Guiding Goal-Directed Therapy

Abstract

Several studies have demonstrated that perioperative hemodynamic optimization (or ''goal directed therapy'') using minimally invasive hemodynamic monitoring technologies has the ability to improve postoperative patients' outcome with lower complication rates, shorter hospital lengths of stay, and lower cost of surgery. This specific concept of goal-directed therapy (GDT) uses perioperative cardiac output monitoring and manipulation of physiologic parameters (dynamic parameters of fluid responsiveness) to guide intravenous fluids and inotropic therapy with the goal of ensuring adequate tissue perfusion. Recently, the evidence related to the implementation of GDT strategies has been considered strong enough to allow for the creation of national recommendations in the UK, in France, and by the European Society of Anaesthesiology. The aims of the programs are to apply best practices to high-risk surgical patients and requires the participation of all clinicians involved in patients' care. Considering the potential clinical and economic benefits of GDT protocols and the positive recommendations from influential scientific societies, more and more hospitals around the world have become interested in implementing hemodynamic optimization in their departments. This review provides the information about the evolution of hemodynamic monitoring from invasive to the more recent noninvasive devices, and how these devices can be used in the operating rooms through well-defined algorithms of GDT.

Perioperative goal-directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis

“…The results of this meta-analysis show that it is better to perform perioperative therapy than to restrict it to the postoperative period. These results are consistent with the latest reviews in which the role of GDHT was described in different types of patients according to their surgical risk [9].…”

“…The primary reason for performing this therapy and this monitoring is that it can improve the results in terms of survival and quality of life, as shown by recent meta-analyses [7] and studies analyzing long-term complications [8]. The importance of perioperative hemodynamic optimization has increased in the last decade and has evolved together with hemodynamic monitoring technology [9], shifting the use of the pulmonary artery catheter to cardiac surgery and high-risk patients, in the same way as the initial supraphysiological targets for DO 2 [10] have shifted to so-called functional hemodynamic monitoring parameters [11], although recently a meta-analysis showed the benefits of GDHT with supranormal hemodynamic targets for DO 2 [12]. Similarly, recent meta-analyses have shown the usefulness of intraoperative GDHT in noncardiac surgery [13].…”

Гемодинамічний Моніторинг В Практиці Інтенсивної Терапії Критичних Станів

“…Существует ряд способов измерения сердечного выброса, кото-рые различаются степенью инвазивности и непре-рывным или прерывистым методом исследования [7][8][9].…”

Haemodynamic monitoring in the peri‐operative period: the past, the present and the future

“…Traditionally, anaesthetists have used parameters such as heart rate (HR), blood pressure (BP), central venous pressure (CVP) and urine output to guide their peri‐operative care, but although readily available, these variables have consistently shown to be neither sensitive or specific enough to provide an accurate evaluation of the cardiovascular status as a whole . Both HR and CVP have been proven to be inaccurate indicators of volume status , and research has shown that the relationship between arterial pressure, ventricular stroke volume and venous return is non‐linear, thereby preventing the arterial pressure from being used as an endpoint for cardiac output monitoring and optimisation .…”

“…This is the focus of cardiovascular modelling . Another approach is to consider the ability of a device to detect changes in cardiac output following a therapeutic intervention, particularly in haemodynamically unstable patients as this will have a direct impact on the therapeutic intervention . The analysis of the general trend over the specific measurement could also be argued as of greater clinical significance.…”