Perioperative Goal-directed Therapy Research Articles

Fluid management in the septic peri-operative patient.

This review provides insight into recent clinical studies involving septic peri-operative patients and highlights gaps in understanding fluid management. The aim is to enhance the understanding of safe fluid resuscitation to optimize peri-operative outcomes and reduce complications. Recent research shows adverse surgical and clinical outcomes with both under- and over-hydration of peri-operative patients. The kinetic of intravenous fluids varies significantly during surgery, general anaesthesia, and sepsis with damage to endothelial glycocalyx (EG), which increases vascular permeability and interstitial oedema. Among clinical anaesthesia, neuraxial anaesthesia and sevoflurane have less effect on EG. Hypervolemia and the speed and volume of fluid infusion are also linked to EG shedding. Despite improvement in the antisepsis strategies, peri-operative sepsis is not uncommon. Fluid resuscitation is the cornerstone of sepsis management. However, overzealous fluid resuscitation is associated with increased mortality in patients with sepsis and septic shock. Personalized fluid resuscitation based on a careful assessment of intravascular volume status, dynamic haemodynamic variables and fluid tolerance appears to be a safe approach. Balanced solutions (BS) are preferred over 0.9% saline in patients with sepsis and septic shock due to a potential reduction in mortality, when exclusive BS are used and/or large volume of fluids are required for fluid resuscitation. Peri-operative goal-directed fluid therapy (GDFT) using dynamic haemodynamic variables remains an area of interest in reducing postoperative complications and can be considered for sepsis management (Supplementary Digital Content). Optimization of peri-operative fluid management is crucial for improving surgical outcomes and reducing postoperative complications in patients with sepsis. Individualized and GDFT using BS is the preferred approach for fluid resuscitation in septic peri-operative patients. Future research should evaluate the interaction between clinical anaesthesia and EG, its implications on fluid resuscitation, and the impact of GDFT in septic peri-operative patients.

The effects of perioperative goal-directed therapy on acute kidney injury after cardiac surgery in the early period

Background: This study aims to investigate the effects of goaldirected fluid therapy on the development of acute kidney injury in the perioperative period in patients undergoing cardiopulmonary bypass. Methods: Between November 2019 and May 2021, a total of 60 patients (46 males, 14 females; mean age: 62.5±9.6 years; range, 44 to 76 years) who were scheduled for elective coronary artery bypass grafting or valve surgery under cardiopulmonary bypass were included in the study. The patients were divided into two groups as the study group (Group S, n=30) and control group (Group C, n=30). The patients in Group C were treated with standard therapy, while the patients in Group S were treated with goal-directed fluid therapy. The Kidney Disease: Improving Global Outcomes (KDIGO) classification and renal biomarkers were used for the evaluation of acute kidney injury. Results: Acute kidney injury rates were similar in both groups (30%). Postoperative fluid requirement, intra-, and postoperative erythrocyte suspension requirements were significantly lower in Group S than Group C (p=0.002, p=0.02, and p=0.002, respectively). Cystatin-C was lower in Group S (p<0.002). The kidney injury molecule-1, glomerular filtration rate, and creatinine levels were similar in both groups. The length of hospital stay was longer in Group C than Group S (p<0.001). Conclusion: Although goal-directed fluid therapy does not change the incidence of acute kidney injury in patients undergoing cardiac surgery, it can significantly decrease Cystatin-C levels. Goal-directed fluid therapy can also decrease fluid and erythrocyte requirements with shorter length of hospital stay.

Current Commonly Used Dynamic Parameters and Monitoring Systems for Perioperative Goal-Directed Fluid Therapy: A Review.

Goal-directed fluid therapy (GDFT) is usually recommended in patients undergoing major surgery and is essential in enhanced recovery after surgery (ERAS) protocols. This fluid regimen is usually guided by dynamic hemodynamic parameters and aims to optimize patients' cardiac output to maximize oxygen delivery to their vital organs. While many studies have shown that GDFT benefits patients perioperatively and can decrease postoperative complications, there is no consensus on which dynamic hemodynamic parameters to guide GDFT with. Furthermore, there are many commercialized hemodynamic monitoring systems to measure these dynamic hemodynamic parameters, and each has its pros and cons. This review will discuss and review the commonly used GDFT dynamic hemodynamic parameters and hemodynamic monitoring systems.

Comparison of Stroke Volume Variation-based goal-directed Therapy Versus Standard Fluid Therapy in Patients Undergoing Head and Neck Surgery: A Randomized Controlled Study

Background:Perioperative fluid therapy is used to avoid dehydration and hypovolemia. Optimum perioperative fluid administration may improve postoperative outcomes after major surgery, and the optimal strategy remains controversial and uncertain.Aims:The primary outcome was the total amount of intraoperative fluids given between perioperative goal-directed fluid therapy (GDFT) guided by a hemodynamic monitoring system and standard fluid therapy based on “mean arterial pressure-diuresis” data in patients undergoing head and neck surgery. The secondary outcomes were the hemodynamics and laboratory variables, postoperative complications, length of mechanical ventilation, intensive care unit and hospital stay.Study Design:A randomized controlled study.Methods:Sixty patients were scheduled and randomized into two groups of 30 patients each: in the study group, an arterial pressure catheter was inserted and connected to the FloTrac system, whereas in the control group, an arterial pressure catheter was inserted and integrated into the hemodynamic monitoring system with a special transducer. The control group had fluids administered at the discretion of the anesthesiologist according to the mean arterial pressure >65 mmHg and diuresis >0.5 ml/kg/h. In the study group, fluid management was administered to achieve a target value of ≤13% through the stroke volume variation.Results:The total amounts of fluid in the intraoperative period were different between the groups, with the study group receiving significantly more fluids (P = 0.0455). The length of hospital stay was significantly longer in the study group than in the control group (P = 0.012), but prolonged oxygen demand was significantly more frequent in the control group than in the study group (P = 0.017). No difference was found in hemodynamics, lactate kinetics, and vasoactive agent requirements.Conclusion:The standard fluid therapy guided by conventional circulatory parameters appears sufficient for patients with low-to-moderate risk during head and neck surgery.

Goal-directed fluid therapy in gastrointestinal cancer surgery

Objective: To investigate the effects of perioperative goal-directed fluid therapy (GDFT) on intraoperative fluid balance, postoperative morbidity, and mortality. Methods: This is a prospective randomized study, and 90 patients who underwent elective open gastrointestinal cancer surgery between April 2017 and May 2018 were included. Patients were randomized into 2 groups that received liberal fluid therapy (the LFT group, n=45) and goal-directed fluid therapy (the GDFT group, n=45). Patients’ Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (CR-POSSUM) physiological score, Charlson Comorbidity Index (CCI), perioperative vasopressor and inotrope use, postoperative AKIN classification, postoperative intensive care unit (ICU) hospitalization, hospital stay, and 30-day mortality were recorded. Results: The volume of crystalloid used perioperatively and the total volume of fluid were significantly lower in the GDFT group compared to the LFT group (P<0.05). CR-POSSUM physiological score and CCI were significantly higher in the GDFT group (P<0.05). Although perioperative vasopressor and inotrope use was significantly higher in the GDFT group (P<0.05), postoperative acute kidney injury development was not affected. Postoperative mortality was determined to be similar in both groups (P>0.05). Conclusion: Although GDFT was demonstrated to be a good alternative method to LFT in open gastrointestinal cancer surgery, and it can prevent perioperative fluid overload, and the postoperative results are comparable in the two groups.

Incidence and risk factors associated with human albumin administration following total joint arthroplasty: a multicenter retrospective study

BackgroundEnhanced recovery after surgery (ERAS) program advocates implementation of perioperative goal-directed fluid therapy and reduced application of colloidal fluids. It should be used reasonably selectively in high-risk patients despite the clear efficacy of human albumin (HA). Therefore, it is vital to identify the risk factors for the use of HA. This study aims to determine the incidence and risk factors of HA administration in patients undergoing total hip or knee arthroplasty (THA, TKA).MethodsWe identified patients undergoing THA or TKA in multiple institutions from 2014 to 2016 and collected patient demographics and perioperative variables. The criterion of HA administration was defined as a postoperative albumin level < 32 g/L or 32 to 35 g/L for at-risk patients. We compared 14 variables between patients who received HA administration and those who did not after stratification by the preoperative albumin (pre-ALB) level. Multivariable regressions identified the independent risk factors associated with HA administration.ResultsIn total, 958 (20.3%) of 4713 patients undergoing THA and 410 (9.7%) of 4248 patients undergoing TKA received HA administration. In addition to pre-ALB < 35 g/L, preoperative anemia (odds ratio [OR] 2.12, P = 0.001; OR 1.39, P < 0.001) and drain use (OR 3.33, P = 0.001; OR 4.25, P < 0.001) were also independent risk factors for HA administration after THA regardless pre-ALB < 35 g/L or not, and patients undergoing TKA diagnosed of rheumatoid arthritis or ankylosing spondylitis tended to receive HA administration regardless pre-ALB < 35 g/L or not (OR 3.67, P = 0.002; OR 2.06, P < 0.001).ConclusionsThe incidence of HA administration was high in patients undergoing THA or TKA, and several variables were risk factors for HA administration. This finding may aid surgeons in preoperatively identifying patients requiring HA administration and optimizing perioperative managements.

Perioperative goal-directed therapy in high-risk abdominal surgery. A multicenter randomized controlled superiority trial

Study objectiveThe potential of perioperative goal-directed therapy (PGDT) to improve outcome after high-risk abdominal surgery remains subject of debate. In particular, there is a need for large, multicenter trials focusing on relevant patient outcomes to confirm the evidence found in small, single center studies including minor complications in their composite endpoints. The present study therefore aims to investigate the effect of an arterial waveform analysis based PGDT algorithm on the incidence of major complications including mortality after high-risk abdominal surgery. DesignProspective randomized controlled multicenter trial. SettingOperating theatres and Post-Anesthesia/Intensive Care units (PACU/ICU) of four tertiary hospitals in The Netherlands. PatientsA total number of 482 patients undergoing elective, abdominal surgery that is considered high-risk due to the extent of the procedure and/or patient comorbidities. InterventionsHemodynamic therapy using an age-specific PGDT algorithm including cardiac index (CI) and stroke volume variation (SVV) measurements during a 24-h perioperative period starting at induction of anesthesia. MeasurementsThe average number of major complications (including mortality) within 30 days after surgery, the number of minor complications, hospital and PACU/ICU length of stay (LOS), amounts of fluids and vasoactive medications used. Complications were graded using the Accordion severity grading system. ResultsThe average number of major complications per patient was 0.79 (PGDT group) versus 0.69 (control group) (p = 0.195). There were no statistically significant differences in the number of minor complications, hospital LOS, PACU/ICU LOS, or grading of complications. Patients in the PGDT group received more fluids intraoperatively, more dobutamine intra- and postoperatively, while patients in the control group received more phenylephrine during the operation. ConclusionsPGDT based on a CI and SVV driven algorithm did not result in improved outcomes after high-risk abdominal surgery. Clinical trial registrationNetherlands Trial Registry: NTR3380.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Perioperative fluid management-Goal Directed Therapy (GDT)

Perioperative goal-directed hemodynamic therapy is a protocolized treatment strategy aimed at optimization of global cardiovascular dynamics, including oxygen delivery to tissues and organ perfusion pressure. This is achieved by titrating fluids, vasopressors, and inotropes to predefined physiological target values of hemodynamic variables. Its scope is to reduce complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections), decrease major abdominal and systemic postoperative complications, length of stay and postoperative morbidity and mortality mainly in high-risk patients undergoing major surgery. Identifying patients in whom perioperative goal-directed hemodynamic therapy can actually improve postoperative outcomes is crucial. This is a review focusing on all the aspects of GDFT compared to standard fluid therapy during surgery.

PSU8 Cost-Effectiveness Analysis of Perioperative Goal-Directed Fluid Therapy (PGDT) for High-Risk Hip Replacement Surgery from the Public Healthcare Perspective in Mexico

Since Perioperative Goal Directed Therapy (PGDT) is considered the standard care for patients submitted to high-risk surgeries for reducing intrahospital complications, we aimed at estimating the incremental cost-effectiveness ratio of the PGDT performed with HemosPhere platform, in high-risk hip replacement surgeries, from the institutional perspective in Mexico.

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association.

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.

Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery

BackgroundAppropriate perioperative fluid management is of pivotal importance to reduce postoperative complications, which impact on early and long-term patient outcome. The so-called perioperative goal-directed therapy (GDT) approach aims at customizing perioperative fluid management on the individual patients’ hemodynamic response. Whether or not the overall amount of perioperative volume infused in the context of GDT could influence postoperative surgical outcomes is unclear. MethodsWe conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of GDT approach between study population and control group in reducing postoperative complications and perioperative mortality, using MEDLINE, EMBASE and the Cochrane Controlled Clinical trials register. The enrolled studies were grouped considering the amount infused intraoperatively and during the first 24 h after the admission in the critical care unit (perioperative fluid).ResultsThe metanalysis included 21 RCTs enrolling 2729 patients with a median amount of perioperative fluid infusion of 4500 ml. In the studies reporting an overall amount below or above this threshold, the differences in postoperative complications were not statically significant between controls and GDT subgroup [43.4% vs. 34.2%, p value = 0.23 and 54.8% vs. 39.8%; p value = 0.09, respectively].Overall, GDT reduced the overall rate of postoperative complications, as compared to controls [pooled risk difference (95% CI) = − 0.10 (− 0.14, − 0.07); Chi2 = 30.97; p value < 0.0001], but not to a reduction of perioperative mortality [pooled risk difference (95%CI) = − 0.016 (− 0.0334; 0.0014); p value = 0.07]. Considering the rate of organ-related postoperative events, GDT did not reduce neither renal (p value = 0.52) nor cardiovascular (p value = 0.86) or pulmonary (p value = 0.14) or neurological (p value = 0.44) or infective (p value = 0.12) complications.ConclusionsIrrespectively to the amount of perioperative fluid administered, GDT strategy reduces postoperative complications, but not perioperative mortality.Trial RegistrationCRD42020168866; Registration: February 2020https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866

The effect of compliance with a perioperative goal-directed therapy protocol on outcomes after high-risk surgery: a before-after study

Perioperative goal-directed therapy is considered to improve patient outcomes after high-risk surgery. The association of compliance with perioperative goal-directed therapy protocols and postoperative outcomes is unclear. The purpose of this study is to determine the effect of protocol compliance on postoperative outcomes following high-risk surgery, after implementation of a perioperative goal-directed therapy protocol. Through a before-after study design, patients undergoing elective high-risk surgery before (before-group) and after implementation of a perioperative goal-directed therapy protocol (after-group) were included. Perioperative goal-directed therapy in the after-group consisted of optimized stroke volume variation or stroke volume index and optimized cardiac index. Additionally, the association of protocol compliance with postoperative complications when using perioperative goal-directed therapy was assessed. High protocol compliance was defined as ≥ 85% of the procedure time spent within the individual targets. The difference in complications during the first 30 postoperative days before and after implementation of the protocol was assessed. In the before-group, 214 patients were included and 193 patients in the after-group. The number of complications was higher in the before-group compared to the after-group (n = 414 vs. 282; p = 0.031). In the after-group, patients with high protocol compliance for stroke volume variation or stroke volume index had less complications compared to patients with low protocol compliance for stroke volume variation or stroke volume index (n = 187 vs. 90; p = 0.01). Protocol compliance by the attending clinicians is essential and should be monitored to facilitate an improvement in postoperative outcomes desired by the implementation of perioperative goal-directed therapy protocols.

The association between arterial pulse waveform analysis device and in-hospital mortality in high-risk non-cardiac surgeries.

Perioperative goal-directed fluid therapy is used for haemodynamic optimization in high-risk surgeries. Cardiac output monitoring can be performed by a specialized pressure transducer for arterial pulse waveform analysis (S-APWA). No study has assessed whether real-world use of S-APWA is associated with post-operative outcomes; therefore, using a Japanese administrative claims database, we retrospectively investigated whether S-APWA use is associated with in-hospital mortality among patients undergoing high-risk surgery under general anaesthesia. Adult patients who underwent high-risk surgery under general anaesthesia and arterial catheterization between 2014 and 2016 were divided into S-APWA and conventional arterial pressure transducer groups, then compared regarding baseline factors and outcomes. Logistic regression analysis was performed to compare in-hospital mortality. Subgroup analyses evaluated S-APWA efficacy and outcomes based on the type of surgery and patients' comorbidity. S-APWA was used in 6859 of 23655 (29.0%) patients; the crude in-hospital mortality rate was 3.5%. Adjusted analysis showed no significant association between S-APWA use and in-hospital mortality rate (adjusted odds ratio [aOR]=0.91; 95% confidence interval [CI]: 0.76-1.07; P=.25). S-APWA use was associated with significantly lower in-hospital mortality in patients undergoing vascular surgery (aOR=0.67; 95% CI: 0.49-0.94), and significantly higher in-hospital mortality in patients undergoing lower limb amputation (aOR=2.63; 95% CI: 1.32-5.22). S-APWA use and in-hospital mortality were not significantly associated with other subgroups. S-APWA use was not associated with in-hospital mortality in the entire study population. However, S-APWA was associated with decreased in-hospital mortality among vascular surgery and increased in-hospital mortality among lower limb amputation.

Is perioperative goal-directed therapy able to reduce surgical complications in different surgical settings? A meta-analytic study

IntroductionGoal directed therapy (GDT) is a method aiming at optimizing doses and timing of fluids, inotropes and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. Several meta-analyses confirm that GDT can reduce postoperative complications in high risk patients, and a recent trial suggests its significant effect also in low-moderate risk patients. The aim of the present meta-analysis is to investigate the effect of GDT on postoperative complications, in both high and low risk patients. Moreover, we stratified the effect of GDT in different kind of surgical procedures.MethodsRandomized controlled trials (RCTs) on perioperative GDT in adult surgical patients were included. The primary outcome measure was complications, defined as number of patients with a least one postoperative complication. A subgroup-analysis was also performed including RCTs with a mortality rate in control group <10%, and considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery and so on. Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs).ResultsIn 47 RCTs, 2329 patients developed at least one complication: 1030 out of 2781 (37%) were randomized to perioperative GDT, and 1299 out of 2772 (47%) were randomized to control. Pooled OR was 0.58 and 95% CI was 0.47-0.70. The sensitivity analysis confirmed main result. The subgroup analysis including only studies in which the mortality rate in the control group was higher than 10% showed significant results (OR 0.51, 95% CI 0.35-0.74, p=0.004, 10 RCTs), as well as a statistical significant effect was observed in those RCTs with a mortality rate in control group <10% (OR 0.59, 95% CI 0.47-0.74, p<0.0001, 37 RCTs). The subgroup analysis enrolling major abdominal patients showed a significant result (OR 0.69, 95% CI 0.57-0.83,p <0.0001, 29 RCTs, 3881 patients) as well as a significant effect was observed in those RCTs enrolling exclusively orthopedic (OR 0.48, 95% CI 0.30-0.79,p=0.004, 6 RCTs, 501 patients) and neurosurgical procedures (OR 0.40, 95% CI 0.21-0.78, p=0.008, 2 RCTs, 208 patients).ConclusionsThe present meta-analysis suggests that GDT can reduce postoperative complication rate in high risk as well as in low risk patients. Moreover, the beneficial effect of GDT on postoperative morbidity is significant on major abdominal, orthopedic and neurosurgical procedures. However, heterogeneity was found in some subgroups, reducing the strength of the results. Several well-designed RCTs are needed to further explore the effect of GDT in low risk patient and in different kind of surgeries.

The role of goal-directed therapy in the prevention of acute kidney injury after major gastrointestinal surgery: Substudy of the OPTIMISE trial.

Acute kidney injury (AKI) is an important adverse outcome after major surgery. Peri-operative goal-directed haemodynamic therapy (GDT) may improve outcomes by reducing complications such as AKI. To determine if GDT was associated with a reduced incidence of postoperative AKI according to specific renal biomarkers. Prospective substudy of the OPTIMISE trial, a multicentre randomised controlled trial comparing peri-operative GDT to usual patient care. Four UK National Health Service hospitals. A total of 287 high-risk patients aged at least 50 years undergoing major gastrointestinal surgery. The primary outcome measure was AKI defined as urinary neutrophil gelatinase-associated lipase (NGAL) at least 150 ng ml 24 and 72 h after surgery. Secondary outcomes were between-group differences in NGAL measurements and NGAL : creatinine ratios 24 and 72 h after surgery and AKI stage 2 or greater according to Kidney Disease Improving Global Outcomes (KDIGO) criteria within 30 days of surgery. In total, 20 of 287 patients (7%) experienced postoperative AKI of KDIGO grade 2 or 3 within 30 days. The proportion of patients with urinary NGAL at least 150 ng ml 24 or 72 h after surgery was similar in the two groups [GDT 31/144 (21.5%) patients vs. usual patient care 28/143 (19.6%) patients; P = 0.88]. Absolute values of urinary NGAL were also similar at 24 h (GDT 53.5 vs. usual patient care 44.1 ng ml; P = 0.38) and 72 h (GDT 45.1 vs. usual patient care 41.1 ng ml; P = 0.50) as were urinary NGAL : creatinine ratios at 24 h (GDT 45 vs. usual patient care 43 ng mg; P = 0.63) and 72 h (GDT 66 vs. usual patient care 63 ng mg; P = 0.62). The incidence of KDIGO-defined AKI was also similar between the groups [GDT 9/144 (6%) patients vs. usual patient care 11/143 (8%) patients; P = 0.80]. In this trial, GDT did not reduce the incidence of AKI amongst high-risk patients undergoing major gastrointestinal surgery. This may reflect improving standards in usual patient care. OPTIMISE Trial Registration ISRCTN04386758.

Which type of fluid to use perioperatively?

Fluid administration in the perioperative period is daily clinical practice for all anesthesiologists. The goal of fluid administration is to increase cardiac output in order to ultimately improve oxygen delivery to the tissues. Fluid therapy can be given as maintenance or as replacement fluid therapy. For both of these therapies balanced crystalloids belong to the first line of treatment. Colloids are used for fluid replacement as well, but are given for more specific indications such as hypovolemia as a consequence of blood loss. Fluids, as any other intravenous drug, have indications, contra-indications, and potential side-effects. No conclusive evidence exists over the way and amount of fluids that should be administered, and several strategies have been developed, e.g., restrictive or liberal fluid therapy or perioperative goal-directed therapy (PGDT). Restrictive fluid therapy uses limited amounts of fluid compared to liberal fluid therapy, however no clear definitions of restricted or liberal fluid therapy are available. PGDT uses hemodynamic variables to assess fluid responsiveness and to guide fluid therapy in order to optimize the hemodynamic status of the patient. Future directions in fluid administration are to use personalized hemodynamic target values and to use PGDT in closed-loop systems. Most important, fluids should be administered with the same caution that is used with any intravenous drug.

Automated systems for perioperative goal-directed hemodynamic therapy.

Perioperative goal-directed hemodynamic therapy (GDHT) has evolved from invasive "supra-physiological" maximization of oxygen delivery to minimally or even noninvasively guided automated stroke volume optimization. Over the past four decades, investigators have simultaneously developed novel monitors, updated strategies, and automated technologies to improve GDHT. Decision support technology, which proposes an intervention based on the patient's real time physiologic status, was an important step towards automation. Closed-loop systems have now been created to both increase GDHT compliance and decrease physician workload. These automated systems offer an elegant approach to optimize cardiac output and end-organ perfusion during the perioperative period. Most notably, automated preload optimization guided by dynamic indicators of fluid responsiveness has shown its feasibility, safety, and impact. Making the leap into fully automated GDHT has been accomplished on a small scale, but there are considerable challenges that must be surpassed before integrating all hemodynamic components into an automated system during general anesthesia. In this review, we will discuss the evolution and potential future of automated GDHT during the perioperative period.

Perioperative Goal Directed Therapy (PGDT) in Spinal Surgery in the Prone Position

Perioperative Goal Directed Therapy (PGDT) in Spinal Surgery in the Prone Position

Efficacy of Perioperative Goal-directed Fluid Therapy in Preventing Cerebral Desaturation and Postoperative Cognitive Dysfunction After Beach Chair Position Shoulder Surgery

Efficacy of Perioperative Goal-directed Fluid Therapy in Preventing Cerebral Desaturation and Postoperative Cognitive Dysfunction After Beach Chair Position Shoulder Surgery