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Goal-Directed Therapy: Optimizing fluid management in your patient

Pinsky, Michael R (2012) Goal-Directed Therapy: Optimizing fluid management in your patient. Initiatives in Safe Patient Care. 1 - 12.

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Surgical trauma often exposes patients to periods of cardiovascular insufficiency, either because of anesthesia-induced loss of vasomotor tone and baroreceptor responsiveness, or because of blood loss and mechanical obstruction to blood flow. In all cases, cardiac output will fall and if the heart rate remains constant, stroke volume will fall as well. If there is sustained cardiovascular insufficiency with inadequate O2 delivery to the tissues, then end-organ dysfunction may occur, resulting in increased patient morbidity and mortality. Although most surgery does not result in profound tissue hypoperfusion causing organ system function, some degree of hypoperfusion does occur. Since surgical stress also stimulates a vigorous cytokine storm, the combination of relative hypoperfusion and immune modulation will alter the microcirculation, causing subclinical injury. Until ~20 years ago, it was felt that these concerns were primarily academic and did not affect patient outcomes. However, in the 1980s, William Shoemaker and colleagues documented that a surgery-associated reduction of global oxygen delivery (DO2), calculated as the product of cardiac output and arterial oxygen content, resulted in a deficiency relative to the preoperative basal oxygen delivery/oxygen consumption. Importantly, if this decreased DO2 caused O2 consumption to also fall, then it was assumed to reflect a surgery-induced "oxygen delivery debt." The magnitude of this oxygen debt was uniquely associated with the patient outcome in that both morbidity and mortality were associated with the highest levels of oxygen debt. Although their initial clinical trial to target what they referred to as "survivor levels" of DO2 was successful, subsequent trails were uniformly negative or actually resulted in a worse outcome. It was presumed at the time that the risks associated with aggressive resuscitation and vasoactive drug therapies needed to achieve these levels of DO2 could be detrimental.


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Item Type: Article
Status: Published
CreatorsEmailPitt UsernameORCID
Pinsky, Michael Rpinsky@pitt.eduPINSKY0000-0001-6166-700X
Date: 2012
Date Type: Publication
Access Restriction: No restriction; Release the ETD for access worldwide immediately.
Journal or Publication Title: Initiatives in Safe Patient Care
Publisher: Saxe Healthcare Communications
Page Range: 1 - 12
Institution: University of Pittsburgh
Schools and Programs: School of Medicine > Critical Care Medicine
Refereed: Yes
Related URLs:
Additional Information: Includes Panel Discussion: Optimizing Fluid Management: Opinions from the Experts beginning on p. 5.
Date Deposited: 22 Aug 2012 21:01
Last Modified: 30 Jan 2020 16:57


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