1. Do we need CO monitoring for ERAS Protocols?
Dr. Timothy Miller
Associate Professor of Anesthesiology
Chief, Division of General, Vascular and Transplant Anesthesia
Duke University Medical Center
President Elect,
American Society for Enhanced Recovery

2. Disclosure Consultant and research funding - Edwards Lifesciences
Consultant - Cheetah Medical
Advisory board - Baxter

3. Goals of fluid therapy Maintain central euvolemia
Avoid salt and water excess

4. Adapted from: Bellamy, BJA 2006
The Challenge
Volume Load
OPTIMAL
Edema
Organ Dysfunction
Adverse outcome
Hypoperfusion
Overloaded
Hypovolemic
BOWEL
ISCHEMIA
BOWEL WALL EDEMA
Complications
Adapted from: Bellamy, BJA 2006

5. Brandstrup “Restriction” Study - liberal fluid use causes harm*
Complications * % *
The study group observed a dramatic reduction in perioperative complications, both major, minor, as well as total. This included significant differences in tissue healing and cardiopulmonary complications.
Brandstrup. Ann Surg. 2003; 238:241-8

6. A rational approach to fluid therapy1
Maintenance
Amount
Preoperative deficits
The deficit after usual fasting is low
Insensible perspiration
The basal fluid loss via insensible perspiration is approximately 1ml/kg/h during major abdominal surgery
Third space
A primarily fluid-consuming third space does not
exist
Urine Output
Should be replaced
Volume
Amount
Plasma losses from the circulation due to fluid shifting of acute bleeding
Timely replacement with an iso-oncotic colloid via a goal-directed approach
1. Chappell D, Jacob M, Hofmann-Kiefer K, et al. A Rational Approach to Perioperative Fluid Management. Anesthesiology. 2008; 109:

7. Goal-Directed Fluid Therapy

8. GDT reduces complications
OR 0.44 [ ] p<
Anesth Analg 2011;112:1392–402

9. A minimally invasive cardiac output monitor should be considered in all major surgery
Anesth Analg Jun;112(6):1274-6

10. NICE Guidelines
March 2011
Compared with conventional clinical assessment (with or without invasive cardiovascular monitoring) the Esophageal Doppler is associated with reduced:
postoperative complications
use of central venous catheters
in-hospital stay
The case for adopting it in the NHS is supported by the evidence
NOTES FOR PRESENTERS:
Guidance in full:
The case for adopting the CardioQ-ODM in the NHS, when used as described on the next slide (Guidance 2), is supported by the evidence. There is a reduction in postoperative complications, use of central venous catheters and in-hospital stay (with no increase in the rate of re-admission or repeat surgery) compared with conventional clinical assessment with or without invasive cardiovascular monitoring. The cost saving per patient when the CardioQ-ODM is used instead of a central venous catheter in the perioperative period, is around £1100, based on a 7.5-day hospital stay.
Additional information
Clinical outcomes relevant to using the CardioQ-ODM are mortality, perioperative complications, reductions in the use of central venous catheters, length of critical care and in-hospital stay and re- admission rates.
Image: showing the CardioQ-ODM monitor and probe. Image reproduced with kind permission of Deltex Medical Group plc.

11. The world changes quickly……..

12. What is Enhanced Recovery?
Evidence-based multidisciplinary care pathway aimed at:
Reducing dip in function to facilitate recovery
Reducing length of stay and complications
Reducing cost
Improving the quality of care
Increasing value = quality/cost
Reducing variability

13. Unwanted variation Differences that cannot be explained
by illness, medical need, or the dictates
of evidence-based medicine.
BMJ Qual Saf 2011;20: 36-40

14. Duke Enhanced Recovery Pathway
Preoperative
Intraoperative
Postoperative
Identify patients
Antibiotics before incision
Early feeding
Educate about program
Thromboprophylaxis
Early mobilization
Screen for malnutrition
Minimally invasive surgery (if possible)
Early removal of urinary catheter
Smoking cessation
Multimodal analgesia
No NG tube or drains
Selective bowel preparation
Regional anesthesia
Optimize fluid regimen
Encourage clear fluids until 2 hours before surgery
Avoidance of salt and water overload
Optimize analgesia regime
Carbohydrate drink
Goal Directed Fluid Therapy
Stimulation of gut motility

15. Duke Inpatient Colectomy Data Continued improvement!!
Principal Procedure: 1731,1732,1733,1734,1735,1736,1739,4503,4526,4541,4549,4552,4571,4572,4573,4574,4575,4576,4579,4581,4582,4583,4592,4593,4594,4595,4603,4604,4610,4611,4613,4614,4643,4652,4675,4676,4694
-3 ERAS surgeons only
-2013 Readmits only Jan-Mar (denom=52, cost only Jan-Mar too)
-ALOS is 4-5 days less than non ERAS colorectal surgeons
-dUHs system readmits
Run date 8/19/13

17. Enhanced Recovery Outcome studies
WMD = weighted mean difference, RR = relative risk, “--" = not reported,
NS = not significantly different, denoting safety.
*Meta-analyses of RCTs only
**Systematic review including non-RCTs
*** Standardized mean difference now WMD
Holubar, Miller. ASER Manual, unpublished

18. Does GDT offer any advantage over a restrictive fluid protocol within an Enhanced Recovery pathway?

19. Conceptual model of perioperative fluid changes and fluid therapy
Minto, Scott, Miller. Anesthesiology Clinics ; 33:35-4

20. Major abdominal surgery with EBL > 500 ml
RCT, 100 patients
Major abdominal surgery with EBL > 500 ml
No ERAS - All patients were fasted and received bowel prep, no laparoscopic surgery, no early feeding
Intraoperative ED-guided GDT vs. Control
GDT group : 10% algorithm with esophageal doppler
Control group: standard care (blinded to ED)
Gan Anesthesiology 2002; 97:820-6

21. Elective open or laparoscopic colectomy
RCT, 85 patients
Elective open or laparoscopic colectomy
ERAS protocol: No routine bowel prep, CHO drink, Thoracic Epidural, Early mobilization and feeding
Intraoperative EDM-guided GDT vs. Control
Fluid “restriction” or zero balance group: max 1500ml crystalloid and 500ml colloid
GDT group: max 1500ml crystalloid (baseline fluid restriction) + 10% algorithm with esophageal doppler
Blood loss could be corrected for in a 1 : 1 ratio using colloid,
Srinivasa 2013; 100: 66-74

22. Gan vs. Srinivasa Gan Type of surgery Major abdominal
All open. No ERAS. Fasted. Bowel prep.
Total fluid in GDFT group
5420
Total fluid in control group
4775
Change in FTc during surgery
Increased in GDFT group
Intraoperative SV during surgery
Outcome
Reduced postop ileus (5 days vs 3 days)
Reduced LOS (7d vs 5d)
Srinivasa
Colorectal within ERAS
Some laparoscopic
No bowel prep. CHO drink
1994
1614
No change
Miller TE, Mythen. CJA. 2015; 62:

23. 734 medium to high-risk patients
Multicenter RCT
734 medium to high-risk patients
Primary outcome - composite of postoperative complications and mortality
Outcome
GDT
Usual care
P-value
Primary outcome
134 (36.6%)
158 (43.4%)
0.07
Mortality at 180d
7.7%
11.6%
0.08
OPTIMISE. JAMA 2014; 311:

24. GDT meta-analysis - complications
OR 0.77 ( )
p < 0.001
OPTIMISE. JAMA 2014; 311:

25. So where are we now with GDT?

26. GDT within ERAS ERAS has made fluid management easier
Carb-loaded, hydrated patient
Laparoscopic surgery
Small, single center studies - harder to show benefit
Control group management improved
Laparoscopic surgery makes GDFT more complicated
OPTIMISE - reduction in complications, underpowered
No evidence that GDFT causes harm
Complications are expensive!

27. Economic burden of complications
University HealthSystem Consortium (UHC), 2011
In-hospital mortality, hospital length of stay (HLOS) and direct costs were compared between patients with one or more complications (with) and patients without any complications (without).
Manecke, Critical Care 2014, 18:566

28. We are getting better at what we do (in the literature, but are does this apply to the real world)

29. Intra-abdominal procedures 2009-2012
Over 5000 patients
Intra-abdominal procedures
No departmental guidelines on fluid administration
Lilot BJA, doi: /bja/aeu452

30. Strongest predictor for the amount of crystalloid
given was THE ANESTHESIA PROVIDER
Regression modeling - strongest predictor for the rate of crystalloid infusion - anaesthesia provider
At UCI, the lowest provider mean corrected crystalloid
volume was 2.3 and the highest was 11.8.
At VU, the lowest provider mean corrected crystalloid volume
was 2.9 and the highest was 14

31. Can we just use a restrictive approach??

32. Adapted from: Bellamy, BJA 2006
The Challenge
Volume Load
OPTIMAL
Edema
Organ Dysfunction
Adverse outcome
Hypoperfusion
Overloaded
Hypovolemic
BOWEL
ISCHEMIA
BOWEL WALL EDEMA
Complications
Adapted from: Bellamy, BJA 2006

33. DOS fluid volumes and outcomes
Premier database
Over 100,000 patients
Low < 1.7L DOS fluids
High > 5L DOS fluids
Thacker. Ann Surg 2016; 263:502-10

34. Nearly 100,000 patients
MGH
Shin. Annals of surgery. 2017, epub ahead of print

35. Which patients? A risk-adapted matrix to match monitoring needs to patient and surgical risk
Miller TE, Mythen. CJA. 2015; 62:

36. Summary Fluid management is generally still chaotic
Wide variability in practice
Too little fluid
Too much fluid, esp. crystalloid
Liberal fluid use is associated with harm
Fluid protocols have advantages

37. Summary Pressure monitoring has significant limitations
Goal - Directed Fluid Therapy
Physiologically sound
Right Fluid, Right Amount, Right Time
Evidence – based to reduce morbidity, length of stay, and healthcare costs.
Ultimately the need for GDT is surgeon, patient, and institution specific