Clinical review: What are the best hemodynamic targets for noncardiac surgical patients?

Suzana Lobo,Neymar De Oliveira

doi:10.1186/cc11861

Abstract

Perioperative hemodynamic optimization, or goal-directed therapy (GDT), has been show to significantly decrease complications and risk of death in high-risk patients undergoing noncardiac surgery. An important aim of GDT is to prevent an imbalance between oxygen delivery and oxygen consumption in order to avoid the development of multiple organ dysfunction. The utilization of cardiac output monitoring in the perioperative period has been shown to improve outcomes if integrated into a GDT strategy. GDT guided by dynamic predictors of fluid responsiveness or functional hemodynamics with minimally invasive cardiac output monitoring is suitable for the majority of patients undergoing major surgery with expected significant volume shifts due to bleeding or other significant intravascular volume losses. For patients at higher risk of complications and death, such as those with advanced age and limited cardiorespiratory reserve, the addition of dobutamine or dopexamine to the treatment algorithm, to maximize oxygen delivery, is associated with better outcomes.

Highlights

Noncardiac surgery in high-risk patients is associated with a high incidence of postoperative complications and high mortality rates; multiple organ failure is the main cause of death in these patients [1]
In a study performed in 33 patients, minimization of pulse pressure variation (PPV) to values
Trials that included perioperative interventions aimed at the hemodynamic optimization of higher-risk surgical patients reported significantly reduced mortality rates (pooled odds ratio (95% confidence interval) = 0.32 (0.21 to 0.47); P ≤0.00001)

Summary

Introduction

Noncardiac surgery in high-risk patients is associated with a high incidence of postoperative complications and high mortality rates; multiple organ failure is the main cause of death in these patients [1]. Targeting tissue perfusion in high-risk surgical patients Many small single-center studies have demonstrated impressive reductions in morbidity and mortality associated with a treatment strategy aimed at preemptive optimization by increasing the DO2 index to levels >600 ml/ minute/m2 [35,36,37,38]. In patients with a high risk of perioperative death, PAC-guided hemodynamic optimization using dobutamine to obtain DO2 >600 ml/minute/m2 was associated with better outcomes, whereas fluids alone increased the incidence of postoperative complications [45]. The first group comprises the majority of patients undergoing major surgery, who are at risk of significant volume shifts during surgery because of bleeding or other significant intravascular volume losses For these patients, the use of dynamic indices to ensure normovolemia and preemptive hemodynamic optimization with minimally invasive CO monitoring or surrogates guided by SV or CO responses to fluid challenge is suitable (Figure 1). For these patients we can monitor DO2 continuously, with minimally invasive hemodynamic monitoring or a PAC, initially testing fluid responsiveness and maximizing SV and preemptively augmenting DO2 with dobutamine or dopexamine if necessary to achieve the best possible value

Conclusion

Findings

50. Collaborative Study Group on Perioperative ScvO Monitoring