CLOSED LOOP FLUID

MANAGEMENT
Prof.Brig Saleem Ahmed
Fazaia Medical College
Islamabad
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DO NO HARM
CLOSED LOOP FLUID MANAGEMENT
DEFINITION
ANAESTHETIC APPLICATIONS
CLOSED LOOP SYSTEMS
HOW DO THEY WORK
PARAMETERS TAKEN INTO CONSIDERATION
DYNAMIC AND STATIC INDICES AND THEIR
LIMITATIONS
DISCUSSION ON DIFFERENT TRIALS
CONCLUSION

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 CLOSED LOOP FLUID MANAGEMENT
DEFINITION

An automatic control system in which an

action or operative mechanism is regulated by a
feedback.

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PHASES TO AUTOMATE A SYSTEM
Improved display
Data fusion and integration
Decision support
Open loop
Semi closed loop
Closed loop

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 OPEN vs CLOSED LOOP
OPEN LOOP CLOSED LOOP

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 CLOSED LOOP VS OPEN LOOP
OPEN LOOP
Acts completely on inputs
and output has no effect on
the control action
Mostly stable
There is no effect on gain
Easy to work and implement
Cost effective
CLOSED LOOP
Considers output and alters
it according to the desired
condition. Control action
based on output
Stability is a major issue.
No linear change in system
gain
Complex working principle
and difficult to implement.
expensive
HOW DOES THE CLOSED LOOP WORK
Input from the monitors
Data integration
Decision planned
Action generated
Fluids are delivered in boluses of 100 ml/min
till the target is achieved.

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 FLUID CHALLENGE
Means to assess patients response to fluids
with changes in the dynamic and static indices
of volume, flow and oxygenation.
A prompt increase in intravenous volume and
usually a needed improvement in flow(
cardiac output)

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 PARAMETERS

Basic vitals eg pulse, BP,ECG

Temperature, respiratory rate
Invasive bladder catheterization
Blood sampling for lactate, central venous
oxygen saturation, blood gases

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LESS COMMONLY USED PARAMETERS
Tissue Oxygen and CO2 measured with NIRS
Cardiac output monitoring
Skeletal muscle oxygen saturation

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DYNAMIC INDICES

Systolic Pressure Variation(SPV)

Pulse Pressure Variation(PPV)
Plethysmographic Waveform Variation
 LIMITATIONS OF THE DYNAMIC
PARAMETERS
Arrhythmias
Spontaneous respiration
Tidal volume less than 8 ml/kg
Reduced chest compliance and increased intra
abdominal pressure
Acute Cor Pulmonale with marked ventricular
interdependence.

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 STATIC PARAMETERS
Right or Left ventricular diastolic diameters
derived from TEE or TTE

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 CLOSED LOOP SYSTEMS
Commercial or Industrial
HVAC
Chilled water system
Boiler system
Cooling tower system
Process water loops

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 RENAL GUARD
Automated , accurate patient fluid
management
Fluid intake Urine output
 CLOSED LOOPS IN MEDICINE
Fluid management
Neuromuscular blockade
Insulin therapy
Sedation and anesthesia
Ventilation and oxygenation
Induction of labor with Pitocin
Anesthesia and Analgesia Jan 2012,vol 114, issue 1 P 130-143

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 GOAL DIRECTED THERAPY
Introduced by Emanuel P. Rivers in 2001.
A technique used in critical care medicine
involving intensive monitoring and aggressive
management of perioperative hemodynamics in a
patient with high risk of morbidity and mortality.
Conclusion: provides significant benefit with
respect to patient outcome.
Emanuel River,Brynt,et al NEJM 2001;345:1368-
1377
 GOAL DIRECTED THERAPY

Whether or not GDT truly beneficial remains

unanswered and what fluid to use is also
controversial.
Researchers have used various monitoring
parameters (SV, CO, Mixed venous Oxygen
Saturation) but no single parameter accepted
across the literature.
Wilms H, Mittal et al. J Crit Care 2014;29(2):204-9
Jason B O,Neil and Andrew Shaw---- http://doi.org/10-
1186/S13741-015-0012-1
GDT WITH CLOSED LOOP ASSISTANCE
TARGET : patient spent >85% time in a pre load
independent state i.e pulse pressure variation <
13% , cardiac Index >2.5 litres/min
Concluded. GDFT management using the closed
loop fluid administration system with a non
invasive CO monitoring device was feasible and
maintained a high rate of protocol compliance.
Joostan A, Huethiro, etal. Br J Anaesth 2015 June,
114(6):886-92
 PERIOPERATIVE FLUID PLAN
Patients status eg. age, general health,
physiology and comorbidity,etc.
Surgical risk ---- procedure, approach,
expertise of the surgeon
Selection of hemodynamic monitoring
91% goal achieved ---- physiological targets
obtained.

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COMPOSITION OF FLUID THERAPY
Crystalloids
Colloids
Blood and blood products
The CRISTAL TRIAL (crystalloid vs colloids) 28
days , no difference but 90 days colloids less
mortality
ALBIOS TRIAL. Albumin vs crystalloids in 1818
septic patients found no difference.
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CANDIDATES FOR CLOSED LOOP FLUID
MANAGEMENT
Procedure
Patient factors
Identifying the need for hemodynamic
support

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 IMPROVING PATIENT CARE
New paradigm in critical care medicine
Care providers need data and information to
know what to do?
Heart rate 120,BP 96, Lactate 4, Base deficit-6
-----85% chances that patient needs life saving
intervention--- stop bleeding and Tx 02 units
plasma----go to closed loop ventilation.

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 STUDIES CONDUCTED
US Army Institute of Surgical Research JBSA Fort
Sam Houston developed a closed loop fluid
management system for burn patients. Compared
autonomous with closed loop and concluded that
with implementation of closed loop the
treatment could be started without delay and
chances of over or under resuscitation was
removed.
A phased approach to development of closed
loop and autonomous critical care system by Jose
Salinas, US Army Institute of Surgical Research

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 STUDY CONTINUED
Closed Loop Control of Fluid Therapy for
Treatment of Hypovolemia by George Kramer
PhD, et al. Department of Anesthesiology
University of Texas Medical Branch.

J Trauma 2008;64:S333-341

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 CONTINUED
A number of algorithms were used based on
hemodynamic and volume expansion
properties of each fluid.
Different algorithms have shown to restore BP
equally well during multiple hemorrhages.
It has shown reduced fluid requirements
compared with ATLS and Advanced Burn Life
Support Guidelines
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 CONTINUED
Concluded that a variety of endpoints can be
used to guide fluid therapy, but from practical
point of view BP is likely to be used for clinical
applications of closed loop control for pre
hospital trauma patients.

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 CONTINUED
Rinehart and Colleagues in Vivo study Closed
Loop Fluid Administration Compared to
Anesthesiologist management for Hemodynamic
Optimization and Resuscitation during Surgery
Conclude that the Closed loop fluid management
system used in experiment can perform fluid
resuscitation during mild and severe hemorrhage
and is able to maintain high cardiac output and
stroke volume while reducing hemodynamic
variability.
Anesth Analg 2013 Nov. 117(5) 1119-29

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 CONTINUED
Learning Intravenous Resuscitation (LIR)
LIR system developed by Intelligent Medical
Technologies----- soft ware which integrates
information obtained from the monitors and
using pre programmed algorithm initiates an
action.
Fluids are delivered in bolus and the results
are compared with the set target.
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 END-POINT RESUSCITATION
Mostly restricted to ICUs and Operating
Rooms
Non invasive vital signs, BP,HR,SaO2,RR
Invasive monitoring, bladder catheterization,
serum lactates, venous oxygen saturation,
hematocrit and ABGs.
Additional endpoint variables, require sensor
technology( NIRS), transcutaneous oxygen and
carbon dioxide, skeletal muscle oxygenation
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 END-POINT RESUSCITATION
Cardiac Output is the ideal or gold standard of
cardiovascular function

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 CONCLUSION
Dynamic parameters like stroke volume
variable(SVV) have been shown to be accurate
predictor of fluid responsiveness
Perioperative optimization based on fluid
management and stroke volume(SV)
optimization(PGDT) has been shown to improve
patient outcome specially for subjects undergoing
moderate to high risk abdominal surgeries.
Ref : Joseph Rinehart, MD, department of
Anesthesiology and perioperative care UCI
Medical Centre, Orange, CA
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 CONCLUSION
Various endpoints can be used to guide fluid
therapy.
Unique algorithms must be employed for
different fluids based on hemodynamic and
volume expansion properties of each fluid
While closed-loop systems can positively
impact outcomes, still much work needs to be
done in terms of their effect on clinical and
logistic outcome.
THANK YOU