who's doing goal directed therapy in the o.r.?

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caligas

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Any thoughts on the various algorithms?

Most useful monitoring devices (we have Edwards rep coming next week)

general pearls?

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Any thoughts on the various algorithms?

Most useful monitoring devices (we have Edwards rep coming next week)

general pearls?
Have done it since day one. My goal is not to have the patient die in the OR.
 
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We have something called the ECOM tube (http://www.cardiacengineering.com/ECOM.pdf) for measuring cardiac output and stroke volume variability, in part, because it was invented and developed by a clinician/scientist who is now our service chief. I'm not sure if it's any better or worse than any of the other devices out there; they all rely on certain underlying assumptions.

There is no organized push to encourage/require its use in certain types of cases, or any sort of algorithm for decision-making around fluids when a patient has the monitor in place. That said, I use it for big open abdominal cases, liver resection, re-do hips, and major vascular stuff. I use SVV as ONE parameter (along with the BD, lactate, and the usual metrics). There are various algorithms out there, or you could review the Methods sections of some of the studies of the device trials themselves to get a good sense for how they're used.
 
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general pearls?

The point of goal directed therapy (for fluids) is to give the patient fluids when they need them and not give them when they don't. There are a dozens of ways to measure this and I doubt that any of them are significantly better than others.
 
I'm with Urge here. Of course we always attempt to maximize the pts parameters when possible but I am not sure this is always ideal. Keep them alive, priority número uno.

But attempting to meet certain goals may actually miss the bigger picture. I mean, who hasn't given some bicarb before dropping the pt off in the ICU to make the pH look better? Obviously, not improving the pts status. I think goal directed care is for times when we are not totally assaulting the pt. Let the physiology work and assist were possible is the goal. But we don't have that luxury in the OR.

I am not familiar with the "algorithms" you speak of so maybe I'm completely off base here.

Oh, and I suck at acronyms. What's SVV?
 
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Thanks Kazuma.
So what ways are you guys measuring SVV? How are they working for you?

I was trained to use the pulse ox and A-line when available. Is the newer system any better? Remember this, I've been around long enough to see a lot of gimmicks come and go. There was a time when we even called the BIS a gimmick, otherwise known as a nursing tool.

Gimmicks so far off the top of my head:
-That stupid vein locator light contraption
-there was one that measured ABG's transcutaneously
- various cardiac output contraptions.
- central lines that measure more than just CVP.
And dare I say it:
- ultrasound for regional (this one may be necessary for younger docs these days).
 
Thanks Kazuma.
So what ways are you guys measuring SVV? How are they working for you?

I was trained to use the pulse ox and A-line when available. Is the newer system any better? Remember this, I've been around long enough to see a lot of gimmicks come and go. There was a time when we even called the BIS a gimmick, otherwise known as a nursing tool.

Gimmicks so far off the top of my head:
-That stupid vein locator light contraption
-there was one that measured ABG's transcutaneously
- various cardiac output contraptions.
- central lines that measure more than just CVP.
And dare I say it:
- ultrasound for regional (this one may be necessary for younger docs these days).
I know some of the CO monitors report SVV. The Vigileo is the one I've seen used the most, but I think a few of our SICU attendings think it is crap. Most of the residents I've chatted with use the quick and dirty a-line gimmick. I'm pretty sure you just change the time displayed on the a-line monitor to see more waves, closer together, and assume that the variation is due to changes in stroke volume. But that comes with a lot of assumptions. Just like the rest of the other ways to "measure" SVV.
 
Goal Directed Therapy!

images

Ever since the Rivers paper, people have been repeating "goal directed therapy" like a parrot. I find it silly. Of course everybody has always had goals. What they did is to treat the cvp and the mixed venous sat. They should have called it "cvp mixed venous therapy".

Have you ever heard people discussing about management and tossing the term "goal directed therapy" for a bunch of stuff that is not related to the original article?
 
And dare I say it:
- ultrasound for regional (this one may be necessary for younger docs these days).

The first 1/2 of my residency, I learned with the nerve stim. I got pretty good at it ... at least, as good as any CA2 can be at anything. :) Call it proficient. Then they put an ultrasound in the preop area, and I did most of my remaining blocks in residency with that. Since then, I haven't always had u/s available, but when it's there, I use it. Likewise, I learned to put in IJ lines with landmarks, finder needle, poor man's CVP with some IV tubing. Got good at it, then u/s came along, and at least for IJs it's standard of care now.

I don't like u/s because it's new or cool. I think we have to be careful about adopting methods or techniques because they sound good, or are intuitive, because the history of medicine is littered with stuff that sounded right but just didn't pan out. However, I don't think ultrasound for blocks is just a fad, or a crutch. Any more than pulse oximetry or capnography.

I'm glad I learned to do IJs by landmarks, because every once in a while I've needed central access in a hurry and being able to just stick a line in under the drapes without waiting for someone to find the u/s machine is valuable. But blocks are never emergencies. These days, everywhere I work, there's always an u/s machine right there, so there's really no time lost. I don't sterile sleeve it for single shot blocks. It's instant, bedside, noninvasive, completely safe imaging that all but guarantees one stick, one needle pass. Good for patient comfort, good for avoiding other structures you don't want to poke ... what's not to like?

$40K for the machine, I guess.



Welcome back, hope you stay.
 
Thanks pgg. I'll stick around as long as I can take the moderators. Gotcha

But seriously, I totally understand your point about the US with respect to anyone trained in the last 10 yrs. I'm just past that FYI. I think it is a good tool for these docs as I stated.

Here's my point, I never had it in training and I got extremely efficient without it. To the point that I have met nobody that can do a procedure quicker than I can. I no they are out there but I haven't met them. And I am the go to person for blocks and lines if needed but luckily my partners never need. However, in my previous group many of them needed. So back to my point, I learned to, use other senses. Just like a blind person uses other senses. I'm not blind cuz I don't use the US, I just learned to "see" with different eyes. But enough about me and my ego.

Let me put it this way. Most people using US add additional time to the procedure. Let's say 3-7min depending on the procedure and the operator. Now let's say I do 10 or more blocks in a day (not the issue in my current practice but definitely in my previous) that adds up to anywhere from 30 min to greater than an hour. I would rather finish my day an hour early.

And please don't use that "standard of care" bull****! Ha ha. Luv ya pgg. Just messing.
 
I propose this as a goal:

Create the smallest net positive fluid balance while still keeping BP, pH, lactate, AG, UOP normal with Hgb > 7-8.

I don't wanna hear about spot SvO2's in the OR, or anywhere. Show me an OR patient doing 1 MET on the table who has a low SvO2, or a patient in septic shock doign 10 METs who has a normal one. Those continuous ScvO2 catheters are cool but so many limitations otherwise.
 
I propose this as a goal:

Create the smallest net positive fluid balance while still keeping BP, pH, lactate, AG, UOP normal with Hgb > 7-8.

I don't wanna hear about spot SvO2's in the OR, or anywhere. Show me an OR patient doing 1 MET on the table who has a low SvO2, or a patient in septic shock doign 10 METs who has a normal one. Those continuous ScvO2 catheters are cool but so many limitations otherwise.

Exactly, and I've watched so many good docs chase the numbers. For what?
 
Thanks pgg. I'll stick around as long as I can take the moderators.

Welcome back! I will try not to be too oppressive.:punch:

Here's my point, I never had it in training and I got extremely efficient without it. To the point that I have met nobody that can do a procedure quicker than I can. I no they are out there but I haven't met them. And I am the go to person for blocks and lines if needed but luckily my partners never need. However, in my previous group many of them needed. So back to my point, I learned to, use other senses. Just like a blind person uses other senses. I'm not blind cuz I don't use the US, I just learned to "see" with different eyes. But enough about me and my ego.

Let me put it this way. Most people using US add additional time to the procedure. Let's say 3-7min depending on the procedure and the operator. Now let's say I do 10 or more blocks in a day (not the issue in my current practice but definitely in my previous) that adds up to anywhere from 30 min to greater than an hour. I would rather finish my day an hour early.

I disagree. Although I trained with a nerve stimulator, I use ultrasound 100% of the time now.

Jet agrees also.

As an elder to most of you young studs out there, I was hesitant to convert to ultrasound guided peripheral nerve blockade since I was pretty deft at all the blind techniques to interscalene, femoral, popliteal, etc blocks.

CHANGE IS HARD. I was comfortable with the blind techniques!!! As ultrasound took hold, though, and more and more of my homies kept saying

DUDE....TAKE THE JUMP...IT'S AWESOME...

I did. Nearly two years ago now.

Know what, ultrasound studs?

YOU WERE RIGHT.

Back then I saw it as more laborious; just added superfluous technology to techniques I was already deft at...I didn't think my blocks could be better:

BZZZZT JET I'M SORRY YOU WERE

WRONG.


Yep.

I'll fess up.

My ultrasound guided blocks are superior to my blind nerve stimulator blocks (with one exception which...uhhhh....is why I'm posting this but we'll get to that in a minute)

More laborious I previously thought?

HAHAHAHAHAHAHAHA how wrong I was.
 
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