8. CardioprotectionPrevention of myocardial ischemia has traditionally focused on maintaining
Myocardial oxygen balance
Heart rate
contractility
afterload
CBF: normal region
CBF: ischemic region
subendocardium
Ischemia
Beta-blocker
Alpha2 agonist
Ca-channel blocker
9. Introduction
Physical Findings (Non-specific)
Clinical signs of hypovolemia are neither sensitive nor specific in the critically ill patient.
Increased sympathetic tone
- Tachycardia, hyperpnea,
- Diaphoresis
Decrease organ perfusion
- Decrease urine output, ileus,
- Altered sensorium,
- Lactic acidosis
- Hypotension occurs late
26. esCO = K × (α × PWTT + β) × HR
α is an experimental constant,
β is calculated based on Pulse-Pressure of IBP or NIBP,
K is calculated based on a given CO value.*
esSV
32. Response to increase
cardiac load obtained
by leg elevation
The ability of the
heart to improve its
performance via
Frank-Starling
mechanism
Anesth Analg 2006;103:289 –96
33. SevofluranePropofol
Anesthetic Induced Physiological Change
Length-dependent Regulation of Myocardial Function Anesthesiology 2001;95:357-63
Both technique: Passive leg elevation or Frank-Starring mechanism
are preserved in perioperative period.
34. DesfluranePropofol
Anesthetic Induced Physiological Change
Length-dependent Regulation of Myocardial Function Anesthesiology 2001;95:357-63
Both technique: Passive leg elevation or Frank-Starring mechanism
are preserved in perioperative period.
43. Bellamy MC. Br J Anaesth. 2006;97:755-757.
Complications
Volume Load
OPTIMAL
Edema
Organ dysfunction
Adverse outcome
Hypoperfusion
Organ dysfunction
Adverse outcome
OverloadedHypovolemic
Optimal Volume Administration
(and the impact of excessive and insufficient administration)
44. Evolution of Fluid Management
The “Conventional” approach
is trying to predict the amount of volume /
fluids needed based upon a the duration and
severity of a particular procedure
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
The “Restrictive” fluid approach is
based on minimizing fluids based on Blood
Pressure
“Goal-Directed Therapy” approach considers
optimizing volume / fluids via the Frank Starling Curve and individualizing to
goals
45. Early Goal-directed Therapy
Supplemental oxygen ± endotracheal
intubation and mechanical ventilation
Central venous and
arterial catheterization
CVP
Crystalloid
Colloid
<8 mm Hg
MAP
8-12 mm Hg
Vasoactive agents
<65 mm Hg
>90 mm Hg
ScvO2
≥65 and ≤90 mm Hg
Goals
achieve
d
≥70%
Hospital admission
Yes
No
Sedation and/or
paralysis
(if intubated)
Transfusion of red cells to
hematocrit ≥30%
<70%
Inotropic agents
<70%
≥70%
Rivers et al NEJM 2001;345:1368
Volume
Pressor
Inotrope
46. StaticCardiac filling pressure
Marik P E et al. Chest 2008;134:172-178Osman D. Crit Care Med 2007; 37:64-8
Preload ≠ Fluid Responsiveness
CVP
SVV & PPV
Dynamic
51. SVV ≥ 12 % SVV < 12 %
200 ml fluid
challenge over 5
min
Measure and record
Cardiac index (CI)
CI > 2.5 CI ≤ 2.5
Start dopamine
And titration
Until CI > 2.5
GDT group
Measure and record
SVV
Give
vasopressors
No
MAP ≥ 65
mmHg
Yes
A comparison of return of gastrointestinal function between
perioperative goal-directed therapy and traditional fluid
therapy in major abdominal surgery patients
: A prospective randomized
controlled study
52. Control GDT p Value
Age (y) 54 ± 10 58 ± 13 0.402
Body mass index (kg/m2) 21 ± 2 22 ± 3 0.097
ASA Classification 2 ± 0 2 ± 0
Operation time (min) 244 ± 97 282 ± 123 0.519
Total blood loss (ml) 850 ± 1409 900 ± 667 0.930
Fluid replacement
- Crystalloid (ml) 3144 ± 4097 1807 ± 696 0.351
- Colloid (ml) 1163 ± 650 879 ± 488 0.874
- PRC (ml) 765 ± 644 572 ± 357 0.161
- FFP (ml) 912 ± 863 755 ± 228 0.119
- Total (ml) 4135 ± 5636 3080 ± 1266 0.617
Lactate (mmol/L)
- Preoperative 1.34 ± 0.45 1.51 ± 0.68 0.560
- Postoperative 4.74 ± 3.89 3.57 ± 1.37 0.481
Return of bowel function (d) 3.0 ± 1.4 0.8 ± 0.6 0.031*
Length of stay in hospital (d) 14.0 ± 7.7 13.1 ± 6.1 0.799
A comparison of return of gastrointestinal function between perioperative goal-
directed therapy and traditional fluid therapy in major abdominal surgery patients
: A prospective randomized controlled study
62. PVI ≥ 17 % PVI < 17 %
200 ml fluid
challenge over 5
min
Estimated Cardiac index
esCCI
esCCI > 2.5 esCCI ≤ 2.5
Start dopamine
And titration
Until esCCI > 2.5
GDT group
Measure and record
PVI
Give
vasopressors
No
MAP ≥ 65
mmHg
Yes
A comparison of return of gastrointestinal function between
perioperative goal-directed therapy and traditional fluid
therapy in major abdominal surgery patients
: A prospective randomized
controlled study
University Hospital