Perioperative Hemodynamic Optimization: A Way to Individual Goals

Abstract

Perioperative goal directed therapy (GDT) and hemodynamic optimization have been on the program of anesthesiology and intensive care meetings for almost 30 years. The idea that morbidity [1,2], incidence of infectious complications [3] and even short term [4] or long-term mortality [5] can be affected by improving hemodynamic status and oxygen delivery to organs at the time of surgical trauma is very attractive. Since 1988 when Shoemaker et al. published their study [6] much has changed in the approach to high-risk surgical patients, including less invasive therapies and new surgical methods. Hemodynamic monitoring options have also increased. But the problem of hemodynamic optimization has scarcely moved from the hypothetical level of controlled trials to every-day practice in many institutions. Although there is a strong movement towards adoption of this principle via national guidelines [7], the community of believers (mostly from the academic field) is opposed by the practicing ‘infidels’. In a recently published survey among North American and European anesthesiologists, only 35 % of respondents used some cardiac output monitoring for high-risk surgical patients [8]. Lees et al. [9] named the following controversies as the major reasons for notadopting GDT:

• The right population (problem with defining the high-risk patient and surgery)

• The protocol itself (heterogeneity of goals, interventions and monitoring tools)

• Logistic reasons (economic and personal issues)