Best Practice & Research Clinical Anaesthesiology 28 (2014) 305e307
Contents lists available at ScienceDirect
Best Practice & Research Clinical Anaesthesiology journal homepage: www.elsevier.com/locate/bean
Preface
Hemodynamic monitoring devices
In the face of increasing financial constraints despite a growing demand for health-care services, physicians of all specialties find themselves challenged by the need to simultaneously improve measurable outcomes while reducing health-care costs. This drive has led anesthesiologists to shift their focus from the operating room to the perioperative period and has directly contributed to the development of concepts such as “goal-directed therapy (GDT),” “enhanced recovery after surgery (ERAS),” and the “perioperative surgical home.” In 1994, a prospective, randomized, controlled trial focused on the optimization of cardiac index and delivery of oxygen (DO2) in critically ill patients demonstrated a significant increase in mortality in the treatment group [1]. It was quickly followed by Shoemaker's classic demonstration of reduced mortality in critically ill patients whose cardiac index and DO2 were maintained in the “supranormal” range [2]. These studies touched off the beginning of the GDT era and the belief that advanced hemodynamic monitoring, when used correctly, might save lives, but were followed by a succession of studies suggesting that the use of invasive hemodynamic monitoring (primarily the pulmonary artery catheter (PAC)) does not improve outcomes and in some cases may cause harm [3e6], eventually leading to a decline in PAC use [7,8]. No hemodynamic monitoring device has been spared the ruthless impartiality of evidence-based medicine. Thirteen years after Rivers' famous (and controversial) single-center trial demonstrated a significant reduction in the mortality of septic patients managed using ScvO2 as a therapeutic endpoint [9], it was eclipsed by the larger, multicentered ProCESS trial [10], which found no difference. Even the utility of blood pressure, considered sacred since the development of the sphygmomanometer by Karl Vierordt in 1855 [11] and a component of the American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring, was recently called into question by a large, randomized, multicenter trial in septic patients [12]. In the face of these negative data, it is easy to become nihilistic about hemodynamic monitoring in general. This would be a mistake. While there have been some highly publicized failures, the goaldirected therapy data, in its totality, has demonstrated improved outcomes in the perioperative patient population [13e15]. Similarly, the data to support esophageal Doppler monitoring in surgical patient populations are so strong (mean weighted-average reduction in length of stay is of 3.7 days) [16e22] that they have been endorsed by both the National Institute for Health (NHS) and National Institute of Health and Care Excellence (NICE) Group [23,24] as well as the Centers for Medicare & Medicaid Services (Agency for Healthcare Research and Quality (AHRQ)) [25]. Twenty years after Hayes' trial, the GDT philosophy is starting to spread to ERAS programs, with Duke University recently demonstrating significant improvements in meaningful outcomes as well as reduced health-care costs using an ERAS program centered around advanced hemodynamic
http://dx.doi.org/10.1016/j.bpa.2014.09.008 1521-6896/© 2014 Elsevier Ltd. All rights reserved.
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Preface / Best Practice & Research Clinical Anaesthesiology 28 (2014) 305e307
monitoring [26]. Particularly exciting is the recent development of the fluid responsiveness concept [27], a paradigm-shifting approach to fluid management that has implications for both critically ill patients [28e30] and those undergoing surgery [31]. Even more exciting, seminal work on microcirculation conducted by Daniel De Backer and Jean Louis Vincent [32], much of which is featured in this issue, have forced us to ask ourselves to redefine the meaning of “hemodynamics.” Over the last 10 years, practicing anesthesiologists have witnessed a virtual explosion of hemodynamic monitoring devices available in the market. The purpose of this issue is to discuss a wide range of hemodynamic monitoring devices, from those that analyze the blood pressure tracings that were qualitatively analyzed by the Egyptians several millennia ago [11] to microcirculation monitors, and everything in between. Only with a thorough understanding of how these devices function, knowledge of their advantages and disadvantages, and an appreciation for how they have been used as a part of protocolized hemodynamic management strategies, can they be used to improve patient outcomes. It should always be kept in mind that biomedical devices are instruments designed to provide actionable information e outside the hands of a skilled clinician, they can only cause harm and increase cost. It is our belief that when used correctly, appropriate hemodynamic monitoring equipment can simultaneously improve the quality of care and reduce health-care costs. This assertion is supported by the thoughtful, thorough, and up-to-date articles contained in this issue and for which we are extremely grateful. We would like to thank the Editorial Board of Best Practice & Research Clinical Anaesthesiology and our coauthors for soliciting, and producing, what we think will be an invaluable collection of technical information, practical descriptions, and evidence-based recommendations regarding hemodynamic monitoring devices available today. Sincerely, References [1] Hayes MA, Timmins AC, Yau EH, et al. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 1994;330:1717e22. *[2] Shoemaker WC, Appel PL, Kram HB, et al. Prospective trial of supranormal values of survivors as therapeutic goals in highrisk surgical patients. Chest 1988;94:1176e86. *[3] Gattinoni L, Brazzi L, Pelosi P, et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med 1995;333:1025e32. *[4] Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003;348:5e14. *[5] Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003;290:2713e20. *[6] Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005;366:472e7. [7] Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993e2004. JAMA 2007; 298:423e9. [8] Koo KK, Sun JC, Zhou Q, et al. Pulmonary artery catheters: evolving rates and reasons for use. Crit Care Med 2011;39: 1613e8. [9] Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368e77. *[10] A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014 May 1;370(18):1683e93. [11] Booth J. A short history of blood pressure measurement. Proc R Soc Med 1977;70:793e9. [12] Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med 2014; 370:1583e93. *[13] Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011;112: 1392e402. *[14] Gurgel ST, do Nascimento Jr P. Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 2011;112:1384e91. *[15] Pearse RM, Harrison DA, MacDonald N, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 2014;311:2181e90. [16] Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 1997;315:909e12. [17] Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002;97:820e6. [18] Venn R, Steele A, Richardson P, et al. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 2002;88:65e71. [19] Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005;95:634e42.
Preface / Best Practice & Research Clinical Anaesthesiology 28 (2014) 305e307
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[20] Noblett SE, Snowden CP, Shenton BK, et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006;93:1069e76. [21] Chytra I, Pradl R, Bosman R, et al. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care 2007;11:R24. [22] Pillai P, McEleavy I, Gaughan M, et al. A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol 2011;186:2201e6. *[23] CardioQ-ODM oesophageal Doppler monitor. 2011 [accessed 04.03.11], http://www.nice.org.uk/guidance/MTG3. [24] Oesophageal Doppler-guided fluid management during major surgery: reducing postoperative complications and bed days. [accessed 31.03.13] http://www.evidence.nhs.uk/. [25] Esophageal Doppler ultrasound-based cardiac output monitoring for real-time therapeutic management of hospitalized patients [accessed 12.09.12] http://www.cms.gov/medicare-coverage-database/details/technology-assessments-details. aspx?TAId¼45&bc¼BAAgAAAAAAAA&. [26] Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052e61. [27] Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008;134:172e8. [28] Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care 2011;1:1. [29] Kalantari K, Chang JN, Ronco C, et al. Assessment of intravascular volume status and volume responsiveness in critically ill patients. Kidney Int 2013;83:1017e28. [30] Bartels K, Thiele RH, Gan TJ. Rational fluid management in today's ICU practice. Crit Care 2013;17(Suppl. 1):S6. [31] Forget P, Lois F, de Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management. Anesth Analg 2010;111:910e4. [32] De Backer D, Donadello K, Sakr Y, et al. Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome. Crit Care Med 2013;41:791e9.
Robert H. Thiele, M.D., Assistant Professor* Departments of Anesthesiology and Biomedical Engineering Director, Technology in Anesthesia and Critical Care Group Co-Director, UVA Enhanced Recovery After Surgery Program University of Virginia, Charlottesville, VA, USA Tong-Joo Gan, M.D., M.H.S., Professor and Chair Department of Anesthesiology, Stony Brook University, NY, USA E-mail address: [email protected] Corresponding author. E-mail address: [email protected] (R.H. Thiele)
Contents lists available at ScienceDirect
Best Practice & Research Clinical Anaesthesiology journal homepage: www.elsevier.com/locate/bean
Preface
Hemodynamic monitoring devices
In the face of increasing financial constraints despite a growing demand for health-care services, physicians of all specialties find themselves challenged by the need to simultaneously improve measurable outcomes while reducing health-care costs. This drive has led anesthesiologists to shift their focus from the operating room to the perioperative period and has directly contributed to the development of concepts such as “goal-directed therapy (GDT),” “enhanced recovery after surgery (ERAS),” and the “perioperative surgical home.” In 1994, a prospective, randomized, controlled trial focused on the optimization of cardiac index and delivery of oxygen (DO2) in critically ill patients demonstrated a significant increase in mortality in the treatment group [1]. It was quickly followed by Shoemaker's classic demonstration of reduced mortality in critically ill patients whose cardiac index and DO2 were maintained in the “supranormal” range [2]. These studies touched off the beginning of the GDT era and the belief that advanced hemodynamic monitoring, when used correctly, might save lives, but were followed by a succession of studies suggesting that the use of invasive hemodynamic monitoring (primarily the pulmonary artery catheter (PAC)) does not improve outcomes and in some cases may cause harm [3e6], eventually leading to a decline in PAC use [7,8]. No hemodynamic monitoring device has been spared the ruthless impartiality of evidence-based medicine. Thirteen years after Rivers' famous (and controversial) single-center trial demonstrated a significant reduction in the mortality of septic patients managed using ScvO2 as a therapeutic endpoint [9], it was eclipsed by the larger, multicentered ProCESS trial [10], which found no difference. Even the utility of blood pressure, considered sacred since the development of the sphygmomanometer by Karl Vierordt in 1855 [11] and a component of the American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring, was recently called into question by a large, randomized, multicenter trial in septic patients [12]. In the face of these negative data, it is easy to become nihilistic about hemodynamic monitoring in general. This would be a mistake. While there have been some highly publicized failures, the goaldirected therapy data, in its totality, has demonstrated improved outcomes in the perioperative patient population [13e15]. Similarly, the data to support esophageal Doppler monitoring in surgical patient populations are so strong (mean weighted-average reduction in length of stay is of 3.7 days) [16e22] that they have been endorsed by both the National Institute for Health (NHS) and National Institute of Health and Care Excellence (NICE) Group [23,24] as well as the Centers for Medicare & Medicaid Services (Agency for Healthcare Research and Quality (AHRQ)) [25]. Twenty years after Hayes' trial, the GDT philosophy is starting to spread to ERAS programs, with Duke University recently demonstrating significant improvements in meaningful outcomes as well as reduced health-care costs using an ERAS program centered around advanced hemodynamic
http://dx.doi.org/10.1016/j.bpa.2014.09.008 1521-6896/© 2014 Elsevier Ltd. All rights reserved.
306
Preface / Best Practice & Research Clinical Anaesthesiology 28 (2014) 305e307
monitoring [26]. Particularly exciting is the recent development of the fluid responsiveness concept [27], a paradigm-shifting approach to fluid management that has implications for both critically ill patients [28e30] and those undergoing surgery [31]. Even more exciting, seminal work on microcirculation conducted by Daniel De Backer and Jean Louis Vincent [32], much of which is featured in this issue, have forced us to ask ourselves to redefine the meaning of “hemodynamics.” Over the last 10 years, practicing anesthesiologists have witnessed a virtual explosion of hemodynamic monitoring devices available in the market. The purpose of this issue is to discuss a wide range of hemodynamic monitoring devices, from those that analyze the blood pressure tracings that were qualitatively analyzed by the Egyptians several millennia ago [11] to microcirculation monitors, and everything in between. Only with a thorough understanding of how these devices function, knowledge of their advantages and disadvantages, and an appreciation for how they have been used as a part of protocolized hemodynamic management strategies, can they be used to improve patient outcomes. It should always be kept in mind that biomedical devices are instruments designed to provide actionable information e outside the hands of a skilled clinician, they can only cause harm and increase cost. It is our belief that when used correctly, appropriate hemodynamic monitoring equipment can simultaneously improve the quality of care and reduce health-care costs. This assertion is supported by the thoughtful, thorough, and up-to-date articles contained in this issue and for which we are extremely grateful. We would like to thank the Editorial Board of Best Practice & Research Clinical Anaesthesiology and our coauthors for soliciting, and producing, what we think will be an invaluable collection of technical information, practical descriptions, and evidence-based recommendations regarding hemodynamic monitoring devices available today. Sincerely, References [1] Hayes MA, Timmins AC, Yau EH, et al. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 1994;330:1717e22. *[2] Shoemaker WC, Appel PL, Kram HB, et al. Prospective trial of supranormal values of survivors as therapeutic goals in highrisk surgical patients. Chest 1988;94:1176e86. *[3] Gattinoni L, Brazzi L, Pelosi P, et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med 1995;333:1025e32. *[4] Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003;348:5e14. *[5] Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003;290:2713e20. *[6] Harvey S, Harrison DA, Singer M, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005;366:472e7. [7] Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993e2004. JAMA 2007; 298:423e9. [8] Koo KK, Sun JC, Zhou Q, et al. Pulmonary artery catheters: evolving rates and reasons for use. Crit Care Med 2011;39: 1613e8. [9] Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368e77. *[10] A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014 May 1;370(18):1683e93. [11] Booth J. A short history of blood pressure measurement. Proc R Soc Med 1977;70:793e9. [12] Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med 2014; 370:1583e93. *[13] Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011;112: 1392e402. *[14] Gurgel ST, do Nascimento Jr P. Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 2011;112:1384e91. *[15] Pearse RM, Harrison DA, MacDonald N, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 2014;311:2181e90. [16] Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 1997;315:909e12. [17] Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002;97:820e6. [18] Venn R, Steele A, Richardson P, et al. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 2002;88:65e71. [19] Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005;95:634e42.
Preface / Best Practice & Research Clinical Anaesthesiology 28 (2014) 305e307
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[20] Noblett SE, Snowden CP, Shenton BK, et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006;93:1069e76. [21] Chytra I, Pradl R, Bosman R, et al. Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care 2007;11:R24. [22] Pillai P, McEleavy I, Gaughan M, et al. A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol 2011;186:2201e6. *[23] CardioQ-ODM oesophageal Doppler monitor. 2011 [accessed 04.03.11], http://www.nice.org.uk/guidance/MTG3. [24] Oesophageal Doppler-guided fluid management during major surgery: reducing postoperative complications and bed days. [accessed 31.03.13] http://www.evidence.nhs.uk/. [25] Esophageal Doppler ultrasound-based cardiac output monitoring for real-time therapeutic management of hospitalized patients [accessed 12.09.12] http://www.cms.gov/medicare-coverage-database/details/technology-assessments-details. aspx?TAId¼45&bc¼BAAgAAAAAAAA&. [26] Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052e61. [27] Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008;134:172e8. [28] Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care 2011;1:1. [29] Kalantari K, Chang JN, Ronco C, et al. Assessment of intravascular volume status and volume responsiveness in critically ill patients. Kidney Int 2013;83:1017e28. [30] Bartels K, Thiele RH, Gan TJ. Rational fluid management in today's ICU practice. Crit Care 2013;17(Suppl. 1):S6. [31] Forget P, Lois F, de Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management. Anesth Analg 2010;111:910e4. [32] De Backer D, Donadello K, Sakr Y, et al. Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome. Crit Care Med 2013;41:791e9.
Robert H. Thiele, M.D., Assistant Professor* Departments of Anesthesiology and Biomedical Engineering Director, Technology in Anesthesia and Critical Care Group Co-Director, UVA Enhanced Recovery After Surgery Program University of Virginia, Charlottesville, VA, USA Tong-Joo Gan, M.D., M.H.S., Professor and Chair Department of Anesthesiology, Stony Brook University, NY, USA E-mail address: [email protected] Corresponding author. E-mail address: [email protected] (R.H. Thiele)
