Goal Directed Therapy
 

Appropriate fluid management plays a pivotal role in the management of patients who are experiencing significant hemodynamic challenges. Suboptimal fluid resuscitation may lead to low perfusion state, while overly-aggressive fluid resuscitation can lead to volume overload and heart failure exacerbation.

Patients who are particularly prone to complications arising from suboptimal fluid management and who benefit greatly from fluid optimization are:
Peri-operative patients: Pre-op/intra-op/post-op and step-down, especially patients in high-risk due to underlying morbidity
 
General and Surgical Intensive Care Unit: Sepsis, Shock, Transplant, Acute Renal Failure, Multi-Organ Failure
 
Emergency Department: Sepsis, Shock, Trauma, Acute MI, Heart Failure, COPD
 
Rather than relying on rule-of-thumb fluid regimens which are modified once or twice a day, in GDT IV fluid regimens are customized repeatedly to the patient's needs in real-time fashion (1).
GDT In Practical Use
 

Several parameters have been studied in the context of GDT protocols and validated. Oxygen Delivery (a product of cardiac output, oxymetry and hemoglobin level) is the most widely and repeatedly validated of those, followed by CVP and ScvO2 (Table references). The latter have been used more in the Emergency Department, where use of CO monitoring had been impractical until recently.
Methods to increase the power of fluid optimization rely on dynamic CO response to simple interventions such as Passive Leg Raising (2) or IV fluid challenge. Such protocols which until recently utilized invasive CO monitoring with the pulmonary artery catheter (PAC) or with invasive arterial line-based peripheral pulse contour devices, have shown that CO-based GDT protocols lead to reduction in mortality, complications, ventilation days and length of hospital stay.
Unfortunately, despite abundant literature supporting the use of CO and Oxygen Delivery-based GDT protocols, adoption of these protocols to clinical practice has been slow to come. This is due to the invasive nature of existing modalities which also require a trained physician significant time to deploy and are associated with a significant cost per case (3).
 
Thus, in order to bring the benefits of GDT to the practical day-to-day of many more patients, numerous experts in intensive care, anesthesia, hemodynamic monitoring and emergency medicine have called for the development of an accurate, non-invasive, continuous and affordable CO monitoring tool that can be used across multiple sites of care. We at Cheetah Medical believe that NICOM technology and the Reliant monitor are the solution to this need.
References
 
1. Michael R. Pinsky, MD, FCCP: Hemodynamic Evaluation and Monitoring in the ICU. Chest. 2007; 132:2020-2029
 
2. Xavier Monnet and Jean-Louis Teboul: Passive leg raising.
Intensive care medicine, Vol. 34, No. 4. (April 2008), pp. 659-663
 
3. Fabian Jaimes , Jorge Farbiarz , Diego Alvarez and Carlos Martinez: Comparison between logistic regression and neural networks to predict death in patients with suspected sepsis in the emergency room. Critical Care 2005, 9:R150-R156
 
4. Jonathan Wilson,  Ian Woods,  Jayne Fawcett,  Rebecca Whall,  Wendy Dibb,Chris Morris,Elizabeth McManus: Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 199,1099-1103
 
5. O. Boyd, R. M. Grounds and E. D. Bennett: A Randomized Clinical Trial of the Effect of Deliberate Perioperative Increase of Oxygen Delivery on Mortality in High-Risk Surgical Patients. JAMA 1993, 2699-2707
 
6. Shoemaker WC: Use of Physiological Monitoring to Predict Outcome And to Assist in Clinical Decisions in Critically Ill Postoperative Patients. AM J Surg 1983, 43-50
 
7. WC Shoemaker, PL Appel, HB Kram, K Waxman and TS Lee: Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients. Chest 1988, 1176-1186
 
8. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds M, Bennet D:Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. Critical Care 2005, R687-693
 
9. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P: Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Brit J Anaest 2002, 65-71.
 
10. Gan TJ, Soppitt A, Maroof M, et al: Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery. Anesthesiology 2002, 820-826.
 
11. McKendry M et al: Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimization of circulatory status after cardiac surgery. BMJ, doi:10.1136/bmj.38156.767118.7C
 
12. Sinclair S, James S, Singer M: Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture. BMJ 1997, 909-912.
 
13. Fenwick E, Wilson J, Sculpher M, Claxton K: Pre-operative optimisation employing dopexamine or adrenaline for patients undergoing major elective surgery. Int Care Med 2002, 599-608.