Endpoints of goal directed therapy in the OR and in the ICU
© Cambridge University Press 2014. Goals of goal directed therapy Ultimately, the aim of goal directed therapy (GDT) is to improve patient outcomes by optimizing tissue perfusion and end-organ function. Adverse outcomes are associated with both under- and over-resuscitation. Inadequate intraoperative resuscitation can lead to decreased circulating volume and resultant hypoperfusion of end-organs, which may predispose patients to adverse perioperative outcomes. On the other hand, excessive intraoperative fluid volumes can result in increased intra- as well as extravascular volumes, which may lead to peripheral and/or pulmonary edema. Of particular importance in gastrointestinal surgery, excessive crystalloid infusion has been associated with bowel wall edema, which may delay gastrointestinal function. Multiple studies have shown that GDT is associated with improved outcomes following moderate to major surgery, with shorter hospital stays, fewer ICU admissions, earlier return of bowel function, and less postoperative nausea and vomiting. There are emerging data that demonstrate a long-term survival benefit (up to 15 years postoperatively) in ICU patients who underwent GDT postoperatively after high-risk surgery. This survival benefit may be due to the ability of GDT to reduce the initial number of postoperative complications. Optimal perfusion may be dependent upon disease process, with various types of shock as well as sepsis being times of high metabolic demand. Shoemaker et al. demonstrated that patients surviving shock states had higher oxygen delivery than non-surviving patients. This realization led to the concept of super-optimization, or using vasopressors and/or inotropic agents to increase oxygen delivery to supranormal values. Outcomes associated with “super-optimization” have been mixed. Some investigators have found that the use of epinephrine and/or dopexamine to increase oxygen delivery (DO 2) during surgery decreased perioperative morbidity and mortality. Similar attempts to super-optimize oxygen delivery in septic ICU patients as well as a mixed group of critically ill patients have not shown to significantly impact mortality. It is notable, however, that these patients generally had their resuscitation started approximately 12 hours after presentation. Follow-up studies in which optimization began immediately upon arrival to the ICU showed a decreased hospital length of stay (LOS) for patients undergoing cardiothoracic surgery as well as high-risk patients undergoing major general surgery.
- Perioperative Hemodynamic Monitoring and Goal Directed Therapy - from theory to practice
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International Standard Book Number 13 (ISBN-13)
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