CME: Perioperative goal directed therapy: can we afford not to do it?

ACCREDITATION EXPIRED: November 01, 2016

Activity Description / Statement of Need:

In this online CME self-learning program:

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to attenuate the stress response during a patient’s surgical procedure and preserve organ function while promoting early recovery. While this approach is not new, it has not always been widely employed in spite of supporting evidence from a range of randomized controlled trials, systematic reviews, and meta-analyses.This literature suggests that ERAS programs are safe, cost-effective, and minimize the length of stay in a hospital without compromising quality of care. ERAS programs are successful in part because they are proactive in nature, comprised of interventions beginning during preoperative planning and continuing through intraoperative management and postoperative care.

One essential component of successful ERAS implementation is effective perioperative fluid management. Fluid administration is a cornerstone of intensive and perioperative care, with the ultimate goal being the maintenance of intravascular volume in a fashion that incurs the fewest complications. There is a wide spectrum of risk inherent in different fluid managements strategies. Clinical manifestations of under-resuscitation include complications ranging from the inconvenient and unpleasant (e.g., dizziness and post-operative nausea and vomiting) to those that acutely complicate the course of care such as: acute kidney injury and impaired wound healing as a result of inadequate blood flow to surgical anastamoses. On the other hand, over-resuscitation engenders risks such as pulmonary edema and function and its ensuing complications, which include post-operative coagulopathy, abdominal compartment syndrome, and gastrointestinal edema among several others.

A representative survey of over 700 consultant surgeons in the U.K. conducted early in the last decade found that less than a third of respondents felt that patients’ fluids and electrolytes were being managed to their satisfaction. Moreover, more experienced surgeons (those in practice over five years) were more likely to favor a restrictive fluid management approach as compared to surgeons who were newer to practice, constituting a variation in care unexplained by a firm rooting in professional guidelines or the biomedical literature. That clinical trials, opinion papers, and a survey of U.S. and European anesthesiologists continue to examine and debate the question of optimal perioperative fluid management strategies suggest that the problem has neither abated over the last decade, nor is it contained within the U.K.’s borders. The variations in practice that exist, in addition to the remedies suggested by the respondents in the survey conducted by Lobo et al., suggest that a practice gap continues to this day. Such strategies include “improvement in education,” with examples of desired activities including “problem-oriented ward rounds, written guidelines, and discussion of patient scenarios.”

Agenda

• Introduction to Perioperative goal directed therapy: can we afford not to do it?
• Hospital discharge and the association with recovery of gastrointestinal (GI) function
• The Duke enhanced recovery after surgery (ERAS) protocol
• Two questions on fluid responsiveness
• Intraoperative fluid optimization and stroke volume variation (SVV)
• SVV and limitations
• Impact of complications from major surgery
• Barriers to the adoption of goal-directed therapy (GDT)

Target Audience:

This program has been designed for a multidisciplinary physician and nurse audience including: ICU / Anesthesia / Peri-op / Intensivists / Trauma / Critical Care

This program is supported by Educational Grants from Edwards Lifesciences.

Release Date: November 01, 2014 -- Expiration Date: November 01, 2016

Faculty: Timothy Miller, MD

Agenda

Learning Objectives

Accreditation

Faculty Disclosure and Resolution of COI

Instructions

System Requirements