Flotrac Sensor

[Catticus11]

I had a patient come from the PACU after a leg revasc with an arterial line attached to a flotrac sensor/transducer. No vigileo or anything like that.

I'm not too familiar with the equipment. What's the point of the flotrac transducer? Did they have more use of it in the OR or is the flotrac sensor/transducer have an advantage that I'm just not aware of.

Thank you!

[Rose_Queen, BSN, MSN, RN]

Is your facility part of an ERAS plan for vascular patients? That may have something to do with it. As for the Vigileo, it is no longer produced or supported, so that may be why you didn't see one.

[ATTACH=CONFIG]24649[/ATTACH]

This is from the Edwards website.

I know that in my facility, the OR has taken a lot of initiatives towards optimizing patient outcomes- we are now prewarming patients in the preop area (used to only use Bair Huggers during the procedure), strict glycemic control, perioperative nutrition, fluid volume management, and other things. It's a big change from the traditional thinking of surgical management- before, during, and after.

And some more info can be found at the ERAS society website.

ENHANCED RECOVERY AFTER SURGERY

ERAS is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery.

ERAS represents a paradigm shift in perioperative care in two ways. First, it re-examines traditional practices, replacing them with evidence-based best practices when necessary. Second, it is comprehensive in its scope, covering all areas of the patient”s journey through the surgical process.

The key factors that keep patients in the hospital after surgery include the need for parenteral analgesia, the need for intravenous fluids secondary to gut dysfunction, bed rest caused by lack of mobility.

The central elements of the ERAS pathway address these key factors, helping to clarify how they interact to affect patient recovery. In addition, the ERAS pathway provides guidance to all involved in perioperative care, helping them to work as a well-coordinated team to provide the best care.

[jj224]

Stroke volume and cardiac output measured with only an A-line. Helps guide fluid management in OR especially

[EllaBella1, BSN]

Do you guys use EV1000s? They have pretty much replaced the Vigileo and are what we tend to use flotrac for in my unit.

[lkasticu]

We utilize the Flotrac in my STICU as an easy method of determining hemodynamics just using an art line. For instance we can determine fluid deficits/response to fluid challenges using SVV or CVP (though I've been told recent studies show CVP is an unreliable indicator) to see if we have a preload problem, or SVRI as an indicator of an afterload problem requiring something like pressor support.

To simplify, say my patient's hypotensive. I can look at the SVV/CVP, give some fluids, and if we see the numbers improve we know the patient will benefit from fluid resuscitation. If the SVRI is low, we know that the patient has an issue with vasodilation; if the fluid challenge doesn't help then a vasopressor will tighten them up and improve BP. No use throwing fluid into a patient in a vasodilated shock state, it'll just leak out into edema. In a cardiac patient we could see stroke volume/cardiac output and know we might want to correct a contractility issue with a positive inotrope like dopamine or dobutamine.

Supposedly some common things can make the numbers off such as an elevated PEEP or APRV, both of which are common in the severe trauma population. Our OR switches patients to a lower PEEP or SIMV whenever they go down, I imagine because they hook patients up to the Flotrac while they're down there. Seems like a good practice to me especially in a vascular surgery (well, you know, my patient derecruits like mad but at least their OR numbers look good).

[offlabel]

Once you start inopressor use the Flotrac loses accuracy. That's why it isn't universally used.

[offlabel]

Supposedly some common things can make the numbers off such as an elevated PEEP or APRV, both of which are common in the severe trauma population. Our OR switches patients to a lower PEEP or SIMV whenever they go down, I imagine because they hook patients up to the Flotrac while they're down there. Seems like a good practice to me especially in a vascular surgery (well, you know, my patient derecruits like mad but at least their OR numbers look good).

Anesthesia in a volume depleted patient, like a trauma patient, causes hypotension because of the effect on venous return, among other things. PEEP has an adverse effect on venous return as well which is why giving less is advantageous in patients like these. It isn't a matter of making numbers look good, it's a matter of mitigating several factors that affect morbidity while creating conditions where surgery can occur.

[lkasticu]

Thank you about the inotrope comment, I wasn't completely aware of that and will look into it. I was moreso joking about the OR numbers thing to an extent. Our trauma residents have a constant battle with OR about this.

While I can see the advantage of this, it's not like we have such a high PEEP for no reason, especially with ARDS/lung trauma patients. They come back from the OR after having their PEEP decreased and they've clearly derecruited and their ABG shows they're backsliding. You've mitigated one potential cause of morbidity but increased another, especially since we would have optimally fixed any volume depletion before the patient goes to the OR anyways.

I suppose anesthesia's priority is to make sure the surgery goes well, doesn't mean they haven't potentially caused more harm in the long run. Still, I won't pretend to be an expert on vent management v. anesthesia when not even our own doctors see eye to eye on this. In the trauma ICU I naturally support my trauma doctors over anesthesia.

[offlabel]

I suppose anesthesia's priority is to make sure the surgery goes well, doesn't mean they haven't potentially caused more harm in the long run. Still, I won't pretend to be an expert on vent management v. anesthesia when not even our own doctors see eye to eye on this. In the trauma ICU I naturally support my trauma doctors over anesthesia.

The anesthesia department might know a thing or two about trauma...that there is an "us v. them culture" in your program doesn't bode well for patients there. Excellent trauma care is a multidisciplinary effort in which each group recognizes and values the others unique contribution to the patient's well being.

Giving the benefit of the doubt to the other groups is critical for professional cohesion and the leap that "de- recruitment" or "backsliding" is the result of some shortcoming on the part of the anesthesia team is a little naïve. Just taking a patient off of the ICU ventilator, hand ventilating to the OR and then putting them onto the anesthesia machine ventilator is enough to create atelectasis, let alone the effects of volatile agents during the surgery. Should appropriate volume resuscitation be withheld in the OR when it's needed even though it may contribute to ALI?

Expecting there to be no consequences from treating serious trauma is just not realistic, and assigning blame when it does happen is unfair and uninformed.

[bclark297]

Anesthesia probably used a Vigileo during the case. They just left the monitor in the OR.

A Flotrac/vigileo can give you CO,CI,SVV, etc. similar to a swan