11.09.12 Email to Nawaf

Hi Nawaf,

I hope you had a good weekend. I'm in the library again today but will

come and try to find you this afternoon or tomorrow morning. In the

meantime here's an update of where I've got to so far, as requested:

PEOPLE I'VE SPOKEN TO/OBSERVED

Paul (cardiac/orthopaedic)

Anif (cardiac)

Robin (paediatric)

Mario (cardiac)

Dominic (cardiac)

General ITU nursing staff

Cardiac ITU nursing staff

MONITORING TECHNIQUES

Pulse power analysis (LiDCO)

Pulmonary artery catheter

Transoesophageal ultrasonography

Transoesophageal doppler

Pulse contour CO (PiCCO)

Bioelectrical impedence cardiography

Venous catheters

POTENTIAL PARAMETERS FOR OPTIMISATION

Stroke volume

Cardiac output

CVP

Arterial pressure

End-diastolic volume (Transesophageal ultrasonography)

Visual assesment of RV stretch

Serum lactate / pH

Tissue oxygen delivery (DO2I) /Oxygen delivery index

Oxygen consumption (VO2I)

Mixed or central venous sats

Systolic flow time (FTc)

KEY PAPERS ADDRESSING POST-SURGERY OPTIMISATION

McKendry et al, BMJ 329: "Randomised controlled trial assessing the

impact of a nurse delivered, flow monitored protocol for optimisation

of circulatory status after cardiac surgery."

Optimised stroke volume index using blood/colloid fluid challenges and

adrenaline/GTN. Monitoring via oesophageal Doppler probe. Length of

hospital stay reduced in study group.

Pölönen et al, Anesthesia and analgesia 90: 1052- "A prospective,

randomized study of goal-oriented hemodynamic therapy in cardiac

surgical patients."

Optimised mixed venous oxygen saturation and arterial lactate

concentration using volume expansion and dobutamine. (Both the study

and control groups were optimised for PCWP, cardiac index, MAP and

Hb). Morbidity and length of stay reduced in study group.

Pearse et al, Critical care 9: R687- "Early goal-directed therapy

after major surgery reduces complications and duration of hospital

stay. A randomised, controlled trial"

Optimised oxygen delivery index using colloid fluid challenges and

dopexamine. Monitoring via LiDCO. Complications and length of stay

reduced in study group.

Pearse et al, Critical care 9: "Changes in central venous saturation

after major surgery, and association with outcome."

Observational study assessing the association of post-operative

complications with ScvO2, DO2I, CI, P-POSSUM score and use of GDT.

ScvO2 is independently associated with incidence of complications.

I'm currently working on a protocol to bring to the meeting tomorrow,

based on the above papers along with what is done in general ITU. I'll

send that to you once I'm finished.

Cheers,

Kieran