient have gut hypoperfusion
triggering of the systemic inflammatory response
Organ Failure
dfdfdf
Morbidity & Death
Identifying the patient who will benefit
Many scoring systems can quantify the risk
Goldman and colleagues cardiac risk index high
risk of mortality in patients with cardiac disease
ASA score is widely accepted as part of
preoperative assessment
Patients:- high risk
Current /previous severe, cardio-respiratory ds
Acute abdominal catastrophe with
haemodynamic instability
Acute renal failure
Severe multiple trauma
Cont…..Evidence of limited physiological reserve in one
/more vital organs in elderly patients more
than 70 yr
Shock
Acute respiratory failure
Septic shock
Surgery: the high-risk
Colorectal, vascular,a intra-abdominal surgery
Trauma surgery involving more than two body cavities or intraperitoneal soiling with bowel contents
Prolonged surgery (>11/2 h)
Emergency surgery
Physiological principles of optimization
Cardiac index ( CI) > 4.5 litre/min /m2
oxygen delivery (DO2I) > 600 ml /min /m2
oxygen consumption(VO2 I) > 170 ml /min/ m2
This last one can’t be altered So not a goal for therapy
CI & DO2 depends on
Cardiac output(HR x Stroke vol.) Cardiac index =
Body surface area
DO2 = CI x (Oxygen content of arterial blood)
= CI x (1.34 x Hb x arterial saturation SaO2)
Optimum O2 delivery obtained by
Manipulation of-
By using---Heart Rate Inotropes
Stroke Vol. FluidHb Blood transfusionO2 Saturation Oxygen
How to perform optimization
Cardiovascular monitors that may be used for goal-directed therapy
---Pulmonary artery catheter
NICO ---Oesophageal Doppler monitor
---Lithium dilution CO (LiDCOplus
---Pulse contour CO (PiCCO)
---Bioelectrical impedance
cardiography and cardiac USG
Pulmonary artery catheter
Recently Use DecreaseParameter obtained is
-- CVP
--Cardiac output
--Cardiac index --SvO2
--DO2 Still It is gold Standard For CV Monitoring
Perioptimization using PAC CI
DO2I> 4.5 litre/min /m2 < 4.5 litre/min /m2
> 600 ml /min /m2 < 600 ml /min /m2
No Further goal-
directed therapy
Cont.. On next page
<4.5,<600…. Cont…
Increase IV Fluid therapy to Pulm. Artery
occlusion pressure of 12-16 mm of Hg
Maintain Hb 8-10 Gm/dL If Decrease BT
Saturation 95% If Saturation Fall O2
Still < 600 ml/mi/m2 Inotrope/inodilator
eg.DOPEXAMINE
Maintain This goal directed therapy
In immediate post operative periodUntill base deficit and lactate level return to
normal
AIM
Mixed Venous saturation is above 70%
Other Cardiovascular monitor1.Oesophageal Doppler monitor:-
Measure Flow velocity In Descinding thoracic
aorta
Can produce estimate of Stroke vol.,CO;
FTc Systolic flow time index of preload
(Normal range 330-360 ms)
FTcFTc < 350 ms Suggest hypovolimia 3ml/kg
in 5-10 min
After Fluid Thrapy of Same patient
Fuid therapy
Stroke Vol.=/ Stroke vol. By 10%
& FTc < 350 ms & FTc > 350 ms
Repeat 3 ml /kg Repeat Untill No
in 5-10 min increase in SV
FTc > 400 ms
No fluid till FTc/SV Decrease by 10%
Cont…
2.Lithium dilution CO (LiDCOplus):-
- Lithium injected iv(C/P)
- Lithium sensor attached to standard arterial line
gives contineous data
-- CO
-- Stroke vol.
-- Stroke Vol. variation
-- Pulse Pressure variability
-- Contineous D O2I
CI Lithium dilution CO Monitor
First trimester pregnancy
Lithium therapy
More suited for post operative period
3. Pulse contour CO (PiCCO):-
Use
-Pulse counter waveform
-Thermodilution technique
large Atery Thermo dilution catheter
(Femoral Brachial Axilarry)
PiCCO Gives,
---- Beat To Beat SV
---- Contineous CO
----SVV
Show ----Global End Diastolic Vol.
Cardiac ---- Intra Thoracic Blood vol.
Preload
---- Extra Vascular lung water
Perioptimization Practical approach
Same Starting Point Fluid loading
Same End Point Adequate O2 Delivery
Post operative Ward Nurses Start
Intra operative Anaesthetist goal directed therapy
Pre optimization Not possible then Intra and post Operative optimization
Post Operative start within 1st post op hr
CONCLUSION
IT IS THE FLUID NOT THE MONITOR MAKE THE DIFFERENCE Partialy correct
NOT ONLY FLUID BUTFLOW IS IMPORTANT