Perioperative goal directed therapy using automated closed-loop fluid management: the future?

Abstract

Although surgery has become much safer, it has also becoming increasingly more complex and perioperative complications continue to impact millions of patients worldwide each year. Perioperative hemodynamic optimization utilizing Goal Directed Therapy (GDT) has attracted considerable interest within the last decade due to its ability to improve postoperative short and long-term outcomes in patients undergoing higher risk surgeries. The concept of GDT in this context can be loosely defined as collecting data from minimally invasive hemodynamic monitors with the intention of using such data (flow-related parameters and/or dynamic parameters of fluid responsiveness) to titrate therapeutic interventions (intravenous fluids and/or inotropic therapy administration) with the ultimate aim of optimizing end organ tissue perfusion. Recently, the increasing amount of evidence supporting the implementation of GDT strategies has been considered so robust as to allow for the creation of national recommendations in the United Kingdom (UK), France, and Europe. These recommendations from such influential scientific societies and the potential clinical and economic benefits of GDT protocols need to also be examined within the current shift from a "pay for service" to a "pay for performance" health care system. This shift is strongly encouraged within emerging systems such as the Perioperative Surgical Home (PSH) paradigm from the United States. As a result, hospitals and clinicians around the world have become increasingly incentivized to implement perioperative hemodynamic optimization using GDT strategies within their departments. Unfortunately, its adoption continues to be quite limited and a lack of standardized criteria for perioperative fluid administrations has resulted in significant clinical variability among practitioners. This current review will provide a brief up-to-date overview of GDT, discuss current clinical practice, analyze why implementation has been limited and finally, describe the newer closed-loop GDT concept along with its potential risks and benefits.Key words: goal directed therapy; hemodynamic optimization; closed-loop; cardiac output Anaesthesiology Intensive Therapy 2015, vol. 47, no 5, 517-523It has been estimated that approximately 240 million anaesthesia procedures are completed worldwide every year [1]. Of these, approximately 10%, or 24 million, are conducted on "high risk" surgical patients. However, this subset disproportionally accounts for more than 80% of perioperative mortality [2]. Moderate risk surgery is much more common as it represents approximately 40% of annual procedures, or 96 million patients. Thankfully, most of these patients continue on to have an uncomplicated postoperative course. However, it is estimated that approximately 30% of these moderate risk surgeries, or 29 million patients a year, end up having a "minor" postoperative complication (most commonly a gut injury inducing delayed enteral feeding, abdominal distension, nausea, vomiting or wound complications) [3]...

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“…The avant-garde preparation for surgery is to administer cooled down fluids until the evening of the day preceding the surgical procedure, and on the surgery day maintaining a 2-h withdrawal period before wheeling the patient to the operating room [38]. The objective is to maintain normovolaemia on admitting the patient to the operating suite [39]. The above protocol is in agreement with the guidelines of the American Society of Anaesthesiologists.…”

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“…Unfortunately, such an approach is very costly in terms of human resources, which limits its implementation [ 40 ]. Over the past decade, members of our team have developed a closed-loop administration system based on the simultaneous analysis of multiple advanced hemodynamic indices provided by a minimally-invasive hemodynamic monitoring device and controlled by a computer [ 27 , 41 – 43 ] (Fig. 1 ).…”

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“…Recently, numerous studies showed that only ± 50% of patients are fluid responsive [15][16][17], which suggests that the patient's preloading condition and fluid responsiveness should be determined before fluid resuscitation is started. For surgical patients, careful management of perioperative fluids with goaldirect therapy can greatly improve outcomes [18].…”