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ESA PGDT Protocol Summary ALIGN Final
ESA PGDT Protocol Summary ALIGN Final
Protocol Summary
APPROVED
APPROVED
SV Protocol
Overview
Using the SV protocol consists in giving successive small (200-250 ml) fluid boluses until
the SV reaches a plateau value (the plateau of the Frank-Starling relationship).
Many single centre randomized controlled trials6-12 and a multicentre quality
improvement program,13 showing a decrease in post-operative complications or hospital
length of stay in the perioperative GDT group, were based on this protocol.
This protocol is now officially recommended by the National Institute for Clinical
Excellence in the UK and by the French Society of Anesthesiology & Intensive Care (SFAR).
Measure SV
ve small
plateau value
s6-12 and a
ng a decrease
of stay in the
ocol.
e National
the French
).
YES
SV increase >10%?
NO
YES
NO
SV reduction >10%
APPROVED
iDO2 Protocol
Overview
Using a iDO2 optimization protocol consists first in optimizing SV with fluid, as described
in the SV protocol.
Once SV has been optimized with fluid, iDO2 is calculated. If iDO2 is <600 ml/min/m2 an
inotrope (dobutamine or dopexamine) is introduced to achieve the iDO2 goal of 600 ml/
min/m2.
Inotropes should not be used or must be discontinued (if already introduced) in case of
tachycardia, cardiac arrhythmia or ischemia.
Several single centre randomized controlled trials, showing a decrease in post-operative
complications or hospital length of stay in the perioperative GDT group, were based on
this protocol.14-19
Keep:
SaO2 >95%
Hb >8 mg/dl
HR <100 bpm
MAP between 60 and 100 mm Hg
O Protocol
timizing
2
Keep:
SaO2 >95%
Hb >8 mg/dl
ated.
Increase of SV >10% or
view
or
blood loss >250 ml
during fluid challenge
al
a iDO2 optimization protocol consists first in optimizing
NO
h fluid, as described in the SV protocol.
d (if already
stable
SV
been optimized with fluid, iDO2 isSVcalculated.
or has
ischemia.
>20 min
2
2 is <600 ml/min/m an inotrope (dobutamine or
amine) is introduced to achieve the iDOYES
showing
2 goal
2
ml/min/m
.
pital
length
YES
Achieve SV max and then target DO2I to 600 ml/min*m2
250 ml HES bolus
NO NO
Increase of SV >10% or
blood loss >250 ml
during fluid challenge
DO2I
NO
SV stable
Dobutamine:
Increase by 3 mcg/kg*min
Decrease or STOP if
HR >100 bpm
or signs of cardiac ischemia
From From
Cecconi Cecconi
et al.19
YES
NO
d on this
pes should not be used or must be discontinued (if already
uced) in case of tachycardia, cardiac arrhythmia or ischemia.
600 ml/min*m2
HR <100 bpm
MAP between 60 and 100 mm Hg
>20 min
NO NO
YES
DO2I
600 ml/min*m2
NO
et al.19
Dobutamine:
Increase by 3 mcg/kg*min
Decrease or STOP if
HR >100 bpm
or signs of cardiac ischemia
HES: Hydroxyethyl
:
Oxygen
Saturation;
Starch; HR: Heart Rate; MAP: Mean Arterial
Pressure;
SaO
Check every 10 minutes
2
If DO I falls below 600 ml/min*m , restart algorithm
SV: Stroke Volume.
2
APPROVED
PPV/SVV Protocol
Overview
Using a PPV/SVV optimization protocol consists in giving fluid to maintain these dynamic
parameters below a predetermined cutoff value.
Several single centre randomized controlled trials, showing a decrease in post-operative
complications or hospital length of stay in the perioperative GDT group, were based on
this protocol.20-24
GDT Group
(ventilate 8 ml/kg)
n giving fluid
edetermined
showing a
tal length of
ed on this
SVV >12%
NO
YES
NO
NO
SVV >12%
YES
YES
Abbreviations:
Arterial
Gases;
Cardiac Output; P-POSSUM:
Abbreviations:
ABGs: ABGs:
Arterial Blood
Gases; Blood
CO: Cardiac
Output;CO:
P-POSSUM:
Portsmouth
Physiologic
and Operative
Severity
Score for
the Enumeration
of for the Enumeration of
Portsmouth
Physiologic
and
Operative
Severity
Score
Mortality and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke
Volume
Variation.
Mortality
and Morbidity Score; PRBCs: Packed Red Blood Cells; SVV: Stroke
Volume Variation.
APPROVED
References
Meta-analysis
1.
2.
3.
4.
5.
SV protocol studies
6. Sinclair et al. BMJ 1997
7. Venn et al. Br J Anaesth 2002
8. Gan et al. Anesthesiology 2002
9. Conway et al. Anaesthesia 2002
10. Wakeling et al. Br J Anaesth 2005
11. Noblett et al. Br J Surg 2006
12. Pillai et al. J Urology 2011
13. Kuper et al. BMJ 2011
APPROVED
APPROVED