Oesophageal Doppler fluid management in the elderly

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Oesophageal Doppler fluid management in the
elderly

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

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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

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Oesophageal Doppler fluid management in the
elderly

• Why ?

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Post operative morbidityProspective 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

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Why?

• Normal intraoperative monitoring of heart rate
  and blood pressure fails to identify
  hypovolaemia.

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Covert Compensated Hypovolemia
11 healthy volunteers. Blood volume reduced by
15-20. All subjects developed CNS symptoms.
Change from baseline - 5 - 6 0 7 - 9 -
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• Heart rate
• Mean arterial pressure
• Cardiac Output
• Lactate / Pyruvate ratio
• Splanchnic blood flow
• Splanchnic blood volume

Price HL et al. Circulation Research
19665469-474
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25-30 Haemorrhage in Man
Controlled haemorrhage
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Hamilton-Davies et al Intensive Care Med
23(3)276-281,1997
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25-30 Haemorrhage in Man
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Hamilton-Davies et al Intensive Care Med
23(3)276-281,1997
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Circulatory changes during laparotomyCan.J.
Anaes 2002 49(3) 302-308

• Many reasons for hypovolaemia
• Starvation
• Blood loss
• Open wound
• Splanchnic circulation reduced first
• Changes in regional circulation during laparotomy
  and ventilation

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Circulatory changes during laparotomy in
rabbitsCan.J. Anaes 2002 49(3) 302-308

• Spontaneous breathing no changes
• IPPV with Zero PEEP - no changes
• Abdomen open, PEEP 12cmH2O
• Mean arterial BP reduced
• Hepatic and renal blood flow reduced to less than
  lt10 of starting value partial recovery at 0
  PEEP
• Carotid and aortic flow less than half
• Abdomen closed similar but less marked

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• Goal directed cardiovascular management improves
  outcome
• Shoemaker
• Boyd
• Wilson
• PAC based, Pre-op. Intensive Care

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Frank Starling Curve
Oesophageal Doppler Monitoring
Cardiac Function Curve
Stroke Volume
? 0
? lt 10
? gt 10
End-Diastolic Volume
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Optimising stroke volume during surgery

• Days in Hospital
• ?
• ?
• ?

CABG (Archives of Surg 1995 130 423) Neck of
Femur BMJ 1997315909 - 12. Major General
Surgery Anesthesiol, 97(4), 820-826, 2002
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• Would a simple, non-invasive, dynamic, flow-based
  fluid protocol improve outcome compared with
  optimal controls?
• Pre-operative iv fluid
• Full standard monitoring incl. CVP
• Target CVP 12-15mmHg

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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

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Worthing Optimisation Research in Major Surgery
(WORMS)

• In addition-
• Gut permeability investigated
• Lactulose-mannitol
• Systemic endotoxin
• Systemic inflammatory markers
• IL-6, C reactive protein,
• Quality of recovery and EORTC questionnaires

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Worthing Optimisation Research in Major Surgery
(WORMS)

• Power 0.8 at p0.05
• Local and published data
• 10 n58
• 20 n64
• Control
• NIBP, ECG, Pulse Oximetry, Capnography
• Central Venous pressure 12 15 mmHg
• Intervention Doppler fluid algorithm

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Worthing Optimisation Research in Major Surgery
(WORMS)

• Balanced anaesthetic technique
• O2 / N2O / Isoflurane
• Fentanyl 1-2µg.Kg-1 Morphine
• Propofol 1.5-3 mg.Kg-1
• Vecuronium
• Crystalloid given pre-operatively and at
  anaesthetists discretion

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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.

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Patient characteristics
 
Control Median (IQR)
Protocol Median(IQR)
Age (years) Mean (sd)
69.6 (10.2)
69.1 (12.3)
Physiological Possum
18 (7.0)
17 (6.5)
Operative Possum
16 (9.0)
15.5 (7.0)
 
BMI
26 (7.25)
24.5 (6.75)
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Operative data
 
Control Median(IQR)
Protocol Median(IQR)
Blood loss (ml)
500 (975)
500 (700)
Per-operative crystalloid (ml)
3000 (1187)
3000 (1750)
Per-op. colloid (ml) Range
1500 (0 4000)
2000 plt0.001 (500-5000)
Urine output 1st 36 hours
2754 (1453)
3649 (2000) plt0.01
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Haemodynamic data
 
Control Median (IQR)
Protocol Median(IQR)
Stroke Volume (ml) plt0.001)
77 (25)
99 (43)
Cardiac Output (l.min-1) plt0.02
5.6 (2.9)
7.25 (2.37)
Oxygen Delivery (ml.min.m2) plt0.011
445 (200)
535 (229)
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Haemodynamic data
 
Control Median (IQR)
Protocol Median(IQR)
CVP overall (mmHg)
13 (5)
14 (5)
CVP End of surgery (mmHg)
13 (5.5)
13 (4.5)
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Post-operative Progress
 
Control Median (IQR)days
Protocol 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)
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Kaplan-Meier Plot
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GI Morbidity

• GI complications
• Control group 29 (45.3) Chi Sq.
• Doppler Group 9 (14)
• Relative Risk (95CI)
• Control 2.035 ( 1.474, 2.810 )
• Treatment 0.379 ( 0.209, 0.686 )
• Risk Ratio 5.3 1

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Serum endotoxin levels
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Intestinal Permeability
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Mortality

• 30 day mortality 0
• 60 day mortality 1 ( 0.78)
• Predicted mortality-
• Median values P-POSSUM 3.3

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Total bed occupancy

• Control group 840 days
• Doppler group 770 days
• Total bed saving 70 days

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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
• CardioQ 5,000 (approx.)

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Can you give too much fluid?

• Brandstrup et al restricted fluids
• Only healthiest patients recruited
• Arbitary and non-individualised protocol
• 6000ml N/Saline given to std. group
• (only 5,000ml iv fluid in Doppler group)
• No bowel prep
• N/Saline continued post-op with oral fluid
• 4,000ml N/Saline in restricted group
• Post op aim to keep weight constant.

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Too much fluid?

• Large saline loads associated with
• Metabolic acidosis
• Poorer outcome
• 4.7 mortality, plus pulmonary oedema in ASA I
  and II patients
• So, restricting fluid protected patients from
  being drowned with Saline

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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?

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IPPV
HEAD DOWN
Reliable CVP?
IPPV PEEP
HEAD UP
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Haemodynamic values at start and end of surgery
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CVP

• Bears no relation to blood volume
• Ref. Baek S, Surgery 197578304-15
• Unreliable readings in theatre
• Unless constantly bolused gives little useful
  information.
• Associated with significant cost and
  complications.

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Oesophageal Doppler

• Beat to Beat stroke volume
• Reliable in theatre environment
• Virtually non-invasive
• Relatively inexpensive
• Easy to use
• No complications reported to date

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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

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Orthopaedic patients

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

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So

• GI morbidity occurs in gt50 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?

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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