Immediate feedback on patient’s fluid and hemodynamic status

Designed to support your clinical decision making

  • Hemodynamic monitor;
  • Non-invasive & minimally invasive;
  • Peri-operative settings;
  • Fluid management;
  • PulseCO™ software.

The new monitor comes with a host of helpful features and functionalities.

LiDCO hemodynamic monitor ports

  • Intuitive interface – Access multiple parameters at the same time
  • Integrated clinical protocols – In-built tools to improve patient care
  • New widescreen display – See more, all at once
  • Battery – Portability and ease
  • Connectivity – HL7 enabled for EMR connectivity
  • Improved menus – Simplified workflow
  • Built in normal parameters – To improve patient care
  • New education screens – Based on the users experience
  • Touchscreen visual feedback – For when working at speed

LiDCO hemodynamic monitor Dimensions Drawing

The LiDCOrapid monitor analyses the blood pressure waveform to provide more information in high-risk surgical and critically ill patients to help with fluid and drug management.

Minimally invasive hemodynamic monitoring icon

The LiDCOrapid uses the PulseCO™ algorithm which converts blood pressure to its constituent parts of flow (CO, SV) and resistance (SVR).  The PulseCO™ algorithm is scaled to each patient with a nomogram using age, height, and weight.  The PulseCO™ algorithm is reliable in unstable patients and in patients on vasoactive drugs.

minimally invasive hemodynamic monitoring icon

LiDCOrapid offers

  • Very easy to set up and use;
  • Designed to be used to help prevent complications in high-risk surgery;
  • Designed to be used for early use in sepsis;
  • The clinician can see why the blood pressure has changed which helps with important clinical decisions;
  • The LiDCOrapid also provides parameters which help to decide when to start and stop giving fluid;
  • Monitoring from a standard radial line and from the non-invasive CNAP™ device;
  • One disposable for both arterial line and non-invasive which is cost effective;
  • Depth of anesthesia monitoring with BIS™.

Refer to the How it works tab and screen guide for further insights into how the flexibility of the displays can help meet your needs.

Nomogram

The LiDCOrapid uses the PulseCO™ algorithm to derive stroke volume (SV) and heart rate from the blood pressure waveform. The key step in the algorithm is the conversion of the blood pressure to volume to account for both aortic compliance and capacitance. The PulseCO™ algorithm uses a patient-specific factor to adjust the aortic capacitance individually for each patient. The factor can be precisely determined by comparing a known cardiac output with the PulseCO™ estimate. This factor does not change for a patient over the short term.

Because the factor does not change, it was possible to develop a nomogram, or mathematical relationship, using the patient’s characteristics to estimate it. The nomogram used in the LiDCOrapid was developed from carefully controlled studies of the PulseCO™ algorithm with precise determinations of cardiac output using Lithium indicator dilution. The result is a robust method for estimation of the factor.

Hemodynamic Window

The LiDCOrapid shows the long-term trend of pressure (MAP, Systolic and Diastolic), Heart Rate (HR) and Scaled Stroke Volume (nSV) or Scaled Cardiac Output (nCO) from the beginning of a procedure. A short term trend of pressure, Heart Rate and Scaled Stroke Volume (nSV) or Scaled Cardiac Output (nCO) is displayed over the current two-minute period.

Dynamic Preload Parameters Windo

This LiDCOrapid window also provides you with access to preload response values or volume status indicators of Pulse Pressure Variation (PPV%) and Stroke Volume Variation (SVV%). For closed chest ventilated patients these volume status measurements provide a way of predicting the likely response to volume infusions. A fluid imbalance can have an adverse effect on a patient’s cardiac performance and, in turn, oxygen delivery to key organs.

Blood Pressure Window

At the touch of a button, the arterial pressure waveform is displayed on the LiDCOrapid screen. The LiDCOrapid algorithm and individualised scaling function converts this pressure into nominal stroke volume and nominal cardiac output.

Event Response Window

Pre-Load Responsiveness via the Event Response Display. The Event Response display allows the user to view a selected hemodynamic variable in a higher resolution during a specific period (e.g. fluid challenge, inotrope change). The LiDCOrapid will display percentage change from the start for the variable as a numeric value. This feature is very useful when evaluating the patient’s response to targeted interventions such as a fluid challenge or changes in inotrope therapy.

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Data Download

The History Screen can be used to review the patient’s hemodynamic changes from a selected baseline. This screen is designed to aid in viewing the relative magnitude of changes in the entire case. The beat-to-beat patient data and event markers are recorded as a file to be reviewed on LiDCOview. A download is enabled through a USB port and memory stick. This powerful tool for data collection provides you with the ability to review, research and train using historical case data.

Elevated PPV predicts increased LOS and morbidity in high risk abdominal surgery

Elevated PPV predicts increased LOS and morbidity in high risk abdominal surgery

Patient Population
High risk abdominal & bariatric surgery.

LiDCO Monitor
LiDCOrapid fluid optimisation.

Trial Design
Prospective observational study.  Maintaining a threshold of 13% for PPV% was deemed adequate fluid management.

Outcome Impact
Patients with PPV maintained at threshold had decreased LOS (10.1 to 6.1 days) and a reduction in postoperative complication rates.

BACKGROUND
High-risk abdominal surgery has been reported to have patient morbidity between 20-40% and a mortality of up to 10%. Intraoperative fluid resuscitation has been shown to reduce morbidity and hospital length of stay (LOS). Functional hemodynamic parameters are sensitive and specific for fluid responsiveness and could be effective to guide intraoperative goal-directed therapy. We performed a prospective observational study to evaluate the effect of LOS in high-risk abdominal surgery patients with adequate resuscitation, based on the percent of intraoperative time that the patient spent below a PPV threshold of 13%.

METHODS
After IRB approval and informed consent, 28 patients of ASA class 2-4 scheduled for major elective intra-abdominal surgery (with potential EBL of 500+cc) were enrolled in this prospective observational trial conducted between 9/2009 and 3/2010. Exclusion criteria were patients with arrhythmias, CHF, or hemodynamically significant heart disease, and patients with intraoperative massive transfusion. Of the 28 patients enrolled, 3 were excluded due to ASA status, unrecorded data (equipment malfunction) and massive transfusion. After induction of GA, a radial arterial line was placed. Hemodynamic values were recorded using the LIDCOrapid. At case termination, audit values of PPV threshold >13% were utilized for analysis as determined by LIDCOview Pro software. All patients were followed prospectively. Patients were divided into adequate resuscitation and inadequate resuscitation groups based on the percent of intraoperative time spent above or below a PPV threshold of 13%. Adequate resuscitation was defined as less than or equal to 25% of intraoperative time spent above a PPV threshold value of 13%. Inadequate resusciation was defined as >25% of intraoperative time spent above a PPV threshold of 13%. The primary analysis was to evaluate for differences in LOS between groups. Secondary anlaysis included a reduction of postoperative complication rates including PONV, cardiac, renal or bowel dysfunction, and mortality if present. Data was analyzed utilizing an un-paired t-test, chi square or fisher’s exact test as appropriate. A p-value of <0.05 was considered significant.

RESULTS

In patients that had adequate resuscitation a significant decrease in LOS was observed from 10.1 to 6.1 days respectively (p<.02 95% CI=-7.20 to -0.79). The adequate resuscitation group had a reduction in postoperative complication rates 7 vs. 1 (P= 0.03). No significant difference was noted between groups with regard to case duration, EBL, crystalloid (5.7 vs. 5.6 l) or colloid administration (0.917 vs. 1.0 l), age, gender or ASA status. There was one patient mortality in the inadequate resuscitation group but this was not statistically significant.

CONCLUSIONS
A significant decrease in LOS was noted in the adequate resuscitation group based on PPV threshold audit analysis of 25% case duration. This group also had a reduction in post-operative complications. Further study utilizing this and other functional hemodynamic parameters to guide intraoperative fluid resuscitation should be performed and could improve the quality and safety of healthcare delivery to these patients.

SVV guide to fluid administration in laparoscopic bariatric surgery

SVV guide to fluid administration in laparoscopic bariatric surgery

Patient Population
Laparoscopic bariatric surgery.

LiDCO Monitor
LiDCOrapid fluid optimisation.

Trial Design
Maintaining SVV% was the goal for fluid optimisation.

Outcome Impact
Using SVV% as the target physicians successfully maintained hemodynamic parameters (cardiac output, stroke volume and heart rate) within 10% of the preoperative level control level.

BACKGROUND
Perioperative fluid administration in morbidly obese patients is critical. There is scarcity of scientific information in literature on amount and rate of its application. Functional parameters (stroke volume variation (SVV), pulse pressure variation) are considered more accurate predictor of volume status of patients than blood pressure and central venous pressure.

METHODS
SVV was used as a guide for intra-operative fluid administration in 50 morbidly obese patients subjected to bariatric surgery. Pulse contour waveform analysis (LiDCO) was utilized to monitor SVV, and a value more than 10% was used as infusion trigger for intraoperative fluid management.

RESULTS
Mean amount of fluid infused was 1,989.90 ml (+/-468.70 SD) for mean 206.94 min (+/-50.30 SD) duration of surgery. All patients maintained hemodynamic parameters (cardiac output, cardiac index, stroke volume, noninvasive blood pressure, heart rate) within 10% of the baseline values. Central venous pressure and SVV showed no correlation, except for short period initially. Renal and metabolic indices remained within normal limits.

CONCLUSION
Obese patients coming for laparoscopic bariatric surgery may not require excessive fluid. Intra-operative fluid requirement is the same as for nonobese patients. SVV is a valuable guide for fluid application in obese patients undergoing bariatric surgery.

Jain A & Dutta A Stroke Volume Variation as a Guide to Fluid Administration in Morbidly Obese Patients Undergoing Laparoscopic Bariatric Surgery. Obes Surg. 2010. DOI 10.1007/s11695-009-0070

Using SVV% as the target physicians successfully maintained hemodynamic parameters (cardiac output, stroke volume and heart rate) within 10% of the pre-operative level control level.

GDFT hemodynamic stability of parturient for cesarean delivery and newborn well-being

GDFT hemodynamic stability of parturient for cesarean delivery and newborn well-being

Patient Population
Hypertensive caesarean section.

LiDCO Monitor
LiDCOrapid fluid optimisation (GDFT).

Trial Design
Randomised SV as target for fluid optimisation vs. routine fluid care.

Outcome Impact
In the GDFT group: heart rate, incidences of hypotension & use of phenylephrine were all lower than in the control group.  In the fetus pH in umbilical artery/vein were significantly decreased, as were incidences of neonatal hypercapnia and hypoxemia.

BACKGROUND
Hypotension induced by combined spinal epidural anesthesia in parturient with hypertensive disorders of pregnancy (HDP) can easily compromise blood supply to vital organs including uteroplacental perfusion and result in fetal distress. The aim of this study was to investigate whether the goal-directed fluid therapy (GDFT) with LiDCOrapid system can improve the well-being of both HDP parturient and their babies.

METHODS:
Fifty-two stable HDP parturient scheduled for elective Cesarean delivery were recruited. After loading with 10 ml/kg lactated Ringer’s solution (LR), parturient were randomized to the GDFT and control group. In the GDFT group, individualized fluid therapy was guided by increase in stroke volume (ΔSV) provided via LiDCOrapid system. The control group received the routine fluid therapy. The primary endpoints included maternal hypotension and the doses of vasopressors administered prior to fetal delivery. The secondary endpoints included umbilical blood gas abnormalities and neonatal adverse events.

RESULTS
The severity of HDP was similar between two groups. The total LR infusion (P < 0.01) and urine output (P < 0.05) were higher in the GDFT group than in the control group. Following twice fluid challenge tests, the systolic blood pressure, mean blood pressure, cardiac output and SV in the GDFT group were significantly higher, and the heart rate was lower than in the control group. The incidence of maternal hypotension and doses of phenylephrine used prior to fetal delivery were significantly higher in the control group than in the GDFT group (P < 0.01). There were no differences in the Apgar scores between two groups. In the control group, the mean values of pH in umbilical artery/vein were remarkably decreased (P < 0.05), and the incidences of neonatal hypercapnia and hypoxemia were statistically increased (P < 0.05) than in the GDFT group.

CONCLUSIONS
Dynamic responsiveness guided fluid therapy with the LiDCOrapid system may provide potential benefits to stable HDP parturient and their babies.

Multimodal intraoperative monitoring: Observational case series in major peripheral vascular surgery

Multimodal intraoperative monitoring: Observational case series in major peripheral vascular surgery

Patient Population
High-risk peripheral vascular surgery.

LiDCO Monitor
LiDCOrapid as the hemodynamic part of a multimodal monitoring approach.

Trial Design
Actual mortality after multimodal approach vs predicted V-POSSUM.

Outcome Impact
30-day mortality at 0.8% significantly lower than the 9% mortality predicted by the V-POSSUM amputation rate less than 2% after one year. Post-operatively only 8% (10 patients) went to a high dependency unit (HDU).

BACKGROUND
Recent guidelines from the National Institute for Health and Care Excellence (NICE) and the UK National Health Service (NHS) have stipulated that intra-operative flow monitoring should be used in high-risk patients undergoing major surgery to improve outcomes and reduce costs. Depth of anesthesia monitoring is also recommended for patients where excessive anesthetic depth is poorly tolerated, along with cerebral oximetry in patients with proximal femoral fractures.

OBJECTIVE
The aims of this descriptive case series were to evaluate the impact of a multimodal intra-operative strategy and its effect on mortality and amputation rate for patients with critical leg ischaemia.

METHODS
In an observational case series, 120 elderly patients undergoing major infra-inguinal bypass between 2007 and 2012 were included in this retrospective analysis of prospectively collected data. Nominal cardiac output (nCO, LiDCOrapid), bispectral index to monitor depth of anaesthesia (BIS, Medtronic) and cerebral oxygenation, rSO2 (Invos, Medtronic) readings were obtained before induction of general anesthesia and throughout surgery. 30-day, 1-year mortality and amputation rates were analysed. Demographics and physiological parameters including correlation with V-POSSUM, age, gender and other co-morbidities were statistically analysed.

RESULTS
Thirty-day mortality rate was 0.8% (n = 1). V-POSSUM scoring indicated a predicted mortality of 9%. Amputation rate was less than 2% at one year. Only 8% of patients (10 of 120) were admitted to a high dependency unit (HDU) postoperatively. 30-day mortality in our case series was lower than predicted by V-POSSUM scoring.

CONCLUSIONS
Use of multimodal intra-operative monitoring with the specific aim of limiting build-up of oxygen debt should be subjected to a randomised controlled study to assess the reproducibility of these results.

Green D, Bidd H, Rashid H. Multimodal intraoperative monitoring: An observational case series in high risk patients undergoing major peripheral vascular surgery. Int J Surg (2014);12(3):231-6. doi: 10.1016/j.ijsu.2013.12.016. Epub 2014 Jan 8.

30-day mortality at 0.8% significantly lower than the 9% mortality predicted by the V-POSSUM amputation rate less than 2% after one year. Post-operatively only 8% (10 patients) went to a high dependency unit (HDU).

Application of LiDCO-Rapid in peri-operative fluid therapy for aged patients total hip replacement

Application of LiDCO-Rapid in peri-operative fluid therapy for aged patients total hip replacement

Patient Population
Total hip replacement.

LiDCO Monitor
LiDCOrapid fluid optimisation.

Trial Design
Randomised LiDCOrapid fluid optimisation vs conventional fluid management.

Outcome Impact
Lactate levels were significantly lower than seen in the conventionally managed subjects vasopressor requirements and complications were also significantly lower in the LiDCOrapid fluid optimized group.

OBJECTIVE
To explore a good strategy for fluid therapy, we observed the effect of application of LiDCOrapid on peri-operative hypotension and complications in aged patients undergoing total hip replacement, performed under combined spinal-epidural anesthesia (CSEA).

METHODS
Forty patients were randomly divided into normal fluid therapy group (group N) and LiDCOrapid guiding fluid therapy group (group L). For group N, anytime mean arterial pressure (MAP) was less than 65 mmHg, a rapid intravenous infusion of 150 ml hydroxyethyl starch solution (HES,130/0.4, 6%) was given. For group L, whenever stroke volume variation (SVV) was more than 10%, HES (130/0.4,6%) was also given to patients until SVV returned to normal limits. After administration of HES, MAP still less than 65 mmHg called for 25-50 μg of phenylephrine to be given to maintain normal MAP in both groups. Heart rate (HR), MAP and lactate level of arterial blood (LAC) was compared between the two groups as prior to anesthesia (T0); instantly (T1), 15 min (T2), 30 min (T3), 60 min (T4), 90 min (T5) after spinal anesthesia; and at the end of surgery (T6).

RESULTS
MAP and HR were significantly higher in group L than in group N at T4 to T6 (all P<0.05). LAC was significantly lower in group L than in group N at T5 and T6 (all P<0.05). Phenylephrine requirements and incidences of peri-operative complications were also significantly lower in group L than in group N (all P<0.05).

CONCLUSION
LiDCOrapid may be used in fluid therapy for aged patients undergoing total hip replacement.

Han G, Liu K, Xue H, Zhao P. Application of LiDCO-Rapid in peri-operative fluid therapy for aged patients undergoing total hip replacement. Int J Clin Exp Med 2016;9(2):4473-4478, www.ijcem.com /ISSN:1940-5901/IJCEM0010819

Lactate levels were significantly lower than seen in the conventionally managed subjects vasopressor requirements and complications were also significantly lower in the LiDCOrapid fluid optimized group.

Restrictive strategy of intra-operative fluid maintenance decreases major complications after high-risk surgery

Restrictive strategy of intra-operative fluid maintenance decreases major complications after high-risk surgery

Patient Population
High-risk general surgery.

LiDCO Monitor
LiDCOrapid fluid optimisation & oxygen delivery (DO2) GDT target.

Trial Design
Randomised GDT with fluid restriction vs GDT with liberal maintenance fluids.

Outcome Impact
Allowed GDT DO2 targeting while restricting maintenance fluids; reducing expected complications rate from 61.5% to 20%.

INTRODUCTION
Optimal fluid management is crucial for patients who undergo major and prolonged surgery. Persistent hypovolemia is associated with complications, but fluid overload is also harmful. We evaluated the effects of a restrictive versus conventional strategy of crystalloid administration during goal-directed therapy in high-risk surgical patients.

METHODS
We conducted a prospective, randomized, controlled study of high-risk patients undergoing major surgery. For fluid maintenance during surgery, the restrictive group received 4 ml/kg/hour and the conventional group received 12 ml/kg/hour of Ringer’s lactate solution. A minimally invasive technique (the LiDCO monitoring system) was used to continuously monitor stroke volume and oxygen delivery index (DO2I) in both groups. Dobutamine was administered as necessary, and fluid challenges were used to test fluid responsiveness to achieve the best possible DO2I during surgery and for 8 hours postoperatively.

RESULTS
Eighty-eight patients were included. The patients’ median age was 69 years. The conventional treatment group received a significantly greater amount of lactated Ringer’s solution (mean ± standard deviation (SD): 4, 335 ± 1, 546 ml) than the restrictive group (mean ± SD: 2, 301 ± 1, 064 ml) (P < 0.001). Temporal patterns of DO2I were similar between the two groups. The restrictive group had a 52% lower rate of major postoperative complications than the conventional group (20.0% vs 41.9%, relative risk = 0.48, 95% confidence interval = 0.24 to 0.94; P = 0.046).

CONCLUSIONS
A restrictive strategy of fluid maintenance during optimization of oxygen delivery reduces major complications in older patients with coexistent pathologies who undergo major surgery.

RCT effect of peri-operative GDHT on cardiac surgery outcomes

RCT effect of peri-operative GDHT on cardiac surgery outcomes

Patient Population
Cardiac surgery.

LiDCO Monitor
LiDCOrapid goal-directed therapy (GDT) targeted cardiac index (CI).

Trial Design
Randomised GDT targeted cardiac index vs standard care.

Outcome Impact
Composite endpoint 30-day mortality and major postoperative complications reduced in the goal-directed therapy group (27.4% vs 45.3%) and GDT patients had less infections (12.9% vs 29.7%), a lower incidence of low cardiac output syndrome (6.5% vs 26.6%), reduced ICU (3 vs 5 days) and hospital stay (9 vs 12 days).

OBJECTIVES
To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery.

DESIGN:
A prospective randomised controlled trial and an updated meta-analysis of randomised trials published from inception up to May 1, 2015.

SETTING
Surgical ICU within a tertiary referral university-affiliated teaching hospital.

PATIENTS
One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair.

INTERVENTIONS
Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64). In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU.

MEASUREMENTS AND MAIN RESULTS
The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed therapy group received a greater median (interquartile range) volume of IV fluids than the usual care group (1,000 [625-1,500] vs 500 [500-1,000] mL; p < 0.001], with no differences in the administration of either inotropes or RBC transfusions. The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037). The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome (6.5% vs 26.6%; p = 0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3-4] vs 5 [4-7] d; p < 0.001) and hospital length of stay (9 [8-16] vs 12 [9-22] d; p = 0.049) in the goal-directed therapy compared with the usual care group. There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410 [11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26-0.63]; p < 0.0001) and decreased the hospital length of stay (mean difference, -5.44 d; 95% CI, -9.28 to -1.60; p = 0.006) with no difference in post-operative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio, 0.61 (95% CI, 0.26-1.47), and p = 0.27.

CONCLUSIONS
Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.

Osawa EA, Rhodes A, Landoni G, Galas FR, et al. Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review. Crit Care Med. 2016;44(4):724-33. doi: 10.1097/CCM.0000000000001479.

Study showed composite endpoint 30-day mortality and major post-operative complications reduced in the goal-directed therapy group (27.4% vs 45.3%) and GDT patients had less infections (12.9% vs 29.7%), a lower incidence of low cardiac output syndrome (6.5% vs 26.6%), reduced ICU (3 vs 5 days) and hospital stay (9 vs 12 days).

Propensity score analysis of ERP in upper gastrointestinal cancer surgery

Propensity score analysis of ERP in upper gastrointestinal cancer surgery

Patient Population
Oesophagectomy & Gastrectomy.

LiDCO Monitor
LiDCOrapid as part of an enhanced recovery program (ERP).

Trial Design
Before vs after ERP (propensity score-matched analysis).

Outcome Impact
ICU stay reduced and LOS reduced by 3 days.

INTRODUCTION
The aim of this study was to examine the influence of an enhanced recovery programme (ERP) on outcomes of upper gastrointestinal (UGI) cancer surgery by means of propensity score-matched analysis.

METHODS
Three hundred consecutive patients diagnosed with UGI cancer were studied prospectively before and after the introduction of an ERP. Multiple regression models, including propensity scores, were developed to assess confounding variables associated with undergoing surgery, and the risk-adjusted association between treatment and length of hospital stay (LOHS).

RESULTS
After regression for confounding factors, a cohort of 252 patients was available of whom 160 received ERP [median age 66 years (IQR 58-73), 119 male, 81 oesophageal, 79 gastric cancer] and 92 control [66 years (IQR 58-74), 74 male, 58 oesophageal, 34 gastric cancer]. ERP operative morbidity (Clavien-Dindo ≥3) and mortality were 13.8 and 3.1 % compared with 17.4 (p = 0.449) and 2.2 % (p = 0.658) in controls. Median ERP critical care and total LOS were 1 (IQR 0-1) and 13 (IQR 10-17) days, compared with 1 (IQR 1-2, p = 0.009) and 16 (IQR 13-26, p < 0.001) days. Multivariable analysis revealed ERP (HR 1.477, 95 % CI 1.084-2.013, p = 0.013), tumour location (HR 2.420, 95 % CI 1.624-3.606, p < 0.001), operative procedure (HR 1.143, 95 % CI 1.032-1.265, p = 0.010), and operative morbidity (HR 0.277, 95 % CI 0.179-0.429, p < 0.001) to be associated with LOHS.

CONCLUSION
An ERP in UGI cancer surgery was feasible, safe, and effective.

Impact of multidisciplinary SOCP on perioperative oesophageal cancer outcomes

Impact of multidisciplinary SOCP on perioperative oesophageal cancer outcomes

Patient Population
Oesophagectomy.

LiDCO Monitor
LiDCOrapid + standardised oesophagectomy pathway (SOCP).

Trial Design
Before vs after SOCP introduction.

Outcome Impact
Lower complications, ICU stay reduced by 1 day, LOS reduced by 10 days (17 to 7 days).

BACKGROUND
Defined clinical pathways can contribute to improved outcomes in patients undergoing oesophageal cancer surgery. A standardized oesophagectomy clinical pathway (SOCP) established at the Virginia Mason Medical Center (VMMC) in Seattle, Washington, USA was introduced into the Royal Surrey County Hospital (RSCH), Guildford, UK in 2011. The aim of this study was to see whether transfer and implementation of an oesophagectomy care pathway could change post-operative outcomes significantly.

METHODS
Three consecutively accrued study groups were examined at the RSCH: patients operated on immediately before the introduction of the SOCP (group 1), patients operated on after the introduction of the SOCP but not included in the pathway (group 2), and patients managed according to the SOCP (group 3). Outcomes were compared with those of patients who had surgery at the VMMC between 2009 and 2011 using the SOCP (group 4).

RESULTS
There were 12 patients in each of the first three groups and 74 in group 4. All groups were similar with respect to body mass index, medical co-morbidities and clinical stage. The median age of patients in group 3 was significantly lower than that in group 1, and median American Society of Anesthesiologists score was significantly better in group 3 compared with group 4. Following initiation of the SOCP there was an increase in immediate extubation (8 of 12 in group 1 versus 12 of 12 in group 3) and first-day mobilization (1 of 12 versus 12 of 12 respectively), and a reduction in complications (9 of 12 versus 4 of 12), length of critical care stay (4 (range 2-20) days in group 1 versus 3 (1-5) days in group 3) and length of hospital stay (17 (12-30) to 7 (6-37) days respectively). Patients not on the pathway but who had surgery during the same interval experienced small but non-significant improvements in length of critical care and hospital stay, and in first-day mobilization.

CONCLUSION
The study demonstrated improvement in short-term outcomes after oesophagectomy following the adoption of an established multidisciplinary standardized post-operative pathway.

RCT effect of peri-operative hemodynamic therapy algorithm major gastrointestinal surgery outcomes

RCT effect of peri-operative hemodynamic therapy algorithm major gastrointestinal surgery outcomes

Patient Population
OPTIMISE – High-risk gastrointestinal surgery.

LiDCO Monitor
LiDCOrapid guided hemodynamic algorithm with dopexamine infusion vs usual care.

Trial Design
Prospective multi-centre randomised.

Outcome Impact
Lower, compound complications (36.6% v 43.4% n.s.) The inclusion of results in a meta-analysis indicates intervention was associated with a clinically significant lower level of complications.

IMPORTANCE
Small trials suggest that post-operative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm.

OBJECTIVE
To evaluate the clinical effectiveness of a perioperative, cardiac output-guided hemodynamic therapy algorithm.

DESIGN, SETTING, AND PARTICIPANTS
OPTIMISE was a pragmatic, multi-center, randomised, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the UK. An updated systematic review and meta-analysis were also conducted including randomised trials published from 1966 to February 2014.

INTERVENTIONS
Patients were randomly assigned to a cardiac output-guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery (n=368) or to usual care (n=366).

MAIN OUTCOMES AND MEASURES
The primary outcome was a composite of predefined 30-day moderate or major complications and mortality. Secondary outcomes were morbidity on day 7; infection, critical care-free days, and all-cause mortality at 30 days; all-cause mortality at 180 days; and length of hospital stay.

RESULTS
Baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups. Care was nonadherent to the allocated treatment for less than 10% of patients in each group. The primary outcome occurred in 36.6% of intervention and 43.4% of usual care participants (relative risk [RR], 0.84 [95% CI, 0.71-1.01]; absolute risk reduction, 6.8% [95% CI, -0.3% to 13.9%]; P = .07). There was no significant difference between groups for any secondary outcomes. Five intervention patients (1.4%) experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group. Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications (intervention, 488/1548 [31.5%] vs control, 614/1476 [41.6%]; RR, 0.77 [95% CI, 0.71-0.83]) and a nonsignificant reduction in hospital, 28-day, or 30-day mortality (intervention, 159/3215 deaths [4.9%] vs control, 206/3160 deaths [6.5%]; RR, 0.82 [95% CI, 0.67-1.01]) and mortality at longest follow-up (intervention, 267/3215 deaths [8.3%] vs control, 327/3160 deaths [10.3%]; RR, 0.86 [95% CI, 0.74-1.00]).

CONCLUSIONS AND RELEVANCE
In a randomised trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output-guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality. However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rates.

TRIAL REGISTRATION:
isrctn.org Identifier: ISRCTN04386758.

Reduced LOS in colorectal surgery after ERP implementation

Reduced LOS in colorectal surgery after ERP implementation

Patient Population
Open or laparoscopic colorectal surgery.

LiDCO Monitor*
LiDCOrapid as part of an enhanced recovery program (ERAS).

Trial Design
Before vs after ERAS introduction.

Outcome Impact
LOS reduced by 2 days (7 to 5), lower urinary infections (13% v 24%) & 30 day readmission rates 9.8% v 20.2%.

BACKGROUND
Enhanced recovery after surgery (ERAS) is a multimodal approach to perioperative care that combines a range of interventions to enable early mobilisation and feeding after surgery. We investigated the feasibility, clinical effectiveness, and cost savings of an ERAS program at a major US teaching hospital.

METHODS
Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, before and after implementation of an ERAS protocol. Data collected included patient demographics, operative, and peri-operative surgical and anesthesia data, need for analgesics, complications, inpatient medical costs, and 30-day readmission rates.

RESULTS
There were 99 patients in the traditional care group, and 142 in the ERAS group. The median length of stay (LOS) was 5 days in the ERAS group compared with 7 days in the traditional group (P < 0.001). The reduction in LOS was significant for both open procedures (median 6 vs 7 days, P = 0.01), and laparoscopic procedures (4 vs 6 days, P < 0.0001). ERAS patients had fewer urinary tract infections (13% vs 24%, P = 0.03). Readmission rates were lower in ERAS patients (9.8% vs 20.2%, P = 0.02).

DISCUSSION
Implementation of an enhanced recovery protocol for colorectal surgery at a tertiary medical center was associated with a significantly reduced LOS and incidence of urinary tract infection. This is consistent with that of other studies in the literature and suggests that enhanced recovery programs could be implemented successfully and should be considered in US hospitals.

*Deltex Medical ODM monitor also used as part of this study

Miller T, Thacker J, White W, Mantyh C, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052–61.

Outcome showed LOS reduced by 2 days (7 to 5), lower urinary infections (13% v 24%) & 30-day readmission rates 9.8% v 20.2%.

Enhanced recovery in the resection of colorectal liver metastases

Enhanced recovery in the resection of colorectal liver metastases

Patient Population
Resection of colorectal liver metastases.

LiDCO Monitor
LiDCOrapid as part of an enhanced recovery program (ERAS).

Trial Design
Before v after an ERAS introduction.

Outcome Impact
The probability that LOS would be > 10 days decreased to 7% from 25% & ICU utilization reduced from 75.5% to 54.7%.

BACKGROUND
There is limited evidence for the use of enhanced recovery after surgery (ERAS) in patients undergoing hepatectomy, and the impact of the evolution of ERAS over time has not been examined. This study sought to evaluate the effect of an evolving ERAS program in patients undergoing hepatectomy for colorectal liver metastases (CRLM).

METHODS
A multimodal ERAS program was introduced in 2/2008. Consecutive patients undergoing hepatectomy for CRLM between 2/2008 and 9/2012 were included in the study. Data were collected prospectively. Retrospective analysis compared an early ERAS cohort (2/2008-4/2010) with a later cohort with a matured ERAS program (5/2010-8/2012).

RESULTS
Length of stay reduced as experience of ERAS increased (Log-rank χ(2) = 10.43, P = 0.001). Although median length of stay remained unchanged (6 days), the probability of hospitalisation beyond 10 days was 25% in the early cohort compared with 7% in the later cohort. Critical care utilization reduced over time (75.5% vs. 54.7%, P < 0.0001). Complications occurred in 38.2%, with no difference in between cohorts. One postoperative death occurred in the early cohort (<0.3%).

CONCLUSIONS:
This study suggests that as the experience of ERAS evolves, there is a progressive reduction in hospitalisation and critical care admission. This is without any increase in morbidity and mortality.

Dunne DF, Yip VS, Jones RP, McChesney EA, et al. Enhanced recovery in the resection of colorectal liver metastases. J Surg Oncol. 2014. doi:10.1002/jso.23616

Study showed probability that LOS would be > 10 days decreased to 7% from 25% & ICU utilization reduced from 75.5% to 54.7%.

RCT enhanced recovery versus standard care following open liver resection

RCT enhanced recovery versus standard care following open liver resection

Patient population
Open Liver Surgery.

LiDCO Monitor
LiDCOrapid as part of an enhanced recovery program (ERP).

Trial Design
Randomised ERP vs standard care.

Outcome Impact
LOS reduced by 3 days. Complications reduced from 27% to 7%.

BACKGROUND
Enhanced recovery programmes (ERPs) have been shown to reduce length of hospital stay (LOS) and complications in colorectal surgery. Whether ERPs have the same benefits in open liver resection surgery is unclear, and randomised clinical trials are lacking.

METHODS
Consecutive patients scheduled for open liver resection were randomised to an ERP group or standard care. Primary endpoints were time until medically fit for discharge (MFD) and LOS. Secondary endpoints were post-operative morbidity, pain scores, readmission rate, mortality, quality of life (QoL) and patient satisfaction. ERP elements included greater preoperative education, preoperative oral carbohydrate loading, post-operative goal-directed fluid therapy, early mobilization and physiotherapy. Both groups received standardized anesthesia with epidural analgesia.

RESULTS
The analysis included 46 patients in the ERP group and 45 in the standard care group. Median MFD time was reduced in the ERP group (3 days versus 6 days with standard care; P < 0·001), as was LOS (4 days versus 7 days; P < 0·001). The ERP significantly reduced the rate of medical complications (7 versus 27 per cent; P = 0·020), but not surgical complications (15 versus 11 per cent; P = 0·612), readmissions (4 versus 0 per cent; P = 0·153) or mortality (both 2 per cent; P = 0·987). QoL over 28 days was significantly better in the ERP group (P = 0·002). There was no difference in patient satisfaction.

CONCLUSION
ERPs for open liver resection surgery are safe and effective. Patients treated in the ERP recovered faster, were discharged sooner, and had fewer medical-related complications and improved QoL.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Patient Population
Emergency Laparotomy Surgery.

LiDCO Monitor
LiDCOrapid as part of an evidence-based care bundle.

Trial Design
Before v after a care bundle introduction.

Outcome Impact
Reduced mortality – 5.97 more lives per 100 patients were saved.

BACKGROUND
Emergency laparotomies in the UK, USA, and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care.

METHODS
The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model.

RESULTS
Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395).

CONCLUSION
Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

The LiDCOrapid with continuous non-invasive arterial pressure (CNAP™) module provides continuous cardiac output non-invasively, without the requirement for an arterial line.

Non invasive hemodynamic monitoring icon

The CNAP™ dual finger cuffs will provide a continuous, non-invasive pressure which is then analysed by the validated PulseCO™ algorithm to derive beat-to-beat hemodynamic data.

non invasive hemodynamic monitoring icon

• LiDCOrapid with CNAP™ is safe and easy to use, allowing for effective hemodynamic management of all surgery types;

• The device allows for monitoring prior to induction as well as throughout surgery. This enables immediate fluid and drug management and the setting of hemodynamic baselines;

•CNAP™ is used with the PulseCO™ ‘pulse power’ algorithm which reliably tracks hemodynamic change in the presence of inotropes and vasoactive drugs;;• The CNAP™ dual finger cuff system is scaled to the brachial artery with an arm cuff to provide a reliable continuous absolute value for blood pressure.

• SVV, PPV, HR and change in SV will be comparable to those derived from an invasive arterial line.


CNAP™, How it works…

The CNAP® uses a vascular unloading technique dates back to the Czech physiologist Jan Peňáz in the 1970s. It is the basic principle for detecting blood volume changes in the finger and transforming plethysmographic signals into continuous blood pressure information.

The dual finger cuff inflates and deflates to maintain a constant blood volume which produces a non-invasive pressure waveform. This is then individually scaled to the patient using a brachial arm cuff measurement.

For cardiac output monitoring, the continuous, non-invasive blood pressure waveform is analysed by the
validated PulseCO™ algorithm.

  • An infrared light source and sensor measure continuous blood volume in the finger;
  • The finger pressure cuff inflates and deflates to maintain a constant blood volume;
  • This counter pressure produces a continuous BP waveform;
  • An absolute BP via the brachial arm cuff is then used to scale this waveform to the brachial artery pressure;
  • The validated PulseCO™ algorithm derives SV, CO, SVR and SVV from the non-invasive waveform.

continuous non-invasive pressure, CNAP

Hemodynamic Training Programme

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World Sepsis Day

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LiDCOrapid – Hemodynamic Monitoring in Action

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