Oesophageal Doppler monitoring, doubt and equipoise: evidence based medicine means change

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

“…It also facilitates near-patient testing of haemoglobin concentration acid/base status and oxygen exchange, the latter two parameters being important in deciding on postoperative destination. The use and method of goal-directed fluid therapy in elderly patients (particularly) undergoing emergency surgery is controversial [52,53]. NCEPOD highlighted hypovolaemia as a major contributor to hypotension during the peri-and postoperative period, particularly after emergency abdominal surgery [1,3].…”

AAGBI recommendations for standards of monitoring during anaesthesia and recovery 2015 - a further example of ‘aggregation of marginal gains’

“…Similarly, NICE guidance on cardiac output monitoring was used to inform the National Technology Assessment Centre guidance on intra-operative fluid management. Local compliance with this guidance was driven through the Commissioning for Quality and Innovation (CQUIN) framework, whereby payments were linked to the use of fluid management monitoring technology for high-risk patients [17]. This afforded clinicians the leverage they required to purchase monitoring equipment that would have been difficult for them to obtain otherwise.…”

Do we need to monitor cardiac output in spontaneously breathing patients?

“…It has been suggested that early goal-directed haemodynamic optimisation, for instance by continuously measuring and optimising stroke volume, may lead to a decreased infection rate, fewer unwanted cardiac events and faster recovery of bowel function, with a reduction in postoperative morbidity [1][2][3][4]. However, the recommendation of the routine use of oesophageal Doppler in major surgery continues to generate ongoing discussion [5][6][7][8].…”