Abstract
Treating critically ill and high-risk patients is one of the greatest challenges in medicine, and it is also a multidisciplinary task. Practice varies country by country resulting in a large scatter in outcome data, which makes the interpretation difficult. Regarding anesthesia and surgery, based on an international 7 day cohort, the EUSOS-study, conducted in 28 countries in Europe including 46,000 patients undergoing inpatient surgery, the overall mortality was 4%, which was higher than expected (1). What is even more surprising that 73% of the patients who died were never admitted to an intensive care unit (ICU). One of the leading reasons of an unfavorable outcome is inadequate perioperative hemodynamic management. Although this statement is widely accepted, yet fluids and catecholamines are commonly prescribed to subjective criteria (2). Several large prospective randomized trials have recently studied the effects of advanced hemodynamic monitoring based perioperative goal-directed therapy (3–7). There is also gathering evidence in other fields of perioperative care that patients should be treated according to individualized, physiology based values rather than guidelines or treatment bundles determined values (8). These results may lead to a paradigm shift in critical care medicine and change our practice from a protocolized “figure based” management to treating patients according to their individual and actual needs.
Highlights
Fluid therapy has a pivotal role in maintaining hemodynamic stability, and it is important to acknowledge that the only reason patients need infusion is to normalize DO2 by increasing stroke volume cardiac output (CO)
Several studies revealed that both intraoperative hypoand hypervolemia can be responsible for post-operative complications and organ failure, while optimization of perioperative hemodynamics may result in improved outcome [3, 4, 9, 10]
In a large multicenter randomized study, we recently reported that a pulse pressure variation (PPV), mean arterial pressure (MAP), and cardiac index (CI)-trending based approach nearly halved post-operative complications in high-risk surgical patients undergoing major abdominal surgery [4]
Summary
Several large prospective randomized trials have recently studied the effects of advanced hemodynamic monitoring based perioperative goal-directed therapy [3,4,5,6,7]. There is gathering evidence in other fields of perioperative care that patients should be treated according to individualized, physiology based values rather than guidelines or treatment bundles determined values [8]. These results may lead to a paradigm shift in critical care medicine and change our practice from a protocolized “figure based” management to treating patients according to their individual and actual needs.
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