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Use of Oesophageal Doppler - Age Anaesthesia Association

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					Oesophageal Doppler fluid
management in the elderly

H.G. WAKELING
Department of Anaesthesia
Worthing Hospital, West Sussex,UK.
CardioQ Specifications

 • 6Kg 4MHz continuous Doppler
   ultrasound
 • Real time aortic blood flow data
 • 6 hour patient probes £45
 • 10 day probe £79
 • Validated for patients: 15Kg – 150Kg
  Oesophageal Doppler fluid
  management in the elderly


• Why ?
      Post operative morbidity
    Prospective study of 443 major surgery patients

• Complications Day 5 Day 8
176 (40%) 109 (25%)
 • GI Dysfunction (%) 55 51
 • Renal (%) 26 25
 • Inability to ambulate (%) 22 18
 • Pulmonary (%) 17 24
 • Infection (%) 12 16
 • Wound complication(%) 3 10
 • Cardiovascular (%) 9 15
                 Why?


Normal intraoperative monitoring of heart
rate and blood pressure fails to identify
hypovolaemia.
     Covert Compensated Hypovolemia
11 healthy volunteers. Blood volume reduced by 15-20%.
All subjects developed CNS symptoms.
                                             Change from
                                               baseline
     Heart rate                                  - 5%
     Mean arterial pressure                      - 6%
     Cardiac Output                               0%
     Lactate / Pyruvate ratio                    +7%
     Splanchnic blood flow                       - 9%
     Splanchnic blood volume                  - 40%***




       Price HL et al. Circulation Research 1966;5:469-474
25-30% Haemorrhage in Man
             Controlled haemorrhage         Re-transfusion
                             l
                             m    l
     160                          m
                             0
                             0    0
                             8    0
                                  8
     140

     120

     100

      80

      60
                                                         Heart rate
      40
                                                         Sys BP
      20

       0
            Base   30   60       90   120   150    180   210

                          Time (minutes)

  Hamilton-Davies et al Intensive Care Med 23(3):276-281,1997
    25-30% Haemorrhage in Man
                     Controlled
                     haemorrhage                   Re-transfusion
                             aemorrhage
              7.45               800ml
              7.40                  800ml
              7.35
Gastric pHi
              7.30
              7.25
              7.20
              7.15
              7.10
              7.05
              7.00
                     Base
                            30   60   90   120   150   180   210


                                  Time (minutes)
          Hamilton-Davies et al Intensive Care Med 23(3):276-281,1997
  Circulatory changes during
          laparotomy
           Can.J. Anaes 2002 49(3) 302-308
• Many reasons for hypovolaemia
  o   Starvation
  o   Blood loss
  o   Open wound
• Splanchnic circulation reduced first
• Changes in regional circulation during
  laparotomy and ventilation
  Circulatory changes during
     laparotomy in rabbits
            Can.J. Anaes 2002 49(3) 302-308
• Spontaneous breathing – no changes
• IPPV with Zero PEEP - no changes
• Abdomen open, PEEP 12cmH2O
  o Mean arterial BP reduced
  o Hepatic and renal blood flow reduced to less than
    <10% of starting value; partial recovery at 0 PEEP
  o Carotid and aortic flow less than half
• Abdomen closed similar but less marked
• Goal directed cardiovascular
  management improves outcome
  o   Shoemaker
  o   Boyd
  o   Wilson

• PAC based, Pre-op. Intensive Care
    Frank Starling Curve
Oesophageal Doppler Monitoring
      Cardiac Function Curve
  Stroke Volume

  0%
  < 10%
  > 10%


                  End-Diastolic Volume
    Optimising stroke volume during
                surgery
                                    Days in Hospital

CABG                                      ↓
(Archives of Surg 1995 130: 423)

#Neck of Femur                            ↓
                                          ↓
BMJ 1997;315:909 - 12.

Major General Surgery
Anesthesiol, 97(4), 820-826, 2002
• Would a simple, non-invasive, dynamic,
  flow-based fluid protocol improve
  outcome compared with ‘optimal’
  controls?
  o   Pre-operative iv fluid
  o   Full standard monitoring incl. CVP
  o   Target CVP 12-15mmHg
Worthing Optimisation Research in
    Major Surgery (WORMS)
•   Prospective, double blind RCT
•   128 patients, colorectal surgery
•   Intervention: Doppler guided colloid fluids
•   10 outcome measure: Length of stay
•   20 outcome measure: Time to full diet

• Sponsored by the Department of Health
R & D Grant SEO252
Worthing Optimisation Research in
    Major Surgery (WORMS)
• In addition:-
  o   Gut permeability investigated
       Lactulose-mannitol
       Systemic endotoxin
  o   Systemic inflammatory markers
       IL-6, C reactive protein,
  o   Quality of recovery and EORTC
      questionnaires
Worthing Optimisation Research in
    Major Surgery (WORMS)
• Power 0.8 at p=0.05
  o   Local and published data
  o   10 n=58
  o   20 n=64
• Control –
  o   NIBP, ECG, Pulse Oximetry, Capnography
  o   Central Venous pressure 12 – 15 mmHg

• Intervention – Doppler fluid algorithm
Worthing Optimisation Research in
    Major Surgery (WORMS)
• Balanced anaesthetic technique
  o   O2 / N2O / Isoflurane
  o   Fentanyl 1-2μg.Kg-1 & Morphine
  o   Propofol 1.5-3 mg.Kg-1
  o   Vecuronium
• Crystalloid given pre-operatively and at
  anaesthetist’s discretion
Worthing Optimisation Research in
    Major Surgery (WORMS)

• Surgical and Nursing staff blinded

• Common patient led recovery pathway

• Fluid prescription on the ward entirely
  at discretion of surgical team.
     Patient characteristics
                 Control       Protocol
                Median (IQR)   Median(IQR)

Age (years)     69.6 (10.2)    69.1 (12.3)
  Mean (sd)

Physiological     18 (7.0)      17 (6.5)
  Possum
 Operative        16 (9.0)     15.5 (7.0)
  Possum
    BMI          26 (7.25)     24.5 (6.75)
              Operative data

                    Control       Protocol
                   Median(IQR)   Median(IQR)

Blood loss (ml)     500 (975)     500 (700)

 Per-operative     3000 (1187)   3000 (1750)
crystalloid (ml)
Per-op. colloid       1500       2000 p<0.001
 *(ml) Range        (0 – 4000)    (500-5000)

Urine output 1st   2754 (1453)   3649 (2000)
  36 hours *                      p<0.01
           Haemodynamic data

                       Control        Protocol
                      Median (IQR)   Median(IQR)

 Stroke Volume          77 (25)       99 (43) *
   (ml) p<0.001)

Cardiac Output          5.6 (2.9)    7.25 (2.37) *
  (l.min-1) p<0.02

Oxygen Delivery        445 (200)     535 (229) *
(ml.min.m2) p<0.011
      Haemodynamic data

               Control        Protocol
              Median (IQR)   Median(IQR)

CVP overall      13 (5)        14 (5)
  (mmHg)

CVP End of      13 (5.5)       13 (4.5)
 surgery
  (mmHg)
   Post-operative Progress

                   Control            Protocol
                Median (IQR)days   Median (IQR)days

Flatus passed         4 (2)              3 (2)

Bowels open           5 (2)              4 (3)

  Full diet           7 (2)              6 (2)

 Discharge         11.5 (4.75)         10 (5.75)
Kaplan-Meier Plot
               GI Morbidity

• GI complications
  o   Control group 29 (45.3%)* Chi Sq.
  o   Doppler Group 9 (14%)
• Relative Risk (95%CI)
  o   Control 2.035 ( 1.474, 2.810 )
  o   Treatment 0.379 ( 0.209, 0.686 )
• Risk Ratio 5.3 : 1
Serum endotoxin levels
Intestinal Permeability
              Mortality

• 30 day mortality 0
• 60 day mortality 1 ( 0.78%)

• Predicted mortality:-
• Median values P-POSSUM – 3.3%
      Total bed occupancy

• Control group 840 days

• Doppler group 770 days

• Total bed saving 70 days
        Financial considerations
•   Item Cost Group Cost
•   CardioQ probe £45 £2,880
•   Colloid solution £3.65 £ 234
•   Total additional cost £ 3,114

• Hospital bed cost £400 £27,740
• Overall saving £384 £24,626
    o   CardioQ £5,000 (approx.)
Can you give too much fluid?
• Brandstrup et al – restricted fluids
  o   Only healthiest patients recruited
  o   Arbitary and non-individualised protocol
  o   6000ml N/Saline given to std. group
        (only 5,000ml iv fluid in Doppler group)
        No bowel prep
  o   N/Saline continued post-op with oral fluid
  o   4,000ml N/Saline in restricted group –
  o   Post op aim to keep weight constant.
            Too much fluid?

• Large saline loads associated with
  o   Metabolic acidosis
  o   Poorer outcome
• 4.7% mortality, plus pulmonary oedema
  in ASA I and II patients
• So, restricting fluid protected patients
  from being drowned with Saline
              WORMS
• Intraoperative Doppler guided fluids are
  associated with shorter length of
  hospital stay after major surgery even
  when control group CVP kept between
  12 and 15mmHg.
• Why?
IPPV
                        HEAD DOWN



       Reliable CVP?
IPPV & PEEP

                       HEAD UP
Haemodynamic values at start and end of surgery
                         CVP

• Bears no relation to blood volume
  o   Ref. Baek S, Surgery 1975;78:304-15
• Unreliable readings in theatre
• Unless constantly bolused gives little
  useful information.
• Associated with significant cost and
  complications.
       Oesophageal Doppler

•   Beat to Beat stroke volume
•   Reliable in theatre environment
•   Virtually non-invasive
•   Relatively inexpensive
•   Easy to use
•   No complications reported to date
         Elderly Laparoscopic
             Gastrectomy
•   10 patients Mean age 80.8 years (75-87)
•   Laparoscopic Distal Gastrectomy
•   30 day mortality – 0%
•   90% 2 year survival

• No HDU requirement
• Doppler fluid management integral to
  anaesthetic technique
      Orthopaedic patients

• Primary Hip replacement
• Elderly slow to mobilise
• Why?
                    So

• GI morbidity occurs in >50% of in patients
  5 and 8 days post-op.
• Stroke volume optimisation (SVO) per-op
  reduces GI morbidity.
• Length of stay reduced in #NOF by SVO
• So is intraoperative hypovolaemia
  contributing in these elderly THR
  patients?
                       Summary
•   ODM Simple, non-invasive, inexpensive
•   Useful circulatory assessment tool in complex lap. surgery
•   Likely to have role in improving orthopaedic recovery
•   Intraoperative ODM shortened length of stay compared
    with CVP managed controls in Colorectal patients:
•   Significantly earlier return of gut function
•   Significant reduction in post-op. complications
•   Significantly better cardiac output and O2 Delivery
•   Significant cost savings.
•   Right Volume Right Fluid Right time

				
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