Perioperative hemodynamic optimization: from guidelines to implementation—an experts’ opinion paper

Abstract

Despite a large body of evidence, the implementation of guidelines on hemodynamic optimization and goal-directed therapy remains limited in daily routine practice. To facilitate/accelerate this implementation, a panel of experts in the field proposes an approach based on six relevant questions/answers that are frequently mentioned by clinicians, using a critical appraisal of the literature and a modified Delphi process. The mean arterial pressure is a major determinant of organ perfusion, so that the authors unanimously recommend not to tolerate absolute values below 65 mmHg during surgery to reduce the risk of postoperative organ dysfunction. Despite well-identified limitations, the authors unanimously propose the use of dynamic indices to rationalize fluid therapy in a large number of patients undergoing non-cardiac surgery, pending the implementation of a “validity criteria checklist” before applying volume expansion. The authors recommend with a good agreement mini- or non-invasive stroke volume/cardiac output monitoring in moderate to high-risk surgical patients to optimize fluid therapy on an individual basis and avoid volume overload. The authors propose to use fluids and vasoconstrictors in combination to achieve optimal blood flow and maintain perfusion pressure above the thresholds considered at risk. Although purchase of disposable sensors and stand-alone monitors will result in additional costs, the authors unanimously acknowledge that there are data strongly suggesting this may be counterbalanced by a sustained reduction in postoperative morbidity and hospital lengths of stay. Beside existing guidelines, knowledge and explicit clinical reasoning tools followed by decision algorithms are mandatory to implement individualized hemodynamic optimization strategies and reduce postoperative morbidity and duration of hospital stay in high-risk surgical patients.

Changes in stroke volume induced by lung recruitment maneuver can predict fluid responsiveness during intraoperative lung-protective ventilation in prone position

“…Prone positioning is commonly employed during various surgical procedures, especially brain and spine surgeries, and induces a decrease in chest compliance and an increase in abdominal pressure, which in turn affects hemodynamics such as decreased venous return and stroke volume. Volume expansion is the first-line treatment for CO reduction during surgery, [ 26 ] but inadequate fluid loading in prone position can lead to an increase in edema of the larynx and pharynx, making extubation difficult in the operating room [ 27 , 28 ]. On the other hand, intraoperative goal-directed fluid therapy based on SV optimization improves postoperative outcomes in surgical patients [ 29 ].…”

Comparison of oscillometric, non-invasive and invasive arterial pressure monitoring in patients undergoing laparoscopic bariatric surgery – a secondary analysis of a prospective observational study

“…Our study did not focus on a cost-effectiveness analysis for the different blood pressure monitoring methods used in the bariatric population and non-manufacturer derived data on this subject is yet limited [ 37 , 38 ]. The acquisition costs could be a barrier to the introduction in anesthesia departments [ 39 ]. Further studies may focus on whether the higher acquisition costs together with personnel and material costs of the different methods impact patient-centered clinical outcomes.…”

Effect Of Goal-Directed Haemodynamic Therapy On Short-Term Postoperative Complications In Patients With Extensive Burns: A Single-Centre Randomised Controlled Trial

“…Early application of haemodynamic monitoring and use of haemodynamic indicators as a guide to maintain perioperative SV through uid loading, thus minimising organ damage associated with inadequate oxygen supply. Fluids and medications are adjusted in a timely manner to avoid organ underperfusion and uid overload [6][7]. Numerous trials and meta-analyses have shown that GDHT reduces postoperative complications and mortality in high-risk surgical patients, regardless of the choice of monitoring method or target variable [8][9].…”