REVIEW   Free access

Minerva Anestesiologica 2019 December;85(12):1315-33

DOI: 10.23736/S0375-9393.19.13584-5

Copyright © 2019 EDIZIONI MINERVA MEDICA

language: English

Clinical guidelines for perioperative hemodynamic management of non cardiac surgical adult patients

Nicola BRIENZA ¹ ✉, Giandomenico BIANCOFIORE ², Franco CAVALIERE ³, Antonio CORCIONE ⁴, Andrea DE GASPERI ⁵, Rosanna C. DE ROSA ⁴, Roberto FUMAGALLI ⁶, Maria T. GIGLIO ¹, Alessandro LOCATELLI ⁷, Ferdinando L. LORINI ⁸, Stefano ROMAGNOLI ⁹, Sabino SCOLLETTA ¹⁰, Luigi TRITAPEPE ¹¹

¹ Unit of Anesthesia and Resuscitation, Department of Emergencies and Organ Transplantations, Aldo Moro University, Bari, Italy; ² Operative Unit of Anesthesia and Transplant Resuscitation, University of Pisa, Pisa, Italy; ³ Unit of Cardiac Anesthesia and Cardiosurgical Intensive Therapy, A. Gemelli University Polyclinic, Sacred Heart Catholic University, Rome, Italy; ⁴ Operative Unit of Anesthesia and Intensive Postoperative Therapy, Department of Critical Area, Colli-Monaldi Hospital, Naples, Italy; ⁵ Operative Unit of Anesthesia and Resuscitation II, Niguarda Ca’ Granda Hospital, Milan, Italy; ⁶ Operative Unit of Anesthesia and Resuscitation I, Milano Bicocca University, Niguarda Ca’ Granda Hospital, Milan, Italy; ⁷ Service of Anesthesia and Cardiovascular Intensive Therapy, Department of Emergency and Critical Area, Santa Croce e Carle Hospital, Cuneo, Italy; ⁸ Department of Emergency, Urgency and Critical Area, Papa Giovanni XXIII Hospital, Bergamo, Italy; ⁹ Department of Anesthesia and Resuscitation, University of Florence, Careggi University Hospital, Florence, Italy; ¹⁰ Unit of Resuscitation and Critical Medicine, Department of Medicine, Surgery and Neurosciences, University Hospital of Siena, Siena, Italy; ¹¹ Operative Unit of Anesthesia and Intensive Therapy in Cardiosurgery, Department of Emergency and Admission, Anesthesia and Critical Areas, Umberto I Policlinic, Sapienza University, Rome, Italy

Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.

KEY WORDS: Perioperative period; Hemodynamics; Fluid therapy; Cardiac output