Perioperative Hemodynamic Optimization: A Way to Individual Goals

  • J. Benes
  • R. Pradl
  • I. Chytra
Part of the Annual Update in Intensive Care and Emergency Medicine book series (AUICEM, volume 2012)


Perioperative goal directed therapy (GDT) and hemodynamic optimization have been on the program of anesthesiology and intensive care meetings for almost 30 years. The idea that morbidity [1,2], incidence of infectious complications [3] and even short term [4] or long-term mortality [5] can be affected by improving hemodynamic status and oxygen delivery to organs at the time of surgical trauma is very attractive. Since 1988 when Shoemaker et al. published their study [6] much has changed in the approach to high-risk surgical patients, including less invasive therapies and new surgical methods. Hemodynamic monitoring options have also increased. But the problem of hemodynamic optimization has scarcely moved from the hypothetical level of controlled trials to every-day practice in many institutions. Although there is a strong movement towards adoption of this principle via national guidelines [7], the community of believers (mostly from the academic field) is opposed by the practicing ‘infidels’. In a recently published survey among North American and European anesthesiologists, only 35 % of respondents used some cardiac output monitoring for high-risk surgical patients [8]. Lees et al. [9] named the following controversies as the major reasons for notadopting GDT:
  • The right population (problem with defining the high-risk patient and surgery)

  • The protocol itself (heterogeneity of goals, interventions and monitoring tools)

  • Logistic reasons (economic and personal issues)


Fluid Responsiveness Pulse Pressure Variation Stroke Volume Variation Cardiac Surgery Patient Goal Directed Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Giglio MT, Marucci M, Testini M, Brienza N (2009) Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth 103: 637–646PubMedCrossRefGoogle Scholar
  2. 2.
    Brienza N, Giglio MT, Marucci M, Fiore T (2009) Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med 37: 2079–2090PubMedCrossRefGoogle Scholar
  3. 3.
    Dalfino L, Giglio MT, Puntillo F, Marucci M, Brienza N (2011) Haemodynamic goaldirected therapy and postoperative infections: earlier is better. a systematic review and meta-analysis. Crit Care 15: R154PubMedCrossRefGoogle Scholar
  4. 4.
    Hamilton MA, Cecconi M, Rhodes A (2011) A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 112: 1392–1402PubMedCrossRefGoogle Scholar
  5. 5.
    Rhodes A, Cecconi M, Hamilton M, et al (2010) Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 36: 1327–1332PubMedCrossRefGoogle Scholar
  6. 6.
    Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS (1988) Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94: 1176–1186PubMedCrossRefGoogle Scholar
  7. 7.
    Powell-Tuck J, Gosling P, Lobo D, et al (2009) British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP). Available at pages/media/download_gallery/GIFTASUP%20FINAL_05_01_09.pdf Accesed Nov 2011Google Scholar
  8. 8.
    Cannesson M, Pestel G, Ricks C, Hoeft A, Perel A (2011) Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care 15: R197PubMedCrossRefGoogle Scholar
  9. 9.
    Lees N, Hamilton M, Rhodes A (2009) Clinical review: Goal-directed therapy in high risk surgical patients. Crit Care 13: 231PubMedCrossRefGoogle Scholar
  10. 10.
    Hofer CK, Cecconi M, Marx G, della Rocca G (2009) Minimally invasive haemodynamic monitoring. Eur J Anaesthesiol 26: 996–1002PubMedCrossRefGoogle Scholar
  11. 11.
    Kirov MY, Kuzkov VV, Molnar Z (2010) Perioperative haemodynamic therapy. Curr Opin Crit Care 16: 384–392PubMedCrossRefGoogle Scholar
  12. 12.
    Boyd O, Jackson N (2005) How is risk defined in high-risk surgical patient management? Crit Care 9: 390–396PubMedCrossRefGoogle Scholar
  13. 13.
    Brienza N, Dalfino L, Giglio M (2011) Perioperative hemodynamic optimization._In: Vincent JL (ed) Annual Update in Intensive Care and Emergency Medicine. Springer, Heidelberg, pp 459–470Google Scholar
  14. 14.
    Van der Linden PJ, Dierick A, Wilmin S, Bellens B, de Hert SG (2010) A randomized controlled trial comparing an intraoperative goal-directed strategy with routine clinical practice in patients undergoing peripheral arterial surgery. Eur J Anaesthesiol 27: 788–793PubMedCrossRefGoogle Scholar
  15. 15.
    Buettner M, Schummer W, Huettemann E, Schenke S, Van Hout N, Sakka SG (2008) Influence of systolic-pressure-variation-guided intraoperative fluid management on organ function and oxygen transport. Br J Anaesth 101: 194–199PubMedCrossRefGoogle Scholar
  16. 16.
    Cecconi M, Fasano N, Langiano N, et al (2011) Goal directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Crit Care 15: R132PubMedCrossRefGoogle Scholar
  17. 17.
    Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED (2005) Early goaldirected therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 9: R687–R693PubMedCrossRefGoogle Scholar
  18. 18.
    Goepfert MSG, Reuter DA, Akyol D, Lamm P, Kilger E, Goetz AE (2007) Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients. Intensive Care Med 33: 96–103PubMedCrossRefGoogle Scholar
  19. 19.
    Kern J, Shoemaker W (2002) Meta-analysis of hemodynamic optimization in high-risk patients. Crit Care Med 30: 1686–1692PubMedCrossRefGoogle Scholar
  20. 20.
    Jhanji S, Vivian-Smith A, Lucena-Amaro S, Watson D, Hinds C, Pearse R (2010) Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Crit Care 14: R151PubMedCrossRefGoogle Scholar
  21. 21.
    Altemeier WA, Sinclair SE (2007) Hyperoxia in the intensive care unit: why more is not always better. Crit Care Med 13: 73–78Google Scholar
  22. 22.
    Lobo S, Salgado P, Castillo V, et al (2000) Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med 28: 3396–3404PubMedCrossRefGoogle Scholar
  23. 23.
    Lobo SM, Lobo FR, Polachini CA, et al (2006) Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients [ISRCTN42445141]. Crit Care 10: R72PubMedCrossRefGoogle Scholar
  24. 24.
    Mythen M, Webb A (1995) Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 130:423PubMedCrossRefGoogle Scholar
  25. 25.
    Sinclair S, James S, Singer M (1997) Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 315: 909–912PubMedCrossRefGoogle Scholar
  26. 26.
    Lopes MR, Oliveira MA, Pereira V, Lemos I, Auler J, Michard F (2007) Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Crit Care 11: R100PubMedCrossRefGoogle Scholar
  27. 27.
    Lee JH, Kim JT, Yoon SZ, et al (2007) Evaluation of corrected flow time in oesophageal Doppler as a predictor of fluid responsiveness. Br J Anaesth 99: 343–348PubMedCrossRefGoogle Scholar
  28. 28.
    Marik PE, Cavallazzi R, Vasu T, Hirani A (2009) Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med 37: 2642–2647PubMedCrossRefGoogle Scholar
  29. 29.
    Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M (2008) A rational approach to perioperative fluid management. Anesthesiology 109: 723–740PubMedCrossRefGoogle Scholar
  30. 30.
    Hiltebrand LB, Kimberger O, Arnberger M, Brandt S, Kurz A, Sigurdsson GH (2009) Crystalloids versus colloids for goal-directed fluid therapy in major surgery. Crit Care 13: R40PubMedCrossRefGoogle Scholar
  31. 31.
    Donati A, Loggi S, Preiser JC, et al (2007) Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Chest 132: 1817–1824PubMedCrossRefGoogle Scholar
  32. 32.
    Collaborative Study Group on Perioperative ScvO2 Monitoring (2006) Multicentre study on peri-and postoperative central venous oxygen saturation in high-risk surgical patients. Crit Care Med 10: R158CrossRefGoogle Scholar
  33. 33.
    Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED (2005) Changes in central venous saturation after major surgery, and association with outcome. Crit Care 9: R694–R699PubMedCrossRefGoogle Scholar
  34. 34.
    Rivers E, Nguyen B, Havstad S, et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345: 1368–1377PubMedCrossRefGoogle Scholar
  35. 35.
    Dellinger RP, Levy MM, Carlet JM, et al (2008) Surviving Sepsis Campaign: international guidelines formanagement of severe sepsis and septic shock: 2008. Crit CareMed 36: 296–327Google Scholar
  36. 36.
    Kapoor P, Kakani M, Chowdhury U, Choudhury M, Lakshmy R, Kiran U (2008): Early goal-directed therapy in moderate to high-risk cardiac surgery patients. Ann Card Anaesth 11: 27–34PubMedCrossRefGoogle Scholar
  37. 37.
    Pölönen P, Ruokonen E, Hippeläinen M, Pöyhönen M, Takala J (2000) A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg 90: 1052–1059PubMedCrossRefGoogle Scholar
  38. 38.
    Shepherd SJ, Pearse RM (2009) Role of central and mixed venous oxygen saturation measurement in perioperative care. Anesthesiology 111: 649–656PubMedCrossRefGoogle Scholar
  39. 39.
    Turek Z, Sykora R, Matejovic M, Cerny V (2009) Anesthesia and the microcirculation. Semin Cardiothorac Vasc Anesth 13: 249–258PubMedCrossRefGoogle Scholar
  40. 40.
    Bonazzi M, Gentile F, Biasi GM, et al (2002) Impact of perioperative haemodynamic monitoring on cardiac morbidity after major vascular surgery in low risk patients. A randomised pilot trial. Eur J Vasc Endovasc Surg 23: 445–451PubMedCrossRefGoogle Scholar
  41. 41.
    Conway D, Mayall R, Abdul-Latif M, Gilligan S, Tackaberry C (2002) Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia 57: 845–845PubMedCrossRefGoogle Scholar
  42. 42.
    Gan TJ, Soppitt A, Maroof M, et al (2002) Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 97: 820–826PubMedCrossRefGoogle Scholar
  43. 43.
    Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P (2002) Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 88: 65–71PubMedCrossRefGoogle Scholar
  44. 44.
    Sandham JD, Hull RD, Brant RF, et al (2003) A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 348: 5–14PubMedCrossRefGoogle Scholar
  45. 45.
    McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M (2004) Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ 329: 258PubMedCrossRefGoogle Scholar
  46. 46.
    Wakeling HG, McFall MR, Jenkins CS, et al (2005) Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 95: 634–642PubMedCrossRefGoogle Scholar
  47. 47.
    Noblett SE, Snowden CP, Shenton BK, Horgan AF (2006) Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 93: 1069–1076PubMedCrossRefGoogle Scholar
  48. 48.
    Chytra I, Pradl R, Bosman R, Pelnár P, Kasal E, Zidková A (2007) Esophageal Dopplerguided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Crit Care 11: R24PubMedCrossRefGoogle Scholar
  49. 49.
    Benes J, Chytra I, Altmann P, et al (2010) Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care 14: R118PubMedCrossRefGoogle Scholar
  50. 50.
    Mayer J, Boldt J, Mengistu A, Rohm K, Suttner S (2010) Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Crit Care 14: R18PubMedCrossRefGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • J. Benes
  • R. Pradl
  • I. Chytra

There are no affiliations available

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