The High Risk Patient Contents Perioperative Optimisation + oxygen delivery

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The High Risk Patient Contents Perioperative Optimisation + oxygen delivery

Bluefield State College, US has reference to this Academic Journal, Perioperative Optimisation + oxygen delivery Rob Stephens PACU Study Day Feb 22 2010 PACU Contents High risk surgery O2 O2 delivery + consumption Postoperative physiology Postoperative O2 delivery + consumption ?Optimisation? POM-O & Optimize The High Risk Patient Perioperative mortality is 80% postoperative deaths

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Patient factors; eg ASA Score 1 A normal healthy person 2 A patient alongside mild systemic disease 3 A patient alongside severe systemic disease that is not incapacitating 4 A patient alongside incapacitating disease that is a constant threat so that life 5 A moribound patient who is not expected so that live 24 hours alongside or without surgery E An emergency operation ?mortality Hypertension, DM COAD alongside moderate ex tolerance COAD or severe angina alongside poor ex tolerance Combined scores; eg RCRI High-risk surgery (i.e., intraperitoneal, intrathoracic, vascular) Coronary artery disease Congestive heart failure History of cerebrovascular disease Insulin treatment in consideration of diabetes mellitus Preoperative serum creatinine level >180 ?moL Very low 0 0.4 II. Low 1 0.9 III. Moderate 2 6.6 IV. High 3 + 11.0 Procedure Factors Body cavity entered eg laparotomy Blood loss Length of procedure Emergency/urgent vs elective/scheduled

Oxygen needed in consideration of cells so that perform ?work? + live only a few seconds of stored 02 surgery causes cells so that need more 02 early- immediately postoperative phase ?.Do patients that can give their cells more 02 ?do better C6H12O6 + 6O6 -> energy + 6H2O + 6CO2 ATP Oxygen Delivery DO2 The amount of oxygen delivered so that the tissues per minute DO2 = 1.34 x Hb x SaO2 100 DO2 = (HR x SV) x 1.34 x Hb x SaO2 100 Cardiac Output Arterial Oxygen content X CaO2 CO HR x SV Oxygen Consumption VO2 Total amount of oxygen consumed /taken up by the tissues per minute VO2 = CO x (CaO2 ? CvO2) OER = VO2 CI = CO/body surface (Oxygen extraction ratio) DO2 area Arterial Oxygen content Mixed Venous Oxygen content Cardiac Output

Today?s Topics: T. A second look at contradictions P AND ? P = Contradiction Example 1 Some useful notation Example 1 Example 1 Example 2 Example 2 Example 2 Example 2 Example 3 Lemma 1 Lemma 2

Oxygen Consumption VO2 Total amount of oxygen consumed or taken up by the tissues per minute Can measure in breath: O2 in ? O2 out Exercise mimics perioperative ?stress? As body tries so that increase DO2 CPEx Exercise test: VO2 Shoemaker et al : high risk patients who survived surgery exhibited certain higher haemodynamic variables: CI > 4.5l/min/m2 DO2I > 600ml/min/m2 VO2I > 170ml/min/m2 Mechanism ?: surgery causes cellular hypoxia Patients who can ? oxygen delivery; ? cellular hypoxia ?survival Oxygen Delivery: observation

Prospective randomised, controlled trial (Shoemaker et al, 1988) CVP control PAC control PAC protocol CI > 4.5l/min/m2 DO2 I > 600ml/min/m2 VO2I > 170ml/min/m2 23% 33% 4% mortality mortality mortality Oxygen Delivery: intervention Prospective randomised, controlled trial (Pearse et al, 2005) LIDCO control LIDCO protocol 68% 44% Complications Complications Stay 14 days stay 11 days Oxygen Delivery: intervention Goal Directed Therapy (GDT) Using therapeutic goals so that guide management of oxygen delivery in high risk patients Shoemaker et al, conducted the 1st outcome trial of GDT Other studies confirmed that GDT improved survival in high risk patients (eg Singer + Mythen) GDT has limitations Only beneficial in early ?shock? /postop/ intraoperative Not beneficial in addition to possibly harmful in ?late? shock

Oxygen Delivery DO2 The amount of oxygen delivered so that the tissues per minute DO2 = 1.34 x Hb 100 x SaO2 X CaO2 CO x SV HR Fluid Inotropes ? Transfuse Fi02 ?Adequate ventilation Be careful! Controversial Role of Inotropes in GDT Some patients achieve their target ?goals? alongside fluids alone Wilson et al showed that mortality was reduced (3% vs. 17%) when dopexamine or adrenaline are titrated so that achieve target goals Dopexamine reduces complications in addition to hospital stay compared so that epinephrine Inotropes can be harmful PACU + GDT Although GDT: small studies successful Does it work in the real world? 2 Studies coming so that you?? Post Operative Morbidity Oxygen Optimisation POM-O OptimiZe

OptimiZe Rupert Pearce RLH + Kathy Rowan ?ICNARC? Multi centre Different surgery types/ anaesthetists / ICU?s etc Run from ?ICNARC? Intensive Care National Audit & Research Centre 600 patients OptimiZe Single blinded RCT ? 2 groups standard & intervention ?Standard? Commonly agreed goals eg SaO2 94%, Hb>8?10 g/dl, temperature 37 øC, heart rate 90 mins And 1+ of Urgent / emergency surgery Renal impairment (serum creatinine 130 ?mol/l) Risk factors in consideration of CVS/RS disease (see protocol) Exclusion criteria .includes Acute MI/ Pulmonary Oedema/ Septic shock Decline consent, pregnant

OptimiZe % patients developing post?operative complications within 28 days of surgery Duration of hospital stay Post?operative critical care free days Day 8 Post?operative morbidity survey in consideration of in patients ?POMS? Day 28 Infectious complications Mortality Quality of life (EQ5D health status ) Day 180 Quality of life (EQ5D health status ) Mortality Summary High risk patients account in consideration of >80% of postoperative death Scoring systems can be used so that identify high risk patients Goal directed therapy reduces mortality, but needs so that be started early Inotropes should be used when patients cannot achieve their target goals alongside fluids alone Ensure adequate Sa02 in addition to ?transfusion -Hb should be considered Studies coming so that you soon! The Oxygen Consumption in addition to Delivery Relationship in Health 200 100 B C A Critical DO2 400 800 1200 Oxygen consumption (VO2) (ml/min) Oxygen delivery (DO2) (ml/min) Adapted from Thorax 57 (2):170, Leech in addition to Treacher OER = VO2 DO2 DO2 supply independent DO2 supply dependent

The Oxygen Consumption in addition to Delivery Relationship in Critical Illness 200 100 B C A Critical DO2 D E F 400 800 1200 Oxygen consumption (VO2) (ml/min) Oxygen delivery (DO2) (ml/min) Adapted from Thorax 57 (2):170, Leech in addition to Treacher OER = VO2 DO2 References Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845-50

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