The place of goal-directed haemodynamic therapy in the 21st century

Abstract

### Key points This article will discuss the history and subsequent development of goal-directed haemodynamic therapy (GDT), reviewing briefly the significant clinical trials of GDT, and finally suggest a practical clinical guide to GDT based on the most up-to-date evidence synthesis. The future role for GDT will also be discussed. The ‘high-risk’ surgical patient may be classified in a variety of ways. One suggested threshold includes those patients who have an individual postoperative mortality risk exceeding 5%, incorporating surgical factors such as complexity and urgency (often emergency), and patient factors such as comorbidities and (increasing) age.1 ‘Extremely high-risk’ patients are those whose postoperative mortality risk is >20%.2 Another classification describes those patients undergoing procedures that carry an inherent mortality rate exceeding 5%. Twenty-five per cent of the surgical population undergoing vascular, upper gastrointestinal, lower gastrointestinal, and hepatobiliary surgery fall into this latter category.3 Measures of cardiovascular fitness can also be used to stratify patient risk. Patients unable to achieve four metabolic equivalents (METS) (such as climbing a flight of stairs or gardening) are designated high risk, as are those with an anaerobic threshold (AT) of <11 ml of oxygen per kilogram per minute (ml O2 kg−1 min−1) on preoperative cardiopulmonary …