modern approaches to fluid resuscitation: modes, … · emanuel rivers, md, ... these disclosures...

Modern Approaches to Fluid Resuscitation: Modes, Metrics, and Maximization

An Educational Symposium

Supported by an educational grant from

Sponsored by:

Modern Approaches to FluidResuscitation:

Modes, Metrics, and Maximization


Sponsored by:

Introduction / Program Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Target Audience / Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . 4

Accreditation Statements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Faculty Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Faculty BiographiesEmanuel Rivers, MD, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Vicente H. Gracias MD, FACS, FCCP. . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Tong J. Gan, MB, FRCA, FFARCSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

PresentationsEndpoints of Resuscitation for Circulatory Shock: When Enough is Enough?

Emanuel Rivers, MD, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Hemodynamic monitoring: Resuscitative end points

Vicente H. Gracias, MD, FACS, FCCP . . . . . . . . . . . . . . . . . . . . . . . 23

Minimally Invasive CO Monitoring and Patient Outcomes

Tong J. Gan, MB, FRCA, FFARCSI . . . . . . . . . . . . . . . . . . . . . . . . . 35

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For more information, please send inquiries to www.med-ce-online.com

Table of Contents

A common theme existing among the medical subspecialties is that there is neither a consensus nor a forum to better understand the issues surrounding fluid resuscitation.Confusion is common as to definitions, indications, current methods of monitoring, and asto what end-points or goals should be achieved. Descriptors such as “wet” or “dry” may bemisleading when the target should be patient specific “euvolemia”. The scope of tissuehypoxia needs to be meaningful to clinicians caring for the critically ill. Modern approachesto resolve these points of confusion are discussed in this half day seminar. Specific proposedalgorithms for specific patient conditions will be presented.

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Introduction/Program Description


11:30 AM – 12:00 Noon Registration

12:00 Noon – 12:15 PM Welcome and introductions

12:15 PM – 1:00 PM Endpoints of Resuscitation for Circulatory Shock: When Enough is Enough.

1:00 PM – 1:30 PM Lunch (provided)

1:30 PM – 2:15 PM Hemodynamic monitoring: Resuscitative end points

2:15 PM – 3:00 PM Minimally Invasive CO Monitoring and Patient Outcomes

3:00 PM – 3:15 PM Break

3:15 PM – 4:00 PM Case based scenarios, Q and A

4:00 PM – 4:10 PM Evaluations

Dates and Locations

June 2, 2007 Saturday Philadelphia, PA The Rittenhouse Hotel

Sept 15, 2007 Saturday San Diego, CA Westgate Plaza Hotel

October 6, 2007 Saturday New Orleans, LA Sheraton New Orleans

October 12, 2007 Friday San Francisco, CA Hotel Monaco

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Agenda

Target AudienceThis program has been designed for a multidisciplinaryphysician and critical-care nurse audience including:Emergency Medicine / ICU / Anesthesia / Peri-op /Intensivists / Trauma / Critical Care

Learning ObjectivesBy attending this program, participants will be able to:

1. Discuss current literature regarding optimal end-pointsand goal-directed resuscitation strategies.

2. Define what comprises: “Too wet, too dry or just right?”Striving for euvolemia.

3. Answer current questions regarding clinical practice:What protocols, which monitoring tool: pressure basedor flow based, what parameters for what patient and inwhat environment?

4. Through case based scenarios describe where thespecific type of monitoring may be optimally applied.

CME AccreditationThis CME activity has been planned and implemented inaccordance with the Essential Areas and Policies of theAccreditation Council for Continuing Medical Education(ACCME) through the joint sponsorship of The Institute forMedical Studies (IMS) and Med-CE-online.com. IMS isaccredited by the ACCME to provide CME for physicians.IMS designates this educational activity for a maximum of3.0 hours in category 1 credit toward the AMA Physician’sRecognition Award. Each participant should claim onlythose hours of credit that he/she actually spent in the educational activity.

Nurses may claim credit for activities approved for AMAPRA Category 1 Credits™ in most states, for up to 50% of the nursing requirement for recertification. This course is designated for 3.0 AMA PRA Category 1 Credits™.

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As an accredited provider of continuing medical education,it is the policy of the IMS to ensure balance, independence,objectivity, and scientific rigor in all of its educationalprograms. In accordance with this policy, faculty mustdisclose to the participants any significant relationshipswith the commercial companies whose products or devicesmay be mentioned in faculty presentations, or with thecommercial supporter of this continuing pharmaceuticaleducation program. The intent of this disclosure is not toprevent a person with a significant financial or otherrelationship from participating in the planning or review ofprograms, but rather to provide the intended audience withinformation on which they can make their own judgments.It remains for the audience to determine whether theinterests or relationships of planning committee members,reviewers, or cosponsors may influence the presentation withregard to exposition or conclusion. These disclosures willbe available at the program and will be included in theprogram materials.

The faculty for this program has reported the following:

Tong J. Gan, MB, FRCA, FFARCSI reports receiving grant research and travel expense support, and being aconsultant, speakers bureau member, and speaker withhonorarium from Edwards Lifesciences.

Vicente H. Gracias MD, FACS, FCCP reports receiving travelexpense support, and being a speaker with honorariumfrom Edwards Lifesciences.

Emanuel Rivers, MD, MPH reports receiving researchsupport from the National Institute of Allergy and InfectiousDisease, Biosite, Inc., Edwards Lifesciences, andHutchinson Technologies. Within the last year, he hasperformed lectures or served as a panel discussant forBiosite, Eli Lilly and Edwards Lifesciences. He has alsoprovided onetime consultation services for Eli Lilly andChiron. Dr. Rivers has no intellectual properties relatedearly goal-directed therapy.

The entire faculty for this program has reported that theywill not discuss unapproved drug or device uses.

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Faculty Disclosure

Vice Chairman, Director of Research, Department ofEmergency Medicine

Senior Staff Attending, Departments of EmergencyMedicine and Surgery (Surgical Critical Care)

Henry Ford Hospital, Detroit, Michigan

Clinical Professor of Emergency Medicine and SurgeryWayne State University, Detroit, Michigan

[email protected]

Dr. Emanuel Rivers is Vice Chairman and Director ofResearch for the Department of Emergency Medicine. Heis a Senior Staff Attending Physician in the Surgical CriticalCare Unit and the Emergency Department at Henry FordHospital in Detroit, Michigan.

He received his Bachelors of Science, Masters of PublicHealth, and Doctorate in Medicine from the University ofMichigan in Ann Arbor, Michigan.

He completed a residency in emergency and internalmedicine at Henry Ford Hospital, Detroit, Michigan, followedby a fellowship in critical care medicine at the University ofPittsburgh, PA.

He is Board certified in Critical Care Medicine, EmergencyMedicine and Internal Medicine. He also has a specialcompetency in Hyperbaric Medicine.

Dr. Rivers is a fellow and national research award recipientfrom the American College of Emergency Physicians(2005), Society of Academic Emergency Medicine (2000),and American College of Chest Physicians (2000). He isalso a fellow of the American Academy of EmergencyMedicine, American College of Chest Physicians and longstanding member of the Society of Critical Care Medicine.He has been recently inducted into the Institute of Medicine,National Academy of Sciences in 2005. He was voted onof the Top Docs in the city of Detroit for the year 2006.

His interests include the examination and treatment ofcritical illness or the critically ill in the earliest stages ofhospital presentation, which includes the EmergencyDepartment and Intensive Care Unit. Diseases, which areincluded in this area, are patients presenting with shock ofall kinds (septic or severe infection, trauma or hemorrhage,heart attacks, blood clots to the lung and other shockstates such as cardiac arrest). He is examining new waysto improve upon early detection and more aggressivetreatment of these diseases, which cost many lives andconsume tremendous health care resources. He is furtherinterested in evaluating the number of patients who can besaved at this stage and how well were treating thesepatients. This is considered the epidemiology andoutcomes evaluation of early critical illness.

Dr. Rivers is author of over 50 peer review publications,200 abstracts and performed over 500 lectures nationallyand internationally.

He has been part of numerous multi-center trials in sepsisand is nationally and internationally recognized as an expertin shock and sepsis in particular.

BiosketchEmanuel P. Rivers, MD, MPH

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Associate Professor of Surgery

Chief Surgical Critical Care

Medical Director Critical Care

University of Pennsylvania School of Medicine

Philadelphia, PA

Dr. Vicente H. Gracias, MD completed his medical degree atthe University of Utah Medical Center where his interest incritical care and artificial organ systems gainedmomentum. He obtained his general surgical training at theUniversity of Illinois Metro Group Hospitals, which includedCook County Hospital in Chicago. As a Research Fellow atthe University of Illinois his investigations involving cell-membrane signaling and the bio-artificial liver flourished.He completed his fellowship training in Trauma Surgery andSurgical Critical Care at the Hospital of the University ofPennsylvania. He is fellowship trained and board certified inTrauma surgery, General Surgery and Surgical Critical Care.He is currently on faculty at The University of PennsylvaniaSchool of Medicine as Associate Professor of Surgery andholds posts as Section Chief of Surgical Critical Care andCo-Medical Director of Critical Care at the University ofPennsylvania Hospital. He is a funded researcher whosework has crossed into cerebral vascular injury andhemodynamic monitoring in the intensive care unit. Hisfunding supports a full time PhD and a Clinical ResearchAssistant. He has won multiple teaching awards and hasauthored more than 100 peer reviewed manuscripts,abstracts and others works.

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BiosketchVicente H. Gracias MD, FACS, FCCP

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Professor and Vice Chair Department of Anesthesiology Duke University Medical Center Durham, NC

Tong J Gan, is Professor of Anesthesiology, Vice Chair forClinical Research and a Senior Research Fellow at theDuke Center for Integrative Medicine.

Dr. Gan has been the recipient of the Society of AmbulatoryAnesthesia Young Investigator Award and the InternationalAnesthesia Research Society (IARS) Clinical ScholarResearch Award and is a member of several professionalorganizations, including the American Society ofAnesthesiologists and the International AnesthesiaResearch Society. He is the President Elect of InternationalSociety of Anesthetic Pharmacology and Vice President ofSociety of Ambulatory Anesthesia. He serves on theEditorial Board of Anesthesia Analgesia, Acute Pain andClinical Research and is a reviewer for many scientificjournals, including New England Journal of Medicine, TheLancet, Circulations, Alternative Therapies in Health andMedicine, and Pharmacoeconomics.

Dr. Gan has served as invited speaker for many nationaland international professional conferences and as principalinvestigator or co-investigator for many clinical trials. Hisresearch, which has been reported in a multitude of peer-reviewed scientific journals, explores a variety of topics,such as prevention of postoperative nausea and vomiting,fluid management and hemodynamic monitoring duringsurgery, intravenous anesthesia and patients’ perceptionsof the postoperative pain experience. He is the author orco-author of over 100 scientific articles in peer-reviewedmedical journals and numerous abstracts, reviews andchapters published in medical textbooks.

BiosketchTong J. Gan, MB, FRCA, FFARCSI

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BiosketchRichard Allen Williams, M.D.

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modern approaches to fluid resuscitation: modes, … · emanuel rivers, md, ... these disclosures...

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