Is We Is, or Is We Aint: The Dialectics of Aggressive Intraoperative Resuscitation

A. Joseph Layon, MD, FACP

Professor of Anesthesiology, Surgery, & Medicine Division of Critical Care Medicine University of Florida College of Medicine Gainesville, FL

GOOD Florida Gators !

BAD Florida Gators

BAD Florida Gators

Hurricane Francis September 2004

What Has Dialectics to Do with IOR ?

Heraclitus, Plato, Hegel, Kant, Engels, Marx:
Heraclitus (c. 544-483BC) Materialist philosopher and exponent of dialectics Known as "The Obscure Held Fire to be prime material in nature
"The world was created by none of the gods or men, but was, is, and will be eternally living fire, regularly becoming ignited and regularly becoming extinguished" - all things in nature are in

continuous flux, changing into their opposites; struggle is universal, etc.

What Has Dialectics to Do with IOR ?

A thing becomes its opposite.?
How does resuscitation (good, right ?) Turn into. something bad ?

Dialectics !

May also work for discussing / understanding other issues.

What is the real issue here ?

Not what fluid we use perioperatively...

.But rather

IS RESUSCITATION ADEQUATE ?

Are we sure ? How can we be sure ? How can we minimize complications related to resuscitation ?

Resuscitation Concerns

What is shock ?
ie: when is resuscitation needed ?

What are resuscitation endpoints ? Are there problems with resuscitation ? Staged monitoring modalitiesour method

What is Shock ?
SG Gross, 1872
A manifestation of the crude unhinging of the machinery of life.

A Blalock, 1937
A peripheral circulatory failure, resulting from a discrepancy in the size of the vascular bed and the volume of the of the intravascular fluid.
Gross SG, A System of Surgery, Philadelphia, Lea & Febiger, 1872. Blalock A, Arch Surg, 1937;29:837. Porter JM, Ivatury RR, J Trauma, 1998;44:908.

What is Shock ?
ACS, ATLS Manual, 1993
An abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation

ACS COT, ATLS Student Manual, 1993, 77.

What is Shock ?

Thus, resuscitation is complete when:

O2 debt is repaid Tissue acidosis is eliminated Aerobic metabolism restored

Porter JM, Ivatury RR, J Trauma, 1998;44:908. Trauma,

Organ Perfusion in Critically Ill Patients

Cellular energetics and normoxia
fatty acids

O2
ATP = ADP+Pi+H+ (energy)

O2
Cellular energetics and dysoxia

Resuscitation Endpoints
Historical
BP, HR, UOP However... 80%-85% under-resuscitated when values are normalized
Elevated lactate Decreased MVO2

Scalea et al, CCM, 1994;22:1610. Abou-Khalil et al, CCM, 1994;22:633.

Hypovolemic Shock*
Class I
Blood loss Blood volume Heart rate [bpm] Blood pressure Respiratory Rate Urine Output Mental Status Fluid Replacement < 750 ml < 15% < 100 Normal 14-20 > 30 ml/hr Slightly Anxious Crystalloid

Class II
750-1500 ml 15%-30% > 100 Normal 20-30 20-30 ml/hr Mildly Anxious Crystalloid

Class III
1500-2000 ml 30%-40% > 120 Normal to ed > 30 5-15 ml/hr Anxious Confused C/Blood

Class IV
> 2000 ml > 40% > 140 Decreased > 35 Nil Confused Lethargic C/B

*Initial presentation in unresuscitated shock. Modified from COT, ACS: ATLS Provider Manual, Chicago, ACS, 1993; p. 86)

Resuscitation Endpoints
Consecutive blunt injuries
Patients with CHI & ICP monitoring Not RBC, no alteration of therapy 24/30 [80%] with normal resuscitation parameters...

evidence of inadequate tissue perfusion Fluid loading

Lactate > 3 mMol/L MVO2 < 65% Average 8 L BSS & PRBCno elevation of ICP Elevated ICP correlated with lactate, not fluid infused Inadequate resuscitation
Scalea et al, CCM, 1994;22:1610.

Not tachycardic or oliguric, normotensive

Resuscitation Endpoints

Flaws in study
Data array

Normal / Normalized resuscitation parameters

Qualitative in suboptimal O2 transport group Limits group comparison The 24 with inadequate O2 transport and normal resuscitation parameters Versus the other 6

Scalea et al, CCM, 1994;22:1610.

Resuscitation Endpoints
Monitoring in trauma patients
Population Consecutive penetrating injury
Patients < 40 yr Require OR & > 6 UPRBC intra-operatively

Not RBC, no alteration of trauma algorithm

Resuscitation 1 Hr post-op all normotensive and none oliguric ~ 15% had acceptable hemodynamics

Fluid, PRBC, inotropes for normalization of lactate & DO2

Abou-Khalil et al, CCM, 1994;22:633

Resuscitation Endpoints
1 hr Post-Op 8 hr Post-Op 24 hr Post-Op

MAP [mm Hg] HR [bpm] CI [L/min/m 2] DO 2I [mL/min/m 2] Lactate [mMol/L] SvO 2 [%]

106 + 3 104 +3.7 3.1 + .19 b 496 + 35 b 5.1 + .56 b 69 + 8.2 a

103 +2.5 101 + 4 4.5 + .19 732 + 38 3.4 + .31 74 + 4.2

103 + 4.3 96 + 2.6 5.4 + .15 993 + 46 2.2 + .22 79 + 3.1

a = p < 0.05 between 1 and 8 hr periods b = p < 0.05 between 1 and 8, and 8 and 24 hr time periods DO2I & Lactate were the parameters differing between survivors and nonsurvivors 2

Abou-Khalil et al, CCM, 1994;22:633

Resuscitation Endpoints
Which other ones to use ?
Base Deficit Lactate Absolute serum level Time to normalization DO2 (GOHT / EGOHT) pHi

Base Deficit

An approximation of global tissue perfusion

Defined as the # of mM of base needed to titrate 1 L of whole blood to pH 7.4 Sample is 100% saturated, PCO2 = 40, T = 37 C Calculated from ABG based on nomogram

Base Deficit
Stratification of BD.
Mild: 2 to - 5 mM/L Moderate: - 6 to - 14 Severe: < - 15

correlates with fluid/blood requirement in

1st 24 hrs after trauma Worsening BD often implies ongoing bleeding

Porter JM, Ivatury RR, J Trauma, 1998;44:908. Davis et al, J Trauma, 1988;28:1464.

Base Deficit
Retrospective, statistical analysis 1984-90 Predicted Mortality
3,791 / 7,312 consecutive trauma patients With ABG analysis within 24 hrs of admission

Based upon BD-Mortality bi-plot of population Termed 25% risk of death significant
Rutherford et al, J Trauma, 1992;33:417.

500

100

400

80

% M O R T A L I T Y

P A T I E N T S

300 Mortality Number of Pts 200

60

40

100

20

0 0 -5 -10 -15 -20 -25 -30 -35 -40

0 -45

BASE DEFICIT (mMol / L)

Base Deficit
Found
3,083 [80.1%] had BD Normal = + 3 to - 3 mM/L BD < - 15 Marker for increased mortality in Pt < 55 yoa without
TBI

BD of - 8 In Pt > 55 yoa without TBI Or in Pt < 55 with TBI marker for increased mortality
Rutherford et al, J Trauma, 1992;33:417.

Organ Perfusion in Critically Ill Patients

Base Deficit in TRAUMA patients

DO2 BD VO2 LA ER

N = 100 consecutive patients ISS = 25 + 11 + PAC

BD > 4 BD < 4
Kincaid J Am Coll Surg 1998;187:384-392

Organ Perfusion in Critically Ill Patients

BD vs MOSF Post Trauma
40 35 30 25 20 15 10 5 0
% MOSF BD < 4 BD > 4

* p < 0.001
Kincaid J Am Coll Surg 1998;187:384-392

Organ Perfusion in Critically Ill Patients

BD vs Mortality Post Trauma
60 50 40
BD < 4

30 20 10 0

BD > 4

% Mortality

* p < 0.001
Kincaid J Am Coll Surg 1998;187:384-392

Base Deficit
Implication
Adds information to other scoring systems An adjunct to clinical judgement Not a good prognostic indicator In presence of pre-existing acid-base disorders

Rutherford et al, J Trauma, 1992;33:417 Vincent JL, Acta Anaesth Scand, 1995;39 [Suppl107]:261

Blunt Head Trauma

Lactate
Metabolism
Cul-de-sac product of glycolysis Pyruvate + NADH + H LDH Lactate + NAD A marker of global tissue perfusion [or its lack] Produced esp in gut, brain, skin, muscle, RBC 15 to 20 mEq / kg / day produced normally
Reutilization keeps level @ 0.7-1.3 mEq/L Metabolism Liver 50% Kidneys 25%-30% RBCs
Vincent JL, Acta Anaesth Scand, 1995;39 [Suppl107]:261

Lactate and the Krebs Cycle

[P:L usually ~ 10:1]

Stimulated by DCA

Gluconeogenesis via Cori Cycle

Organ Perfusion in Critically Ill Patients

Lactic Acidosis : general considerations

DO2 = CO X CaO2 LA is not associated to hypoxemia unless CO is limited

LA is not associated to acute anemia unless Hgb level is below 7g / dl

CO is redistributed in more vital organs that can increase O2 extraction

Vincent Acta Anaesthesiol Scand 1995;39(suppl 107): 261-6

O2 Debt, Lactic Acid & Survival Rate

LD50 ~ 4 LD90 ~ 8

Vincent Acta Anaesthesiol Scand 1995;39(suppl 107): 261-6

Organ Perfusion in Critically Ill Patients

Lactic Acid in 48 patients in septic shock

*
DO2
S = surviving, 56% NS = non-surviving, 44%

VO2

Lactic Acid
Bakker Chest 1991;99:956-62

Organ Perfusion in Critically Ill Patients

Dichloroacetate to treat lactacidemia and survival

N = 252 ~ 60% Septic shock 36% to 40% Hem / Cardio shock Mortality 53% to 56%

Stacpoole N Engl J Med 1992;327:1564-9

 Potential limitations of LA measurement

Liver failure Washout phenomenon Global vs regional tissue perfusion Other causes of elevated lactate Huckabee / Cohen and Woods list
Biguanide intoxication Fructose infusion Inborn errors of metabolism Neoplastic disease Alcohol intoxication Malnutrition Decompensated DM

O2 Debt, Lactic Acid & Survival Rate

An obsolete system

Mixed hypoxic / metabolic problems

Vincent JL, in Tobin et al, Chapt 23 Vincent JL, Acta Anaesth Scand, 1995;39 [Suppl107]:261

Organ Perfusion in Critically Ill Patients

Supranormal DO2
Shoemaker Arch Surg 1990;125:1332-1338 Tuchschmidt Chest 1992;102:216-220 mixed pts Boyd JAMA 1993;270: 2699-0 7 septic and SIRS Fleming Arch Surg1992;127:1175-79 trauma Yu Crit Care Med 1998;26(6): 1011-9 Bishop J Trauma 1995;38:780-87 review Gattinoni N Engl J Med 1995;333:1025-32 Berlauk Ann Surg 1991;214: 289-97

Hayes NEngl J Med 1994;330:1717-22 Heyland Crit Care Med 1996; 24:317-324

GOHT: DO2 as Endpoint Criteria Goals

Critically ill, septic shock, ARDS, med-surg patients RCT, N = 100 consecutive patients, + PAC

CI > 4.5, DO2I > 600, VO2I > 170 Fluid, Hgb for Starling curve Then entry if < 3 goals met Rx: Dopa 2, Dobut 5-200 mcg/kg/min for goals, NE for BP Ctrl: Dopa 2, Dobut if CI < 2.8, NE for BP
Hayes et al, NEJM, 1994;330:1717

GOHT: DO2 as Endpoint

Group/Outcome
N= Age [median] APACHE [median] 50 64 18

Control
50 62 18

Treatment

Mortality*
ICU LOS [median] Hosp LOS [median]

34%
10 24

54%
10 19

Who uses 200 mcg / kg / min of dobutamine ?

BUT: Survival of patients [inc. unrandomized, N = 9] who achieved target goals [31/33] was 94%
Hayes et al, NEJM, 1994;330:1717

 Criteria

GOHT: DO2 as Endpoint

> 50 yoa SIRS / sepsis / severe sepsis / septic shock / ARDS Two subgroups: 50 to 75 & > 75 yoa RPCT, N = 105 patients

Goals

Protocol Grp: DO2I > 600 Control Grp: DO2I 450 to 550 Within 24 hrs of Dx or PAC placement Maintained while PAC in place or until disease improved Exclusion Criteria: pre-met protocol goal, DNR, Rxed by nonstudy MD for > 24 hrs after PAC, 1 MD denied
Yu et al, CCM, 1998;26:1011

GOHT: DO2 as Endpoint Interventions:

Treated to SBP > 100 torr, UOP > 50 mL/hr, SvO2 > 65%, & randomized DO2I Therapy to achieve these: PCWP 15-18

Elevated SVRI = Afterload reduction Dobut or Dopa 3 to 20 Amrinone 750 mcg/kg bolus, then 5 to 20 Epi / NE titrated to BP or CO
Or until HR > 120 or 10% above baseline, if baseline > 120 bpm

Xlloid/colloid, PRBC if Hgb < 12 gm/dL

Yu et al, CCM, 1998;26:1011

GOHT: DO2 as Endpoint

50-75 yoa Protocol [n = 43] 469 + 146 126 + 38
[22]
c

Initial DO2Ia Initial VO2I

[n = b]

50-75 yoa Control [n = 23] 450 + 90 118 + 29

[13]

>75 yoa Protocol [n = 21] 453 + 112 108 + 34

[9]

>75 yoa Control [n = 18] 420 + 118 88 + 25

[12]

Initial Lactate 24 hr DO2I 24 hr VO2I

[n = b]

2.5 + 1.7 594 + 111d 116 + 28

[25]

2.2 + 1.4 534 + 95d 116 + 23

[12]

3.4 + 2.3 584 + 162d 93 + 13

[10]

3.7 + 2.8 468 + 84 95 = 21

[12]

24 hr Lactate

1.8 + 1d

1.5 + 0.9

2.1 + 0.08d

2.3 + 1.7

a: DO2I, VO2I are in mL/min/m2. b: numbers smaller due to technical restrictions. c: in mM/L. d: initial versus 24 hr measurements p < 0.05

Yu et al, CCM, 1998;26:1011

GOHT: DO2 as Endpoint

50-75 yoa Protocol [n = 43] Mortality [%] 9 [21]a MOD Mortality [%] PAC Days Ventilator Days ICU Days Hospital Days 7 [16]a 15 + 14 21 + 28 28 + 36 51 + 59 50-75 yoa Control [n = 23] 12 [52] 11 [48] 16 + 20 16 + 16 27 + 34 44 + 46 >75 yoa Protocol [n = 21] 12 [57] 10 [48] 10 + 7 14 + 13 15 + 13 24 + 19 >75 yoa Control [n = 18] 11 [61] 10 [56] 12 + 7 15 + 18 17 + 9 28 + 27

a: Protocol compared to Control, p < 0.05

Yu et al, CCM, 1998;26:1011

What About: Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic ShockStarting in the ED ?

Early GOHT
Early Goal-Directed Therapy (EGOHT)
Involves adjustments of Cardiac preload, afterload, contractility to balance O2 delivery with O2
demand

Purpose

Study Design

Evaluate the efficacy of EGOHT in ED patients With severe sepsis or septic shock (prior to ICU admission) PRC, partially blinded, single center trial

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368.

EGOHT
Inclusion:
Meet 2 of 4 SIRS Criteria AND Unresponsive shock SBP < 90 mm Hg
After fluid challenge 20 to 30 ml/kg over 30 min period OR

Blood lactate concentration > 4 mMol / L

Exclusion:

< 18 years, pregnant, acute CVA, ACS, acute pulmonary edema, status asthmaticus, dysrhythmias, active GIB, Sz, OD, TI, trauma, emergent surgery, uncured cancer (during chemotherapy), immunosuppression, DNR status
Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT
Protocol
263 patients enrolled 133 standard; 130 EGOHT

All patients received CVP & A-line Standard:

CVP 8 to 12, pressors to keep MAP > 65 mm Hg and UOP 0.5 ml/kg/hr

EGOHT:
As above + (continuous ScvO2 monitoring in ED) RBCs for Hct < 30% & ScvO2 < 70%

Dobutamine added for failure Titrate to 20 ug/kg/min

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT
Patient Randomized Early Goal-Directed Therapy Standard Therapy

CVP > 8-12 mm Hg CVP > 8-12 mm Hg MAP > 65 mm Hg MAP > 65 mm Hg Urine Output > 0.5 ml/kg/hr Urine Output > 0.5 ml/kg/hr ScvO2 > 70% SaO2 > 93% Antibiotics given at discretion of Hct > 30% treating clinicians

At least 6 hours of EGOHT

Transfer to ICU
ICU MDs blinded to study treatment

As soon as possible

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT
Results: Treatments Received in Initial 6 hours

Fluids (mL, mean)

Standard Therapy
3500 19

EGDT

5000 RBCs (% patients) Pressor (% patients) 30 Dobutamine (% patients)

64 27 14

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT Patients: More Fluids, RBCs & Dobutamine (Initial 6 Hours of Treatment)
6000 5000
Percent of Patients

75%

4000 3000 2000 1000 0 Fluids in mL (mean)

50%

25%

0% RBCs
Pressors

Dobutamine

EGT Traditional
Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT
Results (initial 6 hours)
Vital Signs / Resuscitation End Points:
No significant difference mean HR, CVP, lactate concentrations, or pH values MAP significantly lower in Traditional Therapy group, P < 0.001
But all patients met goal of > 65 mm Hg

ScvO2 of > 70% was more frequently met by EGOHT patients, P<0.001 Combined goals for CVP, MAP, & UOP Achieved by more EGOHT patients, P<0.001
In traditional Therapy group

ScvO2 lower (P < 0.001) BD greater (P=0.006)

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT
Results (7 to 72 hours)
Vital Signs / Resuscitation End Points:

Compared to EGOHT, TT patients had:

Higher heart rate (P=0.04) Lower MAP (P<0.001) Lower ScvO2 (P<0.001) Higher LA concentration (P=0.02) Greater BD (P<0.001) Lower pH (P<0.001)

Both groups had similar CVP (P=0.68)

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT
Results (7 to 72 hours)
Disease Severity: APACHE II, SAPS II, & MODS
Significantly higher in TT than EGOHT patients (P<0.001 for all comparisons)

Coagulation Parameters:

TT compared to EGOHT patients:

Higher PT (P=0.001) Fibrin-split products concentration (P<0.001), D-dimer levels (P=0.006)

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT Results: 28 Day Mortality

60 50 40 30 20 10 0 49.2%

P = 0.01*
33.3%

Standard Therapy n=133

EGDT n=130

Key difference was in sudden CV collapse, not MOSF

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

The Importance of EGOHT for Septic Shock

EGOHT* in patients
with severe sepsis produced:
42% in RR of inhospital and 28-day mortality (P=0.009, P=0.01) 33% in RR of death at 60 days (P=0.03)
80 70 60 50 40 30 20 10 0
In-hospital mortality (all patients) 28-day mortality 60-day mortality

NNT to prevent 1

event (death) = 6 to 8

EGT Standard Therapy

*Aggressive resuscitation begun in emergency department

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

EGOHT: Mortality Results

TT (n = 133) n (%) In Hospital All patients Severe sepsis Septic shock 28-day 60-day 59 (46.5) 19 (30.0) 40 (56.8) 61 (49.2) 70 (56.9) EGOHT (n = 130) n (%) 38 (30.5) 9 (14.9) 29 (42.3) 40 (33.3) 50 (44.3) 0.58 0.46 0.60 0.58 0.67 0.009 0.06 0.04 0.01 0.03 RR P-value

Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

GOHT: DO2 as Endpoint

Conclusions:
Ultra-high doses of inotropes may be unwise At least to 75 yoa EGOHT improves overall mortality Increasing DO2I in first 24 hrs decreased ICU mortality In > 75 yr group Increasing DO2I did not increase survival
Unclear whynumbers of patients studied ?

EGOHT (Rivers) High TT mortality.why ?

Inadequate resuscitation ?
Yu et al, CCM, 1998;26:1011 Hayes et al, NEJM, 1994;330:1717 Rivers E, Nguyen B, Havstad S, et al, N Engl J Med 2001;345:1368

GSW Head

Organ Perfusion in Critically Ill Patients

Gut Barrier Failure and MOSF

Sentinel organ for early ischemia

Unlike lactate and BD...
Global markers of tissue perfusion

pHi is marker of regional blood flow Gut mucosal tissue

Among first affected in shock Last restored with resuscitation

Ischemia / reperfusion injury Bacterial translocation, MSOF

Organ Perfusion in Critically Ill Patients

Gastric Tonometry
CO2 freely diffuses in tissues PCO2 in balloon in equilibrium with mucosal PCO2 Arterial HCO3- = mucosal HCO3pHi = 6.1 + (log [HCO3-] / mucosal PCO2)

PHi - pHa gap

PtCO2 - PaCO2 gap

Organ Perfusion in Critically Ill Patients

Shock Mesenteric ischemia Malnutrition Trauma Sepsis
Gut Bacterial Translocation and MOSF

MOSF

Translocation

Organ Perfusion in Critically Ill Patients

Gastric tonometry Normal individuals CRF individuals

pHi = 7.38 + 0.06 pHa = 7.37 + 0.04 pHi - pHa gap = 0.02 + 0.01 PtCO2 - PaCO2 gap = 8 to 10 mm Hg

pHi = 7.20 + 0.17 pHa = 7.41 + 0.17 pHi pHa gap = 0.16 + 0.19 PtCO2 PaCO2 gap = 17 + 15

Diebel Surgery 1993;113:520-6

Organ Perfusion in Critically Ill Patients

pHi vs PtCO2
PHi vs intamucosal electrodes in septic pigs pHi - pHa gap vs PtCO2 - PaCO2 gap in humans

PCO2
pHi

electrode pHi

pH
Antonnson Am J Physiol 1990;259:G519-23

Bernardin Intens Care Med 1999:269-73

Organ Perfusion in Critically Ill Patients

Gastric tonometry and cardiac surgery
8

Change in pHi Change in pH

0 pre CPB after CPB

Gardeback Acta Anaesth Scand 1995;36:313-6 Gardeback Acta Anaesth Scand 1955;39:1066-70

Organ Perfusion in Critically Ill Patients

What is the best site of monitoring in the gut ?

R2 for gut ischemia

Stomach 0.29 + 0.52 Small bowel 0.76 + 0.25 Colon ??

control hypovolemic shock

SMA occlusion min

Tonometric probe in terminal ileum

Walley J Appl Physiol 85(5);1770-7, 1998

Schlichting CCM 1995; 23:1703-1710

Organ Perfusion in Critically Ill Patients

Gastric tonometry and intra / postoperative monitoring
40

30

% of Patients

20

pHi < 7.32 pHi > 7.32

10

0 ICU mortality at 72 h

Mythen Intens Care Med 1994;20:99-104

Gys CCM 1988;16:1222-4

Organ Perfusion in Critically Ill Patients

Gastric tonometry and intra / postoperative monitoring
5

Days

3
pHi < 7.32 pHi > 7.32

$ 13,267 $ 5,811
pHi Groups

ICU length of stay & cost

Mythen Intens Care Med 1994;20:99-104

Organ Perfusion in Critically Ill Patients

Gastric tonometry and trauma

pHi < 7.32

pHi > 7.32

MOSF ratio ICU stay Mortality ratio

5.4 46 4.5

1
13

Roume J Trauma 1994;36:313-6

Kirton Chest 1995;39:1066-70

Organ Perfusion in Critically Ill Patients

Gastric tonometry and weaning from mechanical ventilation

Mohsenifar Ann Int Med 1993;119:794-798

Organ Perfusion in Critically Ill Patients

Gastric tonometry and clinical correlation

Prospective, academic institution, 25 Pts., 76% blunt injury

4 Surgical Attendings guess pHi Based upon:

Clinical evaluation, CI, DO2, VO2, MAP or MPAP, stroke volume index, PWP, CVP, SVO2

pHi of 7.35 cut off point

pHi clinically overestimated 42% of the time
Santoso Eur J Surg 1998; 164: 521-526

pHi
Objective
Compare Global with regional resus indicators in moderate
trauma

Criteria
Prolonged / substantial hypotension in ED or OR ISS > 25 Initial BD < - 5mM / L or lactate > 4 mM / L Excluded if exsanguinating within 24 hrs of Ivatury et al, J Am Coll Surg, 1996;183:145 admit

pHi
Goals
Group I: pHi > 7.3 PCWP to 18, Hct to 35%, dobutamine as needed
pHi kept in range

Intra-abdominal complications treated as appropriate Group II: DO2I > 600 & / or VO2I > 150 pHi placed, numbers not calculated until study end Both groups received LD dopamine

Outcome Measures
Survival [D/C from hospital] Incidence of MSOF
Ivatury et al, J Am Coll Surg, 1996;183:145

pHi
Group I: pHi
N = 30

Group II: DO2I

N = 27 714 + 167 171 + 35 4.7 + 1.2 74.1 + 7.2 - 4.6 + 3.9 2.1 + 1.4 7.29 + 0.22 23.3 + 13.2 24.3 + 38.4 23.6 + 18.6 25.2 + 14.9

Values at 24 hrs
DO2I [n = 56] VO2I [ n = 56] CI [n = 54] SvO2 [n = 57] BD [n = 52] Lactate [n = 49] pHi [n = 55]* 684 + 173 178 + 47 4.5 + 1.4 72.7 + 9.6 - 0.6 + 3.6 2.2 + 1.5 7.39 + 0.13 22.6 + 13.9 16.4 + 12.1 18.5 + 12.4 24.4 + 19.6

Optimization Times [hr]

Lactate < 2.5 DO2I > 600 VO2I > 150 pHi > 7.3 BD > - 2
* p = 0.03

Ivatury et al, J Am Coll Surg, 1996;183:145

pHi
Outcomes
Neither primary endpoint significant Subgroup analysis pHi optimized by 24 hrs vs not optimized [all patients]

No correlation between regional [pHi] and global indices of

tissue perfusion
BD: r = 0.46 DO2I: r = 0.12 SvO2: r = 0.21 Lactate: r = - 0.32
Ivatury et al, J Am Coll Surg, 1996;183:145

Mortality: 3/44 [6.8%] vs 7/13 [53%], p = 0.006

pHi
Objective
Relationship between pHi and morbidity / mortality At 24 hrs, unstable trauma patients acutely resuscitated in
ICU

Criteria

PR consecutive series Retrospective data analysis N = 19, APACHE II > 15, ISS > 15 Blinded pHi monitoring, patients resuscitated with PAC pHa < 7.35, BD < - 2.3 mM/L, lactate > 2.3 mEq/mL
Kirton et al, Chest, 1998;113:1064

pHi
Measured Outcome
ISS / APACHE II SOI scoring systems CI, DO2I, VO2I, pHa, BE, Lactate, pHi, mortality

NS: APACHE II, ISS, pHa, BE, CI, DO2I, VO2I at 24 hrs pHi < 7.32 vs pHi > 7.32 Mortality: 50% vs 11%, 2 p = 0.07 MSOF: 60% vs 11%, 2 p = 0.03 ICU Stay: 46 + 15 vs 13 + 9 days, p < 0.01
Kirton et al, Chest, 1998;113:1064

pHi
Implications
pHi < 7.32 at 24 hrs of resuscitation Highly sensitive for death

Highly sensitive for MSOF

83% sensitive, 61% specific

Risk: 4.5 for death, 5.4 for MSOF

86% sensitive and 66% specific

Significantly different than pHi > 7.32, p < 0.01

Lactate > 2.3 mM / L at 24 hrs of resuscitation Risk: 3.0 for death and 3.6 for MSOF
Kirton et al, Chest, 1998;113:1064

Whats It All Mean, Mr. Natural ?

Key is resuscitation
Tools are a means to get there

More invasive tools = better chance to get

there
But more risk

Proposed algorithm for resuscitation

Resuscitation Stepped Algorithm*

Phase 1 Phase 2 Phase 3 Phase 4

(ACS-COT Criteria) (ACS-

pHi > 7.35 or gradient < 10 Blood Lactate in normal range

SsvcO2 > 70% LidCO CardioQ (Doppler US CO) Other CCO Less Invasive

PA Catheter

SBP > 90 mm Hg Pulse < 100 Respirations 14 to 20 Mental Status: Oriented x 3 UOP > 30 mL / hour
*Proposed

Base Deficit < 4

Whats It All Mean. ?

Pressors
Only a means to keep BP until resuscitation complete

Problems with Anesthesia..

Physiology
Vasodilation IAA and regional agents Negative inotropic state IAA Altered regional blood flow: Peripheral vasodilation with evaporative heat / fluid loss Decreased GFR 2 altered RBF Altered ADH, ACTH, aldosterone release Third space losses Aggressive resuscitation may result in fluid overload
Ratner & Smith, Surg Clin NA, 1993;73:229

Causing Perioperative Problems

Weight gain (5-10 kg) & systemic edema
Decreased chest wall compliance Decreased mobility & skin breakdown Impaired wound healing 2 decreased PtiO2 GI tract edema Ileus Intolerance of enteral nutrition In presence of TBI / CNS pathology Cerebral / spinal cord edema
Ratner & Smith, Surg Clin NA, 1993;73:229 Joshi, Anesth Analg, 2005;101:601-605

Causing Perioperative Problems

Systemic edema may ultimately result in:
Increased ICU LOS Need for dialysis Prolonged MV days Increased total hospital days & cost

Support for Less Aggressive IOR ?

90 ASA-PS I-III Major Elective Surgery, Adult
Randomized to colloid versus crystalloid Same anesthetic technique HS-NS, HS-BSS, LR Resuscitated to endpoints: Volumes:

UOP < 0.5 mL / Kg/ min SBP < 90 mmHg / 20% below baseline HR > 110 / > 20% above baseline 1301 / 1448 / 5946 mL for HS-NS / HS-LR / LR Nausea (p = 0.007), Nausea severity (p = 0.003) Vomiting (p = 0.01), Antiemetic use (p = 0.005) Severe pain (p = 0.005), Periorbital edema / Diplopia (p= 0.003)

Colloid group had less:

Moretti, et al, Anesth Analg. 2003;96:611-617

Support for Less Aggressive IOR ?

Transthoracic Esophagectomy, N = 112
Retrospective, non-randomized Restrictive versus non-restrictive fluids Crystalloid 4-5 mL / kg / hr to a fluid balance:

Same anesthetic technique [combined] Same demographics & surgical duration Outcome:
IO Fluid Balance: 749 vs 2386 mL Decreased pulmonary complications & LOS

[Fluid + Blood] [UOP + Blood loss] = 1-2 mL / kg / hr, CVP < 5

Joshi, Anesth Analg, 2005;101:601-605 Kita, et al, JCA 2002;14:252-256

Kita, et al, JCA 2002;14:252-256

Support for Less Aggressive IOR ?

48 consecutive SICU Patients
Three groups of increased BW evaluated: < 10% 11% - 20% > 20% Based upon % increase in BW from preoperative weight Mortality:

Vasopressor Use

< 10% BW: 10.3% versus > 10% BW: 31.6% (p < 0.0008) < 10% BW: 3.6 days versus > 10% BW: ~ 17 days (p < 0.04)

Lowell, et al. CCM 1990;18:728-733

What Does It All Mean ?

Careful resuscitation
Utilizing appropriate endpoints CVP BE Lactate pHi GOHT Can help prevent fluid overload Resulting in improved outcome

Hurricane Katrina 2005

Only One Thing Is Truly Inexcusable

Incompetence