SPECIAL ARTICLES
The Role of Perioperative Goal-Directed Therapy in the E ra of Enhanced Recovery After Surger y a n d P e r io p e r a t iv e S u r g ic a l H o me
I
N THIS ISSUE OF the Journal of Cardiothoracic and Vascular Anesthesia, 3 manuscripts focusing on perioperative goal-directed therapy (PGDT) are presented. The first manuscript, by Holder and Pinsky1 from the University of Pittsburgh Medical Center, discusses the use of applied physiologic principles to drive PGDT therapeutic algorithms. The second paper, by Waldron et al.2 from Duke University, discusses the evidence supporting the use of PGDT in the perioperative setting and summarizes the effect of this approach on postoperative patients’ outcome after major surgery. Finally, the third manuscript, by Ebm et al.3 from Saint Georges Healthcare Trust in London, explores the cost effectiveness of PGDT in high-risk surgical patients. After several decades of research on the topic, the evidence supporting the positive effect of fluid management and hemodynamic optimization strategies based on PGDT protocols is growing. The recently published OPTIMISE trial conducted in more than 700 patients in multiple institutions suggests that this approach decreases postoperative complications for high-risk patients,4 and its associated editorial by Elliot Bennett Guerrero in the Journal of the American Medical Association states that, “Goal-directed therapy is best achieved in environments that emphasize a multidisciplinary team approach to patient care, including anesthesiologists, surgeons, intensivists, and nurses. This multidisciplinary approach is exemplified in the “Perioperative Surgical Home,” (PSH) which is gaining momentum in the United States (US) as an innovative model aimed to improve clinical outcome and reduce costs.”5 As a matter of fact, PGDT strategies have been recommended in several European countries6–8 and are an essential part of the enhanced recovery after surgery (ERAS) concept, which, in some ways, is the European counterpart of the PSH model.9,10 So how would the PSH and ERAS models change the way PGDT strategies are applied during surgery? The PSH model of care is defined as “a patient-centered, physician-led multidisciplinary, and team-based system of coordinated perioperative care, which guides and coordinates care from the decision to operate until 30-days after discharge from hospital.”11 The triple-aim of this model is improved quality of care, improved services to patients and their families and reduced cost.11 The main focus of the PSH model will be on coordination of the perioperative care continuum by anesthesiologists (up to 30 days postdischarge from the hospital), consistent application of best evidence/best practices to decrease overall variability, and improved efficiency of care through use of process improvement management techniques, such as Six Sigma and LEAN methodologies.11 In this model, and similarly to the ERAS protocols, it will be important to implement clinical interventions that are linked to improved clinical outcome and
decreased cost, and PGDT as well as multimodal pain management will be important elements of these models of care.12 However, because the PSH model aims at a revamping of the whole perioperative process and includes many elements, futures studies will need to evaluate the impact of PGDT in systems where the whole perioperative care is optimized. Indeed, most previously published studies have evaluated the impact of PGDT in settings where no ERAS or PSH models were already implemented. Considering the potentially significant treatment-effect of a massive change in the way perioperative care is delivered, it is not guaranteed that the effect of a PGDT strategy would have the same effect in such a system. As a matter of fact, recent studies conducted in Denmark, where ERAS strategies were initially described, suggest that in a system where perioperative care is otherwise optimized, crystalloid restriction strategies do as well as PGDT strategies.13 On the other hand, it is more likely that complex/major surgeries would require more than a restrictive approach because most of these surgeries induce significant changes in hemodynamics that would benefit from a more rational management.1,2 Today, PGDT is a good way to standardize fluid management and hemodynamic optimization and it has potential to improve patients’ outcome and to decrease cost when conducted in the right patient population. PGDT will be best achieved in systems applying the PSH model of care and/or ERAS bundle and may actually be one of the most important elements for the implementation of these models of care. ACKNOWLEDGMENTS Maxime Cannesson is a consultant for Covidien, Edwards Lifesciences, Masimo Corp., is the founder of Sironis, and received research funding from Edwards Lifesciences and Masimo Corp. Fiyinfoluwa Ani has no conflict of interest to declare. Zeev Kain is a Director of the Academic Component for the board of Directors of the American Society of Anesthesiologists and is part of the speakers’ bureau of Merck Pharmaceuticals.
Maxime Cannesson, MD, PhD Zeev N. Kain, MD, MBA Department of Anesthesiology and Perioperative Care University of California Irvine, Irvine, CA
© 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.09.015
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 6 (December), 2014: pp 1633–1634
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CANNESSON AND KAIN
REFERENCES 1. Holder AL, Pinsky MR: Applied physiology at the bedside to drive resuscitation algorithms. J Cardiothorac Vasc Anesth 28: 1642-1659, 2014 2. Waldron NH, Miller T, Gan TJ: Perioperative goal directed therapy. J Cardiothorac Vasc Anesth 28:1635-1641, 2014 3. Ebm CC, Sutton L, Rhodes A, Cecconi M: Cost-effectiveness in goal-directed therapy: are the dollars spent worth the value? A systematic review. J Cardiothorac Vasc Anesth 28:1660-1666, 2014 4. Pearse RM, Harrison DA, MacDonald N, et al: Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 311:2181-2190, 2014 5. Bennett-Guerrero E: Hemodynamic goal-directed therapy in highrisk surgical patients. JAMA 311:2177-2178, 2014 6. NICE draft guidance on cardiac output monitoring device published for consultation. Available at: http://www.nice.org.uk/newsroom/ pressreleases/DraftGuidanceOnCardiacOutputMonitoringDevice.jsp. 7. European Society of Anaesthesiology: Perioperative goal-directed therapy protocol summary. Available at: http://html.esahq.org/patient safetykit/resources/downloads/05_Checklists/Various_Checklists/Perio
perative_Goal_Directed_Therapy_Protocols.pdf. Accessed February 13, 2014 8. Vallet B, Blanloeil Y, Cholley B, et al: Guidelines for perioperative haemodynamic optimization. Ann Fr Anesth Reanim 32:e151-e158, 2013 9. Cannesson M, Kain Z: Enhanced recovery after surgery versus perioperative surgical home: is it all in the name? Anesth Analg 118: 901-902, 2014 10. Cannesson M, Ani F, Mythen MM, et al: Anaesthesiology and perioperative medicine around the world: different names, same goals. Br J Anaesth. Epub 2014 Aug 21 11. Kain ZN, Vakharia S, Garson L, et al: The perioperative surgical home as a future perioperative practice model. Anesth Analg 118: 1126-1130, 2014 12. Garson L, Schwartzkopf R, Vakharia S, et al: Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg 118:1081-1089, 2014 13. Brandstrup B, Svendsen PE, Rasmussen M, et al: Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth 109: 191-199, 2012
The Role of Perioperative Goal-Directed Therapy in the E ra of Enhanced Recovery After Surger y a n d P e r io p e r a t iv e S u r g ic a l H o me
I
N THIS ISSUE OF the Journal of Cardiothoracic and Vascular Anesthesia, 3 manuscripts focusing on perioperative goal-directed therapy (PGDT) are presented. The first manuscript, by Holder and Pinsky1 from the University of Pittsburgh Medical Center, discusses the use of applied physiologic principles to drive PGDT therapeutic algorithms. The second paper, by Waldron et al.2 from Duke University, discusses the evidence supporting the use of PGDT in the perioperative setting and summarizes the effect of this approach on postoperative patients’ outcome after major surgery. Finally, the third manuscript, by Ebm et al.3 from Saint Georges Healthcare Trust in London, explores the cost effectiveness of PGDT in high-risk surgical patients. After several decades of research on the topic, the evidence supporting the positive effect of fluid management and hemodynamic optimization strategies based on PGDT protocols is growing. The recently published OPTIMISE trial conducted in more than 700 patients in multiple institutions suggests that this approach decreases postoperative complications for high-risk patients,4 and its associated editorial by Elliot Bennett Guerrero in the Journal of the American Medical Association states that, “Goal-directed therapy is best achieved in environments that emphasize a multidisciplinary team approach to patient care, including anesthesiologists, surgeons, intensivists, and nurses. This multidisciplinary approach is exemplified in the “Perioperative Surgical Home,” (PSH) which is gaining momentum in the United States (US) as an innovative model aimed to improve clinical outcome and reduce costs.”5 As a matter of fact, PGDT strategies have been recommended in several European countries6–8 and are an essential part of the enhanced recovery after surgery (ERAS) concept, which, in some ways, is the European counterpart of the PSH model.9,10 So how would the PSH and ERAS models change the way PGDT strategies are applied during surgery? The PSH model of care is defined as “a patient-centered, physician-led multidisciplinary, and team-based system of coordinated perioperative care, which guides and coordinates care from the decision to operate until 30-days after discharge from hospital.”11 The triple-aim of this model is improved quality of care, improved services to patients and their families and reduced cost.11 The main focus of the PSH model will be on coordination of the perioperative care continuum by anesthesiologists (up to 30 days postdischarge from the hospital), consistent application of best evidence/best practices to decrease overall variability, and improved efficiency of care through use of process improvement management techniques, such as Six Sigma and LEAN methodologies.11 In this model, and similarly to the ERAS protocols, it will be important to implement clinical interventions that are linked to improved clinical outcome and
decreased cost, and PGDT as well as multimodal pain management will be important elements of these models of care.12 However, because the PSH model aims at a revamping of the whole perioperative process and includes many elements, futures studies will need to evaluate the impact of PGDT in systems where the whole perioperative care is optimized. Indeed, most previously published studies have evaluated the impact of PGDT in settings where no ERAS or PSH models were already implemented. Considering the potentially significant treatment-effect of a massive change in the way perioperative care is delivered, it is not guaranteed that the effect of a PGDT strategy would have the same effect in such a system. As a matter of fact, recent studies conducted in Denmark, where ERAS strategies were initially described, suggest that in a system where perioperative care is otherwise optimized, crystalloid restriction strategies do as well as PGDT strategies.13 On the other hand, it is more likely that complex/major surgeries would require more than a restrictive approach because most of these surgeries induce significant changes in hemodynamics that would benefit from a more rational management.1,2 Today, PGDT is a good way to standardize fluid management and hemodynamic optimization and it has potential to improve patients’ outcome and to decrease cost when conducted in the right patient population. PGDT will be best achieved in systems applying the PSH model of care and/or ERAS bundle and may actually be one of the most important elements for the implementation of these models of care. ACKNOWLEDGMENTS Maxime Cannesson is a consultant for Covidien, Edwards Lifesciences, Masimo Corp., is the founder of Sironis, and received research funding from Edwards Lifesciences and Masimo Corp. Fiyinfoluwa Ani has no conflict of interest to declare. Zeev Kain is a Director of the Academic Component for the board of Directors of the American Society of Anesthesiologists and is part of the speakers’ bureau of Merck Pharmaceuticals.
Maxime Cannesson, MD, PhD Zeev N. Kain, MD, MBA Department of Anesthesiology and Perioperative Care University of California Irvine, Irvine, CA
© 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.09.015
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 6 (December), 2014: pp 1633–1634
1633
1634
CANNESSON AND KAIN
REFERENCES 1. Holder AL, Pinsky MR: Applied physiology at the bedside to drive resuscitation algorithms. J Cardiothorac Vasc Anesth 28: 1642-1659, 2014 2. Waldron NH, Miller T, Gan TJ: Perioperative goal directed therapy. J Cardiothorac Vasc Anesth 28:1635-1641, 2014 3. Ebm CC, Sutton L, Rhodes A, Cecconi M: Cost-effectiveness in goal-directed therapy: are the dollars spent worth the value? A systematic review. J Cardiothorac Vasc Anesth 28:1660-1666, 2014 4. Pearse RM, Harrison DA, MacDonald N, et al: Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 311:2181-2190, 2014 5. Bennett-Guerrero E: Hemodynamic goal-directed therapy in highrisk surgical patients. JAMA 311:2177-2178, 2014 6. NICE draft guidance on cardiac output monitoring device published for consultation. Available at: http://www.nice.org.uk/newsroom/ pressreleases/DraftGuidanceOnCardiacOutputMonitoringDevice.jsp. 7. European Society of Anaesthesiology: Perioperative goal-directed therapy protocol summary. Available at: http://html.esahq.org/patient safetykit/resources/downloads/05_Checklists/Various_Checklists/Perio
perative_Goal_Directed_Therapy_Protocols.pdf. Accessed February 13, 2014 8. Vallet B, Blanloeil Y, Cholley B, et al: Guidelines for perioperative haemodynamic optimization. Ann Fr Anesth Reanim 32:e151-e158, 2013 9. Cannesson M, Kain Z: Enhanced recovery after surgery versus perioperative surgical home: is it all in the name? Anesth Analg 118: 901-902, 2014 10. Cannesson M, Ani F, Mythen MM, et al: Anaesthesiology and perioperative medicine around the world: different names, same goals. Br J Anaesth. Epub 2014 Aug 21 11. Kain ZN, Vakharia S, Garson L, et al: The perioperative surgical home as a future perioperative practice model. Anesth Analg 118: 1126-1130, 2014 12. Garson L, Schwartzkopf R, Vakharia S, et al: Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg 118:1081-1089, 2014 13. Brandstrup B, Svendsen PE, Rasmussen M, et al: Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth 109: 191-199, 2012
