benoit.vallet@chru-lille.fr

Pôle d’Anesthésie Réanimation

Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?

Le Remplissage est plus Compliqué qu’il n’y Parait !

Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?

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

Précharge

Volume d’Ejection Systolique (VES)

VOLUME ADDITIONNEL

NON REPONDEUR

REPONDEUR

Le Remplissage est plus Compliqué qu’il n’y Parait !

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…

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

7.43

3.39

15.59

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

Mortality 1.7% 3.3% NS

37 3817 17

Length of stay (dys) 9 (8-12) 10(8-19) 0.0421

I

37 3817 17

• 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

• 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

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)

J A

m C

oll S

urg

2008

;207

:935

-41

Am

ou

nt

of

IV c

ollo

id f

luid

• 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

2008;207:935-41Peri -operative Fluid Optimization with the ODM

Esophageal Doppler Monitoring vs Control

Length of Stay

Sub-Category Colorectal

• 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

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

Il Existe des Recommandations !

Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?

• 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

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

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

Preload

SV

Fluid NON responsive

Fluid responsive

SV Guided Fluid Management

Stroke Volume Guided Fluid Therapy

© NICE 2012

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

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

Br J Anaesth 2009;103:678-84

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

SVV Flotrac/Vigileo

Edwards

Eur J Anaesthesiol 2010;27:555-61

SVV SVV

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

Anesth Analg 2010;111:910-4

PVI/SpO2

Masimo

PVI

13%

Anesth Analg 2010;111:910-4

Les Indices Dynamiques Changent le Pronostic !

Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?

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 =

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

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:

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

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

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

SVV

ScvO2CVP

• 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)

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

SVV

ScvO2CVP

SVV

ScvO2CVP

SVV

ScvO2CVP

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

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

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)

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)

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

Goal-Directed Intraoperative Therapy Reduces Morbidity

and Length of Hospital Stay in High-Risk Surgical PatientsDonati et al. Chest 2007;132:1817–24

On Peut Raffiner les « Goals » !

Hémodynamique au Bloc Opératoire : Quoi de Neuf en 2012 ?

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

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

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

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

• 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

benoit.vallet@chru-lille.fr

Pôle d’Anesthésie Réanimation

Merci!