Perioperative Goal

Directed TherapyImproving the Quality of

Care for Our Surgical Patients

DESIRÉE CHAPPELL, CRNA

ERAS TEAM LEAD

NORTON AUDUBON HOSPITAL, LOUISVILLE, KY

Disclosure

Edwards Lifesciences, Speakers Bureau

American Society for Enhanced Recovery,

Board of Directors

Overview

Perioperative Goal Directed Therapy (PGDT)

Enhanced Recovery (ER)

The Norton Audubon Experience

CRNA opportunities within Enhanced Surgical Recovery Programs

Goal of

Intraoperative

Fluid

Management

Maintain

Intravascular Fluid Volume

LV Filling Pressures

BP/CO

Oxygen Delivery

Manage

Preoperative Status

Surgical Considerations

Postoperative Needs

1 liter

Normal

Saline

Prowle, J. R. et al. Nat. Rev. Nephrol. 6, 107–115 (2010)

Fluid Administration Gone WRONG

SWEET

SPOT

Traditional

Fluid Therapy

Vital Signs

Dogma/ Clinicians

Crude Markers

of

Hypovolemia

• BP

• HR

• UOP

• EBL

Blood Pressure =

Late Indicator

Assumption:

MAP=CO

If BP = CO

If BP = CO

1,2Hamilton et al, ICM 1997Pressure FLOW

Traditional

Fluid Therapy

Provider Variability

Vital Signs

Dogma/ Clinicians

Variability of

Providers

50%Patients

4-10 ml/kg/hr

50%Patients

Outside Range

The strongest predictor of corrected crystalloid infusion was the anesthesia providers regardless of patient factors.

Lillot BJA 2014

Colon

Surgery• Significant

Variability in DOS fluid admin

• Variability leads to poor outcomes

Perioperative Fluid Utilization Variability and Association

With OutcomesConsiderations for Enhanced Recovery Efforts in Sample US Surgical

PopulationsJulie K.M. Thacker, MD, William K. Mountford, PhD,y Frank R. Ernst, PharmD, MS,z

Michelle R. Krukas, MA,z and Michael (Monty) G. Mythen, MBBS, MD, FRCA, FFICM, FCAI (Hon)Annals of Surgery 2015

Conventional

Stolting et. al. Basics of Anesthesia, 5th ed. Elsevier - China, p. 349, 200

Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005; 103: 419-28 7

Restrictive

Perioperative Goal-Directed Therapy

Str

oke

Vo

lum

e

Preload

Evolution of Fluid Management

Liberal

Frank-Starling Curve

GOAL Directed Fluid Therapy

ABP

Continuous NON/MINinvasive

CO

Cardiac Output/ Index

SV

Stroke Volume/ Index

SVV

Strove Volume Variation (SVV)

Parameters of

FLOW

Cardiac Output/ Index

Stroke Volume

Stroke Volume

Variation

A calculated percentage of

variation between the Stroke

Volumes…

Preload

Stroke

Volume

0

SVV > 13%

Journal of Cardiothoracic and Vascular

Anesthesia, Vol 24, No 3 (June), 2010: pp

487-497

Fluid Bolus

Preload

Dependence

Optimization

J.Bloomstone M.D. 2011

High Resp

Variation= Fluid

responsiveness

Low Resp

Variation=

Decreased Fluid

responsiveness

SVV < 13%

Limitations of SVV

pontaneous Ventilation

idal Volume (<8cc/Kg)

pen Chest

neumoperitoneum

ustained Cardiac Arrhythmias

Kuper et al BMJ. 2011; 342:d3016

Nice/Kuper

Protocol

WHO?

ASA 1•Procedure Specific

ASA2/3

•Procedure Specific

•NON Invasive

ASA>4

•Procedure Specific

•Critical State

•NON⇾ Min-Invasive

ALL Surgical

Patients!Degree of

intervention-

Pathway/Patient

dependent

WHEN

PreOPOptimization

IntraOP

Pre/Post Incision

Post Op Rescue/ Tx

Real –Time Hemo-

Dynamic Data

Clinical Judgement

Fluid Therapy Protocols

ACTION

Perioperative Goal Directed Therapy

• Cont BP

• CO

• SV

• SVV

• Knowledge

• Experience

• Evidenced

Based

Simulator

Simulator

Simulator

Simulator

Don’t Get Caught

up in the

“NUMBERS”

Knowledge and

Experience

Optimization using GDFT

PGDT Reduces Complications

Evidence

:

30+ positive RCTs 14+ meta-analyses

Reduction by1-2(avg. days)

in Length of Stay

32-55% reduction in Post-Surgical Complications

1-2

30+ positive RCTs

14+ meta-analyses1 Hamilton M, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical

patients. Anesth Analg. 2011;112(6):1392-1402 Grocott, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. BJA, 2013.3 Corcoran et al. Perioperative Fluid Management Strategies in Major Surgery: A Stratified Meta-Analysis. Society of Critical Care Anesthesiologists. 2012 ; 114 (3)

PGDTReduces Complications

Reduces Variance

Improves Outcomes

Successful Recovery

The Norton Audubon

ExperienceERAS IMPLEMENTATION OVER 2 YEARS

Background

Baseline 2014

Measure

Average Std

dev

# Discharges

Length of

Stay11.13

7.69 159

Measure

Average Std

dev

# Discharges

Variable

Direct Cost

$10,72

9

$8,590159

Clinical Effectiveness ERAS Report –

Colorectal ProceduresBaseline 2014/ Improvement 2015-2016

Improvement

2015

Improvement

2016

Average per patient Std dev #

Discharges

Average per patient Std dev #

Discharges

Length of Stay 5.143.68 66

6.24.45 69

Average per patient Std dev #

Discharges

Average per patient Std dev #

Discharges

Variable

Direct Cost

$6,261$2,951 66

$7,087$4,780 69

Variable Direct Cost Buckets

Norton Audubon Results

Reduction

LOSReduction

V/D

COSTS

CRNAs role in

PGDT InitiativeHOW CRNAS IMPROVE INTRAOPERATIVE CARE

CRNAs

leading the

PGDT/ER

Movement

CRNAs

As

Ambassadors

Care ProvidersFacilitators

Educators Active Participants

Where to Begin

Lit. review

Current Practice?

Ask for DATA

The Face of

ESR

Enhanced Surgical Recovery

in your Practice

Change is

ConstantPGDT = ESR

Standard

Of Care

CRNAs as Leaders

ESR =

BEST PRACTICE!

Enhanced Surgical Recovery

in your Practice

Change is

ConstantPGDT = ESR Standard

Of Care

CRNAs as Leaders

ESR = BEST PRACTICE!