Goal-Directed Therapy and Fluid Optimization

Goal-directed therapy is a technique to guide administration of fluid and drugs to achieve certain hemodynamic goals. Protocols based on goal-directed therapy have been proven to reduce morbidity and mortality rates for patients suffering from severe sepsis and septic shock [1,5] and patients undergoing high to medium risk surgeries. [2,3,4]

Guiding Resuscitation in Sepsis: “Early” Goal Directed Therapy Matters

Using goal directed therapy during the initial hours of sepsis is critical to improve patient outcome. Jones et al (2008) conducted a systemic review of randomized trials comparing resuscitation targeting specific hemodynamic endpoints (goal-directed therapy) to standard resuscitation in sepsis. A meta-analysis of trials initiated within 24 hours of the onset of sepsis (6 trials, 740 patients) showed “early” goal directed therapy improved mortality compared to standard resuscitation (39% versus 57%, odds ratio 0.50, 95% Confidence Interval [CI] 0.37-0.69). In contrast, a meta-analysis of trials initiated after 24 hours of the onset of sepsis (3 trials, 261 patients) showed goal directed therapy do not improve mortality compared to standard resuscitation  (64% versus 58%, odds ratio 1.16, 95% CI, 0.60-2.22).

Surgery: Goal Directed Therapy Improves Outcome 

The use of goal directed therapy to guide fluid administration and drug titration improved mortality and morbidity rates in a wide variety of surgeries. Corcoran et al (2012) conducted a meta-analysis of 23 trials comparing goal-directed therapy with non-goal directed therapy.  Goal-directed therapy groups had a lower risk of pneumonia (risk ratio [RR] 0.7, 95% CI 0.6-0.9), renal complications (RR 0.7, 95% CI 0.5-0.9), and shorter length of hospital stay (mean reduction 2 days, 95% CI 1-3) compared to the control group. Phan et al (2007) also showed a similar reduction in length of stay in their meta-analysis for goal-directed therapy compared to a control (weighted reduction 2.3 days, 95% CI 1.8-2.9).

Hamilton et al. (2011) conducted a systemic review of 29 goal directed therapy trials that involved 4,805 patients. They found that the use of goal directed therapy signification reduced mortality (pooled odds ratio 0.48, 95% CI 0.33-0.78) and surgical complications (odds ratio 0.43, 95% CI 0.34-0.53). They also conducted a subgroup analysis of the different monitoring techniques and hemodynamic goals. Mortality was significantly reduced in studies using cardiac index and oxygen delivery as goals. Morbidity was significantly reduced regardless of monitoring technique used (CVP, pulse contour, Doppler echocardiography, etc.).

Pediatrics and Neonatal: Goal Directed Therapy  

ACCM guidelines outlines an algorithm for time-sensitive, goal directed therapy to guide resuscitation in pediatrics and neonates with septic shock that is shown to improve patient outcome. The ACCM guidelines are considered best practice for resuscitation in children. The ACCM guidelines state that “goal-directed therapy to achieve a target cardiac output is highly recommended and has been shown to improve patient outcome”. [5] Bedside cardiac output monitoring can also be used to differentially diagnose fluid-resistant septic shock, identifying cold shock versus warm shock. [6]

EC™ Monitors

The ICON and AESCULON work by Electrical Cardiometry (EC™), a patented, innovative method for acquiring non-invasive beat-to-beat cardiac output measurements. The monitors are extremely easy to use, taking less than 3 minutes to provide a hemodynamic assessment. Accurate hemodynamic assessments are necessary to guide fluid resuscitation and goal-directed therapy, practices shown to improve patient outcome and reduce length of stay. [1,2,3,4,5,6]

EC monitors are the only operator-independent, non-invasive hemodynamic monitors FDA cleared for use in adults, pediatrics and neonates. Over 20 clinical publications have validated the accuracy and clinical utility of the monitors, including studies comparing EC monitor with thermodilution [7] and transespogeal doppler echocardiography [8] in adults and thermodilution, [9] transthoracic echocardiography [10,11] and direct Fick [12] in pediatrics and neonates.

How does EC™ empower clinicians to make better decisions?

Blood pressure, heart rate and other information typically available to clinicians do not paint a complete picture of a patient’s hemodynamics. Guiding therapy by traditional parameters makes it very difficult to decide whether volume, inotropes, or vasopressors would be best for the patient.  

With the ICON and AESCULON, the user gets a complete picture of the patient hemodynamics using a method that is quick, easy, safe, and accurate. The parameters provided by EC fill in the blanks of traditional monitoring, helping physicians guide fluid resuscitation and drug therapy in a targeted, continuous manner. In addition to providing familiar parameters, such as Cardiac Output and Stroke Volume measurements, there are several parameters unique to EC that provide enhanced indications of preload, including stroke volume variation (SVV), flow time correct (FTC), and thoracic fluid content (TFC). 

References:

1. Jones AE, Brown MD, Trzeciak S, Shapiro NI, Garrett JS, Heffner AC, Kline JA. The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis. Crit Care Med. 2008;36(10):2734.

2. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114(3):640.

3. Phan TD, Ismail H, Heriot AG, Ho KM. Improving perioperative outcomes: fluid optimization with the esophageal Doppler monitor, a metaanalysis and review. J Am Coll Surg. 2008;207(6):935.

4. 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 Jun;112(6):1392-402

5. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666.

6. Brierley J, Peters MJ. Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. Pediatrics. 2008 Oct; 122(4):752-9.

7. Zoremba N, Bickenbach J, Krauss B, et al. Comparison of electrical velocimetry and thermodilution techniques for the measurement of cardiac output. Acta Anaesthesiol Scand 2007; 51:1314–1319.

8. Schmidt C, Theilmeier1 G, Van Aken H, et al. Comparison of electrical velocimetry and transoesophageal Doppler echocardiography for measuring stroke volume and cardiac output. British Journal of Anaesthesia 95 (5): 603–10 (2005)

9. Spar D, Vincent J, Torres A, et al. Comparison of noninvasive measurement of cardiac output, electrical velocimetry with thermodilution measurement of cardiac output in children. Poster presented at CHOP 2011.

10. Noori S, Drabu B, Soleymani S, Seri I. Continuous non-invasive cardiac output measurements in the neonate by electrical velocimetry: a comparison with echocardiography. Arch Dis Child Fetal Neonatal Ed. 2012 Jan 31.

11. Rauch R, Welisch E, Lansdell N, Burrill E, Jones J, Robinson T, Bock D, Clarson C, Filler G, Norozi K. Non-invasive measurement of cardiac output in obese children  and adolescents: comparison of electrical cardiometry and transthoracic Doppler echocardiography. J Clin Monit Comput. 2012 Nov 21.

12. Norozi K, Beck C, Osthaus WA, Wille I, Wessel A, Bertram H. Electrical velocimetry for measuring cardiac output in children with congenital heart disease. Br J Anaesth. 2008 Jan;100(1):88-94. Epub 2007 Nov 16