Goal Directed Therapy

Created: June 28, 2021

Last Updated: November 18, 2023

Contributor(s):

Alexander Gregory MD

Kevin Lobdell MD

Seenu Reddy MD

Amanda Rea DNP CRNP AGACNP-BC CCRN CMC CSC E-AEC

Patrick Farrer MSN RN

Corey Hammac MSN APRN AGACNP-BC

ERAS Cardiac Collaborative Network

Editor(s):

Cheryl Crisafi MSN RN CNL

Amanda Rea DNP CRNP AGACNP-BC CCRN CMC CSC E-AEC

Gina McConnell RN BSN CCRN

Shannon Crotwell RN BSN CCRN

Alexander Gregory MD FRCPC

Sponsor

Becton, Dickinson and Company

Summary

Enhanced recovery after surgery efforts aim to decrease surgical stress, maintain physiologic functional capacity, and facilitate postoperative recovery through standardized use of best practices. Goal-directed therapy is a recommended component of cardiac surgical enhanced recovery. Goal-directed therapy is associated with favorable results in heterogeneous patient populations (both surgical and nonsurgical), despite differing goals and variations in monitoring and therapeutic strategies. Novel data sources, along with advanced data management and analytics such as artificial intelligence, will converge to extend our insight into risk assessment and mitigation strategies. This learning module will explore the Who, What, When, Why, and How clinicians can apply a standardized framework to optimize flow and oxygen delivery in critically ill patients and patients undergoing major surgery.


Enhanced recovery after surgery efforts use evidence-based practice methods to decrease surgical stress, maintain physiologic functional capacity, and facilitate postoperative recovery. The importance of attempting to achieve these goals is underscored by the high rate of complications after surgery. According to the World Health Organization’s most recent update, an estimated 313 million surgical procedures were performed worldwide in 2012. Depending on the type of surgery and presurgical comorbidities, 30% to 40% of patients will develop complications; in as many as 20% of patients, these complications will be severe and possibly life threatening. This is especially true for cardiac procedures. The results of the International Surgical Outcomes Study showed that complication rates were greatest (57%) for patients who underwent cardiac surgery. Thus, making even small decreases in the frequency of complications can affect thousands of patients.

A long history of related experience, research, and evaluation of the physiologic, metabolic, and inflammatory insults of surgery, trauma, and shock provide important perspectives for understanding enhanced recovery after surgery efforts. Goal-directed therapy (GDT) is a strongly recommended component of cardiac surgical enhanced recovery. With its focus on such concepts as physiologic reserve, negative base excess, oxygen debt and debt repayment, potential downregulation of oxygen demand, and tissue oxygenation, GDT aims to provide clinicians with a guide to targeted resuscitation. Although most GDT studies emphasize physiologic metrics such as cardiac output, systemic blood pressure, and right and left heart filling pressures, it is also important to acknowledge the complex interplay of surgical insult on metabolism, inflammation, and coagulation.

Goal-directed therapy for cardiac surgery patients is included in the consensus recommendations (class 1, level B-R) published by the ERAS Cardiac Society. Goal-directed therapy uses advanced hemodynamic monitoring techniques to guide clinicians with administering fluids, vasopressors, and inotropes to avoid hypotension and low cardiac output.

_______________________________________________________________________________________________________________________________


ERAS Cardiac VTC Disclaimer:

The VTC, and all included content, is intended to inform ERAS Cardiac Members in a multitude of topics related to enhanced recovery. The information included has been provided by other enhanced recovery experts and should be used for educational purposes only. It is not intended to describe, recommend, or suggest any specific medical practice or intervention, nor should it be considered as formal medical advice or consultation. The ERAS Cardiac Society cannot guarantee that the information on the VTC is accurate or complete in every respect. Therefore, ERAS Cardiac Society is not responsible for any errors or omissions in the content, or medical results that occur with the application of the information obtained while using the VTC. All healthcare professionals should continue to use sound clinical judgment and prescribe therapies based on the best medical knowledge at their disposal.

All the material presented on the VTC is the intellectual property of the ERAS Cardiac Society, its contributors, and its sponsors. Unless explicitly stated, the information, images, audio, video, and other content may not be reproduced (in whole or in part) in any way without the written permission of the ERAS Cardiac Society.

If you have any questions or comments about the ERAS Cardiac VTC, please email: VTC@erascardiac.org

Educational Materials

GDT in Cardiac Surgery
This video is a recorded session from the ERAS Cardiac Virtual Meeting in 2021. Speakers and discussants include members of our international network of ERAS experts. In this session, participants discuss GDT in cardiac surgery.
GDT: An Overview
Watch as Amanda Rae DNP summarizes the principles of GDT, physiologic parameters, monitoring options, and implementation strategies.
Hemodynamic Management of the Cardiac Surgical Patient (1of3)
Hemodynamic Management of the Cardiac Surgical Patient - part 1 of 3. In this opening segment, Dr. Dan Fox and Dr. Seenu Reddy review the driving factors and key concepts for the use of goal-directed hemodynamic management in the cardiac surgery patient. [Sponsored]
Hemodynamic Management of the Cardiac Surgical Patient (2of3)
Hemodynamic Management of the Cardiac Surgical Patient - part 2 of 3. In this section, Dr. Dan Fox and Dr. Seenu Reddy explore how to target the underlying physiology using advanced hemodynamic monitoring to individualize care of the cardiac surgery patient. [Sponsored]
Hemodynamic Management of the Cardiac Surgical Patient (3of3)
Hemodynamic Management of the Cardiac Surgical Patient - part 3 of 3. In this closing section, Dr. Dan Fox and Dr. Seenu Reddy explore two simulated case studies providing insight into everyday application of goal-directed hemodynamic management. [Sponsored]
Top Med Talk on GDT

Previously recorded talk from the archives of TopMed Talk. Discussants review the role of GDT in cardiac surgery.

Top Med Eds

-
DownloadDownload Audio

References:

  1. Giglio M, Dalfino L, Puntillo F, et al. Hemodynamic goal-directed therapy and postoperative kidney injury: an updated meta-analysis with trial sequential analysis. Crit Care 2019;23(1):232.
  2. Weiser TG, Haynes AB, Molina G, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ 2016;94(3):201–209F.
  3. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009;361(14):1368–75.
  4. Schilling PL, Dimick JB, Birkmeyer JD. Prioritizing quality improvement in general surgery. J Am Coll Surg 2008;207(5):698–704.
  5. Kahan BC, Koulenti D, Arvaniti K, et al. Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries. Intensive Care Med 2017;43(7):971–9.
  6. International Surgical Outcomes Study (ISOS) Group. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and highincome countries. Br J Anaesth 2017;119(3):553.
  7. Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85(1):109–17.
  8. Dunham CM, Siegel JH, Weireter L, et al. Oxygen debt and metabolic academia as quantitative predictors of mortality and the severity of the ischemic insult in hemorrhagic shock. Crit Care Med 1991;19(2):231–43.
  9. Barbee RW, Reynolds PS, Ward KR. Assessing shock resuscitation strategies by oxygen debt repayment. Shock 2010;33(2):113–22.
  10. Rixen D, Siegel JH. Bench-to-bedside review: oxygen debt and its metabolic correlates as quantifiers of the severity of hemorrhagic and post-traumatic shock. Crit Care 2005;9(5):441–53.
  11. Lima A, van Bommel J, Jansen TC, et al. Low tissue oxygen saturation at the end of early goal-directed therapy is associated with worse outcome in critically ill patients. Crit Care 2009;13(Suppl 5):S13.
  12. Warren OJ, Smith AJ, Alexiou C, et al. The inflammatory response to cardiopulmonary bypass: part 1–mechanisms of pathogenesis. J Cardiothorac Vasc Anesth 2009;23(2):223–31.
  13. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345(19):1368–77.
  14. ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocolbased care for early septic shock. N Engl J Med 2014;370(18):1683–93.
  15. ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371(16):1496–506.
  16. PRISM Investigators, Rowan KM, Angus DC, et al. Early, goal-directed therapy for septic shock - a patient-level meta-analysis. N Engl J Med 2017;376(23): 2223–34.
  17. Shoemaker WC. Cardiorespiratory patterns of surviving and nonsurviving postoperative patients. Surg Gynecol Obstet 1972;134(5):810–4.
  18. Shoemaker WC, Appel PL, Kram HB, et al. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988;94(6):1176–86.

Additional Educational Resources:

To access additional educational and reference materials on the application of advanced hemodynamic monitoring please visit the Edwards Clinical Education website.


Visit our advanced hemodynamic monitoring solutions page to review our full portfolio and to connect with your local support team to partner on implementing a protocolized approach to managing hemodynamics.

Next