Keep an Eye on Costs

Transcription

1 Pulsion Session State of the Art Hemodynamic Monitoring I Keep an Eye on Costs (Erasmus Room) Tuesday 24 March 2009 Manu Malbrain Intensive Care Unit ZiekenhuisNetwerk Antwerpen Campus Stuivenberg Antwerpen, Belgium

2 Biggest Manu Bias Malbrain = WSACS ICU Director and manager ZNA STER Founding President WSACS ( Chairman WCACS 2007 ( Educational Grant: 2003 ESICM Chris Stoutenbeek Award Member Medical Advisory Board Pulsion Medical Systems KCI Benelux Spiegelberg Holtech Medical Thanks to to F. F. Michard Neutec European Patent Holder CiMON (PMS) Research Project: Draeger, Edwards, Bard, Wolfe Tory Fees Honoraria: GSK, MSD 2

3 WSACS Executive Committee : Your Servants WSACS Jan De Waele, B CTWG Zsolt Baogh, AUS Secretary WCACS Michael Sugrue, AUS President Manu Malbrain, B Founding President Treasurer Rao Ivatury, USA Vice-President Mike Cheatham, USA President-Elect

4 MANAGEMENT SCHOOL Costs a lot No teaching Self development PULSION SESSION Costs Nothing A lot of teaching Self development

5 Who actually uses less invasive HD monitoring?

6 What type of LIHD? NiCO 2 LiDCO PiCCO Doppler Vigileo

7 Availability of Cardiac Output Equipment in UK ICU s % Intermittent PAC Continuous PAC Doppler Pulse Contour Other Neil Neil

8 Ideal Cardiac Output Monitor Ideal System Real Time beat to to beat CO Real Time Preload + Afterload Adequacy data Minimally invasive Widely applicable Simple to to Operate and Understand Measured variables Clear Data Display + Interpretation Nurse driven at at the bedside Neonates to to adults 8

9 NiCO2 NiCO2 LiDCO CEDVi Why $AV costs? Ideal Situation? Monitor PiCCO Tonometer Evita 4 HemoSonic 9

10 SEPSIS cost implications Risen by 329%/ 20 years 30% of ICU patients Carries a high mortality Most common cause of death in ICU Worldwide 1400 deaths/day In the TOP league of death causes Angus D et al. Crit Care Med Jul;29(7):

11 a UK perspective Severe sepsis or septic shock Admissions Total 21,025 ICU mortality n(%) Total 6,534 (31.1%) HOS mortality n(%) Total 8,372 (39.8%) ICNARC 6 month Raw data, prior to adjustment for 65% submission, 70% admission 11

12 a UK perspective Lung Colon Breast Sepsis Lung 1 Colon 2 Breast 3 Sepsis 4 cancers cancers 1,2,3 4 Intensive Care National Audit Research Centre (2005) 12

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15 NiCO2 NiCO2 LiDCO CEDVi How to $AV costs? Ideal Situation? Monitor PiCCO Tonometer Evita 4 HemoSonic 15

16 16 CO$T$ FOR KNOWL DG device PiCCO LiDCO NiCO2 HemoSonic CEDVI device PiCCO Lidco NiCO Hemosonic CEDVI device PiCCO Lidco NiCO Hemosonic CEDVI device PiCCO Lidco NiCO Hemosonic CEDVI DEVICE SET-UP MEASURE DAY

17 Cost per day Evolution 600 Cost ( ) PiCCO LiDCO NiCO2 HemoSonic CEDVI Time (days) 17

18 Cumulative Cost ( ) CEDVI LiDCO PiCCO NiCO2 HemoSonic Time (days) PAC LiDCO PiCCO Malbrain M. M. Yearbook ISICEM 2005:

19 80% SCORES 70% 60% 50% 40% 30% 20% PiCCO Lidco NiCO Hemosonic CEDVI 10% 0% CO$T Cost 70% 60% 50% 40% 30% 20% 10% Effectiveness FF CT PiCCO LiDCO NiCO HemoSonic CEDVI 0% Keep an Cost-Effectiveness eye on costs 19

20 CO$T FF CT RATiO LiDCO PiCCO NiCO HEMOSONiC Malbrain M. M. Yearbook ISICEM 2005:

21 How to be More Cost Effective? $P ND MOR MORE COSTS = MORE EFFECTIVE? $AV MOR LESS COSTS = MORE EFFECTIVE? $ MOR SAME COSTS = MORE EFFECTIVE? 21

22 How to be more cost effective $ MOR SAME COSTS = MORE EFFECTIVE $ MOR THAN OTH RS

23 $ MOR THAN OTH RS 23

24 $ THE MORE YOU LOOK TODAY MOR THE MORE YOU SEE YOU WILL LEARN THAN THE MORE YOU LEARN TO SEE MORE OTH RS THE MORE YOU KNOW WHAT YOU KNOW 24

25 MAP=51 $ PAOP=7 CI=2.1 MOR GEDVi=580 LACTATE=6 THAN P/F=179 CVP=5 OTH RS EVLWi=21 25

26 MAP=51 CI=2.1 LACTATE=6 CVP=22 26

27 Pleural effusions Atelectasis Hemorrhage Herniation Diaphragm $ MOR PAOP=25 GEDVi=575 Pleural pressure? PEEP? - IAP? Cardiac compliance? Lung compliance? THAN OTH R$ After Thoracocenthesis 1050mL P/F=124 EVLWi=8 27

28 Available technologies for continuous Cardiac Output Fick Difficult, large room for error, Gold standard NiCO2 Bioimpedance Variable ICU accuracy Cardiodynamics Doppler Accurate, but user dependent HemoSonic, Deltex, WAKI Pulse Contour Analysis PiCCO PulseCO Vigileo Thermodilution Vigilance PAC, CEDVi (PiCCO) Indicator Dilution Invasive (LiDCO) 28

29 Evidence Based Medicine $ MOR THAN OTH RS Does my new monitoring device does as well as the gold standard? Does my new monitoring device give new or additional information? Does the interpretation of the data change my treatment? SV GEDVi EVLWi Does the new variable driven treatment change patient outcome? DO 2 29

30 The Parachute Study WHAT DO WE KNOW WHAT THIS STUDY ADDS Widelyused Gravitational challenge Prevent death death Prevent injury injury Adverse effects effects Failure Failure Iatrogenic Studies Studies free freefall fall no no100% mortality No No RCCT RCCT on onparachute Basis Basis for forparachute use use Purely Purelyobservational Efficacyexplainedby Healthy cohort cohort He He who whobelieves in in EBM EBM Comes Comesdown to toearth with witha bump bump Gordon C S Smith, Jill P Pell BMJ 2003; 327:

31 $ MOR THAN OTH R$ SV GEDVi EVLWi DO 2 31

32 Improve Outcome FLOW PRELOAD ORGAN Use the right parameters O 2 XYGEN 32

33 Improve Outcome SV/CO FLOW GEDVi/SVV PRELOAD PPV/SVRi dpmax ORGAN GEF/EVLWi Use the right parameters S cv VO 2 O 2 XYGEN VO 2 /DO 2 33

34 ARE YOU GETTING ENOUGH FOR YOUR MONEY 34

35 Do MoRE WiTH MoRE LeSS 35

36 $ MOR THAN OTH R$ SV 36

37 SV/CO

38 Landmark PAPER 38

39 Optimisation PROTOCOL Using a PAC does not alter outcome Protocolised care affects outcome Postop complications ICU and HOS stay Total cost Mortality

40 McKendry M, M, McGloin H, H, Saberi D, D, Caudwell L, L, Brady AR, Singer M. M. Randomised Randomised controlled controlled trial trial assessing assessing the the impact impact of of a a nurse nurse delivered, delivered, flow flow monitored monitored protocol protocol for for optimisation optimisation of of circulatory circulatory status s status after after cardiac cardiac surgery. surgery. British Medical Journal 2004; 329(7460): 258. SV/CO Sinclair Wakeling McKendry Control group Protocol group Control group Protocol group Control group Protocol group Control group Protocol group 40

41 McKendry BMJ BMJ 2004; 329: 329: SV/CO 41

42 McKendry BMJ BMJ 2004; 329: 329: SV/CO 174 CABG pts analysed Protocol: SVI > 35 ml/m 2 Postop complications: 26 (2 deaths) vs. 17 (4 deaths) HOS stay reduced from 13.9 to 11.4 days HOS bed days reduced: 18% ICU bed usage reduced: 23% DeLTEX 42

43 Sinclair S et et al. British Medical Journal 1997; 315(7113): Intraoperative Intraoperativeintravascular intravascular volume volume optimisation optimisation and and length length of of hospital hospital stay stay after aafter repair repair of of proximal proximal femoral femoral fracture fracture 40 patients Hip replacement SV Flow CO 43

44 Sinclair S, James S, Singer M British Medical Journal 1997; 315(7113): patients Hip replacement HOS ac ac Discharge time HOS tot 44

45 Wakeling HG et et al. Br J Anaesth 2005: 95(5): Intraoperative Intraoperative oesophageal oesophageal Doppler Doppler guided guided fluid fluid management management shortens shortens postoperative postoperative hospital hospital stay stay after after major major bowel bowel surgery surgery DeLTEX 45

46 $ MOR THAN OTH R$ SV GEDVi 46

47 PPV PRELOAD Lopes/Angus GEDVi Göpfert ITBVi Csontos Control group Protocol group Control group Protocol group Control group Protocol group Control group Protocol group 47

48 Göpfert MS, Reuter DA, Akyol D, D, Lamm P, P, Kilger E, E, Goetz AE. Goal-directed fluid fluid management reduces reduces vasopressor and and catecholamine use use in in cardiac cardiac surgery surgery patients. Intensive Care Med 2007; 33: 33: CABG patients Less pressors GEDVi 48

49 Lopes MR, Oliveira MA, Pereira VO, Lemos IP, IP, Auler JO JO Jr, Jr, Michard F. F. Goal-directed fluid fluid management based based on on pulse pulse pressure pressure variation variation monitoring during during high high risk risk surgery surgery R100 Crit Care 2007;11(5): R100 PPV 33 patients High risk surgery Shorter stay Less complications 49

50 Csontos C, Foldi V, Fischer T, Bogar L. L. Arterial Arterial thermodilution in in burn burn patients patients suggests suggests a a more more rapid rapid fluid fluid administration during during early early resuscitation. Acta Anaesthesiol Scand 2008; 52:742-9 ITBVi 24 patients >15% TBSA burns Higher S cv O cv 2 Less MOF 50

51 $ MOR THAN OTH R$ SV GEDVi EVLWi 51

52 ORGAN FUNCTION PROTOCOL 52 patients EVLWi Fluid resitriction CONTROL 49 patients PAOP EVLWi Control group Protocol group Control group Mitchell Protocol group Mitchell JP et et al. Am Rev Respir Dis 1992; 145(5): Improved Improved outcome outcome based based on on fluid fluid management management in in critically critically ill ill patients patients requiring requiring pulmonary pulmonary artery artery catheterization. 52

53 $ MOR THAN OTH R$ SV GEDVi EVLWi DO 2 53

54 DO 2 DETERMINANTS DO 2 54

55 DO 2 Direct COSTS a very small investment for a much greater return 55

56 SvO 2 DETERMINANTS SvO 2 56

57 SvO 2

58 S cv O 2 Rivers 58

59 OXYGENATION PROTOCOL 130 patients EGDT S cv O 2 Rivers CONTROL 133 patients standard Control group Protocol group Control group Protocol group Rivers E. et al. N Engl J Med 2001; 345(19): Early goal-directed therapy in in the the treatment of of severe sepsis and septic shock

60 RCCT s showing benefit EBM = 17 RCCT s 60

61 $ MOR THAN OTH R$ SV GEDVi EVLWi DO 2 61

62 YOU NEED TO $P ND TO SAVE LIVES SAVE TIME $AV MONEY SEE MORE 62

63 YOU NEED TO $P ND TO SAVE LIVES 63

64 YOU NEED TO $P ND TO SAVE TIME 64

65 YOU NEED TO $P ND TO $AV MONEY 65

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67 Net Hospital Savings Savings/patient per LOS reduction ( )

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69 WiTH PiCCO2 YOU $ MOR THAN OTH R$ SV GEDVi EVLWi DO 2 69

70 YOU NEED TO $P ND TO SAVE LIVES SAVE TIME $AV MONEY SEE MORE 70

71 The bottom line is Think different and produce great results Join the WSACS clinical trials working group Leave your at WSACS Booth! 71

72 ACS Update workshop ISICEM Brussels 23 march June 25-27, 2009 Visit the WSACS Booth ! It is time to pay attention

73 Join WSACS Information Visit the WSACS Booth: Main Entrance HALL