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Pôle d’Anesthésie Réanimation
Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?
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Le Remplissage est plus Compliqué qu’il n’y Parait !
Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?
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Risque de Morbidité
Post-OpératoireEXCES
DEFICIT
Précharge
VOLUME ADDITIONNEL
Le Remplissage est plus Compliqué qu’il n’y Parait !
Ischémie
Hypoxémie
ERO
Oedème
Hypoxémie/hyperoxie
ROS
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Précharge
Volume d’Ejection Systolique (VES)
VOLUME ADDITIONNEL
NON REPONDEUR
REPONDEUR
Le Remplissage est plus Compliqué qu’il n’y Parait !
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VOLUME ADDITIONNEL
EXCES
DEFICIT
Précharge
Volume d’Ejection Systolique
Le Remplissage est plus Compliqué qu’il n’y Parait !
« Maximaliser »
le VES…
Augmenter
l’œdème…
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Pulmonary edema and LIS were not affected by the type of fluid loading in the
steep part of the cardiac function curve in both septic and nonseptic patients
About 300 mL more crystalloid than colloid fluids were administered
Crystalloid or Colloid Fluid Loading and Pulmonary Permeability, Edema, and
Injury in Septic and NonSeptic Critically Ill Patients with Hypovolemia
Van der Heijden M et al. Crit Care Med 2009; 37:1275–1281
PLI: pulmonary
leak index
COP: Colloid
osmotic pressure
LIS: lung
injury score
Crystalloid Colloid
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7.43
3.39
15.59
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1.539 patients treated in the UK
POSSUM physiology scores ranged from 12 to 52
POSSUM operative severity scores ranged from 6 to 37
The cohort had a mean (s.d.) (median, interquartile range) operative
severity score of 16·5 (6·2) (16, 11–20)
Overall, the mean (s.d.) (median, interquartile range) postoperative length
of stay in hospital was 11·8 (11·6) (9, 5–14) days
Observed death rate was 9.9%
POSSUM Mortality Rates after Surgery
Bennett-Guerrero et al. Br J Surg 2003; 90:1593–8
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Mortality 1.7% 3.3% NS
37 3817 17
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Length of stay (dys) 9 (8-12) 10(8-19) 0.0421
I
37 3817 17
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• All eligible patients within 7 days ; 28 European countries ; >35.000 patients
recruited ; October-December 2011 : dissemination of findings
• Research questions
– 1. What is the in-hospital mortality rate for patients undergoing non-cardiac surgery?
– 2. What is the duration of hospital stay?
– 3. What is the current standard of peri-operative critical care provision?
– 4. What is the current standard of haemodynamic (cardiac output) monitoring?
– 5. Is there any evidence of differences in the standard of peri-operative care provision?
– 6. Is there any evidence of differences in hospital stay and mortality?
– 7. What factors determine planned and unplanned admission to critical care after
surgery?
– 8. Are the factors associated with critical care admission similar to those associated with
post-operative death?
EuSOS:
European Surgical Outcomes StudyPearse RM, Rhodes A, Moreno R, Pelosi P, Spies C, Vallet B, Metnitz P, Bauer P, Vincent JL
Eur J Anaesthesiol 2011;28:454-6
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• All eligible patients within 7 days ; 28 European countries ; >35.000 patients
recruited ; October-December 2011 : dissemination of findings
• Research questions
– 1. What is the in-hospital mortality rate for patients undergoing non-cardiac surgery?
– 2. What is the duration of hospital stay?
– 3. What is the current standard of peri-operative critical care provision?
– 4. What is the current standard of haemodynamic (cardiac output) monitoring?
– 5. Is there any evidence of differences in the standard of peri-operative care provision?
– 6. Is there any evidence of differences in hospital stay and mortality?
– 7. What factors determine planned and unplanned admission to critical care after
surgery?
– 8. Are the factors associated with critical care admission similar to those associated with
post-operative death?
EuSOS:
European Surgical Outcomes StudyPearse RM, Rhodes A, Moreno R, Pelosi P, Spies C, Vallet B, Metnitz P, Bauer P, Vincent JL
Eur J Anaesthesiol 2011;28:454-6
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46539 pts, 1855 died (4.0%)
3585 pts (7.7%) admitted to Critical Care [length
of stay of 1.2 days (0.9-3.6)]
73% of patients who died were not admitted to
Critical Care at any stage after surgery
The following factors were found to be
independently related to hospital death: age,
ASA score, country, surgical procedure, urgency
of surgery, grade of surgery, metastatic disease,
cirrhosis
Both crude hospital mortality rates
and adjusted odds ratios varied widely between countries (OR 0.45 [95% CI 0.14-1.4] to 10.9 [7.5-
15.8]) as did critical care admission rates (0 -
16.1%)
EuSOS:
European Surgical Outcomes StudyPearse RM, Moreno R, Bauer P, Pelosi P, Metnitz P, Spies C, Vallet B,
Vincent JL, Hoeft A, Rhodes A. Lancet 2012; under review
3.2 (2.5 - 3.9)
2.0 (1.1 - 2.8)
6.8 (5.4 - 8.2)
3.6 (3.2 - 3.9)
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J A
m C
oll S
urg
2008
;207
:935
-41
Am
ou
nt
of
IV c
ollo
id f
luid
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• There is little evidence to support preferential use of any particular type of fluid during esophageal Doppler guided optimization
• Many of these fluids have not been evaluated in patient populations in whom optimization is being applied or proposed, and the potential for harm cannot be excluded
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2008;207:935-41Peri -operative Fluid Optimization with the ODM
Esophageal Doppler Monitoring vs Control
Length of Stay
Sub-Category Colorectal
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• 29 Studies
• 3 Major exclusions –
Drug studies
• 3 zero mortality
studies
OR 0.48 [0.33-0.7]
p=0.0002
Mortality
5.9% 9.4%
Preemptive Haemodynamic Intervention to Improve Outcome in
Moderate & High Risk SurgeryA Systematic Review & Meta-analysis by Hamilton/Cecconi/Rhodes
Anesth Analg 2011;112:1392-402
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OR 0.44 [0.35-0.55]
p<0.00001
• 23 Studies
• 3 Major exclusions –
Drug studies
• 3 zero mortality
studies
Complications
18.0% 29.8%
Preemptive Haemodynamic Intervention to Improve Outcome in
Moderate & High Risk SurgeryA Systematic Review & Meta-analysis by Hamilton/Cecconi/Rhodes
Anesth Analg 2011;112:1392-402
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Il Existe des Recommandations !
Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?
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• 13. In patients undergoing some forms of orthopaedic and abdominal surgery, intra-operative treatment with intravenous fluid to achieve an optimal value of SVshould be used where possible as this may reduce postoperative complication rates and duration of hospital stay
– Orthopaedic surgery: Evidence level 1b
– Abdominal surgery: Evidence level 1a
• 4. In « High Risk Surgical Patients, it is recommended to titrate intraoperative fluid loading by guiding the SV in order to reduce postoperative morbidity, hospital length of stay, and in patients benefiting from digestive surgery, the digestive function recovery (strong agreement)
The NICE and French Society Recommendations
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Preload
SV
Fluid responsive
SV Guided Fluid Management
Assessment of preload reserve : Detecting patients who will be able to turn fluid loading into a significant increase in SV (“Fluid responsiveness”)
Œsophageal Doppler Guided Therapy
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Preload
SV
Fluid NON responsive
Fluid responsive
SV Guided Fluid Management
Assessment of preload reserve : Detecting patients who will be able to turn fluid loading into a significant increase in SV (“Fluid responsiveness”)
Œsophageal Doppler Guided Therapy
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Preload
SV
Fluid NON responsive
Fluid responsive
SV Guided Fluid Management
Stroke Volume Guided Fluid Therapy
© NICE 2012
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Preload
SV
SV Guided Fluid Management
1er bolus
<10% augmentation VES
>10% augmentation VES
Arrêt remplissage
Nouveau bolus
Baisse du VES > 10%
RFE Sfar-AdarpefStratégie du remplissage vasculaire péri-
opératoire
Goal-Directed Therapy
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Preload
SV
PPV Intellivue
Philips
SVV Flotrac/Vigileo
Edwards
PVI/SpO2
Masimo
SVV PPV PiCCO plus Pulsion
PPV S/5
GE
Fluid NON responsive
Fluid responsive
SV Guided Fluid Management: Maximizing SVSVV (PPV) Guided Fluid Management: Minimizing SVV (PPV)
Goal-Directed Therapy
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Br J Anaesth 2009;103:678-84
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PPVref
PPVauto
SVVauto
Br J Anaesth 2009;103:678-84
0.2
0.4
0.6
0.8
1.0
Se
nsi
tiv
ity
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
0.0
PPV-Philips; 12.5% se 89.7 – sp 89.5
PPV-ref; 12.5% se 93.1 – sp 94.7
SVV-Vigileo; 10.5% se 89.7 – sp 84.2
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SVV Flotrac/Vigileo
Edwards
Eur J Anaesthesiol 2010;27:555-61
SVV SVV
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PVI/SpO2
Masimo
SVV Flotrac/Vigileo
Edwards
Eur J Anaesthesiol 2010;27:555-61
Non invasive
PVI PVI
The best threshold values to predict fluid responsiveness were > 11% for SVV and > 9.5% for PVI
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Anesth Analg 2010;111:910-4
PVI/SpO2
Masimo
PVI
13%
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Anesth Analg 2010;111:910-4
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Les Indices Dynamiques Changent le Pronostic !
Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?
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Stroke Volume
P = cyclic changes in preload induced
by mechanical ventilation
Large SVV
Stroke Volume Variation (SVV)
EXPINSP
SVmin
SVmax
Preload (P)
SV
me
an
SVmax - SVmin
SVmean
SVV =
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Preload (P)
Stroke Volume
P = cyclic changes in preload induced
by mechanical ventilation
Large SVV20.5%
4.5%
VOLUME LOADING
P
Small SVV
Stroke Volume Variation (SVV)
Fluid NON responsive
Fluid responsive
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Preload (P)
Stroke Volume
P = cyclic changes in preload induced
by mechanical ventilation
Large SVV
VOLUME LOADING
Stroke Volume Variation (SVV)
Fluid NON responsive
Fluid responsive
Arrhythmias (irregular HR)
Spontaneous breathing (irregular RR)
HR/RR is < 3.5
Vt <7 mL/kg
Open chest (false negative)
Acute RV failure (false positive)
SVV cannot be assessed
In case of:
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Preload (P)
Stroke Volume
P = cyclic changes in preload induced
by mechanical ventilation
Large SVV
VOLUME LOADING
Fluid NON responsive
Fluid responsive
The gray zone approach: avoids the binary constraint of a “black or white” decision
that does not fit the reality of clinical or screening practice
9%-13%
25% of patients
are in the GZ
Using the Gray Zone Approach to Assess the Ability of Pulse Pressure Variations to
Predict Fluid Responsiveness During General Anesthesia M Cannesson, Y Le Manach, CK Hofer, DG Altman, JJ Lehot, B Vallet, B Tavernier
Anesthesiology 2011;115:231-41
Multicenter study (Lille, Lyon, Paris, Zürich, Irvine)
414 patients studied during anesthesia
Volume expansion and CO monitoring
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Preload (P)
Stroke Volume
PPV SVV < 10%
PPV SVV >> 12%
Pulse Pressure Variation (PPV)
Stroke Volume Variation (SVV)
Grey
Zone
Exclusion of fluid
responsiveness
with near
certainty
-> sensitivity and
NEGATIVE
predictive value
Prediction of fluid
responsiveness
with near certainty
-> specificity and
POSITIVE
predictive value
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Preload (P)
Stroke Volume
PPV SVV < 10%
PPV SVV >> 12%
Pulse Pressure Variation (PPV)
Stroke Volume Variation (SVV)
?
Exclusion of fluid
responsiveness
with near
certainty
-> sensitivity and
NEGATIVE
predictive value
Prediction of fluid
responsiveness
with near certainty
-> specificity and
POSITIVE
predictive value
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SVV
ScvO2CVP
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• The patients in the Vigileo group received more colloid (1425 ml [1000-1500]
vs. 1000 ml [540-1250]; P = 0.0028) intraoperatively
• Fewer Vigileo patients developed complications (18 (30%) vs. 35 (58.3%)
patients; P = 0.0033)
• The overall number of complications was also reduced (34 vs. 77
complications in Vigileo and Control respectively; P = 0.0066)
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dPPV
Can Changes in Arterial Pressure Be Used to Detect Changes
In Cardiac Output During Volume Expansion in the Perioperative Period?Y Le Manach, CK Hofer, JJ Lehot, B Vallet, JP Goarin, B Tavernier, M Cannesson
Anesthesiology 2012; under review
Only absolute changes in PPV (dPPV) detect a >15% increase in CO
Inconclusive Zone
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SVV
ScvO2CVP
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SVV
ScvO2CVP
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SVV
ScvO2CVP
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High
(>3.5 L/min.M²)
Fluid
challenge
CCO
SVV
Low
(<2.5 L/min.M²)
HypovolemiaMyocardial
dysfunction
Dobutamine
Normal>75 %
Low<70 %
Oxygen therapy,
Increase PEEP
Do
nothing
ScvO2
Normal (>95%)
(increased O2ER)
SaO2
Low
(hypoxemia)
SVV >12%SVV <10%
Keep mean arterial pressure >70 mmHg
Goal-Directed Therapy: ScvO2-SVV Guided Protocol
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Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical PatientsDonati et al. Chest 2007;132:1817–24
Intervention
Fluid RBC
dobutamineto maintain
ERO2 < 27%
(≈ ScvO2 > 73% since
ScvO2 ≈ 1 - ERO2) during surgery and the
post-operative period
(24h)
135 patientsElective major abdominal
surgery or abdominal
aortic surgery (ASAIII; n = 94)
Normal>73 %
Low<73 %
Oxygen therapy,
Increase PEEP
Do
nothing
ScvO2
Normal (>95%)
(increased ERO2)
SaO2
Low
(hypoxemia)
Fluid
challenge,RBC…
CVP
HypovolemiaMyocardial
dysfunction
Dobutamine
CVP<10 mmHgCVP>10 mmHg
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Total Perop Postop
Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical PatientsDonati et al. Chest 2007;132:1817–24
Intervention
Fluid RBC
dobutamineto maintain
ERO2 < 27%
(≈ ScvO2 > 73% since
ScvO2 ≈ 1 - ERO2) during surgery and the
post-operative period
(24h)
135 patientsElective major abdominal
surgery or abdominal
aortic surgery (ASAIII; n = 94)
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Total Perop Postop
44.1%2.6+4.0µg/kg/min
4.5%0.4+2.2µg/kg/min
Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical PatientsDonati et al. Chest 2007;132:1817–24
Intervention
Fluid RBC
dobutamineto maintain
ERO2 < 27%
(≈ ScvO2 > 73% since
ScvO2 ≈ 1 - ERO2) during surgery and the
post-operative period
(24h)
135 patientsElective major abdominal
surgery or abdominal
aortic surgery (ASAIII; n = 94)
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MA
P
A
B
Scv
O2
Uri
ne
Ou
tpu
t
Lact
ate
Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical PatientsDonati et al. Chest 2007;132:1817–24
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Goal-Directed Intraoperative Therapy Reduces Morbidity
and Length of Hospital Stay in High-Risk Surgical PatientsDonati et al. Chest 2007;132:1817–24
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On Peut Raffiner les « Goals » !
Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?
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Occurrence of postoperative complications in:
- all patients (dotted lines)
- patients with ScvO2 >70% (solid line)
AUC- 0.751 (95% CI 0.71 to 0.79) for Pcv-aCO2 in a ll patients
- 0.785 (95% CI 0.74 to 0.83) for Pcv-aCO2 in patients with
ScvO2 >70%
ScvO2 = 70.5%
P(cv-a)CO2 = 6 mmHg
P(cv-a)CO2 = 5 mmHg in patients with ScvO2 >70%
ScvO2 and P(cv-a)CO2 as Complementary Tools for GDT
DURING High Risk SurgeryFutier E, Robin E, Jabaudon M, Guerin R, Petit A, Bazin JE, Constantin JM, Vallet B
Crit Care 2010 Oct 29;14(5):R193
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6 mmHg
Complications
SV (ml) MAP (mmHg)
ScvO2 P(cv-a)CO2
ScvO2 and P(cv-a)CO2 as Complementary Tools for GDT
DURING High Risk SurgeryFutier E, Robin E, Jabaudon M, Guerin R, Petit A, Bazin JE, Constantin JM, Vallet B
Crit Care 2010 Oct 29;14(5):R193
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Variables PCO2 gap >6 mmHg
(n = 78)
PCO2 gap <6 mmHg
(n = 37)
p value
Ventilator-free days, days 4.1 3.4 5.6 3.8 0.047
Total duration of MV, days 2.6 4.3 0.7 1.8 0.001
Length of ICU stay, days 6.9 4.5 6.3 4.1 0.49
Length of hospital stay,
days29.5 21.9 20.4 13.2 0.007
28-day mortality 9 (11.5%) 0 0.056
Outcome in Patients with High and Low Values of PCO2 gap
at ICU Admission
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SvO2(%) 49+2 57+3 61+2 60+2
VO2
(ml/min.m2) 113+9 112+11 112+8 127+10
P(v-a)CO2 Increase Reflects Flow-to-CO2 Production Adequacy
Teboul et al. Crit Care Med 1998;26:1007-10
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• 1) Le monitorage de la précharge-dépendance évalue la volémie « efficace »
• 2) Il peut être réalisé par un « test de remplissage » si le patient est en ventilation spontanée (anesthésie locorégionale)
• Trendenlenburg (test réversible)
• Administration de remplissage et suivi du paramètre de réponse à l’↑ de précharge(pression, surface, volume, débit…)
– Non invasif
– Invasif
• 3) Il peut être réalisé par monitorage de la PPV-SVV chez le patient sédaté-intubé-ventilé et/ou le suivi de la réponse au remplissage
• Pour le PPV : En rythme sinusal et un ratio HR/RR >3.5
• Pour le débit cardiaque : Avec un moniteur invasif ou non
• 4) Cette prise en charge individualisée comporte par ailleurs :• Le maintien d’une PAM > 60 mmHg
• Le monitorage de la ScvO2 (+ lactate ou CO2gap) en cas d’utilisation d’inotropes
Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?
Conclusions